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The American Journal of Managed Care December 2016
Getting From Here to There: Health IT Needs for Population Health
Joshua R. Vest, PhD, MPH; Christopher A. Harle, PhD; Titus Schleyer, DMD, PhD; Brian E. Dixon, MPA, PhD, FHIMSS; Shaun J. Grannis, MD, MS, FAAFP, FACMI; Paul K. Halverson, DrPH, FACHE; and Nir Menache
The Health Information Technology Special Issue: Current Trends and Future Directions
Joshua R. Vest, PhD, MPH
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How Health Plans Promote Health IT to Improve Behavioral Health Care
Amity E. Quinn, PhD; Sharon Reif, PhD; Brooke Evans, MA, MSW; Timothy B. Creedon, MA; Maureen T. Stewart, PhD; Deborah W. Garnick, ScD; and Constance M. Horgan, ScD
Accountable Care Organization Hospitals Differ in Health IT Capabilities
Daniel M. Walker, PhD, MPH; Arthur M. Mora, PhD, MHA; and Ann Scheck McAlearney, ScD, MS
Building Health IT Capacity to Improve HIV Infection Health Outcomes
Hannah Rettler, MPH; R. Monina Klevens, DDS, MPH; Gillian Haney, MPH; Liisa Randall, PhD; Alfred DeMaria, MD; and Johanna Goderre, MPH
Telemedicine and the Sharing Economy: The "Uber" for Healthcare
Brian J. Miller, MD, MBA, MPH; Derek W. Moore, JD; and Chester W. Schmidt, Jr, MD
Assessing Electronic Health Record Implementation Challenges Using Item Response Theory
Kitty S. Chan, PhD; Hadi Kharrazi, MD, PhD; Megha A. Parikh, MS; and Eric W. Ford, PhD, MPH
Payer—Provider Patient Registry Utilized in a Behavioral Health Home
Michele Mesiano, MSW; Meghna Parthasarathy, MS; Shari L. Hutchison, MS, PMP; David Salai, BS; Suzanne Daub, LCSW; Mary Doyle, MHIS; and James M. Schuster, MD, MBA
US Hospital Engagement in Core Domains of Interoperability
A. Jay Holmgren, BA; Vaishali Patel, PhD; Dustin Charles, MPH; and Julia Adler-Milstein, PhD

How Health Plans Promote Health IT to Improve Behavioral Health Care

Amity E. Quinn, PhD; Sharon Reif, PhD; Brooke Evans, MA, MSW; Timothy B. Creedon, MA; Maureen T. Stewart, PhD; Deborah W. Garnick, ScD; and Constance M. Horgan, ScD
Commercial health plans promote the use of health IT to support behavioral health care access and delivery.
ABSTRACT

Objectives: Given the large numbers of providers and enrollees with which they interact, health plans can encourage the use of health information technology (IT) to advance behavioral health care. The manner and extent to which commercial health plans promote health IT to improve behavioral health care is unknown. This study aims to address that gap.

Study Design: Cross-sectional study.

Methods: Data are from a nationally representative survey of commercial health plans regarding administrative and clinical dimensions of behavioral health services in 2010. Data are weighted to be representative of commercial managed care products in the United States (n = 8427; 88% response rate). Approaches within the domains of provider support, access to care, and assessment and treatment were investigated as examples of how health plans can promote health IT to improve behavioral health care delivery.

Results: Health plans were using health IT approaches in each domain. About a quarter of products offered financial support for electronic health records, but technical assistance was rare. Primary care providers could bill for e-mail contact with patients for behavioral health in about a quarter of products. Few products offered member–provider e-mail, and none offered online appointment scheduling. However, online referral systems and online provider directories were common, and nearly all offered an online self-assessment tool; most offered online counseling and online personalized responses to questions or problems.

Conclusions: In 2010, commercial health plans encouraged the use of health IT strategies for behavioral health care. Health plans have an important role to play for increasing health IT as a tool for behavioral health care.

Am J Manag Care. 2016;22(12):810-815
Take-Away Points

This study examined how a nationally representative sample of commercial health plans encouraged the use of health information technology (IT) to support providers, facilitate access to behavioral health care, and increase opportunities for behavioral health assessment and treatment. 
  • Health plans have an important role to play for increasing health IT as a tool for behavioral health care. 
  • A significant minority of health insurance products allowed primary care providers to bill for e-mail communication with patients about behavioral health issues. 
  • Most products supported online behavioral health referrals, assessment, and treatment. 
  • Expanding the reach of health IT in behavioral health care could facilitate coordination and integration of behavioral health and general medical care.
Rapid developments in health information technology (IT) are changing the medical and behavioral health care services landscape. With the goals of improving healthcare quality, cost, efficiency, and access,1-6 health IT is the use of electronic information systems that store, retrieve, share, and enable the use of health data to support and streamline healthcare processes. Health IT innovations include a breadth of technologies, from electronic health records (EHRs) and electronic health tools, such as clinical reminders, patient portals, and mobile health applications, to broader tools that enhance patient activation and enable patient-reported outcomes. Although a large-scale investment in health IT adoption and implementation is taking place across the country, behavioral health has largely been left out of the initial wave of infrastructure development.7

Most behavioral health providers were not eligible for federal EHR “Meaningful Use” incentives under the Health Information Technology for Economic and Clinical Health (HITECH) Act.7 Additionally, many remain ineligible for incentives under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which supplements the Meaningful Use program and emphasizes the role of health IT in supporting quality improvement and payment reform.8,9 Although MACRA is Medicare-specific, commercial health plans often take up innovations promulgated through Medicare first. Behavioral health providers generally trail in the adoption, implementation, and use of EHRs.10-13 Moreover, behavioral health providers—particularly specialty addiction treatment organizations—often lack the resources and infrastructure to implement health IT initiatives,11,14-16 resulting in a growing health IT divide between general medical and behavioral health.7,13,17

Expanding the reach of health IT in substance use and mental health treatment is likely to be a key facilitator for coordinating and integrating behavioral health and general medical care.16,18,19 The Affordable Care Act of 2010 encourages investment in integrated healthcare systems, such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs), which require continued momentum toward expanding the reach of health IT into behavioral health. A premise of HITECH, and the broader movement toward EHR adoption and implementation, is that EHR systems will facilitate coordination and integration of care.3,16 Accomplishing these goals will likely require incorporating behavioral health into the health IT environment,10 particularly by establishing EHR interoperability and linking clinical data within and between healthcare facilities.16,19 Much remains unclear regarding the overall scope of health IT progress in meeting the goals of improving healthcare quality and decreasing healthcare costs,6,20 and especially, to what extent the investment in health IT will alter or improve how behavioral health care is accessed and delivered, and how it ultimately improves patient outcomes.7,21

As healthcare quality stakeholders, and given the large number of providers and enrollees that they reach, health plans have a key role in encouraging health IT to improve healthcare delivery. Health IT research to date has primarily centered on the role of providers and hospitals; the extent to which health plans influence health IT use to facilitate the delivery of care is still relatively unknown. Two studies found a weak relationship between payer mix and health IT adoption in hospitals, noting no significant associations with commercial insurance.22,23 Few, if any, studies directly examine the relationship of health plans and health IT as it pertains to behavioral health.

In this analysis, we explored how commercial health plans encourage health IT as a way to support providers, facilitate access to behavioral health care, and increase opportunities for behavioral health assessment and treatment. We examined how these strategies vary by how behavioral health care is managed, as having multiple organizations involved may create complexities in implementing health IT approaches. Behavioral health care management may be contracted to an organization outside of the health plan. Some arrangements may promote a specialized focus on behavioral health, while others may promote connections between behavioral health and medical care. Knowing the role that health plans might play in promoting health IT in behavioral health care is critical for moving health IT implementation efforts forward, as health plans often influence the activities of providers in their networks.

 

METHODS

Data Source


Data are from the third round of a nationally representative telephone survey of commercial health plans regarding administrative and clinical dimensions of alcohol, drug, and mental health services.24 The survey used a panel design with replacement, as described in previous research.24 The primary sampling units were 60 nationally representative market areas.25 The second stage sampled health plans within market areas.

Senior health plan executives were asked about their top 3 commercial products—based on enrollment—for the 2010 benefit year. The sample included 438 eligible plans, of which: 389 responded to the administrative module (89% response rate), reporting on 939 products; and 385 responded to the clinical module (88%), reporting on 925 products. Results are reported at the product level and weighted based on responses to the clinical module (n = 8427). Health plans were ineligible if they had fewer than 300 individuals (600 covered lives) enrolled, did not offer behavioral health benefits or comprehensive products, or only offered Medicaid/Medicare products. The study was approved by the Institutional Review Board of Brandeis University.

Variables

Health IT variables. Plans were asked about several health IT approaches within the domains of provider support, access to care, and assessment and treatment as examples of how health plans can encourage the use of health IT to improve care delivery. Approaches to support providers included 2 strategies that health plans may use to attract and retain providers in health plan networks (financial support for EHRs and technical assistance for health IT), and whether primary care providers are allowed to bill for e-mail contact with patients specifically regarding behavioral health issues. Approaches to facilitating member access to behavioral health care included offering an online provider directory, online appointment scheduling, online referral system, and provision by the health plan for members to e-mail providers. Approaches to improve behavioral health care delivery addressed both assessment and treatment strategies, and included online self-assessment tools, online personalized responses to questions or problems, and online counseling.

Contracting arrangement. Products were categorized by their approach to managing behavioral health services. Four arrangements were identified: 1) products with specialty external arrangements contracted with a managed behavioral health organization for the delivery and management of behavioral health services; 2) products with hybrid-internal arrangements used a specialty behavioral health organization that is part of the same parent organization as the health plan to manage behavioral health services—these internal behavioral health organizations also have external contracts with other health plans; 3) internal products directly administered behavioral health services; and 4) comprehensive products contracted with a single vendor for both general medical and behavioral health provider networks. Comprehensive contracts, which were reported by only 4 products in 2010, are included in the Table in the total column only.

Statistical Analyses

The findings reported are national estimates. The data are weighted to be representative of plans’ commercial managed care products in the United States. SUDAAN software version 11 (RTI International, Research Triangle Park, North Carolina) was used for estimation of the sampling variance given the complex sampling design. The results reported are based on nonmissing values; missing is less than 5%, unless otherwise noted in the Table. Significant differences by contracting arrangement are based on pairwise t tests with a .05 significance level, adjusted for multiple tests using the Bonferroni correction.

RESULTS

Provider Support


To encourage providers to join and remain in their networks, about a quarter of products offered financial support for EHRs, but only 4.5% of products offered technical assistance for health IT needs. These strategies were not specific to behavioral health providers, and may have applied to all providers in the network. Internal and hybrid-internal products were more likely than specialty external to provide financial support for EHRs, while internal and specialty external products were more likely than hybrid-internal products to provide technical assistance for health IT needs.

Many products supported electronic communication between providers and patients, with 27.8% of products that could answer this question allowing primary care providers to bill for e-mail contact with patients specifically for behavioral health problems. However, 34% of products did not know if billing for e-mail contact was allowed. Products with hybrid-internal contracts were more likely to support e-mail contact (38.3%) than products with internal (2.0%) or specialty external (0.8%) contracts.

Access to Care

Products also promoted health IT to facilitate member access to behavioral health services and patient interaction with providers. About 90% of products offered an online provider directory for behavioral health care, and approximately 70% of products offered an online referral system or online personalized responses to questions or problems; few offered member–provider e-mail and none offered online appointment scheduling. Health IT strategies to improve access to care varied significantly by contracting arrangement and product type. Hybrid-internal and internal products were more likely to offer these services than specialty external products.

Fewer than 10% of products facilitated members e-mailing providers for behavioral health problems. This trend was primarily driven by specialty external products, with 66.3% facilitating member–provider e-mails. None of the hybrid-internal products, and only 7.5% of internal products, offered member–provider e-mail for behavioral health problems.

Care Delivery

 
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