ACA and Mental Health Care

VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA and the Health Sector >> ACA and Mental Health Care (last updated 11.27.19)
Lead Editor – Dana Beezley-Smith, Ph.D.

Also see Access to Mental Health Care

Overview

According to the American Psychological Association, the ACA’s goal for mental health/substance abuse care is to extend coverage to millions of uninsured people, reduce health care costs for those with and without insurance, and fully integrate psychological services into primary care, preventive services and benefit packages. The movement to large integrated service delivery teams within medical settings, patient-centered medical homes, and accountable care organizations has led many to speculate that there will be no place for small, private, independent practices and individualized treatment. Services, say some, will need to be spread an inch deep and a mile wide to accommodate increased numbers of patients. State and national mental health/substance abuse organizations and federal agencies have generally highlighted new opportunities for behavioral health professionals.

General Impact on the Mental Health Field

Valant Analysis

“There are three major impacts that the Affordable Care Act (ACA) will have on the Behavioral Health Care industry (BHC). First, it will strengthen behavioral health care benefits through stronger and more complete recognition of parity. Second, we will see an increase in the pool of patients on insurance, in particular on Medicaid. This will therefore increase the number of patients who will seek and receive mental health care, especially in public health settings. Third, the ACA will change incentives to support integrated, value based care.

These changes will have different impacts on the different segments of the BHC market, which can be divided into three sections as follows:

1. Cash only fee for service where payer payments are made for out of network benefits or not at all and the patients assume most of the responsibility

2. Public mental health facilities and private facilities that serve public mental health patients

3. Employer based payer system

The ACA will dramatically increase the size of the BHC market. For those in the cash only fee for service segment of the market, impacts will be minimal. Medicaid roles will increase which, along with parity, will enlarge the public behavioral health care market. Meanwhile, parity and the trend towards care management in primary care settings will have opposing effects on the employer based behavioral health care payer system. Those within this market can prepare by doing the following: ” (Dr. David Lischner, 11.20.13)

Psych Central Analysis

  • What Health Care Reform Means for Mental Health.“These are all great steps forward, especially for everyone who sees a therapist or takes an antidepressant or other psychiatric medication—or needs to. However, the devil is always in the details.” (PsychCentral, 11.3.09)
  • An Update on How the U.S. Affordable Care Act Impacts Mental Health Care. “Some of the initial rosy predictions about the ACA are likely not to pan out quite as we had hoped. While the Act will indeed expand coverage and treatment options for millions of Americans who previously had little or no choice, it may also inadvertently take away some treatment options currently in widespread use.” (PsychCentral, 11.1.13)

American Psychological Association (APA) Analysis

  • Embracing Health Care Reform. “Implementing health-care reform is still a work in progress, Katherine C. Nordal, PhD, said in the opening session of the 2014 State Leadership Conference. ‘It’s no news flash that the rollout of the Affordable Care Act has been chaotic,’ said Nordal, executive director for professional practice in APA’s Practice Directorate and the APA Practice Organization (APAPO). ‘But there are hopeful signs, especially related to the goal of increasing the ranks of Americans with health coverage.’… The law has also changed psychology’s advocacy strategies, Nordal said. ‘The way the Affordable Care Act is unfolding reminds us that no single advocacy strategy for psychology can address the diverse legislative, regulatory and marketplace environments we see from one state to another,’ she said.” (American Psychological Association Monitor, May, 2014)
  • APA Members Discuss Benefits and Implementation Challenges of Integrated Health Care. “A congressional briefing outlined the benefits of integrated health care and its implementation challenges while highlighting the gains large clinics have seen putting integrated care into practice… The briefing identified the challenges facing training, health care delivery and financing that hinder the implementation of integrated care, and highlighted the gains large clinics have seen using this model. ‘This information suggests that in the current environment of health system change, the time is right to advance integrated care as the most effective means to improve health,’ said Doug Tynan, PhD, director of integrated health care with APA’s Center for Psychology and Health.” (American Psychological Association, 11.12.14)
  • Letter to CMS Administrator Slavic. “Request for Information Regarding Implementation of the Merit-Based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models.” (American Psychological Association Practice Organization, November 13, 2015)

New Roles for Behavioral Health Providers

Overview

  • What is Population Management? “The U.S. Agency for Healthcare Research and Quality (AHRQ) recently coined the term ‘practice-based population health’ (PBPH), in which the term ‘population’ refers to any group of people under the care of single physician, group practice, PCMH or ACO. Primary healthcare is increasingly moving in the direction of a PBPH (Practice-Based Population Health) model, which assumes that medical providers are responsible for increasing the overall health of the population they manage, and not just for treating individual patients who present in their office for care. This shift is driven primarily by financial changes in healthcare reform… With the rise of PHM, the focus is no longer on treating an individual, but treating the population or community that you serve.” (New York State Psychological Association, January, 2014)
  • Behavioral Health and Health Care Reform Models: Patient-Centered Medical Home, Health Home, and Accountable Care Organization. Addresses “the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient Centered Medical Home, the Health Home initiative within Medicaid, and the Accountable Care Organization. To incorporate behavioral health into health reform, policymakers and practitioners may consider embedding in the reform efforts explicit tools – accountability measures and payment designs – to improve access to and quality of care for patients with behavioral health needs.” (J Behav Health Serv Res. 2013 January; 40(1): 121–132. doi:10.1007/s11414-012-9306-y.)

Affiliation with Accountable Care Organizations

  • Psychologists Push for Spot Early in Health Care Reform. “In preparing for the next wave of health care reform, Georgoulakis compared aspects of the ACOs to the Physicians Quality Reporting System (PQRS) that offers incentives to clinicians who routinely use quality measures. ‘If one reviews what has happened over the last few years, you can see that providers who participated in the PQRS program have a leg up over everyone.’ Robert McGrath, Ph.D., director of the clinical psychology program at Fairleigh Dickinson University and a participant in the NYSPA Think Tank, said, ‘I’ve come to believe many psychologists find the uncertainty of what is happening anxiety-provoking and want to sit on the sidelines. Everyone shares in this uncertainty, and this is exactly the time we can play our biggest role by informing state authorities about the importance of behavioral health care for the emerging system.’” (The National Psychologist, July/August, 2011)
  • Mental Health in ACOs: Missed Opportunities and Low-Hanging Fruit. “Explicit incentives for improved mental healthcare under CMS regulations governing ACOs are primarily related to quality measures of depression screening and patient satisfaction. The only ACO performance measure under the MSSP focusing on mental healthcare requires screening for depression and documentation of a follow-up treatment plan, which may lead to improved outcomes among patients with mental illness. However, incentives for improving mental healthcare beyond screening across the wider range of type and severity of mental health conditions were not incorporated into the MSSP ACO final rule released in November 2011. At best, it may be argued that many of the ACO quality measures, such as patient/caregiver experience via communication with physician, physician ratings, and shared decision making may improve mental healthcare delivery and patient satisfaction. Lack of explicit regulations and incentives for mental health in the ACO rules represent a serious missed opportunity.” (American Journal of Managed Care, 3.12.13)
  • Accountable Care Organizations: The Impact on Behavioral Health Providers. “Integration recommendations: 1) Integrate with a Federally Qualified Health Center (FQHC) and/or Rural Healthcare Center (RHC) – These organizations are eligible for CMS shared savings models; 2) FQHC’s will be required to partner with community mental health organizations; 3) Integrate with health systems and organizations authorized to develop ACO’s. Including: Primary Care, Patient Centered Medical Homes (PCMH), mature Independent Physician Associations (IPA)’s, multi-specialty groups, hospitals and health plans; 4) Do nothing. This WILL result in the profound reduction of patients utilizing services.” (Modern Practices, 6.20.13)

Findings

  • Early Efforts By Medicare Accountable Care Organizations Have Limited Effect On Mental Illness Care And Management. “We examined changes in mental health spending, utilization, and quality measures associated with ACO contracts in the Medicare Shared Savings Program and Pioneer model for beneficiaries with mental illness, using Medicare claims for the period 2008–13 and difference-in-differences comparisons with local non-ACO providers. Pioneer contracts were associated with lower spending on mental health admissions in the first year of the contract, an effect that was attenuated in the second year. Otherwise, ACO contracts were associated with no changes in mental health spending or readmissions, outpatient follow-up after mental health admissions, rates of depression diagnosis, or mental health status. These results suggest that ACOs have not yet focused on mental illness or have been largely unsuccessful in early efforts to improve their management of it.” (Health Affairs, July, 2016)

Integration with Medical Practices

  • Treatments of Physical and Mental Health are Coming Together. “Physicians and therapists traditionally haven’t collaborated much when treating the same patient, but the federal healthcare law is spurring a change.” (Los Angeles Times, 6.9.13)
  • Primary Care Openings Abound Now for Psychologists. “According to Nick Cummings, Ph.D., former APA president and founder of the DBH program, ‘The ACA is a mish mash and one of its problems is that it was designed by people who haven’t ever seen a patient. But the barn door for integration of behavioral health care with primary care medicine is wide open and won’t go away.’” (The National Psychologist, 11.13.13)
  • ACA Opens Doors for Bold New Ideas in Mental Health Treatment. “‘Conversations are taking place that never used to take place,’ said Rusty Selix, executive director for the California Council of Community Mental Health Agencies. ‘Am I seeing all the new models emerge yet? No. But we’re having the conversations we never had before, and there’s a lot of hope as we move forward that we are going to change paradigms and give people timely mental health care.’ Among those conversations is the idea of bringing mental health to the primary care level by connecting those in need through their regular doctor’s visit. While these doctors may identify a patient’s mental health needs, few patients follow up with referrals, Selix said.” (USC Annenberg, 9.4.14)
  • Bridging The Gap Between Behavioral And Primary Health Care For Low-Income Patients. “To make it easier to access mental health and substance use treatment, and deliver the type of care that low-income patients need and want, we must integrate and reshape our existing systems of care. Doing this will require three things: 1. Putting the patient at the center of system transformation. This means providers and practices will have to (1) work with their patients to redesign the way that care is delivered and (2) open themselves up to new partnerships and care models. 2. Engaging new partners, services, and supports in the community—beyond the clinical setting. For example, Community Partners In Care has developed model community engagement and training resources for faith-based, social service, and advocacy partners to use to implement evidence-based depression care. This is especially critical to building culturally responsive systems of care and prevention for California’s diverse population. 3. Confronting how primary and behavioral health care have historically been funded. This requires advocating for policy changes that facilitate more collaborative systems. Integrated care delivery can’t be sustained without integrated financing and shared accountability.” Blue Shield of California Foundation. (Health Affairs Blog, 5.16.15)
  • The Role of the Integrated Care Psychiatrist in Community Settings: A Survey of Psychiatrists’ Perspectives. “Consulting psychiatrists working in integrated care participated in an online survey about their experiences, opinions, and advice. A convenience sample of 52 psychiatrists from around the country who were working in integrated care responded. Respondents reported that they address a wide variety of clinical problems with a range of treatment strategies. Most reported positive experiences, which were summarized in four themes: working in a patient-centered care model, working with a team, the psychiatrist’s role as educator, and opportunities for growth and innovation.” (Psychiatry Online, 6.2.15)
  • A New Model for Behavioral Health for Kids. “What we are trying to do here at CHOP, similar to many health systems across the country, is improve access to high-quality behavioral healthcare by embedding behavioral health providers right into the primary care practice. We are hoping that by doing so, we can get families in to see behavioral health providers faster, that we can catch kids’ difficulties earlier, and prevent these issues from becoming more long-standing problems. We can also capitalize on the relationship that families have with their pediatricians to help build trust in mental health treatment and reduce the stigma related to mental health treatment. That is really what we are trying to accomplish in integrated behavioral health in primary care. Again, this is hoping to get kids in earlier so that we are helping to reduce the likelihood that these problems will become longer-standing, more pervasive issues that require higher levels of care.” (Medscape Perspective, 11.30.18)

Psychiatric Collaborative Care Model

  • Collaborative Care Models for Beneficiaries With Common Behavioral Health Conditions.“Collaborative care typically is provided by a primary care team, consisting of a primary care provider and a care manager, who works in collaboration with a psychiatric consultant, such as a psychiatrist. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. Several resources have been published that describe collaborative care models in greater detail and assess their impact, including pieces from the University of Washington, the Institute for Clinical and Economic Review, and the Cochrane Collaboration.” (Centers for Medicare & Medicaid Services, 11.16.15)
  • In its 2017 payment rule (11.2.16), CMS finalized payments for codes that describe specific behavioral health services furnished using the psychiatric Collaborative Care Model. In this model, patients are cared for through a team approach, involving a primary care practitioner, behavioral health care manager, and psychiatric consultant for services which extend beyond the scope of an office visit.

Findings

  • Integrated Care at Work. “A Pennsylvania health group that serves 2.6 million has improved patient care and lowered costs by including psychologists in primary care.” (American Psychological Association Monitor, 7.8.14)
  • Simpler Depression Therapies? “Psychological treatments for depression in primary care patients are increasingly available and being studied around the world, but their efficacy is still unclear… The researchers found evidence that psychological treatments are effective in depressed primary care patients but that, of the approaches studied, substantial evidence suggests that interventions that are less resource intensive, such as guided self-help cognitive-behavioral therapy (CBT), no or minimal- contact CBT, remote therapist-led CBT, or problem-solving therapy, might have effects similar to more intense in-person treatments. These results are of great interest and suggest that we should be considering combining less resource-intensive forms of psychological therapy with our other interventions for depression.” (Medscape Psychiatry, 5.1.15)
  • A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care.“This unique large-scale initiative to spread the collaborative care DIAMOND model for depression appears to have improved patient satisfaction, but it had little impact on other patient outcomes. Despite good evidence of implementation of practice systems important to collaborative care, and despite enrolled patients reporting receiving more desired care processes, patients receiving DIAMOND care had neither better depression outcomes nor better improvement in work productivity or health status.” (Annals of Family Medicine, September/October 2015)
  • Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost. “Objective: To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs… Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.” (JAMA, 8.23/30.16)
  • Outcomes of Integrated Behavioral Health With Primary Care. “This study used a convergent mixed-methods design, merging findings from a quasi-experimental study with patient interviews conducted as part of Advancing Care Together, a community demonstration project that created an innovation incubator for practices implementing evidence-based integration strategies. The study included 475 patients with a 9-item Patient Health Questionnaire (PHQ-9) score ≥10 at baseline, from 5 practices. Statistically significant reductions in mean PHQ-9 scores were observed in all practices, ranging from 2.72 to 6.46 points. Clinically, 50% of patients had a ≥5-point reduction in PHQ-9 score and 32% had a ≥50% reduction. This finding was corroborated by patient interviews that demonstrated positive experiences with behavioral health clinicians and acquiring new skills to cope with adverse situations at work and home.” (Journal of the American Board of Family Medicine, 2017;30(2):130-139)

Affiliation with Patient-Centered Medical Homes

See also Patient-Centered Medical Homes

  • Joint Principles: Integrating Behavioral Healthcare into the Patient-Centered Medical Home. “The incorporation of behavioral health care has not always been included as practices transform to accommodate to the PCMH ideals. This is an alarming development because the PCMH will be incomplete and ineffective without the full incorporation of this element, and retrofitting will be much more difficult than prospectively integrating into the original design of the PCMH. Therefore we offer a complementary set of joint principles that recognizes the centrality of behavioral health care as part of the PCMH.” American Academy of Physicians. (Annals of Family Medicine, March/April 2014 Vol. 12 No. 2)
  • The 2014 National Committee for Quality Assurance Standards Encourage Support For Patients’ Behavioral Health. “This includes disclosing to patients a (PCMH) practice’s behavioral health care capabilities and collaborating with behavioral health care providers.” (NCQA, 3.10.14)
  • Task Force on Patient-centered Medical Homes: How Psychologists Enhance Outcomes and Reduce Costs. “The Task Force on Patient-centered Medical Homes was established in 2014 by APA President Nadine Kaslow, PhD. Goals of the task force include: Evaluating and communicating data demonstrating the extent to which psychologists in patient-centered medical homes are ‘value added’ vis-à-vis enhancing patient and family behavioral and physical health outcomes; enhancing patient and family satisfaction with care; ensuring more cost-effective services; improving quality of life; reducing health disparities; and improving job satisfaction for health professionals. (American Psychological Association, November, 2014)
  • Psychology’s Expanding Roles in Patient Homes. “Helping to optimize patient care is just one of several opportunities psychologists see in the move toward PCMHs. In addition to providing psychosocial interventions for patients, psychologists can design and lead patient-centered care programs — on smoking cessation or diabetes management, for example — evaluate systems, provide mental and behavioral health consultations and measure quality-improvement outcomes, says clinical psychologist Joan Asarnow, PhD, another task force member. ‘It’s what we do best as psychologists — evaluating whether interventions work, and when we find interventions that work, we try to disseminate them into the world,’ Asarnow says. Psychologists’ training also prepares them to build teams, a skill that’s increasingly necessary as team-based care continues to become more widespread, says Cheyenne Hughes-Reid, PhD, a pediatric psychologist with Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware (see Leading the Charge article). In fact, she says, psychologists’ training in decision-making and systems change are essential to moving toward the PCMH model. ‘We can provide some really good resources to patients and be of great support to our medical colleagues about how to make this happen and make it sustainable.’” (American Psychological Association Monitor, November, 2014)
  • Integrated Medical-Behavioral Care Compared With Usual Primary Care for Child and Adolescent Behavioral Health: A Meta-analysis. “Given the current transformation in the US health care system and increased incentives for integrated medical-behavioral health care, these data documenting the benefits of integrated care enhance confidence that we are on a course that will yield improvements in the lives of youth and families. These data also underscore the critical need to strengthen our research base, learn from the real-world experiments happening within our medical and behavioral health care systems, and achieve the triple aims of health care reform: to improve care and patient experience and outcomes of care while reducing per capita costs.” (JAMA Pediatrics, 8.10.15)
  • PCMH PRIME: A New Integrated PCMH Approach. “In Massachusetts, practices that go through the recognition process can earn PCMH PRIME certification if they meet at least 7 out of 13 behavioral health criteria, including:
    • Co-locating or entering into formal agreements with behavioral healthcare providers.
    • Integrating behavioral healthcare providers into the practice site.
    • Performing comprehensive health assessments that include screening for behavioral health conditions like depression, post-partum depression, anxiety, developmental delays and substance use disorder.
    • Having a system for identifying high-risk patients for targeted care management.
    • Tracking and following up on referrals to specialists, including behavioral healthcare providers.
    • Medication-assisted treatment (MAT) for patients with addiction.

    The PCMH PRIME certification is voluntary. The Commonwealth’s Health Policy Commission does offer technical assistance to practices that undergo certification. The details are here and here.” (NCQA Blog, 2.18.16)

  • Integrated Care Offers Opportunities for Early Career Psychologists. “A key component to population-based care within the PCBH model is the use of a behavioral health consultant or ‘BHC.’ The BHC is responsible not only for providing brief consultations (e.g., 20 to 25 minute brief behavioral interventions) for patients but also impacts the primary care patient population by: 1) providing education to the primary care team (e.g., primary care providers, nursing, social work) on behavioral health issues in primary care through close proximity to the primary care team (e.g., seeing patients in exam rooms, charting in the nurses’ station rather than working in a private office); and 2) creating clinical pathways for common health conditions in primary care which may include group visits and classes.” (National Psychologist, 4.9.17)

Integration with Larger Behavioral Health Practices

  • Health Law Nudges Therapists Toward Group Practice. “The changes are part of a remaking of a system that has long treated the mind as separate from the body. ‘If you look how many airlines there are today versus 10 years ago; if you look at hardware stores versus Home Depot and Lowe’s; it’s really a monopoly economy,’ said Linda Rosenberg, president of the National Council for Behavioral Health. ‘And I think solo practitioners are going to be employees of big systems.’” (The California Report, 10.24.13)
  • The Affordable Care Act’s Effect on Mental Health Practitioners. “As people realize that their insurance policies cover these treatments it is highly likely more will seek out mental health and addiction treatment programs, which of course is beneficial to the mental health industry as a whole. However, these new individuals, as well as those already seeing mental health professionals, will have new expectations. The most important of which is that they will expect their psychiatrists and therapists to take insurance. Therefore, those that don’t take insurance will begin to notice a decline in new patients and even the departure of some of their less loyal patients. While those that do take insurance will see an upswing in patients. Of course it is not all that simple to deal with the giant bureaucratic maze that is the insurance industry and billing services can charge anywhere from 5% to 15% of billings to do it for you. Additionally, insurers rarely pay individual practitioners their full hourly rates. The prospect of dealing with these substantial hurdles will certainly frighten most solo practitioners and those in small private practices (which most psychiatrists and therapists are). However, these individuals are in luck because their colleagues in the general medical field that have private practices have faced the same challenges for some time now and have come up with a highly effective solution in the form of Independent Practitioner Associations (IPA).” (Ali Beheshti, J.D., 12.12.13)
  • ACA Likely to Create More Large Care Provider Groups. “Less than six months after passage of the Affordable Care Act (ACA), the administration’s health czar and two colleagues wrote in the Annals of Internal Medicine that ‘the economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups.’…Psychologists don’t necessarily have to seek employment with hospitals and other large systems to become involved in ACOs or PCMHs. Large practices may contract to receive capitated monthly reimbursements, and insurers may ask network psychologists to join their ACOs. Practices may also attempt FFS referral relationships with ACOs/PCMHs. However, psychologists can expect both entities to refer sparingly in efforts to save money, and some may use other disciplines for mental health and substance abuse (MHSA) services.” (The National Psychologist, July/August, 2014)

Integration with Federally Qualified Health Centers (FQHCs)

This report describes the current financing and delivery of behavioral health services at Federally Qualified Health Centers (FQHCs) and the future incentives available under the Patient Protection and Affordable Care Act (ACA) of 2010 for FQHCs and behavioral health providers to join forces to promote improved integration of primary care and behavioral health services. By becoming an FQHC, providers of care can access enhanced funding through Medicare and Medicaid, as well as receive grants from the Health Resources and Services Administration (HRSA) to help offset the cost of covering care for the uninsured. Additionally, this enhanced financing can offer advantages for behavioral health providers to integrate services with FQHCs. However, integration can come in many different forms and present potential difficulties to organizations that are not well informed about FQHC financing mechanisms and their challenges.
FQHCs provide comprehensive primary health care to the uninsured and medically underserved. In 2010, nearly 20 million patients were served at over 1,100 FQHCs operating in over 8,000 sites across the United States. It is estimated that FQHCs may serve 40 million patients by 2015 as a result of the passage of the ACA. The ACA encourages integration of primary care and behavioral health services. The National Association of Community Health Centers’ (NACHC) 2010 Assessment of Behavioral Health Services at FQHCs found over 70% of FQHCs provide mental health services, 55% provide substance abuse services, and 65% provide components of integrated care, such as a shared treatment plan.
There are different types of health centers, many of which may be FQHCs, including community, rural, and migrant health centers, and specific health center programs, such as homeless, public housing, and school-based health center programs.

The Future of Independent Practice

Predictions of Demise

  • The Plight of the Small Practitioner. “A round of steep fee cuts, as well as significant delays in receiving payment, make ‘expansion of insurance much less helpful to private and smaller providers. So, while behavioral health concerns are recognized as one of the main drivers of out of control costs, there’s relatively little in the ACA that does anything to help make it affordable to offer behavioral health services in any volume,’ says Block.” (New England Psychologist, 2.1.13)
  • The Affordable Care Act and Behavioral Health: The Shape of Things to Come. “There were several key points I picked up at the conference. 1. In five to seven years there will be no private practitioners. Private practitioners will be a dinosaur. 2. Accountable Care Organizations will be the future, either as a single entity covering a minimum of 2400 people (about 3 doctors) or much larger entities. 3. These ACOs or ‘Health Homes’ will receive so many dollars to manage all the care for a designated population. In many accounts the insurance and the service delivery will be one in the same. 3. Behavioral health will need to be integrated into these models. 4. At the conference you heard the speakers say that this will change the way primary care physicians are trained. I think this will also effect how psychologists and other behavioral health specialists are trained to work within the collaborative care model. 5. What role will psychologists play in these ACOs/Home health models?The group today suggested their will be a growing need for prevention, education, peer support specialists as the ACA is implemented. They emphasized the growing need for behavior specialists in helping to manage chronic illnesses “metabolic syndromes” with motivational interviewing, family support and treatment. Treatment is more likely to be 15 minute increments built in within the primary care office.” (Summary by Attendee at June 10, 2013, conference, the Center for Public Service Psychiatry of Western Psychiatric Institute in conjunction with the Clinic and Community Care Behavioral Health Organization)
  • What’s a Psychologist to Do? “If you are nearing retirement, perhaps nothing. The current fee-for-service system, even within Medicare, will continue to co-exist for at least some time. But if you are mid- or early career, you can anticipate competition from the cost and quality focused (with data to support) ACOs that will be increasingly attractive to health care consumers, both individual and organizational. Most rural providers and those with highly specialized practices will enjoy some isolation, at least initially, from these dynamics as will those whose practices are primarily or entirely private pay. But if psychology is to continue to serve the majority of the general population, we will likely find that the health care of a great many of those individuals who will benefit from increased access will be coordinated by ACOs.” (The National Psychologist, 7.24.13)
  • Private, Personal Outpatient Psychotherapy Could Disappear. The Affordable Care Act intends that mental health interventions be brief and provided in the context of medical health care teams. “It won’t happen right away, but private practice will essentially be a thing of the past, as 95 percent of practitioners will be on salary, either working in government-sponsored systems or large healthcare companies… Under the ACA, mental health services will continue to be mostly psychotropic-prescribing psychiatry,’ Cummings says. ‘Most psychotherapy that is referred will be secondary to medication—which is unfortunate because, in most cases, psychotherapy is less effective when used secondary to meds.’ He says another unfortunate effect of ACA will be that ‘the psychotherapy that is done will be the vapid, less effective, cognitive-behavioral therapy, while active, deep, and incisive therapy that incorporates psychodynamics will all but disappear.’” (Psychotherapy Networker, 3.4.14)
  • The Grand Challenge of ACA-Era Mental Health Care; Full Integration with Primary Health Care? “‘The grand challenge,’ Manderscheid said, ‘is how can we foster the development of health homes and ACOs without losing many of our behavioral health providers along the way? The ‘mom and pop’ operations are going to be gone. I expect a lot of behavioral health entities to disappear during the next five to ten years. But we need to be very careful and attentive to what we want to keep and what we can afford to lose.’” (LDI Health Economist, February, 2014)
  • “If the nation’s new Affordable Care Act (ACA) can help mental health professionals increase their services, it will be up to psychologists to make it happen by being key players in whatever venue they choose to participate. The government is not going to make it easier for psychology to take its rightful place at the health care table, nor will organized medicine and insurance companies be leaders in welcoming psychologists into the coming integrated care system… Woody said it is important that psychologists in independent practice remain realistic about their futures. ‘It’s not going to be our world. It’s going to be a medical world,’ he said… Woody said attendance at the Florida Psychological Association convention has been cut in half during the last two years because so few psychologists can afford to attend, since their practices are being hurt by services provided by social workers and other mental health professionals. He predicted that independent practice will cease to exist before long.” (The National Psychologist, September/October, 2014)
  • Health Care Reform: The Good, The Bad and The Ugly: Part 1. “In the midst of so much discussion of health care reform, it is easy to feel overwhelmed and wondering whether there is a meaningful role for psychologists in these new models. A starting point may be to ask ourselves what we can contribute to a health care team that is unique and highlights our value as a team member. Some have argued that psychologists who primarily define their role relative to providing psychotherapy in independent practice are limiting their skill set and placing themselves at a disadvantage in a changing health care environment. The reality is likely that many health care systems will have a difficult time justifying why they should hire a psychologist to do therapy when they can hire a social worker or counselor to provide the same services for less money… Some psychologists may decide not to change the way they practice. The prevailing opinion is that this will likely work for another five years, give or take.” (Ohio Psychological Association 7.22.15)

Changing Role for Independent Practitioners

  • Patient Engagement: The Critical Need for Psychologists. “Not every patient will have their behavioral health needs met exclusively with brief interventions provided within a medical setting. These settings will benefit from having access to a robust base of independently practicing psychologists. These highly trained independent practitioners will be crucial to the success of medical settings as they collaborate around more complex patients. These complicated patients will require skilled psychologists to provide treatment to manage health risks. It is essential those patients not fall through the cracks and compromise their health further leading to significantly higher costs of treatment. Psychologists provide significant benefits in patient care when working alongside their medical colleagues. As healthcare continues to evolve, it will be critical to ensure patients have complete care which includes integrated access to skilled psychologists.” Somjee, Lubna. New York State Psychological Association (No date recorded).
  • Psychotherapy in 2022: A Delphi Poll on Its Future. “A newer idea expected to drive change is integrated primary care providing higher quality care while helping to control costs. Health care reform is further reflected in the second highest ranked change in therapy formats—psychological care becomes an integral part of medical homes—and in the fourth highest ranked scenario that predicts psychotherapists will routinely treat the behavioral components of health problems and chronic illnesses. Whither the future of psychotherapy? In 2022, we expect briefer episodes of individual, group, and couple treatments increasingly conducted by master’s-level professionals involving evidence-based methods and relationships; theoretical formulations and clinical methods more associated with the cognitive, integrative, multicultural, and mindfulness orientations; and progressively more on the Internet, smart phones, and social networking. Some professional psychologists will find opportunity in these probable developments, whereas others will curse them, but they are coming.” (Professional Psychology: Research and Practice. American Psychological Association. 2013, Vol. 44, No. 5)
  • The Juggernaut of Healthcare. “The Affordable Care Act has permanently replaced health care with health insurance (possible payment for care) guaranteeing payers a 20% profit and decision control of all payments and therefore services (‘care’). As with all things political it was a compromise – providing (but not guaranteeing) the opportunity for access to minimal care to almost everyone in exchange for ceding control to corporations. For example, payers dealt with the costs of removing the limits on ‘preexisting conditions’ or other increased expenses by raising the copayments to unrealistic levels (50% of our usual fees) and the deductibles to multiple thousands of dollars… But I see the future of psychologists  as outside formal psychology. I call it FOPINIP for the ‘future of psychologists is not in (what is currently called) psychology.’” Zuckerman, Edward. (The Clinician’s Toolbox, 2015)
  • ACA Less Friendly to Psychologists Than Expected. “The ACA was never intended to expand access to the type of private outpatient psychotherapy Americans have come to expect. In fact some 2014 analysts predicted that independent psychotherapy providers would be forced to shutter their businesses… The ACA calls for a redistribution of MHSA resources, with a change in emphasis from care of the individual to ‘population management’ and ‘an inch deep and mile wide’ approach… Psychologists are advised to join medical practices, hospital systems, large behavioral health entities and public clinics.” (National Psychologist.com, May/June 2019)

Third-Party Payer Challenges

  • Disparate Essential Health Benefits.“ACA ensures that, except for ‘grandfathered’ health plans, all health plans offered in the individual and small group markets as of February 2014, both inside and outside the health insurance exchanges, must offer the core package of essential health benefits. Even so, these plans will still vary regarding the extent to which they cover essential health benefits, including mental health benefits. The exchanges will offer plans that have different deductible levels and payment levels in order to provide options for individuals based on the coverage they need and affordability.” (American Psychological Association Practice Central, 3.14.13)
  • What Can Psychologists Do? “The large influx of newly-ensured people into the health care system will call for larger numbers of providers, including psychologists. It is important that psychologists adapt to these changes in order to successfully engage with consumers, Medicaid and the health insurance exchanges.” The organization recommends psychologists consider participation in plans in both Medicaid and the exchanges “in order to ensure continuous care for your patients who may fluctuate between the systems.” (American Psychological Association, 8.29.13)
  • APAPO Addressing Issue with Connecticut Exchange Plan. “The coalition sent a Sept. 29 letter (PDF, 515KB) to Connecticut Lieutenant Governor Nancy Wynan, chairperson of the Board of Directors for the state-run health insurance exchange known as Access Health CT. The letter expressed concern with the behavioral health fee schedules published by HealthyCT, one of the QHPs participating in Connecticut’s HIE. Under that plan’s reimbursement system, only medical doctors and advanced practice registered nurses (APRNs) are reimbursed for neuropsychological assessment…As the coalition letter emphasizes, ‘Restricting reimbursement for psychological assessment to practitioners not trained to perform the services (APRNs) or with very few qualified practitioners (MDs) will dramatically limit access to neuropsychological services for Connecticut citizens.’” (American Psychological Association Practice Central, 10.10.13)
  • Expect to be Paid Less Under ACA, Psychologist Says. “Doctors and other health care providers who have joined the Obamacare exchange health care network will receive payments about 40 percent below the current payment schedule they have with Anthem Blue Cross, a New Hampshire psychologist said last week. The exchange payments resemble those of Medicare, the government-run health insurance for the elderly and disabled, said Evan Greenwald, director of The Counseling Center of Nashua.” (New Hampshire Union Leader, 11.18.13)
  • Obamacare Rate Changes for Behavioral Health and Psychiatry. “Healthcare companies participating in the new healthcare exchanges under the Affordable Care Act  (AKA: Obama Care) may have changed your rates already. Did you know that your contracts and rates with payors may have changed without signing a new contract?” (Modern Practices, 12.30.13)
  • Hope, Hurdles In Mental Health: A Medicaid Managed Care Firm’s First Year. “The new approach to doling out Medicaid money comes with tougher scrutiny of social workers, psychologists, counselors and other care providers. Some have opted out or been dropped… The auditing that thinned the ranks is likely to be a good thing in the long run, she said, but it left the county with service gaps Cardinal is still trying to fill… Kristin Rogentine-Lee, a Charlotte psychologist who does testing and therapy for children, is one of those who opted out. She said Cardinal reviewed paperwork from 10 sessions and demanded that she repay $700. The errors they cited were minor, she said, such as failing to note a patient’s progress toward goals on one form. For children with deeply troubled lives, each session doesn’t necessarily bring measurable gains. ‘It’s quantifying something that’s nonquantifiable,’ Rogentine-Lee said. “I can see accountability and oversight, but nitpicking over these little things?’” (Kaiser Health News, 4.30.15)

Third-Party Free Practices

  • What Do Global Payments Mean to You? “You will not get paid per service hour anymore. Insurance companies will not contract with individuals or small business at all. This is huge. Read those two sentences again. Since fee-for-service will cease to exist, you will have two choices: 1. Join an accountable care organization and get paid a salary. 2. Continue in your own practice with a focus on great service, high end customer care, convenience and get paid directly by clients for all of these benefits… Once the letter arrives saying, ‘Join an ACO or lose income,’ it’s too late to ramp up a new business plan. We got that letter from Blue Cross this month and STILL many of my colleagues are in denial.  You’re smart, you’re here and ready to learn… get ahead of the changes that are a few months or years away. You (and your bank account) will thank you later.” (Healthcare Reform and Psychologists, 7.19.12)
  • In Era of Mental Health Parity, “Cash-Only” Providers Urged to Accept Insurance. “‘Providers need to change their way of doing business,’ said Lieberman, who practices psychiatry at Columbia University Medical Center… He said he hoped that the mental health parity law would eventually lead to higher reimbursement rates for psychiatrists and other providers — but that they also will have to accept payments ‘below what the concierge or premium rates were. They need to accept that we’re in a country where we’re reforming healthcare, we’re trying to provide care to the entire population and not just segments of the population, and still keep it an affordable amount of national expenditures,’ Lieberman said. Psychiatrists who want to maintain their income, he said ‘will need  to see more patients’ and clinics ‘will need to increase the efficiencies.’” (WNYC News, 11.8.13)
  • Increased Patient Access Falling Short. “Some argue that cash-only practices contribute to the scarcity of care opportunities. ‘Many mental health providers don’t take insurance,’ New York City’s NAMI director Wendy Brennan told New York Public Radio. ‘With greater access to care, at least on paper, that problem is only going to get more severe.’ Recent research in Massachusetts, the birthplace of reform, finds continued barriers to care include ‘low insurance reimbursement rates and clinicians who increasingly rely on clients paying out of pocket.’ MHSA providers ‘are intentionally taking on more private pay clients’ with one in six refusing to accept any insurance. ‘More than 80 percent say they turn away at least one patient each month.’” (The National Psychologist, July/August, 2015)
  • ACA Eroding Employee Insurance, Increasing Demands on Providers. “The movement to ‘pay for performance’ is occurring ‘much faster and sooner than anyone expected,’ according to The Trust’s Dan Taube. ‘There’s less money, more requirements,’ and since referrals will be electronic, ‘referral patterns are going to be more challenging.’ It will be ‘harder to sustain solo private practice in this environment.’ However, the speakers also saw the potential for independent practices to survive outside the third-party system. ‘A group of people will become disaffected by the system,’ especially those valuing privacy and separate mental health records. Some patients will prefer cash practices due to dissatisfaction with the ACA’s more ‘manualized and automated’ treatment protocols. ‘The ACA system,’ explained Taube, won’t provide ‘longer-term dynamic services.’… The Trust projects that third-party-free psychology practices may keep afloat through creative marketing, development of new product packages and niche specialties, and in the future, remote digital service provision.” (The National Psychologist, November/December, 2015)

Behavioral Health and Electronic Records

  • Caution Flags Raised over ACA Electronic Records Requirement. “‘Do you want to share your psychotherapy records with your proctologist?’ Koocher asked, pointing out that until electronic record keeping becomes more sophisticated, everyone involved in an ACO, PCMH or other integrated health care system will have access not only to a patient’s physical health record, but their mental health records as well.” (The National Psychologist, September/October, 2014)
  • Feds Release Strategic Health IT Plan.“Like the previous plan, the new one aspires to integrate behavioral health information into healthcare in general, but it lays out few concrete goals for achieving that objective, such as getting all behavioral health providers to use electronic health records… ONC is exploring options such as using accountable care organizations to accelerate adoption of EHRs in behavioral health, DeSalvo added.” (Health Leaders Media, 12.9.14)
  • Psychologists’ Reaction to Minnesota’s Mandatory EHRs. Survey is found here. “It is striking to note that 30 respondents state that they plan to retire specifically because of the mandate. Also, only about 7% have purchased an EHR in response to the mandate… Another striking finding is that about 43% of the respondents are ‘extremely’ concerned about confidentiality problems that may be associated with EHR communications.” (Mental Health Concierge, 1.18.15)
  • Federal Health Records Program Leaves Some Medical Professionals Out of the Loop. “Mental-health clinics, psychologists and psychiatric hospitals were left out of the incentive and penalty program, along with nursing homes, emergency medical services and others. It has been estimated by the consulting firm Avalere Health that including them would require an additional $1 billion… ‘If a broad base of health professionals had access to mental-health records that include psychotherapy notes, I am concerned about the potential for privacy violations… not only for the patient, but also for the others who are involved in the patient’s life,’ he said… Recent provider backlash against the current government incentive program may also be a roadblock. Earlier this year, 37 medical societies led by the American Medical Association asked federal regulators to shift direction, arguing that today’s electronic records systems are cumbersome, inefficient and can present safety problems for patients.” (Washington Post, 3.5.15)

Quality Measurement

Evidence-based Care

  • You Won’t Believe The Government is Supporting this Crackpot Mental Health Therapy. “As mental health reform makes its tortured way through Capitol Hill, one of the major sticking points is the fate of the agency that oversees federally-funded mental health services, the Substance Abuse and Mental Health Services Administration (SAMHSA). This agency has been under scrutiny for failing to pay adequate attention to the needs of severely mentally ill people, such as those suffering from bipolar disorder or schizophrenia, in favor of those with milder conditions. Rep. Tim Murphy (R-PA) has been especially critical of SAMHSA – appropriately so – and his bill would tighten quality control over the agency. The latest piece of evidence that SAMHSA needs a major overhaul is its decision to support a highly questionable treatment called Thought Field Therapy (TFT), which it recently added to its National Registry of Evidence-based Programs and Practices (NREPP).” (Forbes, 3.29.16)

Agency for Healthcare Research and Quality (AHRQ) Standards 

Analysis

  • The Affordable Care Act: An Opportunity for Improving Care for Substance Use Disorders? “The Patient Protection and Affordable Care Act (ACA) will greatly increase coverage for treatment of substance use disorders. To realize the benefits of this opportunity, it is critical to develop reliable, valid, and feasible measures of quality to ensure that treatment is accessible and of high quality. The authors review the availability of current quality measures for substance use disorder treatment and conclude there is a pressing need for development, validation, and use of quality measures. They provide recommendations for research and policy changes to increase the likelihood that patients, families, and society benefit from the increased coverage provided by the ACA.” (Psychiatry Online, 3.1.15)
  • Quality Indicators for Physical and Behavioral Health Care Integration. “Almost a decade ago, the Institute of Medicine issued a report on adapting Crossing the Quality Chasm for mental health and substance abuse care. The Institute of Medicine Committee noted that the quality measurement infrastructure and capacity to develop and effectively apply quality measurement and improvement strategies in this area are significantly underdeveloped, especially linkages among the silos of mental health, substance use, and general health care. Although the committee also issued recommendations to build this infrastructure and overcome measurement barriers, relatively few of the recommendations have been implemented in a robust manner… If designed and implemented correctly, measures associated with best practices and outcomes for integrated care can increase accountability across health care settings, diminish disincentives to serve and treat these complex patients, broaden dissemination of research-proven models that improve patient outcomes, and enhance the efficiency of the health care system as a whole.” (JAMA, 6.4.15)
  • Standardized Evaluation of Mental Health Treatment on the Way. “Starting in 2017, the Joint Commission will require the 2300 behavioral healthcare organizations it accredits to initiate standardized measurement of interventions designed to improve patients’ mental health outcomes. ‘We’re going to put in place a measurement-based care requirement,’ said Margaret VanAmringe, the Joint Commission’s executive vice president for public policy and government relations’… How do we determine what works?’ Dr Nussbaum asked. The Joint Commission hopes to help answer that question with its new requirement, VanAmringe told Medscape Medical News. The current standard for the 2300 behavioral healthcare organizations it accredits requires outcomes assessments, but there is no requirement to use standardized measurement tools or to aggregate patient data, she added. The new policy will require a standardized method of measurement that is sensitive enough to show that an intervention improved a patient’s outcome. Organizations will also be required to assess outcomes on a population-wide basis and to use the information for continuous quality improvement.” (Medscape Medical News, 2.25.16)

Measurement Resources

  • Achieve Success with PQRS: A Psychologist’s Guide for Mastering the Measures. Addresses “Origins & History of PQRS, Pros and Cons of Participation, Claims-based vs Registry Reporting, Mastering the Measures, Guide to Understanding Registry Measures, Future Directions of Quality Initiatives, and the 3 R’s: Resources, References, & Reassurance.” Hartman-Stein, Paula. Center for Healthy Aging, December 2015.

Integrated Care Resources