A new type of medical organization is expected to rise to prominence in the coming years and could impact many psychiatrists and other small- and solo-practice physicians.
Accountable care organizations (ACOs) aim to coordinate care among multiple clinicians treating the same patients for varying conditions, improve patients' clinical outcomes, and lower the cost of that care. The movement to shift physicians away from independently operating solo or small practices to large practices or physician-hospital partnerships is being driven by the new health care reform law, private insurers, and an expected decline in reimbursements.
John McIntyre, M.D., a member of the AMA's Council on Medical Service (CMS) and a former APA president, said the AMA is working to identify ways that coming ACO regulations could keep that payment model from "squeezing out" small and solo practitioners in favor of large practices and hospital-led groups.
But even with better protections under the ACO system, small- and solo-practice psychiatrists will need to better integrate their patient care with that provided by other physicians, because all public and private payment systems are moving to reward such integration, McIntyre told Psychiatric News.
Integration "is now the exception rather than the rule among psychiatrists," he said.
APA plans to advise psychiatrists during the transition to this new model, McIntyre noted. For instance, in September APA's Board of Trustees approved a position statement calling for increased coordination of care between psychiatrists and primary care physicians. The need for such integration was demonstrated by research estimating that 25 percent of the patients of primary care physicians have comorbid and diagnosable psychiatric disorders and would benefit from psychiatric and integrated care. The gap between the episodes of treatment provided by psychiatrists and the estimated patient need is more than 368,000 annual visits.
"These individual visits are rarely, if ever, identified and addressed in the current fragmented health system...," said the APA position statement. "The integration of psychiatric care and primary care has consistently been demonstrated [in numerous randomized, controlled trials] to enhance access, improve quality, enhance individual outcomes, and diminish costs."
Better patient care coordination by psychiatrists and other physicians, according to research summarized in the position statement, would improve patient health and lower costs stemming from untreated mental illness. The position statement urges changes in state and federal laws and regulations to encourage greater collaboration and integration of psychiatry and primary care.
Karen Sanders, associate director for publically funded services in APA's Office of Healthcare Systems and Financing, said psychiatrists have recently begun asking her and organizations long focused on integrated care models about how they might fit into such programs.
"Up until now psychiatrists have been noticeably absent [from discussions about increasing integrated care], so psychologists have been filling the gap," she told Psychiatric News.
To support psychiatrists interested in integrated care programs, APA recently launched a list serve focused on distributing and exchanging related information among members. By early November, the list serve had attracted more than 20 psychiatrists.
Psychiatrists also have begun to attend meetings of national groups focused on integrated care, such as the Patient Centered Primary Care Collaborative (PCPCC), which is a coalition of employers, insurers, physicians, and patient advocates focused on improving quality and lowering costs. Such groups have long been dominated by primary care physicians, and as a result, many of the integrated care programs in private and public insurance will be designed around those clinicians.
Psychiatrists may qualify as the designated physician coordinating all of a patient's care in some of these health care systems. For example, through the new health care reform law's initiative to encourage integrated care groups, such as medical homes, individual psychiatrists can qualify as the central primary care providers to patients with serious and persistent mental illness. However, psychiatrists can attain that status only if they meet specific standards, which will be spelled out in future regulations.
Many psychiatrists, Sanders said, may better fit into ACOs created by the health care reform law to receive much higher reimbursements in exchange for improving care while lowering costs. These organizations, likely either physician networks or physician and hospital partnerships, will be more clearly detailed in future federal regulations.
Some private insurers and employers are already funding their own versions of ACOs. One example that includes psychiatrists is the Care Community of North Carolina. This organization has used aspects of a medical-home model to assign patients to a primary care physician, who then coordinates any care needed from other specialists. The organization also includes extra support, such as nurses on call to handle patient inquiries or emergencies and to decide whether a patient's condition requires a physician's attention.
"So there are models where providers can be loosely affiliated but still be linked in so that they can improve care through health information technology [HIT] improvement [and] performance-measurement initiatives and still be able to change the payment model from one that is more fee-for-service based to one that is value based," said Mark Zezza, Ph.D., a research director at the Engelberg Center for Health Reform at the Brookings Institution, in an interview.
Medicare's initial pilot ACO must launch by the beginning of 2012, likely followed by an expansion throughout Medicare several years later. Medicare will pay ACOs through a global budget. ACOs that are able to meet quality-of-care indicators while finding ways to hold down overall costs can divide the remaining funds among their members as profit. ACO-driven payment models are intended to replace the existing fee-for-service payment system by paying their physician members for all the health needs of a set number of patients based on their health conditions.
ACOs that fail to meet certain quality and cost-savings targets will face lower payments from Medicare. Likewise, individual clinicians who continue as unintegrated fee-for-service medical specialists are expected to face declining referrals, as ACOs look to partner with physicians who have shown they can lower costs and increase quality of care.
"The primary care doctors are going to have to work well with the specialists, and it is going to involve major cultural change in a lot of cases," Zezza said.
Although future private and publically funded ACOs will undoubtedly seek to include psychiatrists, the design of these ACOs will likely vary. Some ACOs are expected to use formally contracted specialists who will be committed solely to that ACO. But other ACOs will likely be open to nonexclusive agreements with specialists. That won't be an option for primary care physicians because each will be limited to treating patients in only one ACO, according to the health care law.
"Specialists can work with multiple ACOs, so maybe nothing has to change too much in terms of their business practices," Zezza said.
Physicians could benefit from ACO participation by taking advantage of HIT or cost-saving initiatives in those specific ACOs.
"So ideally it would help them become more efficient and work better with primary care physicians," Zezza said.
Fred Ralston Jr., M.D., president of the American College of Physicians, told Psychiatric News that psychiatrists considering the future of the practice of medicine should weigh "the hassles" and cost of joining an ACO against "the risk of being left out of an ACO that directs patients to other physicians in their specialty."
Psychiatrists interested in ACOs, Sanders said, should look for private insurers or employers in their area that are already launching such initiatives for information on whether psychiatrists would fit in that specific type of ACO. The PCPCC identifies emerging collaborative care pilot projects across the nation on its Web site.
More information on local collaborative care initiatives is posted at <www.pcpcc.net/pcpcc-pilot-projects>.