Families, Systems, & Health 2014, Vol. 32, No. 2, 145–146
© 2014 American Psychological Association 1091-7527/14/$12.00 http://dx.doi.org/10.1037/fsh0000043
COMMENTARY
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Collaborative Family Healthcare Association Commentary on the “Joint Principles: Integrating Behavioral Health Care Into the Patient-Centered Medical Home” Christine Runyan, PhD
Parinda Khatri, PhD
University of Massachusetts Medical School
Cherokee Health Systems, Knoxville, Tennessee
The Collaborative Family Healthcare Association (CFHA) welcomes the opportunity to comment on the complementary set of Joint Principles underscoring the Integration of Behavioral Health Care Into the Patient-Centered Medical Home (The Working Party Group on Integrated Behavioral Healthcare et al., 2014). CFHA is an organization that promotes comprehensive and cost-effective models of health care delivery that integrate mind and body, individual and family, patients, providers, and communities. CFHA appreciates that the Joint Principles do not explicitly endorse any single model of collaboration between behavioral health and medical practice. Rather, they broadly emphasize integration, affirming the only way to have a whole person orientation is to adopt a biopsychosocial-spiritual perspective. This commentary will highlight areas of notable strength within the Joint Principles, as well as challenge the language, if not perspective, on a few critical elements. Keywords: Collaborative Family Healthcare Association, Patient Centered Medical Home
CFHA offers strong support for the positions: (a) the separation of behavioral health and primary care promulgates costly fragmentation of care; and (b) effective integrated care needs to occur across multiple parameters including shared medical records, registries, revenue streams, training, responsibility for patient care plans, and risk for outcomes. Financing health care under divided fee-forservice models propagates all downstream fragmentation and has been the principal barrier to seamlessly integrating behavioral health care into the PCMH. The Joint Principles advocate
Christine Runyan, PhD, Department of Family Medicine, University of Massachusetts Medical School; Parinda Khatri, PhD, Cherokee Health Systems, Knoxville, Tennessee. Special thanks to the Board of Directors of the Collaborative Family Healthcare Association for their review and input of this commentary. Correspondence concerning this article should be addressed to Parinda Khatri, PhD, Cherokee Health Systems, 2018 Western Avenue, Knoxville, TN 37921. E-mail: [email protected]
for pooled and flexibly applied funding streams. One frequently proposed payment model includes per-member per-month (PMPM) bundled payments for medical homes to include behavioral health/substance misuse screening and early intervention, as well as team-based care coordination. No further evidence is needed to conclude behavioral health care carve-outs and fee-for-service funding create strong disincentives to care for people in whom behavioral, emotional, and physical symptoms refuse to adhere to biomedical doctrines (Melek, 2012; Blount et al., 2007). The Department of Defense Military Health System is leading the way on this front with fully integrated funding for full-time PCMH behavioral health providers (Hunter & Goodie, 2012). Another innovative example is Massachusetts’ Medicaid Primary Care Payment Reform (PRPC), which uses a PMPM and shared risk/savings model to care for the medical and behavioral health needs of this vulnerable population within the PCMH (see www.nashp.org for an overview of Massachusetts’ Primary Care Payment Reform Initiative). Currently, the predominant payment mod-
145
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
146
RUNYAN AND KHATRI
els across the country are organized around reimbursement systems (e.g., fee for service) that reinforce fragmented care. Consequently, the philosophy of funding health care “piece by piece” has prevented the necessary paradigm shift toward global financing strategies that would more effectively support fully integrated primary care behavioral health services. CFHA is in full support of unified/integrated funding for PCMH behavioral health services and has a policy agenda to inform Federal and State policy to that end. Integrated care must also penetrate into all operational layers, including shared medical records, registries, training, responsibility for patient care plans, and shared risk for outcomes. Accomplishing this demands consensus on the pertinent process and outcome measures to evaluate integrated behavioral health services. The Joint Principles aptly call for more “research to better define the optimal provision of whole person health services in the PCMH, with attention to patient, practice, training and financing issues.” CFHA fully endorses this and is well positioned to lead empirical advancements on defining meaningful process and outcome metrics. With respect to promoting a skilled workforce to provide integrated care, CFHA envisions seamless collaboration between psychosocial, biomedical, nursing, and other health care providers. CFHA provides a platform to help restructure and strengthen our health care training environments to produce providers across disciplines who are familiar and experienced with team-based care and appreciate each other’s education, training, talents, and roles. There are two areas in which CFHA feels compelled to highlight where the Joint Principles fall short on the strength of their advocacy. First, the Joint Principles could underscore further the vital role of the family in a PCMH. CFHA’s central tenant is that clinical events always occur at biological, psychological, social, and spiritual levels, and that patient, family, and community are integrated elements of a single ecosystem. A greater recognition of the incalculable influence of the family (as defined by the patient) on a patient’s health status and care would add depth and breadth to the Joint
Principles. Second, the supposition of a physician-led health care team proposes an overly narrow model. Integrated health care systems should appreciate the patient as the functional ‘team lead’ and encourage flexibility for any member of the team, including the family, to interchangeably take a lead role depending on the circumstance. In sum, the Joint Principles do an exceptional job at fostering a health care delivery model that integrates mind and body. Still, the language implies that we are bringing together two distinct and separate entities. It is all one. When patients experience the health care system as unified and integrated across disciplines, mind– body dualism can cease to exist in both form and function. References Blount, A., Schoenbaum, M., Kathol, R., Rollman, B., Thomas, M., O’Donohue, W., & Peek, C. J. (2007). The economics of behavioral health services in medical settings: A summary of the evidence. Professional Psychology: Research and Practice, 38, 290 –297. doi:10.1037/0735-7028.38 .3.290 Hunter, C. L., & Goodie, J. L. (2012). Behavioral health in the department of defense patientcentered medical home: History, finance, policy, work force development and evaluation. Translational Behavioral Medicine, 2, 355–363. doi: 10.1007/s13142-012-0142-7 Melek, S. (2012). Bending the Medicaid healthcare cost curve through financially sustainable medical-behavioral integration. Milliman Research Report. Retrieved from http://publications.milliman.com/publications/ health-published/pdfs/bending-medicaid-cost-curve.pdf Primary Care Patient Reform Initiative overview. Retrieved from http://nashp.org/med-home-states/ massachusetts The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . deGruy, F. (2014). Joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm .1633 Received February 25, 2014 Revision received March 7, 2014 Accepted March 11, 2014 䡲
© 2014 American Psychological Association 1091-7527/14/$12.00 http://dx.doi.org/10.1037/fsh0000043
COMMENTARY
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Collaborative Family Healthcare Association Commentary on the “Joint Principles: Integrating Behavioral Health Care Into the Patient-Centered Medical Home” Christine Runyan, PhD
Parinda Khatri, PhD
University of Massachusetts Medical School
Cherokee Health Systems, Knoxville, Tennessee
The Collaborative Family Healthcare Association (CFHA) welcomes the opportunity to comment on the complementary set of Joint Principles underscoring the Integration of Behavioral Health Care Into the Patient-Centered Medical Home (The Working Party Group on Integrated Behavioral Healthcare et al., 2014). CFHA is an organization that promotes comprehensive and cost-effective models of health care delivery that integrate mind and body, individual and family, patients, providers, and communities. CFHA appreciates that the Joint Principles do not explicitly endorse any single model of collaboration between behavioral health and medical practice. Rather, they broadly emphasize integration, affirming the only way to have a whole person orientation is to adopt a biopsychosocial-spiritual perspective. This commentary will highlight areas of notable strength within the Joint Principles, as well as challenge the language, if not perspective, on a few critical elements. Keywords: Collaborative Family Healthcare Association, Patient Centered Medical Home
CFHA offers strong support for the positions: (a) the separation of behavioral health and primary care promulgates costly fragmentation of care; and (b) effective integrated care needs to occur across multiple parameters including shared medical records, registries, revenue streams, training, responsibility for patient care plans, and risk for outcomes. Financing health care under divided fee-forservice models propagates all downstream fragmentation and has been the principal barrier to seamlessly integrating behavioral health care into the PCMH. The Joint Principles advocate
Christine Runyan, PhD, Department of Family Medicine, University of Massachusetts Medical School; Parinda Khatri, PhD, Cherokee Health Systems, Knoxville, Tennessee. Special thanks to the Board of Directors of the Collaborative Family Healthcare Association for their review and input of this commentary. Correspondence concerning this article should be addressed to Parinda Khatri, PhD, Cherokee Health Systems, 2018 Western Avenue, Knoxville, TN 37921. E-mail: [email protected]
for pooled and flexibly applied funding streams. One frequently proposed payment model includes per-member per-month (PMPM) bundled payments for medical homes to include behavioral health/substance misuse screening and early intervention, as well as team-based care coordination. No further evidence is needed to conclude behavioral health care carve-outs and fee-for-service funding create strong disincentives to care for people in whom behavioral, emotional, and physical symptoms refuse to adhere to biomedical doctrines (Melek, 2012; Blount et al., 2007). The Department of Defense Military Health System is leading the way on this front with fully integrated funding for full-time PCMH behavioral health providers (Hunter & Goodie, 2012). Another innovative example is Massachusetts’ Medicaid Primary Care Payment Reform (PRPC), which uses a PMPM and shared risk/savings model to care for the medical and behavioral health needs of this vulnerable population within the PCMH (see www.nashp.org for an overview of Massachusetts’ Primary Care Payment Reform Initiative). Currently, the predominant payment mod-
145
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
146
RUNYAN AND KHATRI
els across the country are organized around reimbursement systems (e.g., fee for service) that reinforce fragmented care. Consequently, the philosophy of funding health care “piece by piece” has prevented the necessary paradigm shift toward global financing strategies that would more effectively support fully integrated primary care behavioral health services. CFHA is in full support of unified/integrated funding for PCMH behavioral health services and has a policy agenda to inform Federal and State policy to that end. Integrated care must also penetrate into all operational layers, including shared medical records, registries, training, responsibility for patient care plans, and shared risk for outcomes. Accomplishing this demands consensus on the pertinent process and outcome measures to evaluate integrated behavioral health services. The Joint Principles aptly call for more “research to better define the optimal provision of whole person health services in the PCMH, with attention to patient, practice, training and financing issues.” CFHA fully endorses this and is well positioned to lead empirical advancements on defining meaningful process and outcome metrics. With respect to promoting a skilled workforce to provide integrated care, CFHA envisions seamless collaboration between psychosocial, biomedical, nursing, and other health care providers. CFHA provides a platform to help restructure and strengthen our health care training environments to produce providers across disciplines who are familiar and experienced with team-based care and appreciate each other’s education, training, talents, and roles. There are two areas in which CFHA feels compelled to highlight where the Joint Principles fall short on the strength of their advocacy. First, the Joint Principles could underscore further the vital role of the family in a PCMH. CFHA’s central tenant is that clinical events always occur at biological, psychological, social, and spiritual levels, and that patient, family, and community are integrated elements of a single ecosystem. A greater recognition of the incalculable influence of the family (as defined by the patient) on a patient’s health status and care would add depth and breadth to the Joint
Principles. Second, the supposition of a physician-led health care team proposes an overly narrow model. Integrated health care systems should appreciate the patient as the functional ‘team lead’ and encourage flexibility for any member of the team, including the family, to interchangeably take a lead role depending on the circumstance. In sum, the Joint Principles do an exceptional job at fostering a health care delivery model that integrates mind and body. Still, the language implies that we are bringing together two distinct and separate entities. It is all one. When patients experience the health care system as unified and integrated across disciplines, mind– body dualism can cease to exist in both form and function. References Blount, A., Schoenbaum, M., Kathol, R., Rollman, B., Thomas, M., O’Donohue, W., & Peek, C. J. (2007). The economics of behavioral health services in medical settings: A summary of the evidence. Professional Psychology: Research and Practice, 38, 290 –297. doi:10.1037/0735-7028.38 .3.290 Hunter, C. L., & Goodie, J. L. (2012). Behavioral health in the department of defense patientcentered medical home: History, finance, policy, work force development and evaluation. Translational Behavioral Medicine, 2, 355–363. doi: 10.1007/s13142-012-0142-7 Melek, S. (2012). Bending the Medicaid healthcare cost curve through financially sustainable medical-behavioral integration. Milliman Research Report. Retrieved from http://publications.milliman.com/publications/ health-published/pdfs/bending-medicaid-cost-curve.pdf Primary Care Patient Reform Initiative overview. Retrieved from http://nashp.org/med-home-states/ massachusetts The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . deGruy, F. (2014). Joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm .1633 Received February 25, 2014 Revision received March 7, 2014 Accepted March 11, 2014 䡲
