Organizational and Financial Integration of Behavioral Health into Accountable Care Organizations

Transcription

1 Organizational and Financial Integration of Behavioral Health into Accountable Care Organizations Aricca Van Citters, MS Valerie Lewis, PhD Karen Schoenherr, BA Stephen Bartels, MD, MS

2 ACO adoption is happening rapidly Medicare Pioneer ACO program: 32 sites in 2012 Shared Savings Program: 114 sites in 2012, 106 in 2013 Medicaid State initiatives in place in OR, MN, NJ New underway in TX, ME, MA Private payers

3 What is an Accountable Care Organization? Dartmouth definition: group of providers collectively held responsible for the cost and quality of care for their patient population ACO contract: the contract with a payer that defines each of the above

4 Real examples of ACOs Dartmouth Hitchcock Arizona Connected Care FQHC Urban Health Network

5 What we know about behavioral health in ACOs Not all ACOs are thinking about behavioral health Site visits to emerging commercial ACOs in 2011 Safety net ACOs are thinking about behavioral health Interviews with safety net providers spring 2012 Even within an ACO, there can be large variation across providers and practices Site visit to FUHN fall 2012, spring 2013

6 Study Objective & Research Questions Objective: To determine the extent to which behavioral health (BH) services are currently integrated into accountable care organizations (ACOs). Research Questions: Extent of BH integration into ACOs ($, providers, programs) Factors associated with greater BH integration

7 Rationale for Integrated BH and PH BH problems prevalent Any mental illness 20% of adults (age 18+) Substance abuse or dependence 8% (age 12+) BH problems associated with Greater medical comorbidity, decreased physical health and QOL, high health costs and service use Integrated care: Can improve mental and physical health outcomes Can be delivered at the same cost as traditional care Woltmann, 2012 Am J Psychiatry New financing model provides opportunity to redesign care

8 National Survey of ACOs Fielded November 2012 May 2013 Respondents and response Respondents: site identified executive or senior management leadership (i.e. CEOs, Executive Directors, Medical Directors) Went to 301 organizations Response rate ~65% Variety of domains: Organizational structure, contracts, motivations and challenges, capabilities (care management, HIT, quality improvement) Behavioral health: Total cost of care, providers, BH programs in primary care

9 ACO contracts typically include BH in total cost of care metrics 100% 92% Percent of ACOs 80% 60% 40% 20% 69% 0% Largest Commercial Contract All ACOs (n=131)* (n=70) Type of Contract

10 ACO contracts typically include BH in total cost of care metrics 100% 92% Percent of ACOs 80% 60% 40% 20% 69% 0% Largest Commercial Contract All ACOs (n=131)* (n=70) Type of Contract * Missing data on 14, 7 of whom are Medicaid ACOs

11 Over 1/3 of ACOs have NO formal relationship with BH Providers No Formal Relationship, n=51 36% Within the ACO, n=61 43% Contracted Externally, n=29 21%

12 Few ACOs have nearly complete integration of BH programs in primary care 100% 80% Mean=4.3 on a 1 9 Likert scale Number of ACOs 60% 40% 41% 44% 20% 14% 0% Little or none (n=60) Some (n=64) Nearly complete / Level of Integration complete (n=21)

13 Univariate relationships of with level of BH integration in primary care Governance, leadership, & structure Governance: Leadership style (physician led vs. other) BH organizational factors: Relationship with BH providers, Inclusion of BH in total costs Structure: Any FQHC, Any hospital, Integrated delivery system Payer: Medicaid contract, Pioneer contract, Risk bearing MSSP contract, private contract, multi payer ACO, # of contracts Capabilities Care management factor score Health information management factor score

14 Analytic approach: Dependent variable: Integration of BH programs into primary care (1 9 scale) Independent variables: Structure: FQHC, Hospital Payer: Medicaid, Pioneer Care management capabilities Relationship to BH providers Internal, Contracted

15 Predictors of BH integration in primary care Variable B Coefficient SE Constant **.853 Medicaid ACO contract CMS Pioneer contract.898 *.424 Any FQHC.947 **.329 Any hospital Care management capabilities.882***.135 BH providers contracted externally BH providers within ACO 1.489***.344 Adj r 2 =0.427 F(7,120)=14.5, p<.001

16 Not Pioneer Pioneer Integration is greater if BH providers are No FQHC included within the ACO One or More FQHCs Some Care Mgmt Comprehensive Care Management No Formal Relationship Contracted Outside Within the ACO Level of BH Integration in Primary Care

17 Not Pioneer Integration is greater Pioneer for ACOs with more advanced care management capabilities No FQHC One or More FQHCs Some Care Mgmt Comprehensive Care Management No Formal Relationship Contracted Outside Within the ACO Level of BH Integration in Primary Care

18 Not Pioneer ACOs that include an FQHC have higher levels of Pioneer BH integration No FQHC One or More FQHCs Some Care Mgmt Comprehensive Care Management No Formal Relationship Contracted Outside Within the ACO Level of BH Integration in Primary Care

19 Not Pioneer Pioneer No FQHC One or More FQHCs Pioneer ACOs have higher levels of BH integration Some Care Mgmt Comprehensive Care Management No Formal Relationship Contracted Outside Within the ACO Level of BH Integration in Primary Care

20 Limitations & Strengths Limitations Data collected from survey of executive leaders Opportunity to misinterpret questions Potential difficulty estimating care capabilities across ACO NSACO includes few questions on behavioral health integration. No information on integration in non primary care settings Cannot separate mental health from substance abuse services No information on other recognized dimensions of integration Strengths First systematic and national assessment of ACOs Initial findings can inform future work

21 Takeaways: Integration of BH in Primary Care Most are responsible for BH in total cost of care Over 1/3 have no formal relationship with BH providers Few report nearly or fully complete integration of BH programs in primary care Greater integration of BH programs is predicted by: Internal BH providers More advanced care management capabilities Pioneer ACO contract Inclusion of an FQHC Next steps: Qualitative analysis of BH integration in ACOs Awareness and advocacy

22 Questions Contact: