The Impact of Healthcare Reform on Psychotherapy Services
Outlines and describes reasons for healthcare reform, discusses ways these reforms will transform behavioral health and psychotherapy services. Illustrates the goals of Patient-Centered HealthCare and processes leading to that goal.
Healthcare reform is all around us. Behavioral health and psychotherapy will not be exempted from these changes. Mental health professionals do not yet experience the full impact of healthcare reform legislation, but it impacts are surfacing regionally and nationally in both obvious and subtle ways. Providers know something is happening, but don't see it fully or feel it yet. The effects are not unlike those of tornados or floods in other parts of the country. Many providers seem to believe they are shielded from these changes. Perhaps they feel shielded because their fees-for-service are good or insurance payers are not auditing practices in their area, right now. In many states, healthcare policies are changing so quickly that a considerable interaction with knowledge experts is required to understand the consequences of the economic, regulatory and the legislative forces at work.
Reasons for Healthcare Reform
Healthcare reform is based on public and legislative consensus that healthcare services are often fragmented, uncoordinated and insufficiently accountable. For many patients, satisfaction with care they receive is low. And patients who have emergencies, illness, or disease are often unable to afford or obtain health and wellness care. Referrals and coordination of care practices have been inefficient. There have not been effective means to assure that physical and mental health needs are met.
There are failures in the provision of healthcare and significant inefficiencies. Public health suffers as a result, the cost of healthcare goes up. Until the recent decade, the focus of healthcare services was concentrated on treating serious and life threatening disease an injury rather than prevention. Improvements in quality, savings, and better patient care result when the focus shifts to collaboration and prevention. The Health Information Technology for Economics and Clinical Health Act (HITECH) and the Patient Protection and Affordable Care Act (ACA) have been central to the resurgence of healthcare management by public and commercial health care payment sectors. In the mid 1980’s and early 1990’s, managed care meant “restricting care” based on criteria that that were not transparent or accountable. In 2013 the focus moved toward on ensuring access, improved general health and cost reduction.
Beginning with the ACA, healthcare reform focused on the quality of care. This focus requires that healthcare be measured, accountable, transparent, affordable and available. As a result of the ACA and the HITECH, fee-for-service mental health services will be shifting to coordinated and accountable care as illustrated in Figure 1.
The Triple Aim of healthcare reform is to (1) insure reasonable access to care and a positive patient experience, (2) improve patient and group health and well-being, and (3) to manage and contain costs. These three goals are to be implemented in a manner that is transparent and accountable. Measures of the Triple Aim are being created, evolving and used. Both healthcare providers and payers will be accountable.
Mental Health Transformations
Insurance payers have begun to signal that they want to contract with groups rather than individuals. Many payers are open about this preference. And the preference makes sense. It costs less and it requires psychotherapists to be accountable to their peers. Privately, insurance payer representatives state that it is their job to reduce the cost of care any way they can legally do and that it is providers’ job to assert them selves.
Groups of physicians have responded effectively to payers because they are organized, they have business consultants, data and financial resources. Mental health professionals can not respond effectively when they operate in isolated private practice. Especially when they rely on paper charts. Barriers to individual practitioner’s ability to form practice groups exist in their inability to collectively gather local data and provide credible arguments for the quality of their care. Individual practitioners are powerless to counter the pressures that can be exerted by insurance companies and government supported insurance actions. However, by “grouping up,” psychotherapists can create avenues of influence. Psychotherapists who form larger groups or associations of practice groups can create efficiencies of scale and consumer benefits that solo and small group practice professionals cannot.
Payers are interested in group contracts in part because single provider contracts are an economic burden to them. Further, payments to providers are shifting from “claims–based” to “inherent value”, "added value" and “pay-for-performance” (P4P) criteria. Private employers, and commercial payers, are following this lead by asking for quality of care that is measurable as opposed to earlier payment models that restricted care without accountability.
Mental health services, under the ACA, have parity with medical care. Mental health services are now considered specialty care as are other points of care such as neurology, cardiology, etc. Just as for other specialty care providers; third-party paid mental health services must become coordinated and accountable. In medicine, primary medical care is becoming the care coordination center in new models called Primary Care Medical Homes (PCMH) and Patient Centered Primary Care Homes (PCPCH). Hospitals and hospital systems are purchasing medical practices and forming Hospital Medical Homes (HMH) and Accountable Healthcare Systems (AHS) designed to manage care in communities and regions.
The Patient Protection and Affordable Care Act (ACA) was written in part to assure that health plans coverage for mental health services are on par with physical illnesses. In Oregon, the ACA was adopted as state law and is being implemented in Coordinated Care Organizations (CCOs) that are similar and in most ways identical to Federal Accountable Care Organizations (ACOs.) Healthcare infrastructure is adapting on a state by state basis.
While traditional solo practice fee-for-service will remain for the near term, psychotherapists will over time find it increasingly necessary to coordinate care, provide measures, and demonstrate accountability for services they provide. Figure 1 describes the changes taking place in mental health services. In this new system of care, patient screenings, referrals, progress and outcomes will be tracked by physicians and payers. The move from fee-for-service to coordinated care will require changes in the way psychotherapists practice. Psychotherapists are not specifically required by the ACE to be accountable for the services they provide. Physicians, however, are directly responsible, and have financial incentives to measure and manage the quality of services that psychotherapists provide. Since physicians are required to coordinate and measure the quality of care, they are also in position to manage and direct behavioral and mental health services over time.
Figure 1.
Michael G. Conner, PsyD is a psychologist in private practice and an owner of Private Practice Cloud, LLC a healthcare operation support business. His business currently supports The American Mental Health Alliance Oregon (AMHA-OR). Dr. Conner is a member of the Board of Directors of Mentor Research Institute (MRI). He acknowledges Michaele P. Dunlap, PsyD, Board Secretary of AMHA-OR, and President of MRI, as co-author of this article.