Are Psychiatrists Prepared for Health Care Reform? Yes and No

Many psychiatrists are prepared or are preparing to practice in service delivery models consistent with the Affordable Care Act (ACA)—including the collaborative care model—but a substantial number are not, and more outreach is necessary to engage psychiatrists in health care reform.

Those are the findings from a cross-sectional survey of U.S. psychiatrists appearing in the August 15 Psychiatric Services in Advance.

More than 60 percent of psychiatrists are assuming some kind of role consistent with health care reform, such as participation in a team service delivery model, but engagement in integrated care models is less common. The study also underscored the need to prepare psychiatrists for merit-based payment reforms.

“Although many psychiatrists are prepared to practice in models of care that are being implemented under the ACA, our findings highlight opportunities for further workforce development,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., who is a coauthor of the Psychiatric Services study. The lead author of the study is Joyce West, Ph.D., of the American Psychiatric Association Foundation.

“APA has a wide range of resources to help prepare psychiatrists for performance-based payment reforms and to train psychiatrists for participating in the collaborative care model of integrated care,” Levin said.

He especially emphasized the training APA is providing at annual meetings as part of the Transforming Clinical Practice Initiative (TCPI) of the Centers for Medicare and Medicaid Services. “As one of the Support and Alignment Networks (SANs) awarded under the TCPI grant, APA is committed to training 3,500 psychiatrists in the principles and practice of collaborative care, a specific model of integrated care developed by the late Wayne Katon, M.D., Jürgen Unützer, M.D., M.P.H., and colleagues at the AIMS (Advancing Integrated Mental Health Solutions) Center at University of Washington,” said Kristin Kroeger, who is spearheading the SAN grant.

Training was also offered at APA’s 2016 Annual Meeting in Atlanta and will be again in October at IPS: The Mental Health Services Conference (see psychiatry.org/IPS for registration information).

The Psychiatric Services study used data collected from a large probability sample of U.S. psychiatrists who took part in the Study of Psychiatric Practice Under Health Care Reform, which was fielded in fall 2013. A total of 2,800 physicians in the United States who self-identified as psychiatrists and listed direct patient care as their type of practice were randomly selected from the September 2013 release of the AMA Physician Masterfile.

There were 1,188 respondents to the survey. Of these, 1,099 reported currently practicing psychiatry and treating psychiatric patients and provided the sample for this study. A four-page data collection instrument was mailed to the target sample with a $50 gift card to increase response. Three survey mailings were implemented at one-month intervals, followed by reminder postcards.

Most psychiatrists (64 percent) reported assuming at least one of the roles identified as being integral to the successful ACA implementation of health care reform; an additional 14 percent reported being likely or very likely to assume at least one of these roles beginning January 1, 2014.

Most commonly, psychiatrists reported practicing as a member of a team service delivery model (42 percent), providing ongoing mental health treatment for a caseload of patients with more severe mental illness, coordinating with a primary care clinician (41 percent), providing consultation to primary care and mental health clinicians caring for psychiatric patients with diagnostic or therapeutic challenges (39 percent), or providing leadership and supervision for team delivery of psychiatric and general medical care for psychiatric patients (33 percent).

Less commonly, psychiatrists reported that they oversee, track, and review care for psychiatric patients by working with practice leadership to ensure that services are available, appropriate, and well managed (21 percent) or that they currently provide general medical care to psychiatric patients (16 percent).

Here are some findings for specific reform-related categories:

• Integrated Services Delivery Systems: Nearly one-third of the psychiatrists (29 percent) reported they practice in at least one integrated treatment setting, and 13 percent reported they would be likely or very likely to do so beginning January 1, 2014. Eighteen percent of psychiatrists reported working in an integrated treatment setting with co-located and integrated specialty mental health and primary care services, and 15 percent reported working in a primary care treatment setting.

• Payment Reforms: A substantial proportion of psychiatrists (42 percent) reported receiving at least some reimbursement in the form of salary, and 4 percent reported that they would be likely or very likely to receive salary reimbursement beginning January 1, 2014. The other ACA physician payment reform mechanisms were rarely reported. Only 4 percent of the respondents reported fee-for-service reimbursement with a potential financial bonus for containing costs and meeting quality standards; 6 percent reported that they would be likely or very likely to participate in contracts with this type of payment beginning January 1, 2014.

• Electronic Health Records (EHRs): Approximately half the psychiatrists (53 percent) reported using any form of EHR for clinical functions not limited to billing or practice management. Eight percent reported that they planned to use an EHR within the next year, and 4 percent reported that they planned to use an EHR in more than one year. Twenty-one percent reported participating in the Medicare or Medicaid EHR Incentive Program, and 6 percent were planning to participate in the future.

The authors noted that engaging psychiatrists in integrated delivery systems and roles is especially challenging because traditional clinician CPT payment codes are not structured to reimburse for care coordination and for many functions integral to psychiatrists’ participation in team-based services delivery. “The Centers for Medicare and Medicaid Services (CMS) is currently seeking to address this limitation,” they stated.

(In fact, in July CMS released the proposed 2017 Medicare Physician Fee Schedule rule, which included coverage for “Psychiatric Collaborative Care Management Services.” Such coverage would reimburse for consultative services provided to care managers within the primary care physician’s office in the collaborative care model. The proposed rule was published in the Federal Register on July 15. CMS accepted comments on the proposed rule until September 6 and will issue its final rule later this year [Psychiatric News, July 28]).

The authors added, “The movement toward ACO’s and CMS’s aggressive goals of increasing use of global, capitated payments and ‘merit-based’ reimbursement rather than fee-for service payments may also help address this limitation. If successful, this paradigm shift may give health plans the flexibility and financial incentives to engage psychiatrists in salaried arrangements, helping to promote integrated treatment and offering the potential to contain or reduce health care costs, particularly for high-cost patients.” ■