Can the ACO Primary Care Flex Model help connect physical and mental health care?
The link between behavioral health and physical health is well documented. Physical health is greatly affected by behaviors such as smoking, substance abuse, poor diet, lack of exercise, inadequate sleep and more. In addition, mental health issues and social determinants of health, such as lack of housing or transportation, language barriers and food insecurity, impact health.
Primary care physicians are well aware of these problems, but often cannot do anything about them due to a lack of resources. These problems are especially pronounced in underserved populations, such as rural Americans, for whom behavioral health care supports and services are not available or integrated into their primary care.
Lynn Carroll is COO and chief strategy officer at HSBlox, a value-based healthcare administration, payments and billing, and communications and engagement technology and services company. Among its successful launches: enterprise systems for premium billing and collection, digital payments, patient financial engagement, future bundled payments and value-based contract administration.
We interviewed Carroll to talk about the disconnect between physical health and mental health care in the US, how the CMS’ voluntary ACO Primary Care Flex Model aims to help solve some of these issues, and what role information technology can play in healthcare to solve these problems. these challenges and meet the needs of the new CMS program.
Q. What are the problems with the disconnect between physical health care and mental health care in the US?
A. Coordination between primary care physicians and mental health and substance use services is too often poor or non-existent in the US. For example, low-income providers in rural areas may not have the financial resources needed to integrate behavioral care with primary care. A shortage of qualified behavioral health professionals is another barrier to integration.
In addition, primary care physicians report being frustrated that patients seeking access to mental health or substance abuse treatment are unable to do so because they lack insurance or face other challenges related to social determinants of health, such as a lack of transportation or language barriers.
When you combine the lack of integrated services with SDOH-related barriers to access, the inevitable result is that adults from underserved rural populations are less likely to receive mental health care than adults living in metropolitan areas. And when they do access treatment, it is often from a provider who has no specialized training. These are all issues of health inequality, and we must address them if we want to achieve better outcomes while reducing healthcare costs.
Q. How does CMS’ voluntary ACO Primary Care Flex Model plan to help solve some of these issues?
A. The ACO PC Flex model provides an ideal framework for collaborative, team-based care among stakeholders, including primary care providers, clinical and behavioral health specialists, community organizations and payers.
Launching on January 1, 2025, PC Flex will address healthcare equity for underserved populations by increasing access to higher quality primary care. This care may include unique services such as behavioral health integration.
Critically, the model’s new Prospective Primary Care Payment option shifts primary care reimbursement from a fee-for-service, visit-based payment to value-based care models. CMS expects that the PPCP option will be attractive to many low-paying rural ACOs and providers who could benefit from a flexible but predictable revenue stream and who seek closer alignment between primary care providers and behavioral health services for their underserved patient populations.
PC Flex also encourages safety net providers, including Federally Qualified Health Centers and Rural Health Clinics, to form or join ACOs. Overall, PC Flex is structured to ensure more healthcare dollars reach underserved populations.
Q. What role can healthcare information technology play in solving these challenges and meeting the needs of the new CMS program?
A. The right healthcare information technology enables coordination between primary care providers and specialists. The wrong technology does the opposite: it makes coordination difficult or impossible.
Unfortunately, many service providers still rely on outdated or inadequate digital infrastructures that cannot support data exchange or transactions between a network of stakeholders. This network may include behavioral health providers and CBOs, many of which have few digital capabilities but expect smooth reimbursement.
Overcoming this technological barrier requires the implementation of a scalable, cloud-based digital infrastructure that enables a many-to-many network of participants. Furthermore, a robust analytics platform running on top of a digital infrastructure can provide performance transparency, which is essential to ensure the success of VBC contracts.
To achieve CMS’s purpose of rewarding collaborative, team-based care among primary care providers, clinical and Behavioral health specialists, CBOs and payers, healthcare organizations need a scalable digital infrastructure that can meet the demands of a collaborative healthcare network. If supported effectively, these networks can deliver better outcomes for their patient populations while optimizing efficiency and financial performance.
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