APA Objects to URAC Guidelines for Integrated Networks

APA is protesting draft standards issued by the Utilization Review Accreditation Commission (URAC)—a group that accredits accountable care organizations and other clinically integrated care networks—because the standards fail to state that psychiatrists and other behavioral health care providers should be included in such networks.

At press time, APA was awaiting a response to a December 2012 letter to URAC by Irvin “Sam” Muszynski outlining the objections to URAC’s proposed accreditation standards for Clinically Integrated Networks (CLINs). That letter made explicit reference to a guidance issued by the Department of Justice and the Federal Trade Commission (FTC) stating that such networks would not be subject to antitrust violations provided they are “truly and genuinely integrated”—a designation that APA argues makes the inclusion of psychiatrists vital.

“Of specific interest and related to the role of behavioral health providers within a CLIN, the FTC has looked at the composition of CLIN providers and the need of CLIN provider participants to refer patients outside the CLIN to nonparticipating providers,” Muszynski wrote. “Specifically, the composition of a network indicates whether participants can adequately coordinate care in a meaningful way…”

“The FTC is clearly looking to see whether a CLIN acts interdependently and can take care of patients within its own network without the help of nonparticipating physicians,” Muszynski wrote. “In scrutinizing a CLIN, the FTC will ask whether a CLIN’s efficiencies create better patient care at lower costs. Based on the nature of mental health and substance use disorders, their prevalence, and the cost of services, it is important to take a look at these factors to see the impact on a CLIN without the inclusion of behavioral health providers.…When behavioral health problems are not effectively treated, they impair self-care and adherence to medical and mental health treatments and they are associated with increased mortality, substantially increased total health care costs, and decreased work productivity.”

Muszynski urged URAC to revise its draft standards with the following three points in mind:

Behavioral health providers, which include psychiatrists, psychologists, social workers, and mental health nurses, are necessary in-network providers with the same requirements and expectations of other network providers, for all CLINs, whether risk bearing or not, in which behavioral conditions would be expected to contribute to illness and cost outcomes.

Psychiatrist David Katzelnick, M.D., chair of the Division of Integrated Behavioral Health at the Mayo Clinic, told Psychiatric News he believes that the URAC standards were originally intended to require the inclusion of mental health clinicians in integrated care networks. But now that requirement has become “optional.”

“The problem is that if it’s optional, that means it won’t happen,” he said.

Katzelnick said the failure to include mental health in emerging integrated care networks is a legacy of behavioral health “carveouts” and separate payment systems. “This has perpetuated the separation of mental health and general medical care,” he said. “Separate payment systems have made it very difficult to do collaborative care models. You need to have mental health working with a primary care team—that’s what we do here at Mayo, and it is backed up by a great deal of research showing that with patients who have both psychiatric and medical conditions, you need to manage them together, not separately.

“By carving mental health out from the core health care team, it perpetuates the status quo, which has created all kinds of bad care and increased utilization,” Katzelnick said. “My concern is that this model could become the basis for all accountable care organizations. It is really a step backward.” ■