Introduction: Prior research has demonstrated the associations between a strong primary care foundation with improved Quadruple Aim outcomes. The prevailing fee-for-service payment system in the United States reinforces the volume of services over value-based care, thereby devaluing primary care, and obstructing the health care system from attaining the Quadruple Aim. By supporting a shift from volume-based to value-based payment models, the Medicare Access and Children's Health Insurance Program Reauthorization Act may help fortify the role of primary care. This narrative review proposes a taxonomy of the major health care payment models, reviewing their ability to uphold the functions of primary care, and their impacts across the Quadruple Aim.Methods: An Ovid MEDLINE search and expert opinion from members of the Family Medicine for America's Health payment and research tactic teams were used. Titles and abstracts were reviewed for relevance to the topic, and expert opinion further narrowed the literature for inclusion to timely and relevant articles.Findings: No payment model demonstrates consistent benefits across the Quadruple Aim across a limited evidence base. Several cross-cutting lessons from available payment models several recommendations for primary care payment models, including the following: implementing per member per month-based models, validating risk-adjustment tools, increasing investments in integrated behavioral health and social services, and connecting payments to patient-oriented and primary care-oriented metrics. Along with ongoing research in emerging payment models, data systems integrated across health care and social services settings using metrics that can capture the ideal functions of primary care will be critical to the development of future payment models that most optimally enhance the role of primary care in the United States.Conclusions: Although the ideal payment model for primary care remains to be determined, lessons learned from existing payment models can help guide the shift from volume-based to value-based care. To most effectively pay for primary care, future payment models should invest in a primary care infrastructure, one that supports team-based, community-oriented care, and measures the delivery of the functions of primary care. (J Am Board Fam Med 2018;31:588 -604.)
The objective of this study was to characterize financial barriers and solutions for the integration of behavioral health in primary care at the practice and system levels. Semi-structured interviews were conducted March–August of 2015 with 77 key informants. Initially a broad thematic coding approach was used, and data coded as “financing” was further analyzed in ATLAS.ti using an inductive thematic approach by three coders. Themes identified included the following: fragmentation of payment and inadequate investment limit movement toward integration; the evidence base for integration is not well known and requires appropriately structured further study; fee-for-service limits the movement to integration—an alternative payment system is needed; there are financial considerations beyond specific models of payment, including incentivizing innovation, prevention, and practice transformation support; stakeholders need to be engaged and aligned to support this process. There was consensus that the current fragmented, fee-for-service system with inadequate baseline reimbursement significantly hinders progression toward integrated behavioral health and primary care. Funding is needed both to support integrated care and to facilitate the transition to a new model. Multiple suggestions were offered regarding interim solutions to move toward an integrated model and ultimately global payment. Payment, in terms of both adequate amount and model, is a significant obstacle to integrating behavioral health and primary care. Future policy efforts must focus on ensuring stakeholder collaboration, multi-payer alignment, increasing investment in behavioral health and primary care, and moving away from fee-for-service toward a global and value-based payment model.
Integrated care is recognized as a promising approach to comprehensive health care and reductions in health care costs. However, the integration of behavioral health and primary care is complex and often difficult to implement. Successful and sustainable integration efforts require coordination and alignment both within health care organizations and across multiple sectors. Furthermore, implementation progress and outcomes are shaped by the readiness of stakeholders to work together toward integrated care. In the context of a Colorado State Innovation Model (SIM) effort, we examined stakeholder readiness to advance and sustain partnerships for behavioral health integration beyond the period of grant funding. Partnership readiness was assessed using the Readiness for Cross-sector Partnerships Questionnaire (RCP) in spring 2019. Participants from 67 organizations represented seven sectors: government, health care, academic, practice transformation, advocacy, payer, and other. RCP analyses indicated a moderate level of readiness among Colorado stakeholders for partnering to continue the work of behavioral health integration initiated by SIM. Stakeholders indicated their highest readiness levels for general capacity and lowest for innovation-specific capacity. Five thematic categories emerged from the open-ended questions pertaining to partnership experiences: (a) collaboration and relationships, (b) capacity and leadership, (c) measurement and outcomes, (d) financing integrated care, and (e) sustainability of the cross-sector partnership. Partnering across sectors to advance integrated behavioral health and create more equitable access to services is inherently complex and nonlinear in nature. The RCP usefully identifies opportunities to strengthen the sustainability of integrated care efforts.
Background:The historic, cultural separation of primary care and behavioral health has caused the spread of integrated care to lag behind other practice transformation efforts. The Advancing Care Together study was a 3-year evaluation of how practices implemented integrated care in their local contexts; at its culmination, practice leaders ("innovators") identified lessons learned to pass on to others.Methods: Individual feedback from innovators, key messages created by workgroups of innovators and the study team, and a synthesis of key messages from a facilitated discussion were analyzed for themes via immersion/crystallization.Results: Five key themes were captured: (1) frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care; (2) initialize: define relationships and protocols up-front, understanding they will evolve; (3) build inclusive, empowered teams to provide the foundation for integration; (4) Of adults with a behavioral health (BH) disorder, 67% do not receive adequate treatment.1 Untreated BH conditions result in avoidable suffering and increase the cost of care through lack of medical improvement, decreased adherence to treatment, and inappropriate health care utilization. 2Most patients with BH conditions, including children, are seen in medical settings, most commonly primary care (PC), presenting the need and opportunity to replace separated systems of care that do not adequately meet the needs of patients with integrated, "whole-person" care.Integrated behavioral health (or integrated care) is the care that results from a practice team of PC and BH clinicians working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance use conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. The historic, cultural separation of training, payment, and delivery systems for PC and BH have caused the spread of integrated care to lag far behind other practice transformation efforts (eg, the Patient Centered Medical Home [PCMH]). New payment structures and delivery models that support the integration of PC and BH are emerging, facilitating the movement toward integrated care as part of the drive to achieve the This article was externally peer reviewed.
The COVID-19 pandemic has added further urgency to the need for primary care payment reform. Feefor-service payments limit the flexibility of practices to respond to crises and leave practices without sufficient revenues when visit volumes decrease. Historic fee-for-service payments have been inadequate, and prior implementations of prospective payments have encountered challenges; there is a need to bring forward the best available evidence on how to design prospective payments for payers and policymakers. Evidence suggests setting primary care investment at 10% to 12% of the total cost of care, approximately translating to an average $85 per member per month, with significant variation based on age and adjustment for medical and social measures of risk. Enhanced investment in primary care should be aligned across payers and support practice transformation to advanced models of care.
amendment to our article and enthusiastically agree with the assertion that health equity is an important lens through which to gauge the effectiveness of payment models. While we assessed how these models affected health outcomes broadly, we agree that an important addition would be to specifically examine their impact on health equity. As Dr. Fiscella and Dr. Carroll note, risk-adjusted (based on social determinants of health in addition to medical determinants) global payments are one potential path toward equity, by ensuring that adequate resources are dedicated to patients with more complex needs and that there is flexibility in funds to meet social needs in addition to medical needs. In our characterization of payment models we have included whether the model includes risk adjustment. Another consideration relevant to payment models is to include measures of equity in performance metrics. We have raised concerns that models like the Merit-Based Incentive Payment System have the potential to widen existing disparities. 1 There is important work underway to develop measures that adequately assess primary care, including impact on health equity, begun at Starfield Summit III and being continued at the Larry A. Green Center for the Advancement of Primary Health Care for the Public Good. While primary care has been shown to attenuate health disparities, improved payment for primary care is necessary but not sufficient for achieving health equity. Achieving population health equity goals also requires ensuring access to health care for all, looking further upstream to payment for social services, and systematically addressing structural racism and discrimination.
In this editorial we describe the clinician/administrator/researcher experience of frustration or confusion around how to effectively advocate for policy change in health care. By the end of the piece the reader will (a) understand the importance of health professionals' advocacy; (b) know how to use policy papers to advocate; and (c) understand how policy organizations use policy papers. We also discuss the National Academies of Medicine, Science, & Engineering High Quality Primary Care report as an example of a policy paper, introduce our new coeditors for the Policy and Management Department, and describe the Collaborative Family Health Care Association's new policy principles.
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