Implementation of the Patient Protection and Affordable Care Act (ACA) is set to move forward, and up to half of the states have begun implementing a provision urging formation of “health homes.” By including mental health diagnoses as criteria for patients to be enrolled in health homes, the ACA brings treatment of mental health conditions and substance abuse front and center in medical care.
Under Title III of the ACA, value-based purchasing programs for hospitals will link Medicare payments to quality performance on common, high-cost conditions such as cardiac, surgical, and pneumonia care, for example. Title IV places emphasis on prevention and health promotion. This increased emphasis on value-based care will push all medical specialties toward more efficient care models and more preventative care.
One such service model that shows great promise for patients with mental illness in particular is “integrated care.”
To foster integrated care, the ACA’s Title V makes provisions to strengthen primary care in various ways, including provisions that enhance training of primary care physicians, nurses, and pediatricians. While it does not make similarly specific provision for training general adult psychiatrists, it does provide for “mental and behavioral health education and training grants to schools for the development, expansion, or enhancement of training programs in social work, graduate psychology, professional training in child and adolescent mental health (which may include expanded slots for fellowship training in child and adolescent psychiatry), [and] training of paraprofessionals in child and adolescent mental health” and “grants for coordinated and integrated services through the co-location of primary and specialty care in community-based mental and behavioral health settings.”
Thus, under the ACA there will likely be a proliferation of training programs for mental health care providers of allied disciplines such as nurse specialists, social workers, and physician assistants, incentivized by the availability of mental health training grants.
Placing these facts side by side allows us to make the following projections about what the future of mental health services may look like in the post-ACA era:
There will be a significant increase in the numbers of those who can access mental health services, many of whom will seek care in integrated settings such as health homes.
There will not be enough psychiatrists to provide clinical care to meet the needs of this expanded population, at least initially. However, there may be an expansion in residency training slots for child psychiatry that could make up some of the shortfall over time.
This shortfall will most likely be filled by psychiatric nurses, physician assistants and other mental/behavioral health professionals whose training, while not as extensive, is much less expensive than that of psychiatrists.
There will be an expansion in the roles of advanced practice nurses in psychiatry, to include clinical leadership and supervision of other clinical specialists.
In the light of all this, what roles might psychiatrists play in the post-ACA era?
A central role that will remain critical for psychiatrists is providing direct clinical care.
In addition, the proliferation of clinically integrated networks (entities that hold value-based contracts with third-party payers, including Medicare) being driven by an increased emphasis on value-based service, will provide an opportunity for psychiatrists to find expanded roles in planning and operationalizing mental health services, including prevention and wellness care, for entire clinic and insured populations. There will be greater emphasis on the use of data to measure and drive quality of care. This is one area in which psychiatrists’ training is currently lacking and can be improved.
Finally, there will be a need for psychiatrists to maintain current clinical competencies and embrace new ones. Psychiatrists will need to become more comfortable with paying attention to somatic health issues. In recent years, for example, there has been a push for psychiatrists to monitor various parameters such as weight, blood pressure, and waist circumference when prescribing antipsychotics. While the extent to which psychiatrists can be expected to monitor and/or treat nonpsychiatric medical problems remains controversial, there is little doubt that this expectation will remain and perhaps increase.
Another area that psychiatrists will need to embrace more broadly is integrating the treatment of co-occurring substance abuse and mental illness, including medication-assisted treatment, into routine psychiatric practice.
The ACA brings a sea change to all of medicine in this country. While we do not know how the details will play out, psychiatry as a profession will need to adapt and evolve to survive and thrive in this new world. ■