ACOs and Psychiatric Care: New Threat or New Opportunity?

Like many physicians of all specialties, I’m not exactly sure what to make of the proposal for an all-payer ACO model of healthcare for Vermont.  For someone who has spent the vast majority of time doing clinical work, teaching, and research, the prospect of fully understanding the plan seems like a full-time job.  The Vermont Medical Society, among others, has nicely put a copy of the actual proposal as well as other resources on the website.  In looking at it, I note that it takes the first 3 pages of the 44 page proposal just to explain the terms found in the rest of the document.

photo by napong and

photo by napong and

As a psychiatrist, I am very interested in the degree to which the plan could affect our mental health care system for better or for worse.  To that end, I share some specific thoughts about how an all-payer plan might, or might not, fundamentally change the way mental health care is delivered to Vermonters.

First, it seems clear that mental health is front and center in the all-payer plan.  Indeed, 2 of the 4 “population-based health outcomes targets,” which will be one of the main metrics by which the success of the new plan is judged, are directly related to mental health.  One of the targets is to reduce the rate of completed suicides in Vermont to 16 per 100,000 or reduce our national ranking in terms of suicide rate from 7th to at least 20th.   Another target is to reduce the number of substance-abuse related deaths by 10% compared to 2015 levels.  One could even argue that the other two targets that involve 1) keeping flat the prevalence of COPD, diabetes, and hypertension in Vermont, and 2) getting at least 89% of Vermonters paired up with a primary care provider also are closely aligned with mental health, given the increasing research demonstrating that early mental health is not only one of the strongest risk factors for future psychiatric disorders but also for non-psychiatric chronic diseases.

In many ways, it is extremely gratifying to see mental health being given the priority that many of us have felt for a long time it has always deserved.  Yet while the two goals of mortality reduction from suicide and substance abuse are critically important, I hope that we don’t go too far in “teaching to the test,” thereby de-emphasizing many other important mental health initiatives.

Another important point has to do with the implications of doing away with the traditional fee-for-service model of care.  The more that I think about it, the bigger the potential consequences of this change seem.  Psychiatrists will continue to be a scarce resource, and where their time is maximally allocated should be carefully considered.  It might be easy to simply have us continue to go on doing the same thing the same way, but in my view, not at least considering the possibilities for change would be a huge wasted opportunity.

To be sure, I cherish my one-on-one time with children and their families and would be very disappointed to see that time lost to other things.  But I also see the incredible potential of mental health professionals to impact positively on the health of families in creative ways, once the yoke of fee-for-service is lifted.  We may want to consult more closely with primary care providers in their day to day care of Vermonters before they get psychiatrically ill.  We may want to increase our use of technology such as tele-medicine.  We may want to ramp up our use of group treatment relative to individual work.  We may want to work more closely in teams with other types of mental health professionals.  Even things like writing this blog could make a difference.  All of these kids of initiatives were very difficult to enact in a fee-for-service world but, because they can improve both overall mental health and save money, would now be squarely on the table for consideration.

The train is starting to move with us or without us, and we need to invest the effort to figure out where it is going.   There’s no doubt that the system is complicated, that the devil is in the details, and that the landscape ahead is full of both hazards and opportunities.  Ever the optimist, I for one will be trying to hold back my cynicism and look for creative solutions to old problems.


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