By Joseph P. Kennedy III
January 11, 2016
GLOBAL PAYMENT systems are the way of the future in health care reimbursement. They compensate doctors and hospitals based on how well their patients do, instead of for the number of tests and procedures they order. Although the model is still relatively new, nearly four in 10 Massachusetts residents with private health insurance already are enrolled in some kind of global, or “alternative,” payment plan.
The systems — which typically involve giving providers a set budget per patient — have demonstrated the potential to improve patients’ health while keeping spending in check. Unfortunately, there hasn’t been enough attention paid to whether they are making a difference in how behavioral and mental health conditions are treated, despite recognition that the integration of physical and mental care is critical to overall well-being.
A 2008 federal law mandates that insurance companies cover mental and behavioral health conditions no differently than they reimburse for physical ailments, but US Representative Joseph Kennedy III and many others complain that insurers regularly deny or limit coverage for conditions such as depression or drug addiction. Kennedy, a Massachusetts Democrat, last month introduced legislation that would force insurers to publicly report and explain those kinds of claim denials.
The hope is that global payments are providing incentives for insurers and providers to finally raze the longstanding wall between mental and physical health care, since reimbursements are based on patient outcomes. Potential benefits are obvious — people suffering from both diabetes and depression, for example, would be more likely to consult a doctor for diabetes treatment if their mental outlook improved. Conversely, depression might ebb in patients who keep their diabetes under control.
A recent study, however, found that global payment systems haven’t yet helped to further a large-scale holistic approach to health care. The Harvard Medical School report, published in the journal Health Affairs, looked at the Alternative Quality Contract, a system Blue Cross Blue Shield of Massachusetts established in 2009. Haiden Huskamp, a professor of health care policy at Harvard Medical School and one of the study’s authors, said researchers didn’t find evidence that people with mental illnesses or other behavioral problems did better because their health care providers received global budgets instead of fee-for-service payments. That could partly be because the claims data examined were a few years old, she said, and there have been signs of late that global payments are starting to lead to integration of services.
Some steps toward coordination are not complicated, like having primary care doctors conduct depression screenings. But getting physicians and therapists to work more closely with each other still presents significant challenges, ranging from cultural to legal to logistical. “One thing everyone agrees on,” Huskamp said, “is this isn’t easy.”
Dana Gelb Safran, a senior vice president at Blue Cross who oversees performance and improvement, said she believes insurers and providers are becoming more receptive to treatment approaches like art therapy and resilience training that were formerly considered out of the mainstream. Finding more ways to quantify the impact of therapy also will make a difference. Blue Cross’s Alternative Quality Contract pays doctors if they score well in certain categories, but as of last year, only two of 64 measures applied to behavioral health.
For global payment systems to truly succeed — which means healthier patients for less money — they must make the coordination of mind-and-body care routine.