Opportunities and Challenges Lurk for Psychiatrists as ACOs Proliferate

The emergence of accountable care organizations (ACOs) may spur changes in psychiatric care, especially among office-based practitioners. That is the view of Henry Chung, MD, Chief Medical Officer of Montefiore Care Management and Associate Professor of Clinical Psychiatry & Behavioral Sciences at Albert Einstein College of Medicine.

Chung’s third title is Medical Director for the Montefiore ACO, 1 of 32 hospital-physician entities selected in December by the Centers for Medicare & Medicaid Services (CMS) as “pioneer” ACOs. The Affordable Care Act, the big health care reform bill passed by Congress in 2010, established the basic skeletal rules for ACOs, which were viewed as organizations that could better control Medicare costs and improve quality via tighter collaboration between physicians, patients, and hospitals charged with meeting quality yardsticks. A major motivation for ACOs is that they will “share” some of the savings they produce for Medicare, if in fact they meet quality targets and lower health care costs below a certain level.

The Montefiore ACO will assume care of approximately 23,000 patients, all of whom have been receiving care from a primary care physician associated with Montefiore, which includes more than 2100 employed or affiliated physicians. About 191 of those are psychiatrists.

Montefiore-and the other 31 ACOs-will have to meet quality indicators in 33 areas, one of which is depression screening. “That is huge,” stated Chung. If screening is positive, some type of care plan needs to be documented, such as referral or treatment. The pioneer ACOs started collecting data in January. The CMS will be rolling out 2 other ACO models in the future-one called “shared savings,” the other, “advanced payment.” Each of the 3 have different financial structures, but all 3 will pave the way for an assertive Medicare-and private insurance-march into the brave new world of “value-based purchasing” based on tight integration of physician practices under one roof, linked together by care management.

To meet the depression screening requirement, primary care physicians and psychiatrists will lean on depression measurement tools such as the Patient Health Questionnaire (PHQ) 2 and PHQ9, what Chung referred to as the “gold standards in primary care.” He noted there has been minimal uptake of these evidence-based measures outside staff model HMOs such as Kaiser, Group Health, and Intermountain. “Psychiatrists still base diagnosis and treatment decisions on standard interviews or clinical judgment and not on determining a measurable severity score,” he added.

So, for example, Montefiore and other ACOs might establish levels of interaction between a primary care physician and a psychiatrist based on a patient’s PHQ9 score, and also use it as a yardstick to chart success of treatment. If the patient scores below 10 initially, then perhaps the primary care physician doesn’t need to get the psychiatrist involved beyond electronic updates, which might be funneled back and forth via a care manager, who might also have access to a psychiatric social worker. If the PHQ9 score starts at 20, alarm bells would probably go off, requiring the primary care physician to set up a face-to-face consultation with the psychiatrist. The psychiatrist might base his or her decisions going forward, for example, on whether to increase or decrease medication, or change medication, or add psychotherapy based on the patient’s future PHQ9 scores, and attempt to decrease scores below 5, which is consistent with remission.

Chung says there is a “high level” of interest among Montefiore psychiatrists in ACO participation. “Managing these patients alongside their primary care colleagues is something they aspire to,” he explained. “There have not been good systems linking these two worlds.”

But Chung acknowledged potential concerns too. “Psychiatrists may wonder whether higher levels of screening will lead to higher levels of depression diagnosis resulting in them getting inundated with new patients,” he said. “If ACO participation leads to waiting lists and disappointment, that is not good.”

But not only will ACOs stimulate the linking of primary care physicians and psychiatrists, they will promote professional bonding between specialists and psychiatrists. That is the case at Norton Healthcare, which is one of the 5 physician group/hospital combinations participating in an ACO pilot program under the aegis of the Dartmouth Institute for Health Policy & Clinical Practice and Brookings Institution. Norton is using patients assigned to its ACO by Humana and using Dartmouth/Brookings established quality yardsticks. It is not one of the “pioneer” ACOs designated by Medicare.

Mary Helen Davis, MD, is Director of Behavioral Oncology at Norton, so she sees only oncology patients, including those assigned to the Norton ACO. It is a different way to practice for a psychiatrist such as Davis, who previously was at an academic medical center for 12 years and in private practice for 8 years. She only works with oncology patients and their 30 oncologists in a fully integrated oncology practice. “There has been a big push for integration of psychosocial service standards into the practice of oncology and a resulting emphasis on screening for distress and providing an appropriate intervention for identified problems,” she explained. “There has to be a way to get that patient quick access to mental health services and sometimes a psychiatrist, either internally or externally.” External access, or referral to a psychiatrist in the community, can be problematic because of regional shortages of psychiatrists, particularly those willing to accept third-party reimbursements.

Like Montefiore’s Chung, Norton’s Davis noted that psychiatrists face pitfalls and opportunities in terms of ACO participation. They may be viewed by management as revenue depressants. “Psychiatry has to be seen as more than a reimbursed clinical service,” Davis emphasized. “In the hospital system, it is not likely to be a leading revenue generator, so administration and hospital leadership need to view psychiatric services as value added.”