KAUAI, HAWAII – The future of psychiatry in the era of health care reform will involve more team-based integrative care than ever before, according to Dr. James H. Scully Jr.
That means a shift away from the fee-for-service, volume-based model of care to which psychiatrists are accustomed. "We’re going to have to change the way we do business in order to survive," said Dr. Scully, CEO and medical director of the American Psychiatric Association. "We have to change our availability. We can’t say ‘I’ll see the patient in a couple of months’ like we do now sometimes. We’ll have to say ‘I’ll be there this afternoon’ and structure our clinical work around that, not only to do good liaison work but to be able to see the patient."
Dr. James H. Scully, Jr.
Volume-based fee-for-service health care "is a great risk," he said at the annual meeting of the American College of Psychiatrists. "That’s not sustainable [under] the Affordable Care Act. The insurance companies don’t want to do it anymore and certainly the companies who buy health insurance for their employees don’t want to spend money in the way they’ve been spending it."
The Center for Medicare and Medicaid Innovation (CMMI) – part of the Centers for Medicare and Medicaid Services – is funding numerous pilot programs aimed at fostering integrated care in primary and specialty care.
Dr. Scully offered examples of projects that are well developed, in his opinion: North Carolina Center of Excellence in Integrated Care; the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) project; Integrated Behavioral Health Project in California; Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) in Washington State; Mental Health Integration Program, also in Washington State; and TEAMcare, a multidisciplinary collaboration between the University of Washington and the Group Health Research Institute.
"These are all grant funded, so the question is, are they sustainable in the current way we pay for health care?" Dr. Scully asked. "Probably not. We have to change the way we pay for the services. Service delivery models and service payment models are two aspects of how this will get dealt with."
At the same time, mounting evidence from published studies is demonstrating that integrated health care can improve outcomes and lower cost. For example, in one randomized, controlled trial, diabetes patients who participated in the IMPACT program experienced fewer days of depression over a 2 year period compared with patients who received usual care (Diabetes Care 2006;29:265-70).
New payment models also are being developed under the ACA, Dr. Scully said. Many models include bundled payment for episodes of care "where you get a fee for caring for an episode or for a period of time."
Global capitation and partial capitation are being studied as well. "There are lots of different variations to change away from fee-for-service to a different kind of model to get paid for what we do," Dr. Scully said. "It’s an exciting time for us. We can’t walk away from [health care reform efforts]. We could, but I think it would be at our peril in the long-term. I think we have to participate in this and show some leadership. I’m optimistic."
Dr. Scully said that he had no relevant financial conflicts to disclose.