Through an innovative partnership between an academic institution, a national organization, and a not-for-profit health plan, the SHAPE (Sustaining Healthcare Across integrated Primary care Efforts) program aims to address one of the most significant problems facing the field of integrating behavioral health and primary care: financial sustainability. An issue brief by SHAPE indicates that primary care either directly or indirectly manages a large percentage of patients with mental health, behavioral health, or substance abuse disorders. Additionally, primary care providers are uniquely positioned to support behavioral interventions that will address broader public health problems, such as obesity – even when no mental health diagnosis is present. Integrating care for these patients could garner positive impacts including improved access, satisfaction, treatment adherence, cost effectiveness, and clinical outcomes.
The principle investigator on the grant from the University of Colorado Department of Family Medicine, Benjamin F. Miller, PsyD, described some of the problems with trying to finance integrated care. “The barriers and challenges have been well documented in the literature and through our communities,” said Miller. “We know that often separating payment streams forces providers to operate in their respective silos rather than work together in a more collaborative and integrated fashion.”
The primary contract for SHAPE was awarded to the Collaborative Family Healthcare Association (CFHA), a national not-for-profit organization. “CFHA is committed to seeing integrated care become more of a reality in practice,” said Polly Kurtz, CFHA’s Executive Director. “Our members have told us for years that they would be actively working towards integration if only they had a viable financial strategy for sustainability.”
CFHA is holding its annual conference in Denver this October. “We see an opportunity this fall to bring national leaders in integration to Colorado to see how innovative and progressive our integration efforts have become,” says Miller, a past president of CFHA. “We want to help other practices, providers, payers, and policy makers understand what it takes to take integration to scale across their communities.”
Although current integration initiatives are in place throughout Colorado, one challenge to expanded integration is funding. Miller described the importance of ascertaining a financially viable model as a “game changer” for those practices interested in integration. According to the issue brief, a 2011 Colorado Health Foundation survey showed that 78 percent of primary care practices with integrated care that responded indicated their programs were supported primarily through grants. Identified obstacles to sustainability included billing restrictions and reimbursement rates for integrated services.
According to Patrick Gordon, Associate Vice President at Rocky Mountain Health Plans, “The cost of providing adequate, effective financial support for integrated behavioral health in primary care settings is much less prohibitive when it is considered in the context of the entire global budget for care.” Primary care itself represents – at best – only 5-7 percent of current health care spending in most systems and markets today, and integrated behavioral health is only a small component of the overall primary care cost structure. “RMHP is participating in SHAPE because the potential for better patient health and cost savings is primarily driven by behavior”, explained Gordon. “We’d be foolish not to pursue smarter payment arrangements for primary care, where small investments can leverage significant impacts on the total health care spending.”
The SHAPE program was designed to evaluate a new payment scheme and deconstructs the financial barriers to sustaining integrated care models and proposes a solution through changing the payment mechanism for integrated health care to a global payment system. As opposed to a per member per month payment model in some programs, SHAPE’s global payment methodology considers the entire cost of the integrated care model to determine a global budget. Provider payments will be established after considering cost, number of patients (or panel size), patient complexity, and program design and alignment.
The payment model will factor in costs for behavioral health personnel and related interventions, both in-office and through non-traditional methods to manage overall patient health. In addition to the number of patients or panel size served by the proactive, availability of resources that influence the cost to provide services will also be factored into the payment methodology. The patient complexity component of the payment structure allows for risk adjustment for patients requiring more attention and affords providers with the flexibility to ensure the best possible patient care. Payments will be tied to progressive structural milestones achieved by the practice in order to ensure both adequate cash flow and accountability.
CFHA and RMHP have designed SHAPE to reimburse practices in a manner that will incentivize and allow them to proactively identify where there might be gaps in care for their patients to keep them healthy. “The current payment structure doesn’t provide clinicians with the resources to address behavioral health concerns that might exist, often perpetuating or exacerbating the physical health problems,” said Gordon. The SHAPE global payment model addresses this issue by paying practices in a comprehensive manner that allows them to treat the whole patient – without the compromising imitations associated with claims coding, or the need to “earn” revenue through encounter volume in fee for service payment arrangements. According to Gordon, “Much of what actually works is not codeable. We can’t waste time trying to fit square pegs in round holes.”
Six practices throughout Colorado are participating in RMHP’s SHAPE pilot. The results of the SHAPE pilots will provide an interesting look into the sustainability of integrated primary care and global payments in Colorado. More information on SHAPE can be found here.