Medical Practice on Brink of Major Transformation

Life, as we physicians know it, is over. No, I am not referring to the end of days as predicted by the Mayan calendar for December 21, 2012, although by that date we should have some data with respect to the implementation and performance of health care reform and emerging models of health care delivery.

In any case, if you look more deeply into the Mayan predictions, this date merely reflects the end of a cycle, and life begins again with a new calendar. Perhaps our new calendar starts with the Patient Protection and Affordable Care Act (PPACA) of 2010, which heralds a major overhaul of health care delivery systems as we deal with harsh economic realities.

Even predating the passage of this law, groundwork was being laid for alternative care delivery systems, adding the terms "patient-centered medical homes" and "accountable care organizations (ACOs)" to our lexicon.

As psychiatrists we are facing multiple transitions. We can anticipate the end of licensure renewal and the beginning of maintenance of licensure, the end of paper charts and the beginning of electronic medical records, the end of solo practices and the beginnings of larger group and multidisciplinary practices.

All physician and medical leadership groups are trying to comprehend the changes so they can develop plans to cope with and implement reform. Medical homes and ACOs are emerging as potential vehicles to transform health care delivery, drive quality, and reduce cost. A variety of pilot projects is on the launch pad in both the public and private sectors. The AMA has proposed guidelines and principles for emerging ACOs (Psychiatric News, December 17, 2010). Study collaboratives, marketing consultants, and specialty groups are emerging to provide strategies on ACO formation and assessment of competency requirements for ACO readiness.

What Do ACOs Means for Psychiatry?

This is a challenging question because we are in a state of flux and transition. Psychiatrists should familiarize themselves with the PPACA law, reviewing its impact on mental health care and its implementation time lines. It's also crucial to monitor what is developing in your geographic area and to keep abreast of the impact of emerging pilot programs.

Psychiatry is in Transition

The bulk of psychiatric training and practice has focused on treating the individual patient, at times so exclusively that we have developed a reputation for excluding families and limiting information we give to our medical colleagues, all under the guise of confidentiality.

While aspects of our tradition will continue, including the importance of protected information, we must evolve to meet the needs of broader populations. The challenge is to continue to be able to treat the individual yet accommodate and be accountable to group-population needs and to our medical partners.

There will be a trend to incorporate more mental health screening into the medical arena as well as a push to use lower-level providers.

The reintegration of psychiatry and general medical care will have to be bidirectional. In the public sector, remedying the 30 percent foreshortening of lifespan in patients with psychiatric disorders will require access to and availability of primary care practitioners. On the medical side, the management of chronic conditions such as cardiovascular disease, diabetes, cancer, obesity, and other disease states will require input from mental health experts so patients' depression, anxiety, and lifestyle issues can be better managed and more effectively treated.

Health Care Trends Emerge

There is a new vocabulary of buzz words in the era of health care reform. We will soon have to master DSM-5 terminology as well as adding the marketing and business concepts of deliverables, market share, and downstream revenue to our lexicon. Being a member of an ACO implies a willingness to participate in integrated care.

Integrated care may involve structural integration defined as geographical colocation of services, such as psychiatry in the same building or floor as primary care, or it can mean functional integration in which the psychiatrist is part of a medical team or, conversely, the primary care provider is part of the mental health team in public-sector psychiatry.

Medical care is also to become more patient and family centered, placing patients' care in the context of their lives, medical history, comorbid illnesses, and psychosocial matrix. This has been a trend in the management of chronic illness, as exemplified in the field of oncology.

The expectation is that we will move away from incidents of care to greater accountability for the patient across the continuum of care, from inpatient to outpatient with expectations of reducing emergency visits and rehospitalizations. Communication will be an essential component, and implementation of health information technology with shared medical records will become standard. Psychiatrists will have to determine what they share vs. what they protect in the way of locking out information and electronic access. Health care financing will trend away from fee for service to include bundled payment and capitation models.

In addition, multidisciplinary teams will become the rule. The role of psychiatrists and other mental health providers is in flux and will vary from one ACO to another. The role of psychiatric leadership will be critical in this phase, but will inevitably require greater flexibility and ability to supervise and coordinate care with a wide variety of mental health and general medicine professionals.

In many ways the future is now, our choices are to hold on to what we have been doing and ride off into the sunset or gear up and get ready for a Brave New World.

Footnotes

Mary Helen Davis, M.D., is director of behavioral oncology at the Norton Cancer Institute in Louisville, Ky., and is the Area 5 representative on the APA Board of Trustees.