Behavioral Health and healthcare Reform Models: Patient-Centered Medical Home, Health Home, and Accountable Care Organization

Bao Y, Casalino LP, Pincus HA
Source: J Behav Health Serv Res
Publication Year: 2013
Patient Need Addressed: Behavioral health
Population Focus: Complex care, Dual eligible, Medicaid beneficiaries
Intervention Type: Service redesign
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/23188486
Abstract

Discussions of healthcare delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses 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 healths.

Insights Results

Overview of article

  • This paper draws attention to 4 patient populations defined by the severity of their behavioral health conditions and insurance status. It is along these 2 dimensions that important policy initiatives under the Affordable Care Act (ACA) may have the potential to serve people with Behavioral healths. These potentials are discussed in the context of 3 prominent reform models promoted by the ACA: the Patient Centered Medical Home (PCMH), the Health Home initiative within Medicaid, and the Accountable Care Organization (ACO). The paper further discusses tools policymakers and practitioners may consider embedding in the reform efforts to improve access to and quality of care for these patients
  • For context, the concept of PCMH combines the tenets of primary care (first contact, comprehensive and coordinated care) with systematic improvement of the health of the practice’s patient population (via use of electronic information systems, disease management, continuous quality improvement). The Health Home differs from the PCMH in that the former is a legislative provision specifically for Medicaid patients with special emphasis on care coordination activities involving community organizations that are critical in meeting the needs of Medicaid patients. Lastly, ACOs are provider-led organizations that manage the full continuum of care and are accountable for the overall costs and quality of care for a defined patient population. It is worth noting that ACOs and PCMHs/Health Homes are not mutually exclusive. Realization of the ACO goals will require a strong primary care core. The ACO infrastructure beyond the primary care will enable the full realization of the PCMH/Health Home model. It is thus highly likely that ACOs will be built on a base of medical homes
  • The following are the 4 populations of focus in this study: 1) Patients with mild-to-moderate conditions such as anxiety and mild-to-moderate depression who are insured by a commercial health plan or Medicare, but not Medicaid; 2) Patients with mild-to-moderate behavioral health conditions who are insured by Medicaid; 3) Patients with serious and persistent behavioral health conditions (e.g., schizophrenia, bipolar disorders) who have commercial or Medicare insurance, but not Medicaid; and 4) Patients with serious and persistent behavioral health conditions who are insured through Medicaid, including dual eligibles

Results

  • A PCMH may have the greatest potential to serve patients with mild-to-moderate behavioral health conditions (Populations 1 and 2). Patient-centeredness and the whole-person approach, two central qualities of PCMHs, are essential in meeting the needs of these patients since medical and behavioral health conditions frequently co-exist in this population and should be co-managed. Clinically, strong evidence supports a primary care-based, collaborative care approach to manage behavioral health conditions. However, unless it is very large, a PCMH may lack the capacity to care for patients with serious behavioral health conditions (Populations 3 and 4)
  • Medicaid patients with mild-to-moderate behavioral health conditions (Population 2) may be best served by primary care-based Health Homes. Medicaid patients with serious behavioral health conditions (Population 4) may most likely be served by Health Homes based in behavioral health specialty settings (for example, community behavioral health centers). Some primary care-based Health Homes who see a large number of patients with serious behavioral health conditions may have developed referral and care coordination programs with behavioral health and social service providers
  • Mainstream ACOs – those that focus on Medicare and/or commercially-insured populations – have the greatest potential to serve non-Medicaid patients with mild-to-moderate behavioral health conditions (Population 1). These patients are most likely to receive regular primary care from a physician who belongs to a mainstream ACO. Furthermore, mainstream ACOs are likely to have the scale (a relatively large number of patients with mild-to-moderate behavioral health conditions) and devoted resources to ensure access to and coordination with high-quality behavioral health specialists for this population. Because ACOs are payer-specific, mainstream ACOs participating in shared savings programs with Medicare or commercial insurance plans will lack incentives to improve quality and reduce costs for Medicaid patients (Populations 2 and 4)

Key takeaways/implications

  • Implications for behavioral health: Policymakers and practitioners should first identify the patient populations whom a specific reform model has the greatest potential to serve
  • Future research should focus on how patient populations with varying Behavioral healths interact with different providers and how reform models may serve the needs of different populations. It would be valuable to identify critical settings and timings where poor coordination of behavioral and medical care contributes to poor overall patient and cost outcomes. It would be particularly useful to implementers of reform initiatives to know what proven clinical and delivery models are available for which specific settings and populations, what the business case is (in terms of cost of implementation relative to pay-offs), and how to implement and sustain the programs
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