There is increasing recognition across the healthcare continuum of the link between patient behavioral health and clinical outcomes. Unfortunately, alignment between primary care physicians and services for mental health issues, substance use, and other social determinants of health (SDoH) too often range from poor to nonexistent.
“Behavioral health factors have an outsized influence on morbidity and mortality, and are the source of a large portion of family physicians’ frustrations with the health care system,” writes the American Academy of Family Physicians. “It is common to have patients who are unable to access care for mental health or substance use due to lack of insurance coverage or access.”
Underserved populations, such as rural Americans, suffer from health inequity issues because behavioral health support and services either are unavailable or not integrated with their primary care. As the National Institute of Mental Health notes, “Though the prevalence of serious mental illness and most psychiatric disorders is similar between U.S. adults living in rural and urban areas, adults residing in rural geographic locations receive mental health treatment less frequently and often with providers with less specialized training, when compared to those residing in metropolitan locations.”
To encourage greater alignment of behavioral health and primary care, the Centers for Medicare and Medicaid Services (CMS) has created a primary care reimbursement model designed to promote more innovative, team-based, and equitable approaches to care. The ACO Primary Care (PC) Flex Model (which starts on Jan. 1, 2025) will address health equity and drive better outcomes for underserved populations by increasing access to higher-quality primary care. This care can include unique services, such as behavioral health integration.
The model’s new Prospective Primary Care Payment (PPCP) option, which will shift reimbursement for primary care away from fee-for-service, visit-based payment, includes components that make it attractive to ACOs with Federally Qualified Health Center and Rural Health Clinic participants.
For example, an ACO’s PPCP rate can be based on its average county primary care spending rather than on its historical spending. This enables the model to pay an ACO the same rate for a specific patient in a region, before considering social and clinical risk factors. As a result, providers with entrenched patterns of inappropriately low spending for underserved areas and populations can be paid more. The PPCP also includes payment enhancements and adjustments to the county rate, providing additional resources to providers caring for underserved populations.
The ACO PC Flex Model also will help increase health equity for rural Americans and other underserved populations by:
- Incentivizing the formation of new ACOs and supporting existing low-revenue ACOs
- Inducing safety net providers, including Federally Qualified Health Centers and Rural Health Clinics, to either form or join ACOs
- Ensuring more healthcare dollars go toward underserved populations
- Providing primary care practices with the flexible funding needed to improve care coordination and identify and address people’s unmet health-related social needs
CMS expects the PC Flex Model’s PPCP option to appeal to many low-revenue rural ACOs and providers that could benefit from a flexible but predictable revenue stream and that seek better alignment between primary care providers and behavioral health services for their underserved patient populations.
Removing barriers to primary care/behavioral health alignment
Indeed, PC Flex and other value-based care (VBC) payment models provide an ideal framework for collaborative, team-based care across stakeholder entities, including primary care providers, clinical and behavioral health specialists, community-based organizations (CBOs), and payers.
Humana reports that value-based practices “are hiring or partnering with behavioral health specialists and stationing them at primary care centers where physicians with patients in need can quickly and easily connect with qualified help.”
Last fall, Cigna’s Evernorth Health Services launched a value-based care management program for its behavioral health network that uses metrics to measure treatment effectiveness in producing positive outcomes. The goal of the new program is to align providers and payers on treatment measurements that drive improvements in care, cost, and collaboration while removing administrative burdens for providers.
But integrating primary care with behavioral care is a huge challenge for some healthcare organizations, particularly low-revenue providers in rural areas. They may lack the funding necessary to integrate behavioral care with primary care. A shortage of qualified behavioral health professionals can present another integration barrier.
In addition, an outdated or insufficient digital infrastructure may make alignment of primary care with behavioral health services prohibitive and even impossible. Overcoming this technology barrier requires implementation of a scalable, cloud-based digital infrastructure that enables a many-to-many network of participants.
This network may include behavioral health providers and CBOs, many of which have low digital capabilities but expect frictionless reimbursement. Further, a robust analytics platform running on top of a scalable digital infrastructure can provide the transparency into performance, essential to ensure the success of VBC contracts.
Reimbursement Model Alignment with Primary Care
Collaboration between primary care providers and behavioral health specialists is critical to whole-person health. Reimbursement models that align primary care with behavioral health offer low-income provider organizations serving rural Americans and other vulnerable populations an opportunity to enhance coordination, improve outcomes, and generate much-needed revenue.
To fully align primary care with behavioral health services, care organizations need a scalable digital infrastructure that can handle the demands of a many-to-many collaborative care network.
About Lynn Carroll
Lynn Carroll is the COO of HSBlox, an Atlanta-based technology company empowering healthcare organizations with the tools and support to deliver value-based care (VBC) successfully and sustainably.