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Creating comprehensive payment for comprehensive primary care

Virginia Visit
by

CU DFM Research & Policy

on 21 October 2015

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Transcript of Creating comprehensive payment for comprehensive primary care

A framework
To change clinical care, we must
simultaneously
change how we pay for care and operationalize care.
We cannot afford to not integrate
Desire lines
A lesson from business
Design from ground up
Creating comprehensive payment for comprehensive primary care
Benjamin F. Miller, PsyD (@miller7)
Farley Health Policy Center
University of Colorado School of Medicine

The “two pots” of money thing

2000
The care that results from a practice team of primary care and behavioral health 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 abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization.
Critical facet of comprehensive primary care — no different than investments in practice-based care management, measurement and other data use competencies, technology and practice transformation support.
Global payment based upon defined practice budgets for personnel, interventions and related infrastructure – to create team-based, whole-person care (e.g. CoACH)
RMHP payer mix in practice is ~+30%
BH providers are not trapped in a workflow designed to maximize volume-based payments, or pigeon holed into distinct “physical” and “mental health” coding categories.
Primary care practices “own” their own behavioral health resources and are fully accountable for measured outcomes.
farleyhealthpolicycenter.org/cost-assessment-of-collaborative-healthcare/
SHAPE
What business are you in
?
- Blockbuster thought it was all about movies and entertainment, but really it was about retail customer experience
Make sure you are looking at the big picture
; understand fully the context
- Blockbuster did not see the promise/peril of customer convenience until it was too late (never mind the internet)
There is no one right way
; be pattern recognizers and look at the system for seen and unseen connections (Follow the desire lines)
- Blockbuster failed because it was a well-oiled machine; however, it was poorly suited to let in new information
Will you be "Blockbustered" or "Netflixed"
Comprehensive primary care is a “high leverage” investment
Integrated BH is just another (important) aspect of comprehensive primary care
Small part of the total health care budget
Exemplars are performing very well. The question is how to scale this model through accelerated transformation
A few thoughts (lessons learned from other states)
- Consider what impact carving out behavioral health in all forms and permutations does at all levels and all policy processes
- End legacy "home grown" assessment and reporting processes that drain resources and often lack any basis in evidence; end legacy regulatory systems that entrench inefficient, isolated bureaucracies
- See the "system" clearly for what it is now (a 'safety net' and a source of 'specialty care') -- and what it CAN be (a very useful vehicle for community based interventions, a much wider array of social determinant supports and population campaigns)
- Move continuously and constantly, as rapidly as possible, from encounter based payment; reverting to volume in the name of "integration" is an oxymoron. Preserving "mental health system capitation" as a pool in itself, or simply "carving more things in to the carve out" is also at odds with integration
- Close the (often empty) space between primary care and global capitation contracts with payment arrangements that promote "co-management", episodic models where appropriate, shared accountability for medication therapy and costs

- Grant the "mental health system" access to shared gains in the "physical health system", with corresponding downside risk for new work and intervention outcomes outside their existing scope that do not add value
“The evidence suggests that legacy systems and often
antiquated payment policies
limit primary care practices ability to provide integrated care. If 1 size does not fit all for behavioral health, there should be “no wrong door” for patients in our community when it comes to receiving care. All health policies should be measured against the question, “
Will this limit my patients’ choice in receiving behavioral health where they want?
” It will simply be impossible to answer this question with a yes and be in support of integrated care.”
Full transcript