Behavioral Health Recommendations for Accountable Care Organizations

As we begin to chart our course toward Accountable Care Organizations, let us keep in mind that mental health and substance use disorder providers are often starting their journey from a different point of origin than are their medical counterparts. Let’s face it, behavioral health providers are often under-resourced and under-capitalized compared to MSOs, IPAs and hospitals. Facts being what they are, behavioral health is going to require some special handling and it behooves primary care, hospitals, integrated delivery systems and health plans to help them keep pace. While it’s true that all interested parties – behavioral health providers included – need to be able to carry their own weight in business terms, any ACO that fails to properly include behavioral health providers is destined to continue struggling with a significant share of otherwise unmitigated chronic care costs so the value proposition should be clear. In order to achieve a high performance health system that is organized to attain better health, better care, and lower costs, the behavioral health needs of patients and their families must be met with as much ingenuity, quality and precision as other conditions.

Behavioral Health Recommendations for ACOs

The following is a list adapted from one prepared by the Commonwealth Fund this week. Each recommendation amounts to a strong caution for integrated delivery systems who seek to develop ACOs – behavioral health is essential.

  •  Technical Support for Behavioral Health Providers – mental health and substance use disorder treatment providers have a long history of serving populations from the margins where profits are slim. Most behavioral health care provided for in America is financed by Medicare, Medicaid, Federal block grants, State general funds and other government grants. Consequently, the lion’s share of providers are smaller and not-for-profit entities and their transition to ACOs will require a steep curve and additional support in the development of infrastructure. Agencies/communities interested in developing ACOs are advised to extend technical assistance and training to all viable providers. Information technology is chief among the needs for technical assistance.
  • Integrated Care– truly effective ACOs will ensure that a foundation of integrated primary and behavioral health care is available for their members. While the initiative to integrate care has been around for more than a decade, there is a great deal of room for improvement. Accountable care must be highly integrated so the catalyst for improved implementation is certainly there.
  • Accountability for Behavioral Health – the most accurate measures of quality care, patient care experiences, population outcomes, and total costs must include mental health and substance use disorders. ACOs are advised to develop systems of care that can be held accountable for the quality and cost of behavioral health treatment from the beginning.
  • Informed Patients– ACOs must inform, engage and educate patients and their families. Nowhere is the need greatest than among those members and patients with behavioral health conditions. Many decades of fierce stigma and lack of access to services must be overcome with clear, friendly and readily available information and outreach.
  • Commitment to Communities - serving the entire community has long been the mission of behavioral health providers – many of whom also serve social service functions. Linkages between community assets, case management and social work are vitally important to the most vulnerable populations, those suffering from disabilities and those suffering from multiple chronic conditions. The form and function of ACOs must remain true to community involvement and enhancement and avoid devolving into business entities that neglect their social and civic responsibilities.
  • Reward High Performance in Behavioral Health – as much as ACOs represent a gold rush among business interests, it will be critically important that behavioral health providers be included in models that involve shared savings. Shared incentives will not only promote the right kinds of linkages and coordinated care, they will demonstrate a willingness to view behavioral health conditions and providers as equally deserving of respect.
  • Innovative Payment Mechanisms for Behavioral Health – behavioral health providers are eager to look for new and creative ways to be reimbursed. They are uniquely positioned to offer services on case rates and the basis of episodes of care. There are providers that are ready to serve in roles such as health coaches, case managers, and health educators that can be supported by full-time salaries as opposed to purchasing services on a fee-for-service basis.
  • Timely Monitoring - data collection, aggregation, analysis and feedback must include and address behavioral health needs and providers. Without data and reporting, most of our other goals and objectives cannot be met.

4 comments to Behavioral Health Recommendations for Accountable Care Organizations

  • Regarding this “must”:
    “…as much as ACOs represent a gold rush among business interests, it will be critically important that behavioral health providers be included in models that involve shared savings…”

    Who has to authority and the power to make this so? and what is the progress on that front?

    Based on what I see happening around me, I worry that in all this “integration”, behavioral health will continue to be carved out and mental health will continue to be primary health’s stepchildren, with substance use the inlaws of the stepchildren.

    Your thoughts?

    • Thanks for the question, Cindy. To suggest that our providers must be included reflects two concerns: the first is that well-coordinated care accountable to the multiple chronic conditions of the populations being served has to address unmet mental health and substance use disorder needs. It’s a clinical imperative and regulatory mandate reflected in Affordable Care Act and the ACO proposed rules. MH and SUD are specifically cited as chronic conditions. However, that by itself doesn’t assure our providers of anything because it’s not uncommon for FQHCs and PCPs to establish a work-around of their own or one that keeps the business in-house in some fashion. The second concern being addressed here is the well-known need to integrate services and professionals to the extent that ACOs integrate funding. However, that too doesn’t assure us of an outcome. It’s quite conceivable that ACOs simply hire the expertise they need rather than sub-contract for it.

      So where does that leave us? Right where I recommended: MH and SUD providers need to get active in their own networking and marketing. Becoming an active stakeholder (if not shareholder) in an ACO will mean “selling” your services into the mix and negotiating a stake. Serving as an ancillary provider in a peripheral network similarly requires marketing and contracting. ACOs are – from the beginning – a new business model that will require new business relationships and that’s a very active process as opposed to a passive one.

      As for who is in charge, I have already addressed the mandate that MH and SUD be effectively treated by ACOs. However, how ACOs form and institutionalize themselves is up to the ACOs themselves. CMS will not be directing how they form. The responsibility to get out there and market in order to be included is entirely the provider’s.

      Our future is in our hands. How we are precieved is a function of how we present and represent ourselves. If we show up respectful, confident, assertive, integritous, professional and as deserving as anyone else at the table, I believe we will be viewed that way.

      I hope this helps.

  • Hello,

    I am a trustee of a foundation interested in furthering the integration of behavioral health in primary care and other specialties, especially in ACOs. First, how will CMS enforce the mandate you cite above? Second, are there any public or private matching grants for communities or groups that seek to encourage integration? And third, does your staff include consultants who have helped achieve this successfully by working with physicians, hosspitals and various behavioral health providers?


    • Hi Fran. Great questions. Some brief but pointed answers:
      1. How will CMS enforce ACO mandates? Primarily, CMS will use contractual terms and conditions to enforce the model. ACO contracts will be contingent upon performance in a number of critical areas such as: the ability to support necessary infrastructure; to meet access to primary care thresholds; to meet financial requirements; to satisfy outcomes and quality performance metrics; and to comply with reimbursement policies (expect reimbursement reforms, close auditing, and models like Global Payment). Because ACOs are slated for Medicare Shared Savings programs, they will continue to be monitored by Medicare officials, contracted financial auditing firms, and the likes of Medicare QIOs.
      2. Is there any private funding to support development? Yes. There are examples of community foundations, Blue Cross/Shield foundations, private foundations, and others like the Commonwealth Fund that are supporting development from a number of different angles.
      3. We have many senior consultants who have experience with integration efforts and initiatives. Much of the work of AHP, Inc. has been around transformation under contract with the Federal government, many of our partners are managing such projects today, and – importantly – the advent of ACOs is new so very few people can site examples of actual ACO experience. The truth is, actual models like Kaiser, the Cleveland Clinic and Geisinger are few and far between. While there are dozens of start-up ACOs today, they are just that – start-ups. It’s also important to understand the kinds and types of subject matter experts that will be instrumental in these efforts. Experience with Patient-Centered Medical Home model is valuable as is expertise in training and disseminating new clinical models, implementing and optimizing health information technology and managing to Meaningful Use. Business acumen, expertise in governance models, understanding of reimbursement and revenue management, underwriting risk, Medicare policy and regulations, local market research and marketing…all of these skills are drawn upon. This is why we have taken an approach that features strategic and joint venture partners…no small team can manage all of these moving parts. It will take a tailored SWAT team approach in each unique instance.

      I invite you to call on me if you have additional questions. I can be reached at 888-898-3280 ext. 802 or on my cell at 508-395-8429

      Many thanks

      Patrick Gauthier

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