By Katie Kerwin McCrimmon
The biggest obstacle to blending physical and mental health care is money.
Doctors can’t bill insurance companies for treating their patients’ mental health woes and psychologists can’t treat physical ailments. So the two health specialties remain separate, while confused patients get splintered care and often get sicker.
Most experts acknowledge that the system is ridiculous, but feel shackled to insurance company billing codes.
Enter an insurance company that wants to prove once and for all that integrated physical and behavioral health care is both better for patients and less expensive in the long run.
In a new experiment set to start next spring in western Colorado, the nonprofit health insurance company, Rocky Mountain Health Plans, will give hefty “umbrella payments” to three primary care practices that are already working to integrate behavioral health. Also known as “global payments,” the funding will replace traditional “fee-for-service” payments that reimburse doctors for each visit with a patient or each test they order. The insurance company will then encourage the health providers to give patients excellent integrated care. That will vary from site to site and will depend on patients’ needs. Care could include a traditional office visit with a doctor or a health coach, email exchanges, telephone counseling or a typical counseling session. Patients will get all the care in the familiar setting of their primary care office.
At the same time, Rocky Mountain will give the control groups — three other primary care practices that are also trying to integrate behavioral health — reimbursements under the traditional “fee for service” model, where providers bill for appointments and procedures.
Actuaries and data experts will then compare costs and patient outcomes. (Click here to read more about the experiment.)
The aim is to prove quickly that patients do better when doctors are paid to keep patients well rather than worrying about seeing as many patients as fast as possible to keep the cash flowing. Rocky Mountain ultimately wants to change the way it pays providers throughout Colorado and spur change around the country.
“This is not an academic exercise,” said Patrick Gordon, director of government programs for Rocky Mountain and executive director the Colorado Beacon Consortium, a coalition of nonprofit health groups that is seeking to boost the quality and efficiency of health care in western Colorado. “This will be a transformative pilot that is being built with the goal of replicating success across the country.”
Throughout Colorado, Rocky Mountain insures about 220,000 people. Altogether the primary care practices that participate in the pilot will serve 30,000 to 50,000 patients including the full spectrum of privately and publicly-insured patients. The organizers have not yet picked the practices that will participate.
Rocky Mountain is fronting the cash for the reimbursements. A group called the Collaborative Family Healthcare Association will coordinate the project while the Colorado Health Foundation is paying for an evaluation to see how well the three-year program works.
Clinical psychologist Benjamin Miller will evaluate the effort. He is director of the Office of Integrated Healthcare Research and Policy in the family medicine department at the University of Colorado Denver.
“This is a total game changer in every facet,” said Miller. “It’s disruptive innovation. We’re telling the system, ‘We’re not going to play by the old rules anymore. We’re going to play with new rules and we want you to operate as a team.’”
Miller said the experiment “takes off the handcuffs of payment reform” and should produce some useful results.
“Everyone wants to know the answer to sustainability,” he said.
Currently, doctors are stuck trying to string together grants, fudge billing codes or give free office space to counselors in hopes that they’ll provide help to patients while creating their own streams of revenue.
Under the new concept, worries about finances will be gone.
“We’re going to take that off the table. Here is the financial support to make this sustainable,” Gordon said.
Rocky Mountain is pumping millions into covering up-front costs for various efforts to strengthen primary care practices and thereby reduce much more costly health expenditures such as surgeries, ER visits and lengthy hospital stays. The effort to integrate behavioral and physical health is part of the larger vision to bolster primary care.
Gordon could not say exactly how much the integration experiment would cost. But, in the long run, he and others are confident that giving patients much better primary care will help achieve the elusive holy grail of health reform: “bending the cost curve,” or slashing the increasing costs of health care in the U.S.
“We know that behavioral health integration is absolutely essential,” Gordon said. “The cost and structure of the payment model will probably vary from site to site. This project will give us much deeper insights into what those factors are.”
Gordon said initial estimates show that if primary care practices give high quality integrated behavioral and physical health care to all patients in western Colorado who earn at or below 250 percent of the poverty level — or about $56,000 a year for a family of four — health providers could cut the rate of growth in health expenditures by 4 to 5 percent over three years.
“Even relatively modest impacts on (growth) trends can produce more than enough to pay for all of these interventions,” Gordon said. “It also puts us in a position to share gains with government payers and employers.”
The ultimate goal is to make behavioral health sustainable in primary care. That means giving people help with a much wider array of issues beyond traditional mental health concerns such as depression or schizophrenia.
For instance, Gordon cites the potential benefits of a technique called motivational interviewing in which health providers spend time asking patients how they want to change their lives. The technique can help change unhealthy behaviors such as smoking, poor diet or a sedentary lifestyle, all of which lead to poor health outcomes.
“When you engage a patient in what they want for themselves…they are much more likely to …change elements of their own behavior,” Gordon said. “This is very much in contrast with the traditional didactic approach of most conversations between physicians and patients.”
One of the most promising methods for inducing behavior change is to start group visits for people with diabetes, for pregnant moms or for obese people.
“They have proven to be very powerful,” Gordon said. “You get a peer dynamic. And it’s the group that drives the discussion more than an authoritarian physician.”