Few ACOs Pursue Innovative Models That Integrate Care For Mental Illness And Substance Abuse With Primary Care

Abstract

Accountable care organizations (ACOs) may be well positioned to increase the focus on managing behavioral health conditions (mental health and substance abuse) through the integration of behavioral health treatment and primary care. We used a mixed-methods research design to examine the extent to which ACOs are clinically, organizationally, and financially integrating behavioral health care and primary care. We used data from 257 respondents to the National Survey of Accountable Care Organizations, a nationally representative survey of ACOs. The data were supplemented with semistructured, in-depth interviews with clinical leaders at sixteen ACOs purposively sampled to represent the spectrum of behavioral health integration. We found that most ACOs hold responsibility for some behavioral health care costs, and 42 percent include behavioral health specialists among their providers. However, integration of behavioral health care and primary care remains low, with most ACOs pursuing traditional fragmented approaches to physical and behavioral health care and only a minority implementing innovative models. Contract design and contextual factors appear to influence the extent to which ACOs integrate behavioral health care. Nevertheless, the ACO model has the potential to create opportunities for improving behavioral health care and integrating it with primary care.

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

“…ACOs in regions with a low supply of mental health specialists were also looking for ways to integrate mental health care into other settings, typically primary care, to meet patient demand. 56 That is, the MCP-like structure (for instance, an ACO) appeared to those provider organisations joining it to be relevant to their care group(s) and clinical work. 57 In the USA, the criteria of 'relevance' included whether or not the patients would have insurance coverage.…”

“…51 l Mental health services. Lewis et al 56 describe the addition of mental health-workers (e.g. social worker, psychiatrist) to existing primary care teams, so that care management remains with just one provider.…”

“…In some ACOs, the role of consulting mental health specialists included coaching primary care providers in the use of psychiatric medications, assisting with diagnoses, and making appropriate referrals to specialised mental health care services. 56 In the HealthOne Mount Druitt project (Australia), consultations also included 'more informal exchanges of information.' 80 Different patients might also have different but often overlapping provider networks, and these overlaps offered the greatest scope for strengthening care co-ordination.…”

“…Contract design appeared to influence the extent to which ACOs integrated mental care. 56 In practice, the English NHS has so far had little success in commissioning through outcomes-based incentivised contracts for these purposes because of the difficulty in specifying and measuring the relevant outcomes, and then in knowing whether or not to attribute any changes to the providers, care co-ordination or extraneous confounding factors.…”

“…ACOs with 'a comprehensive, chronic care management program' were more likely than others also to have integrated mental and physical care. 56 In Utah, MHI's co-ordinating approach allowed it to replace the traditional model of partitioned-off, sectorised psychiatry with a co-ordinated combination of ambulatory care, specialist secondary, and first-recourse care, which, in turn, allowed territory-wide, whole-population planning of its services (reducing 'medical deserts'), organising support networks to promote preventative care, and developing ambulatory services that linked hospital, medicosocial work and social care. 66 Lewis et al 56 describes two main approaches to overcoming the traditional separation of primary and mental health carei.…”