Largest Effort at Integrated Care Produces Some Good Outcomes, Savings - With a Noteworthy Miss

The study in JAMA represents the largest effort to date to integrate mental health and primary care services across a health system and measure both clinical outcomes and savings.

The largest study to date that documents the integration of primary and mental health care within a single system found both savings and improved outcomes—along with a noteworthy measure that fell short, according to results published this week in JAMA.

The study involved 113 practices and 113,452 unique patients of Intermountain Healthcare who were seen between 2010 and 2013. Intermountain began integration of mental health services in the primary care setting, often called collaborative care, as far back as 2000. Work pioneered at the University of Washington has shown that this approach can produce improved outcomes for patients who suffer from depression and chronic conditions, including diabetes.

While the approach seemed promising, Intermountain wanted to measure its effectiveness compared with traditional primary care—and, specifically, whether it would save money in a large health system. The health system classified practices as “team-based” using criteria from the National Committee for Quality Assurance.

The patients studied were not those with brief encounters with Intermountain—these were patients who had maintained a 10-year continuous relationship with the health system starting in 2003. Thus, the 2003 to 2005 period served as a baseline. Patients were matched by both demographic and health status. All were at least 18 years of age.

For patients with diabetes, quality measures included Intermountain’s 5-part bundle, which is (1) a retinal eye examination within 2 years; (2) a nephropathy screening or prescription of angiotensin-converting enzyme or angiotensin receptor blocker performed in the last year; (3) blood pressure lower than 140/90 mm Hg; (4) low-density lipoprotein cholesterol level lower than 100mg/dL; and (5) glycated hemoglobin level lower than 8% of total hemoglobin.

Of the practices studies, 27 were integrated and 75 were traditional, although some traditional began taking steps toward becoming integrated during the study period.

The integrated practices had better quality of care measures in the 2010 to 2013 study period, including:

  • Higher rates of screening for patients with depression (46.1% integrated vs 24.1% in traditional)
  • Adherence to the 5-part diabetes bundle (24.6% integrated vs 19.5% traditional)
  • Documentation of self-care plans (48.4% integrated vs 8.7% traditional)

Notably, the traditional practices scored higher on control of hypertension below 140/90 mm Hg: 97.7% vs 85.5%. This is offset by the fact that the integrated group had a higher share of patients who made an annual primary visit: 84.2% vs 77.2%.

Service utilization and cost

Across the board, patients in the integrated practices had lower rates of utilization, expressed in visits or admissions per 100 person-years. Rates included:

  • Emergency visits (18.1 integrated vs 23.5 traditional)
  • Hospital admissions (9.5 integrated vs 10.6 traditional)
  • Ambulatory-sensitive emergency visits (3.3 integrated vs 4.3 traditional)
  • Encounters with primary care physicians (232.8 integrated vs. 250.4 traditional)

There were no significant differences in visits to specialists (213.5 integrated vs 217.9 traditional).

Payments received by Intermountain were lower overall to the integrated practices ($3400.62) than the traditional ($3515.71), with the largest drops in the commercial insurance and self-pay categories. Further analysis showed that payments to integrated practices for treatment of chronic conditions, like depression and diabetes, were significantly lower in the integrated practices than in the traditional practices: for active depression, payments were $5260.48 in integrated practices compared with $5545.69 in traditional and in diabetes, payments were $4841.94 in integrated practices compared with $5179.83 in traditional.

The authors noted that while a collaborative approach saves money and produces results, it takes a commitment from all parties and is, in itself, a cost.

“Although the investment costs of the program were lower than the reduction in payments received by the delivery system, the implementation of [integrated] practices was a resource-intensive health reform initiative," they wrote. "It required sustained investment in leadership, clinical and analytic workforce, a robust information system, and additional quality incentives. “Transforming practice culture presents continuous operational challenges of monitoring and rewarding collaboration among teams and across systems of care."

Recognizing this, CMS has proposed providing resources for collaborative care models in the proposed 2017 Physician Fee Schedule for Medicare, which is in the comment period.

Reference

Brennan BR, Brunisholz KD, Dredge C, et al. Association of integrated team-based care with healthcare quality, utilization and cost. JAMA. 2016; 316(8):826-834. doi:10.1001/jama.2016.11232,