The connection between behavioral health and physical health is well-documented. Physical health is greatly affected by such behaviors as smoking, substance abuse, poor diet, lack of exercise, insufficient sleep and more. In addition, mental health issues and social determinants of health, such as lack of housing or transportation, language barriers, and food insecurity, impact health.
Primary care physicians are well aware of these problems, but often are unable to do anything about them due to a lack of resources. These issues are particularly pronounced in underserved populations, such as rural Americans, for whom behavioral health support and services either are unavailable or not integrated with their primary care.
Lynn Carroll is COO and head of strategy at HSBlox, a value-based care administration, payments and invoicing, and communication and engagement technology and services company. Among his successful launches: enterprise systems for premium invoicing and collection, digital payments, patient financial engagement, prospective bundled payments, and value-based contract administration.
We interviewed Carroll to talk about the problems with physical healthcare and mental healthcare being so disconnected in the U.S., how the CMS’s voluntary ACO Primary Care Flex Model aims to help solve some of these problems, and what role healthcare information technology can play to help solve these challenges and fulfill the needs of the new CMS program.
Q. What are the problems with physical healthcare and mental healthcare being so disconnected in the U.S.?
A. Alignment between primary care physicians and services for mental health issues and substance use in the U.S. too often is poor or nonexistent. Low-revenue providers in rural areas, for example, may lack the funding necessary to integrate behavioral care with primary care. A shortage of qualified behavioral health professionals presents another integration barrier.
In addition, family physicians report being frustrated that patients seeking access to mental health or substance use treatment are unable to do so because they lack insurance or face other challenges related to social determinants of health, such as lack of transportation or language barriers.
When you combine lack of integrated services with SDOH-related access obstacles, the inevitable result is that adults from underserved rural populations receive mental health treatment less frequently than adults living in metropolitan areas. And when they can access treatment, it’s often from a provider who lacks specialized training. These are all health inequity issues, and we have to address them if we are to achieve better outcomes while lowering healthcare costs.
Q. How does the CMS’s voluntary ACO Primary Care Flex Model aim to help solve some of these problems?
A. The ACO PC Flex model provides an ideal framework for collaborative, team-based care across stakeholder entities, including primary care providers, clinical and behavioral health specialists, community-based organizations, and payers.
PC Flex, which launches on January 1, 2025, will address health equity for underserved populations by increasing access to higher-quality primary care. This care can include unique services, such as behavioral health integration.
Critically, the model’s new Prospective Primary Care Payment option shifts reimbursement for primary care away from fee-for-service, visit-based payment to value-based care models. CMS expects the PPCP option to appeal to many low-revenue rural ACOs and providers that could benefit from a flexible but predictable revenue stream and that seek tighter alignment between primary care providers and behavioral health services for their underserved patient populations.
PC Flex also incentivizes safety net providers, including Federally Qualified Health Centers and Rural Health Clinics, to either form or join ACOs. Overall, PC Flex is structured to ensure that more healthcare dollars reach underserved populations.
Q. What role can healthcare information technology play to help solve these challenges and fulfill the needs of the new CMS program?
A. The right healthcare information technology enables alignment between primary care providers and specialists. The wrong technology does the opposite: it makes alignment difficult or impossible.
Unfortunately, many provider organizations still rely on outdated or insufficient digital infrastructures that can’t support data exchange or transactions across a network of stakeholders. This network may include behavioral health providers and CBOs, many of which have low digital capabilities but expect frictionless reimbursement.
Overcoming this technology barrier requires implementation of a scalable, cloud-based digital infrastructure that enables a many-to-many network of participants. Further, a robust analytics platform running on top of a digital infrastructure can provide transparency into performance, essential to ensure the success of VBC contracts.
To fulfill CMS’s goal of rewarding collaborative, team-based care across primary care providers, clinical and behavioral health specialists, CBOs, and payers, care organizations need a scalable digital infrastructure that can handle the demands of a collaborative care network. Effectively supported, these networks can produce better outcomes for their patient populations while optimizing efficiency and financial performance.
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Email him: bsiwicki@himss.org
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