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The American Journal of Accountable Care December 2016
Tobacco Control in Accountable Care: Working Toward Optimal Performance
Edward Anselm, MD
High-Dose Flu Vaccine Prevents Symptomatic Influenza and Reduces Hospitalizations
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Beth M. Beaudin-Seiler, PhD, and Kieran Fogarty, PhD
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Christine J. Manta, BA; Richard Caplan, PhD; Jennifer Goldsack, MChem, MA, MBA; Shawn Smith, MBA; and Edmondo Robinson, MD, MBA
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Treating Behavioral Health Disorders in an Accountable Care Organization
Neil D. Minkoff, MD

Treating Behavioral Health Disorders in an Accountable Care Organization

Neil D. Minkoff, MD
Integrating behavioral and physical health services within an accountable care organization offers a significant opportunity to address both behavioral health conditions and substance use disorders, as well as to improve outcomes and reduce costs.
In another study, researchers analyzed Medicare claims for 20% of traditional beneficiaries with a mental health condition who received care in a Pioneer or MSSP ACO between 2008 and 2013 (they could not analyze SUD claims given federal confidentiality laws). They found cost savings in 2012 for Pioneer ACOs, primarily from a reduction in hospitalization, but the savings did not continue in 2013, nor were any savings observed in the MSSP. Neither ACO program showed significant differences in outcomes.28 However, the authors also found little evidence of integration between behavioral and medical management. Instead, the majority of ACOs contracted out behavioral health services. Improving outcomes for individuals with mental health issues, they concluded, required that ACOs adopt evidence-based approaches associated with greater effectiveness in this population, such as integrated services.28

Even if ACOs are providing mental health services, far fewer are providing SUD services.21,29 A survey of 635 substance abuse treatment centers found just 15% had a signed agreement to be included in an ACO, while just 6% and 4%, respectively, planned to be connected with an ACO or were currently negotiating to be connected.21

Publicly owned and private nonprofit SUD treatment facilities, as well as those in more competitive markets and those accredited by the Joint Commission, were most likely to have such contracts.21 However, these contracts don’t necessarily result in fully integrated services; they may only cover referral to behavioral health specialists. In addition, treatment centers in the Northeast were more likely than those in the Southeast and Midwest to sign contracts with an ACO, with those most likely located in states with 50 or more ACOs.21 The authors concluded that the results of the survey “suggest that ACOs are not effectively integrating treatment and services for individuals with SUDs into medical settings.” This, in turn, continues the fragmented, suboptimal, high-cost care received by this high-risk population, most of whom suffer from multiple chronic conditions.21

Yet, most ACOs understand the interrelationship between behavioral and physical health on overall outcomes and costs. An analysis of data from 90 Medicare ACOs between December 2012 and June 2015, including 72 site visits, found that nearly all of the ACO staff interviewed understood that behavioral health disorders contribute to overall health outcomes and spending and that most were working to better coordinate behavioral and physical health services.33 They were working to integrate behavioral health and primary care, increase access to social workers, and enhance referral networks. Some embedded primary care providers in behavioral health facilities and included pharmacists and community resource specialists on treatment teams. One ACO even developed a mental health “center of excellence” for primary care referrals of complex patients who required significant behavioral and physical health services.33 However, the study also found significant barriers to greater integration of behavioral health in an ACO, including a lack of behavioral health care providers, access to data, and sustainable financing models.33

Successfully Integrating Behavioral and Physical Health Services in an ACO

Successful integration of behavioral and physical health services in an ACO should focus on 5 areas: financial incentives, data sharing, legislative changes, quality measures, and alignment with existing initiatives.33

Financial Incentives

Financial incentives in any healthcare delivery system must be aligned with expected outcomes. Thus, the value of integrating behavioral and physical health services is low under a fee-for-service system, which pays for the episode of care provided regardless of outcomes and provides no reimbursement for the additional time and effort required to coordinate care.33 The value is much higher, however, under a capitated system in which providers are essentially paid for keeping their population as healthy as possible.

Thus, value-based reimbursement models have entered the behavioral health sphere in the hope of spurring greater integration and improved outcomes. For instance, Minnesota’s Medicaid program capitates Hennepin Health ACO for behavioral and medical services, which encourages greater coordination between providers.34

Capitation is but one reimbursement model. States may also require that ACOs share savings with behavioral health providers or leave it up to the ACO itself to compensate behavioral health providers. For example, Maine includes behavioral health services within the total cost of care (TCOC) calculations for its ACOs, leaving it up to the organizations to determine how to financially compensate the behavioral health provider. Given that the TCOC impacts the organizations’ receipt of shared savings, this is designed to promote greater accountability across settings.34

Massachusetts embeds behavioral health services within its 3-tier payment system: comprehensive PMPM payments for an optional set of behavioral health services; quality incentive payments based on 23 quality measures, including 4 related to behavioral health; and shared savings payments based on cost savings on non–primary care services, including behavioral health. The higher the level, the higher the potential compensation.34

Data Sharing

Successful ACOs use robust information technology systems to collect and analyze data on their patients. These systems are typically tied into scheduling and revenue cycle systems to provide a holistic view of the state of the practice and patient population at any given time.34 However, medical providers have been upgrading their information technology, particularly their EHR systems, for years thanks to the Health Information Technology for Economic and Clinical Health (HITECH) Act, which offered incentives for the development and meaningful use of such systems. The act, however, excluded mental and behavioral health providers and treatment facilities from this incentive program.34 Thus, behavioral health providers are far behind their physical health counterparts in the collection and use of data.34

This could change if the Behavioral Health Information Technology Act and other legislations pass that are currently pending in Congress. The Behavioral Health Information Technology Act would extend incentives for meaningful use of EHRs to psychologists and mental health professionals who provide clinical care at psychiatric hospitals, mental health treatment facilities, and substance abuse treatment facilities.35 In addition, the Office of the National Coordinator of Health Information Technology has released grants through the State Innovation Models Initiative to enhance IT integration into behavioral health.36 ACOs could also require that their behavioral health providers participate in a joint EHR system and even offset some of the costs.

The lexicon for behavioral health diagnoses that is typically used for structured, coded information in health IT is also lacking. These structured data are required for the type of data analysis and clinical decision support necessary for successful population health management.36 Just as challenging is the lack of interoperability among existing health information systems and the lack of behavioral health data fields in medical EHRs or physical health fields within behavioral health EHRs. Some states are beginning to provide support for more integrated systems, however, while larger ACOs may have the resources to modify existing systems to facilitate greater coordination.34

Legislative Changes

Legislative changes in the federal regulation that prohibits sharing patient information related to alcohol and drug treatment without additional patient consent (beyond the standard HIPAA form) are needed. Without these data, ACOs are unable to provide the level of analytics required to manage the health of a population and identify patients for targeted outreach.33

Billing issues also require changes. Just 28 state Medicaid systems allow providers to bill for primary care and behavioral health services on the same day even though there is no federal restriction. This creates a significant barrier to integrated and coordinated care.34 Some legislative actions may seem minimal, but they can send a powerful message. For instance, in Arizona, it took legislative action to strike down a law that required separate waiting rooms for patients receiving mental health services and those receiving medical care.37

States should also encourage the training of additional behavioral health care specialists. A survey of 90 Medicare ACOs found that a scarcity of mental health professionals posted a significant barrier to the greater integration of behavioral and physical health. The ACOs cited poor Medicare reimbursement as one reason for the low number of providers willing to see Medicare patients.33 Another survey of 2900 primary care providers found that 67% reported difficulties connecting their patients with behavioral health specialists because of a shortage of providers, as well as insurance barriers.38 The survey was conducted in 2009, before the full impact of the Affordable Care Act and expanded access to insurance occurred. We do not yet know if this expansion changed access to providers or if benefits featuring narrow networks, behavioral health carve-outs, and high patient cost share blunted the benefit of this access.

Quality Measures

Quality measures play an integral part in the effort to improve delivery of behavioral and physical healthcare services, ensure appropriate access, and align incentives under value-based reimbursement.39 Although large national databases show 510 quality measures that address behavioral

health, just 5% to 10% are included in major quality reporting programs, such as the Inpatient Psychiatric Facility Quality Reporting Program, the Physician Quality Reporting System, the National Quality Forum, and quality measures for Medicare and Medicaid programs maintained by the Centers for Medicare & Medicaid Services.39,40

Indeed, until recently, just 1 of 33 quality measures required for Medicare ACOs, depression screening, was directly related to behavioral health.41 Yet, the depression screening is much more of a comprehensive primary care measure than measuring behavioral health performance. New measures for 2017 add rates of depression remission and response to treatment at 12 months. Measures involving screening for and treatment of SUDs are under consideration. In addition, several measures, such as shared decision making, medication reconciliation, and patient ratings of physicians, also apply.42

Adherence to behavioral health-related quality measures is poor, however, with reports demonstrating that patients receive recommended care based on quality initiatives about half the time. Conversely, recommended care is provided about two-thirds of the time for other chronic conditions, including diabetes and cardiovascular disease (Figure 239).39

In a recent article in Health Affairs, Pincus et al highlighted 5 key areas for improvement in the realm of behavioral health quality measures39:

• Expanding outcomes measurements built around the concept of “recovery” and including patients and families in their development.

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