The Critical and Evolving Roles for Psychiatry in Health Reform

As leaders of Montefiore Medical Center’s Care Management Organization in New York City and its Bronx Behavioral Health Integration Project (Bronx-BHIP), this month’s authors are a collective powerhouse in creating innovative integrated care models and reimbursement methodologies. They urge us to step up and help lead the way in health care reform. —Jürgen Unützer, M.D., M.P.H.

Health care reform initiatives are rapidly transforming the U.S. health system. In particular, the accountable care Triple Aim to improve care quality and population health while lowering health care costs has become ubiquitous across almost all aspects of primary and specialty care. Of particular interest to psychiatrists is the accelerating recognition that the success and sustainability of accountable care models are critically linked to timely behavioral health access and treatment.

Accountable care organizations (ACOs) often focus on creating integrated models centered on primary care practices. These practices provide preventive and chronic illness care, along with care coordination for patients with complex medical and psychosocial needs. Because evidence-based behavioral integration produces improved quality, lower costs, and seamless and holistic care, there is a strong desire to partner primary care and psychiatry; however, the dissemination of these models has been limited to settings where payment and information sharing are well aligned, such as in multispecialty patient-centered medical homes. Integration models such as collaborative care in primary care settings and provision of primary care for patients with serious mental illness within behavioral health settings are now seen as “must-haves” for ACOs and payers alike. With health reform, financial incentives to encourage integration are finally growing, and the need for psychiatrists to play the key clinical, supervisory, and administrative roles that will allow such models to scale and flourish has never been more pressing and urgent.

Emerging Policy Levers Support Integration

The traditional fee-for-service payment (FFS) mechanism as the sole mechanism for physician and hospital reimbursement is declining in favor of growing value-based payments (VBP) that reward the achievement of Triple Aim outcomes (quality, engagement and satisfaction, and costs). VBP models include some mix of FFS plus bonus incentives, episode-based payments, shared savings payments, and global capitation payments. Psychiatry, following the rest of medicine, will be pulled along this VBP continuum toward a more sustainable payment model that aligns incentives to provide timely patient access and engagement, coordinated care, evidence-based treatments, and outcome measurement.

Government and private payers are now actively providing support (through financial incentives and regulatory/policy changes) to health care providers to (1) integrate medical and behavioral health care at both the treatment and care-management levels, (2) increase the focus on achieving both medical and behavioral health outcomes on patients with comorbid conditions (for example, diabetic quality outcomes as well as depression outcomes), and (3) foster medical and behavioral health provider partnerships that improve information sharing, patient engagement, and shared accountability for health outcomes.

How Can Psychiatry Help Lead the Way?

Psychiatrists have the unique training and expertise to play the essential roles as providers, facilitators, and innovators to support the integration models that are critical to the success of accountable care models. At a population level, their expertise is critical to the implementation of workflows for identifying and monitoring behavioral health care needs for a defined patient population, as well as quality-improvement strategies for the attainment of both medical and behavioral health outcomes.

At the patient level, psychiatrist expertise in the biopsychosocial model of illness, chronic disease and medication management, and interdisciplinary team work are essential to helping patients achieve response and recovery. In late 2015, the Centers for Medicare and Medicaid Services announced that psychiatry will be included as a medical specialty to help align patients in Medicare ACOs. This auspicious development recognizes that after primary care, psychiatry has the same level of importance as cardiology, pulmonology, and a limited number of other specialties that can meaningfully impact the Triple Aim in partnership with primary care. It may also allow psychiatrists treating Medicare ACO patients to become involved in VBP arrangements (such as FFS plus incentive) as a way of rewarding the achievement of quality outcomes.

Psychiatrists in primary care settings must proactively define their role as behavioral health leaders within the health care team, providing training, supervision, consultation, and clinical review, in addition to providing direct patient care. For medically complex and acute patients, psychiatrists will also be asked to have a more direct treatment role in specialty clinics (for example, oncology, cardiology, pain management, and acute and subacute rehabilitation facilities) as these patients often have poorer health outcomes with high utilization.

The ability of psychiatrists to meet the changing demands of our health care system is not possible without embracing technology appropriate to patient choice and setting of care (for example, telemedicine/telepsychiatry, videoconferencing, evisits, online portals). A solid information technology infrastructure is required to maximize productive use of psychiatrist time, successfully manage and follow at-risk populations, guide evidence-based practice, and provide near and real-time data sharing across the continuum of care. Technology can help establish performance benchmarks, monitor care quality and cost savings, support nonbillable activities needed to improve engagement of psychiatric patients who often drop out of care, and promote model sustainability.

Psychiatry has a critical role to play in this time of change. The real question is whether there are enough psychiatrists who will step up and engage in these roles. We sincerely hope so. ■