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The Affordable Care Act and Practice in Psychiatry

Michael H. Ebert, MD (Chair)

Department of Psychiatry, Yale School of Medicine, and the VA Connecticut Healthcare System, New Haven

Robert L. Findling, MD, MBA

Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, and the Kennedy Krieger Institute, Baltimore, Maryland

Alan J. Gelenberg, MD

Department of Psychiatry, Penn State Hershey Milton S. Hershey Medical Center, Hershey, Pennsylvania

John M. Kane, MD

Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks; the Department of Psychiatry, Hofstra North Shore-Long Island Jewish School of Medicine, Uniondale; and Behavior Health Services, North Shore-Long Island Jewish Health System, New Hyde Park, New York

Andrew A. Nierenberg, MD

Bipolar Clinic and Research Program, Depression Clinical and Research Program, and the Department of Psychiatry, Harvard Medical School and Massachusetts General Hospital, Boston

Pierre N. Tariot, MD

Banner Alzheimer's Institute, Alzheimer's Prevention Initiative, and the Department of Psychiatry, University of Arizona College of Medicine, Phoenix

The Affordable Care Act (ACA) is a health care law1 intended to improve access to health care coverage in the United States and introduce protections for people who have health insurance.2 Providers, patients, insurance companies, and government entities will all be affected. The ACA supports establishing national centers of excellence to treat depressive disorders, funding community mental health centers, and providing preventive care. As more Americans gain access to psychiatric treatment, clinicians must be prepared for the upcoming changes.3

A discussion by an expert panel of psychiatrists, chaired by Michael H. Ebert, MD, outlined how the ACA will affect the practice of psychiatry in areas related to integrated care, practitioners, technology, and research. For the complete discussion, see the Commentary “The Effects of the Affordable Care Act on the Practice of Psychiatry” published in the April 2013 issue of The Journal of Clinical Psychiatry.

Focus on Integrated Care

Dr Ebert: Mental health care can be improved through the ACA’s proposed or reinforced care delivery systems, such as community mental health centers with integrated primary and specialty care.3 Insurers have the option to set up collaborations between primary care and mental health care.

Although the VA is not directly impacted by the ACA, the VA has shown how the patient-centered medical home model can improve access to care and how chronic disease management can be facilitated through the coordinated efforts of PACTs.4 For example, a patient with posttraumatic stress disorder, chronic pain, and diabetes can receive care from a psychiatrist, a pain specialist, a rehabilitation therapist, and a primary care physician without having to coordinate the visits himself.5

Dr Tariot: The VA medical home model for integrated care is based on the examples of several care delivery systems, including that of the nonprofit health care organization Kaiser Permanente.4 Kaiser’s multispecialty health centers enable primary care doctors, nurses, specialists, and pharmacists to coordinate care, focus on prevention, and minimize hospital visits.

Dr Gelenberg: The ACA could hurt psychiatric care in some ways, particularly in caring for the chronically mentally ill, because many services that have been previously paid for by states are not regulated or paid for under the new legislation.6

Dr Tariot: Some evidence-based practices for treating severe and persistent mental disorders are not usually covered by health insurance.6

Changes for Practitioners

Dr Ebert: Although there will always be practitioners providing services for those who can pay out of pocket, solo practitioners will be rare in the new, integrated organizational structure if they want to be involved with an insurance network (AV 1).7 Concierge practices increased 30% from 2011 to 2012.8

AV 1. Recent Trends in Physician Search Assignments (00:27)

Data from Merritt Hawkins7

Dr Nierenberg: The future with the ACA is no more fee for service; by 2015, physicians will be paid by value rather than volume. Virtually all physicians are going to be employed. Specialists, like psychiatrists, will function more in a team setting, supervising less expensive personnel to take care of most of the health problems.

Dr Kane: A number of people of all ages will get insurance who did not have insurance before, including those who are mentally ill. The same number of physicians will soon serve more patients, making team care crucial. Specialists are going to move into consultative roles and stop keeping a stable of patients.

Applications for Technology

Dr Kane: To be able to help a larger number of patients, psychiatrists will need to make use, not only of the integrated team approach, but also of new technologies.9 Technology is going to create more efficiencies and better care access through the use of smart phones with apps for disease management and Web-based interventions and psychoeducation (AV 2).

AV 2. Technology Applications in Mental and Medical Health Care (01:19)

Proteus Biomedical retains the copyright for the photograph of the digital pill

Similarly, telemedicine gives clinicians the ability to communicate with patients via 2-way, in-home video, which reduces office visits. There are far fewer reasons for patients to go to a clinic or hospital these days, even with primary care, because physicians do not necessarily have to see them face to face.8

Dr Nierenberg: At MGH, a health information technology system provides support for treatment teams via EHR, patient tracking, and monitoring from home. An experiment between MGH and CMS was designed to improve the coordination of services for high-cost Medicare patients. The project demonstrated reduced costs and improved care, such as fewer emergency department visits, decreased annual mortality rates, and lower hospitalization rates.10

Dr Kane: Access to care and delivery of care are both big areas of change. Current medical students will have different training and practicing methods than we did.

Dr Gelenberg: However, psychiatry is taking an optimistic turn as it explores public health questions and works in tandem with primary care doctors.

More

Opportunities in Psychiatric Research

Dr Tariot: We will certainly have greater opportunities to do effectiveness research, outcomes research, and cost-effectiveness research because we will have larger pools of patients.

Dr Gelenberg: There may be a broader balance of payers for research besides the pharmaceutical companies, such as other agencies and the federal government.

Dr Nierenberg: Studying interventions for high-risk patients remains a problem.

Dr Findling: Getting an at-risk intervention protocol through an IRB review has been one of the most difficult things I have ever done. For some people, it is anathema to treat someone who does not yet have an illness; conversely, others cannot understand why you would want to do a controlled study in people who are at risk for developing a condition that could be prevented.

Dr Nierenberg: The kind of research that is going to be done will have endless resources available. As a result of the ACA and other legislation, the CMS Center for Innovation is investing heavily in the development and testing of new service delivery and payment models to find better, more cost-effective ways to take care of people. Pharmaceutical companies may conduct fewer drug studies and get involved in more partnerships with systems that are studying the effectiveness of care.

Dr Kane: Yes, I think we will have more focus on delivery systems, experiments in innovation, and partnering. New technology, like a chip in a pill to time-stamp when a patient swallows it, will facilitate monitoring. Companies are going to be linking their drug studies to these and other opportunities.

Dr Ebert: Companies are going to be thinking past the traditional “swallow a pill” model to more creative therapeutic concepts like new devices and nanotechnology. There will also be tremendous pressure on drug pricing, which is already happening in Germany and other western European countries.11 The efficacy of a new drug must justify the higher cost or else it will be assigned the same cost as a generic.

Dr Nierenberg: Cost-effectiveness requirements will make the payers (ie, insurers) the larger determiners of what comes from pharmaceutical companies.11

Dr Tariot: Occasionally, an agency will fund research, but it is currently hard to do studies in nonpharmacologic research, which leads to a lot of missed opportunities.

Conclusion

The ACA will affect many aspects of psychiatry and the care of patients with mental health disorders as more Americans gain access to health insurance. As health care shifts to community-based models, specialists and primary care physicians will work together in a collaborative environment to provide integrated care. Solo practices will be harder to maintain under the new legislation, and physician payment will be based on value rather than volume. Advances in technology and better care coordination will help physicians care for more patients, facilitate improved patient monitoring, and enable specialists to consult with other clinicians, caregivers, and patients in remote locations. Research into care delivery systems and preventive medicine will continue to advance. Clinicians face many decisions as the ACA continues to be implemented, but they can be ready for what lies ahead.

Clinical Points

  • Expect additional patients as more Americans receive health care insurance
  • Prepare to work in collaborative care teams that follow the patient-centered care model
  • Use technology to help patients in remote locations and reduce office visits

Abbreviations

ACA = Affordable Care Act, CMS = Centers for Medicare & Medicaid Services, EHR = electronic health record, IRB= institutional review board, MGH = Massachusetts General Hospital, PACT = patient-aligned care team, VA = Veterans Affairs

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References

  1. US Department of Health & Human Services. Key features of the Affordable Care Act, by year. http://www.healthcare.gov/law/timeline/full.html. Accessed May 6, 2013.
  2. American Psychiatric Association. Health Care Reform: A Primer for Psychiatrists: The Patient Protection and Affordable Care Act: Analysis and Commentary from APA Publications and the APA Department of Government Relations. Arlington, VA: American Psychiatric Association; 2012. http://www.appi.org/SiteCollectionDocuments/Journals/PSY/HealthCareReform.pdf. Accessed May 6, 2013.
  3. Moran M. Affordable Care Act has benefits for people with psychiatric illness. Psychiatr News. 2012;47(15):1a–27. http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=1284546. Accessed May 6, 2013.
  4. Klein S. The Veterans Health Administration: implementing patient-centered medical homes in the nation's largest integrated delivery system. http://www.commonwealthfund.org/Publications/Case-Studies/2011/Sep/VA-Medical-Homes.aspx. Published September 13, 2011. Accessed May 6, 2013.
  5. Khanal Y. In the VA system, the future of primary health care. Washington Post. November 30, 2012. http://www.washingtonpost.com/opinions/in-the-va-system-the-future-of-primary-health-care/2012/11/30/c10d5cf0-3b2e-11e2-8a97-363b0f9a0ab3_story.html. Accessed May 6, 2013.
  6. Goldman HH. Will health insurance reform in the United States help people with schizophrenia? Schizophr Bull. 2010;36(5):893–894. PubMed
  7. Merritt Hawkins. 2012 Review of Physician Recruiting Incentives: An Overview of the Salaries, Bonuses, and Other Incentives Customarily Used to Recruit Physicians. Irving, TX: Merritt Hawkins; 2012. http://www.ahaservicesinc.com/wp/wp-content/uploads/2012/07/mha2012incentivesurveyPDF.pdf. Accessed May 6, 2013.
  8. Leonard D. Is concierge medicine the future of health care? Businessweek. November 29, 2012. http://www.businessweek.com/articles/2012-11-29/is-concierge-medicine-the-future-of-health-care. Accessed May 6, 2013.
  9. Rubin EH, Zorumski CF. Perspective: upcoming paradigm shifts for psychiatry in clinical care, research, and education. Acad Med. 2012;87(3):261–265. PubMed
  10. Massachusetts General Hospital. Fact sheet-phase one: MGH Medicare demonstration project for high-cost beneficiaries. http://www.massgeneral.org/News/assets/pdf/CMS_project_phase1FactSheet.pdf. Accessed May 6, 2013.
  11. Stafford N. New drug pricing rules in Germany. http://www.rsc.org/chemistryworld/News/2010/November/18111002.asp. Published November 18, 2010. Accessed May 6, 2013.
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