The Affordable Care Act launched a decade of focus on the move to value-based care, the promise of quality over quantity and a redesigned payment system.
At the center of this has been the primary care doctor and ACOs—the quarterback of the patient experience and the holder of risk, respectively. In a fee-for-service world, which continues to prevail as the predominant methodology for payment, providers are paid for every service provided, regardless of patient outcomes.
Critical components of positive health outcomes are often not reimbursable—for example, ensuring a person has adequate housing, food and community—while components that don’t lead to positive outcomes, like excessive drug screening and testing, are. Primary care doctors, like other clinicians in the system, have to focus on providing services for which they can get paid—often missing opportunities that would drive additional, positive outcomes.
The spirit of value-based care was to change this and focus on quality over quantity. In an ideal value-based world, the primary care doctor has time to build a trusted relationship with each patient, supporting most of her needs, screening for all mental and physical health issues, and coordinating with specialists when necessary. In the real world, there’s a shortage of primary care doctors who are overburdened, lacking the time and resources to spend adequate time to build trusted relationships and a growing belief that individuals shouldn’t have to wait six weeks or more for an appointment.
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In fact, despite the increased focus on primary care as the center, a study published Dec 16, 2019, in JAMA Internal Medicine found that between 2002 and 2015, the percent of Americans with a primary care provider declined 2%. The declines were most pronounced among people under 60. For Americans in their 30s, for example, the figure dropped from 71% to 64%. The reasons for this shift are not discussed in the study, but many potential reasons exist: lack of access, focus on convenience and self-referrals to specialists, among many others. Additionally, people with medical needs requiring specialists are likely engaging with the healthcare system in different ways, building relationships outside primary care.
Value-based care works best when trusted relationships are built, particularly with those who are the most complex with chronic conditions, limited resources and other co-occurring mental and physical health conditions. These are also often the people who have been underserved and marginalized by our healthcare ecosystem and innovation economy. Chronic conditions are defined as medical illnesses which last one or more years and require ongoing medical attention or limit activities of daily living or both. Often, people with a chronic condition have multiple comorbidities, leading to more complexity and the need for personalized treatment, usually delivered by multiple providers and specialists. These individuals are often poorly served by primary care doctors who, despite best efforts, lack the adequate time, resources and specialization to treat these patients effectively.
For most people who are relatively healthy or have well-managed chronic conditions, primary care is the right home, when designed with the right systems, multidisciplinary teams and attention to nonclinical needs like housing, food insecurity and other needs. But for others, trusted relationships are built elsewhere, by specialists and other patient-centered groups. For example, people who have mental health conditions, including SUD and SMI, relationships are developed with mental health practitioners including therapists, psychiatrists and peer recovery specialists. Given the intensity of treatment and the chronic nature of these conditions, the relationship is both frequent and longitudinal, opportune for building trusted relationships and further enhancing and coordinating care. The primary care clinician remains a partner, but is often not fully engaged, equipped to treat or able to spend the necessary time to care for these individuals.
This concept, the specialty medical home model, focuses on patient populations that have similar clinical needs rather than PCP-based models and ACOs which have patients with broad clinical needs. In this model, it’s the specialist who treats the primary diagnosis and is the patient’s main point of contact with the healthcare system, and hence, best suited to own the risk. This model has shown promise and there’s opportunity to expand its adoption, particularly to individuals with mental health and substance use disorders, who historically have been poorly served by our healthcare system.
People with SUD frequently have co-occurring psychiatric conditions as well as physical comorbidities.
They use four to five times the healthcare resources of the average patient and have the added challenge of needing to navigate a healthcare system that has historically separated care for the brain from care for the body. Like other Medical Home models, the patient is at the center, with a multidisciplinary team focused on coordinating and managing the health of the patient. Unlike most Medical Home models, the primary care team is not the key relationship; the mental health care team is. The trusted relationship is built with a therapist, peer/coach, psychiatrist, nurse care manager or prescribing clinician—a team specialized in treating the predominant needs of the patient, identifying and coordinating with other medical professionals for health needs outside their scope.
The concept of a specialty or mental health medical home recognizes that patient relationships are often developed with those who have the strongest understanding of specific patient cohort clinical needs. While the concept is not entirely new and has been cited as an alternative to the PCP-based PCMH and ACO models for individuals with chronic conditions, most of these have focused on medical chronic conditions like diabetes and kidney disease and not mental and behavioral health chronic conditions like SPMI and SUD. We encourage others to embrace this concept as we look to improve health and actualize new models of care delivery and payment.
Corbin Petro is the CEO and co-founder of Eleanor Health, a mental health medical home specializing in addressing the unique and comprehensive needs of individuals with substance use disorder.