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Abstract

Objective:

This study sought to describe the extent to which psychiatrists, prior to insurance expansions under the Affordable Care Act (ACA), reported currently participating or being likely to participate in integrated services delivery models, to assume new roles, to accept new reimbursement structures, and to use electronic health records (EHRs).

Methods:

A cross-sectional probability survey of U.S. psychiatrists was fielded from September to December 2013. In total, 2,800 psychiatrists were randomly selected from the AMA Physician Masterfile, and 45% responded. Of these, 93% (N=1,099) reported treating patients, forming the sample.

Results:

Overall, 29% reported practicing in new ACA or integrated models, and 64% reported assuming at least one new role. Forty-two percent reported currently receiving a salary; other capitated and risk-based reimbursement was rarely used. Half (53%) reported current use of EHRs for clinical functions not limited to billing or practice management; only 21% reported participating in the Medicare or Medicaid EHR Incentive Program. Those who reported currently practicing or being very likely to practice in primary care or integrated treatment settings, to assume at least one ACA role, to receive a salary, or to use an EHR were younger and more racially-ethnically diverse and more likely to see Medicaid and public outpatient clinic patients

Conclusions:

Although substantial proportions of psychiatrists reported current practice in ACA services delivery models and ACA roles, the findings highlight opportunities for workforce development, training, and technical assistance to strengthen participation in these activities. The findings also underscore the need to prepare psychiatrists for merit-based payment reforms and use of EHRs.
The Affordable Care Act (ACA) holds great promise in markedly improving access to mental health and substance use treatment. More than 50 million Americans have obtained mental health coverage since its passage (1,2). The ACA seeks to significantly improve the quality and efficiency of health care delivery for millions of Americans and to have an impact on overall health outcomes for individuals who have mental and addictive illnesses (3,4). New integrated services delivery systems, payment reforms, and health information technologies are three fundamental ACA components designed to address fragmentation of services delivery, improve overall quality and efficiency of care, and reduce costs.
The ACA’s triple aim of improving health, improving health care delivery, and lowering costs (5) requires a paradigm shift in health care systems. These reforms in delivery systems offer the potential to improve care through new integrated delivery models and innovations (6), including patient-centered medical homes or health homes, which seek to provide comprehensive, accessible, patient-centered, coordinated care; and accountable care organizations (ACOs), which assume responsibility for the cost, quality, and outcomes of health care for a defined group of patients (7,8).
Central to this paradigm shift is the expectation that psychiatrists will assume new roles within the reforming health care system, moving from solo and small group practice settings to become central figures in the ACA's new integrated, collaborative care services delivery models. Within these new frameworks, psychiatrists may be members of a team-based service delivery model, supervise team delivery of psychiatric and general medical care, provide general medical care to psychiatric patients, or assume other roles beyond that of a solo practitioner (9).
New health care services delivery frameworks and expanded roles for psychiatrists also require consideration and implementation of new payment models that ensure delivery of high-quality patient care at lower costs and reward quality rather than quantity of services (1014). Achieving the ACA’s triple aim also calls for taking advantage of health information technologies, such as electronic health records (EHRs) and telemedicine. The American Recovery and Reinvestment Act (ARRA) of 2009 included more than $26 billion in funding for physician adoption of EHRs (15) to facilitate care coordination and sharing of information, provide decision support to promote evidence-based treatment and performance monitoring, and reduce inappropriate service use (1618).
The extent to which the nation’s health care systems and clinical workforce will be able to change to meet the expected increase in demand for services—particularly for individuals with mental and substance use disorders—is unclear. Consequently, this study aimed to describe the extent to which psychiatrists, prior to the ACA’s Medicaid and health insurance exchange expansions, reported that they were currently participating or likely to participate in various integrated care services delivery models, to assume new provider roles, to accept new reimbursement structures, and to use EHRs for clinical functions.

Methods

This study used data collected from a large probability sample of U.S. psychiatrists who took part in the Study of Psychiatric Practice Under Health Care Reform, which was fielded in the fall of 2013. A total of 2,800 physicians in the United States who self-identified as psychiatrists and listed direct patient care as their type of practice were randomly selected from the September 2013 release of the AMA Physician Masterfile. The sampling frame excluded residents and those selected in the past 24 months to participate in surveys. Those who had undeliverable addresses, were deceased, or were incorrectly identified as a psychiatrist (N=185) were excluded. Of the remaining 2,615 individuals who were invited to participate, 1,188 (45%) responded. Of these, 93% (N=1,099) reported currently practicing psychiatry and treating psychiatric patients and provided the sample for this study.
A four-page data collection instrument was mailed to the target sample with a $50 gift card to increase response. Three survey mailings were implemented at one-month intervals, followed by reminder postcards. All study procedures were approved by the American Psychiatric Association Foundation Institutional Review Board.
Weighted analyses were conducted using SUDAAN, 11.0.1, statistical software (19). The weights adjusted for the sample design, nonresponse, and physician caseload size to provide estimates that could be generalized to the target population of practicing psychiatrists in the United States. Chi-square tests for categorical variables and Student’s t tests for continuous variables were used to examine the associations between physicians’ characteristics, practice setting types, and sources of payment with the health care reform receptivity measures (that is, participate in various integrated care services delivery models, assume new provider roles, accept new reimbursement structures, and use EHRs for clinical functions).

Results

Sample Characteristics

Most participants were male (65%) and non-Hispanic white (82%) (Table 1). The most common setting for treating patients was solo office practice settings (34% of psychiatrists’ patients), followed by outpatient public clinics (18%) and group office practice settings (20%). The primary sources of payment for psychiatrists’ services were private commercial insurance (30% of psychiatrists’ patients), self-pay (22%), Medicaid (18%), and Medicare (14%).
TABLE 1. Characteristics of 1,099 psychiatrists
CharacteristicN%95% CICharacteristicN% of patients95% CI
Age (mean)1,097a56.756.0–57.4Practice setting (%)1,074a  
Gender    Solo office practice3613433.9–39.4
 Male7116562.0–67.8 Outpatient clinic in a public hospital or freestanding facility1921815.5–19.7
 Female3873532.2–38.0 Group office practice2142014.2–18.4
Race-ethnicity    Outpatient clinic in a private hospital or freestanding facility8075.4–8.1
 White, non-Hispanic7768279.6–84.6 Inpatient unit in a public hospital (includes partial hospitalization)6065.3–8.0
 Asian7686.6–10.2 Inpatient unit in a private hospital (includes partial hospitalization)5554.1–6.3
 Hispanic4153.4–6.2 Otherb112109.2–12.6
 Black, non-Hispanic4043.2–5.9Main source of patient payment (%)1,076a  
 Other61.3–1.4 Private or commercial insurance (includes managed and nonmanaged, excluding all categories below)3173026.0–29.7
Region    Self-payc2392223.3–27.5
 West2592421.1–26.3 Medicaid or CHIP/SCHIP (including Medicaid HMOs)d1891815.4–18.6
 South2392421.1–26.3Medicare (including Medicare HMOs)1551411.5–13.7
 Northeast2572018.2–22.8 Other government or publice1171110.1–13.5
 Midwest2001715.3–19.7 No charge or uncompensated2321.8–2.7
 Mid-Atlantic1441512.9–17.5 Otherf141.8–1.6
Primary psychiatry specialty    Don’t know2321.2–2.8
 General8297572.6–77.9    
 Child and adolescent2342119.0–24.0    
 Psychoanalysis141.3–.7    
 Addiction101.5–1.8    
 Forensic91.5–1.9    
Clinician workload in most recent typical work week       
 N of patients treated (mean)1,080a45.343.2–47.5    
 N of hours providing direct patient care (mean)1,076a34.333.4–35.2    
a
Total N of respondents
b
Includes nursing homes, correctional facilities, assertive community treatment, among others
c
For 34.7% of self-pay patients, psychiatrists reported that the patient received a receipt or bill for services for the patient to submit directly to an insurance company or health plan for reimbursement.
d
CHIP, Children's Health Insurance Program; SCHIP, State Children's Health Insurance Program; HMOs, health maintenance organizations
e
Department of Veterans Affairs, Tricare, state or local funding, among others
f
Includes workers’ compensation, among others

Health Care Reform Roles

Most psychiatrists (64%) reported currently assuming at least one of the roles identified as being integral to the successful ACA implementation of health care reform; an additional 14% reported being likely or very likely to assume at least one of these roles beginning January 1, 2014. Most commonly, psychiatrists reported currently practicing as a member of a team service delivery model (42%); providing ongoing mental health treatment for a caseload of patients with more severe mental illness, coordinating with a primary care clinician (41%); providing consultation to primary care and mental health clinicians caring for psychiatric patients with diagnostic or therapeutic challenges (39%); or providing leadership and supervision for team delivery of psychiatric and general medical care for psychiatric patients (33%) (Table 2). Less commonly, psychiatrists reported that they currently oversee, track, and review care for psychiatric patients by working with practice leadership to ensure that services are available, appropriate, and well managed (21%) or that they currently provide general medical care to psychiatric patients (16%).
TABLE 2. Responses of 1,099 psychiatrists to survey questions about their readiness for and receptivity to reforms under the Affordable Care Act
Question and response optionsCurrently do thisLikely or very likely to do thisNeutral or not at all likely to do thisDon’t know or missing data
N%95% CIN%95% CIN%95% CIN%95% CI
Beginning January 1, 2014, when major health care reforms are implemented, how likely are you to work in a health care delivery system to do the following?            
 Practice as a member of a team service delivery model, working with other providers to provide needed care and services4604238.7–44.79497.1–10.54564138.5–44.48986.8–10.2
 Provide ongoing mental health treatment for a caseload of patients with more severe mental illness than those in my current caseload, coordinating with a primary care clinician4594138.4–44.37075.2–8.24914541.7–47.77975.9–9.1
 Provide consultation to primary care and mental health clinicians caring for psychiatric patients who have diagnostic or therapeutic challenges4383936.5–42.41501411.8–16.04243935.9–41.78786.6–9.9
 Provide leadership and supervision for team delivery of psychiatric and general medical care for psychiatric patients3693330.3–36.09697.4–11.05344945.5–51.610097.7–11.3
 Oversee, track, and review care for psychiatric patients, working with practice leadership to ensure services are available, appropriate, and well managed2252118.2–23.110097.6–11.26255753.6–59.61491411.7–15.8
 Provide general medical care to psychiatric patients (for example, screening and routine preventive care)1741613.7–18.13842.7–5.18067370.4–75.78176.0–9.2
Beginning January 1, 2014, when major health care reforms are implemented, how likely are you to provide services in the following settings?            
 Integrated treatment settings with specialty mental health and primary care services colocated and integrated2071816.3–20.99286.9–10.36886359.8–65.6112108.7–12.4
 Primary care treatment settings1591512.5–16.85954.1–6.87657066.9–72.5116108.8–12.4
 Patient-centered medical or health homes that provide patient-centered, comprehensive, team-based, coordinated care for Medicaid patients9186.6–10.08175.9–9.07596966.4–71.91681513.3–17.7
 Accountable care organizations, which are integrated delivery systems that assume responsibility for the cost, quality, and outcomes of health care5753.9–6.67575.4–8.47286663.3–69.12392219.5–24.5
Beginning January 1, 2014, when major health care reforms are implemented, how likely are you to participate in contracts with insurers, health plans, hospitals, or physician group or practice associations where you would be any of the following?            
 Salaried4694239.0–45.04643.3–5.95084743.6–49.67675.7–8.8
 Reimbursed fee for service with a potential financial bonus, receiving a financial bonus for containing costs and meeting quality standards4242.7–5.16064.4–7.28177471.6–76.91801614.3–18.7
 Reimbursed fee for service with a potential financial bonus or penalty, receiving a bonus for containing costs and meeting quality standards while also sharing financial risk (penalty) if costs exceed targets162.9–2.63332.1–4.28597875.6–80.61911715.2–19.7
 Capitated or paid a per-member per-month case rate151.8–2.42621.6–3.48788077.4–82.21801614.3–18.7
 Partially capitated with payment partially fee for service and partially a capitated or fixed amount131.7–2.02121.3–3.18617875.7–80.72041916.3–21.0
The mean number of health care reform roles psychiatrists reported assuming currently was 1.9 (95% confidence interval=1.8–2.0), with 15% currently assuming one role, 14% currently assuming two, and 36% currently assuming three or more.

Integrated Services Delivery Systems

Nearly one-third of the psychiatrists (29%) reported they currently practice in at least one integrated treatment setting, with an additional 13% reporting they would be likely or very likely to do so beginning January 1, 2014. Eighteen percent of psychiatrists reported currently working in an integrated treatment setting with colocated and integrated specialty mental health and primary care services; and 15% reported currently working in a primary care treatment setting (Table 2). Smaller percentages of psychiatrists reported currently practicing in patient-centered health homes (8%) or ACOs (5%). Most psychiatrists practicing in integrated treatment settings reported practicing in only one (17% of respondents); fewer reported practicing in two (7%) or three or more (5%) integrated settings.

Payment Reforms

A substantial proportion of psychiatrists reported currently receiving at least some reimbursement in the form of salary (42% of psychiatrists); an additional 4% reported that they would be likely or very likely to receive salary reimbursement beginning January 1, 2014 (Table 2). The other ACA physician payment reform mechanisms were rarely reported. Only 4% of psychiatrists reported current fee-for-service reimbursement with a potential financial bonus for containing costs and meeting quality standards; an additional 6% reported that they would be likely or very likely to participate in contracts with this type of payment beginning January 1, 2014. Even fewer psychiatrists reported currently receiving or being likely or very likely to receive the other capitated or at-risk payment mechanisms.

EHRs

Approximately half the psychiatrists (53%) reported currently using any form of EHR for clinical functions not limited to billing or practice management (Table 3). An additional 8% reported that they planned to use an EHR within the next year, and an additional 4% reported that they planned to use an EHR in more than one year. Nearly a quarter of psychiatrists (24%) reported that they did not plan to use an EHR, and 11% were uncertain about when they would use an EHR.
TABLE 3. Responses of 1,099 psychiatrists to survey questions about their readiness and receptivity to use electronic health records (EHRs)
QuestionN%95% CI
Please indicate your current use of EHRs or electronic medical records for clinical functions not limited to billing or practice management   
 Currently use5795349.9–55.9
 Plan on using within the next year9286.7–10.0
 Plan on using in more than 1 year4542.9–5.3
 Uncertain about using122119.3–13.1
 Do not plan on using2572421.3–26.5
Please indicate your participation in the Medicare or Medicaid EHR Incentive Program   
 Currently participate2282118.3–23.2
 Plan on participating5964.4–7.3
 Uncertain whether I will participate2782522.8–28.0
 Do not plan on participating in either program5234945.7–51.8
If you are uncertain about participating in the Medicare or Medicaid EHR Incentive Program, please indicate why you are uncertain   
 Uncertain whether I treat enough Medicare or Medicaid patients451511.3–19.7
 Uncertain about meeting all the program requirements672318.4–28.3
 Do not know enough about the program1786356.7–68.0
 Other752621.6–32.0
One in five psychiatrists (21%) reported currently participating in the Medicare or Medicaid EHR Incentive Program, and 6% were planning to participate in the future. The primary reasons reported for being uncertain regarding program participation were not knowing enough about the program (63%) or being uncertain about meeting all of the program requirements (23%).

Factors Associated With ACA Readiness and Receptivity

Most of the psychiatrist attributes examined were associated with psychiatrists’ participation in various ACA reforms (Table 4). Psychiatrists who reported current or likely future practice in primary care or other integrated treatment settings, assumption of at least one ACA role, engagement in salaried arrangements, or use of an EHR were younger, more racially and ethnically diverse, and more likely to see Medicaid and public outpatient clinic patients. Psychiatrists who reported currently participating or being very likely in the future to participate in risk-sharing arrangements were less likely to see self-pay patients or to see patients in solo office practices.
TABLE 4. Factors associated with readiness and receptivity to participate in various ACA services delivery, payment, and information technology reforms among 1,099 psychiatristsa
CharacteristicN of responsesPractice in a primary care or other integrated settingbAssume ≥1 role central to services integrationcEngage in salaried arrangementsdParticipate in risk-sharing paymentseUse an EHR or participate in the Medicare or Medicaid EHR Incentive Programf
YesNopYesNopYesNopYesNopYesNop
Physician characteristic                
 Mean age1,09755.757.2.03955.659.6<.00153.759.1<.00154.156.8.08553.461.9<.001
 Mean % female1,0973435.7533634.5743832.0332436.0753633.420
 Mean % non-Hispanic white9397785.0088088.0067786.0017583.2937693<.001
Practice setting1,074               
 Mean % of patients in solo practice 1941<.0012658<.001954<.0011735<.0011765<.001
 Mean % of patients in group practice 1522.0051923.2101623.0092719.2652216.047
 Mean % of patients in public outpatient clinics 2713<.001224<.001327<.0011518.548254<.001
Work characteristic                
 Mean N of patients treated in most recent typical work week1,08044.145.9.38944.846.6.56243.846.5.20051.345.0.21848.539.7<.001
 Mean N of hours providing direct patient care in most recent typical work week1,07634.034.4.66534.035.1.32932.535.7<.00137.934.1.15034.733.5.185
Patient payment source1,076               
 Mean % of patients with private insurance 2532.0012835.0022335<.0013429.3082735<.001
 Mean % of self-pay patients 1228<.0011737<.001834<.0011123<.0011438<.001
 Mean % of Medicare patients 1614.0771513.1081713.0021914.0481611<.001
 Mean % of Medicaid patients 2414<.001216<.0012710<.0012017.512246<.001
a
ACA, Affordable Care Act
b
Currently providing or very likely to provide services in primary care or integrated treatment settings or accountable care organizations or health homes
c
Currently or very likely to work in a health care delivery system to perform at least one health care reform role listed in Table 3
d
Currently or very likely to receive payment in the form of a salary
e
Currently or very likely to be reimbursed fee for service with a potential financial bonus or penalty or to receive a capitated or partially capitated rate
f
Currently using an electronic health record (EHR) or participating in the Medicare or Medicaid EHR Incentive Program or planning to do so within the next year

Discussion

A primary strength of this study was the use of a large probability sample of U.S. psychiatrists and their self-reported current and anticipated practices. This study was limited to psychiatrists, who treat an estimated one in five individuals who receive mental health care in the United States (20). The data are based on self-report and may be subject to response, recall, and social desirability biases. Many psychiatrists may have considered that an occasional discussion with a primary care physician or a social worker in a clinic reflected their working in an integrated treatment setting or represented one of the collaborative care roles we studied, thereby inflating our estimates. In addition, the use of simple random sampling resulted in a final sample that primarily reflected psychiatrists from more populous states. Although psychiatrists from 48 states participated in the study, no psychiatrists from Delaware or West Virginia participated.

Participation in ACA Services Delivery Models and Roles

Although a notable proportion of psychiatrists reported being currently engaged in or being likely to become engaged in new roles and integrated treatment settings, most had limited involvement in integrated treatment settings and new roles that are considered essential for health care reforms. The major barriers to psychiatrists’ assuming new roles and working in new models of care include overcoming the inertia associated with established psychiatrists’ current practices and practice settings, general workforce constraints and the limited supply of psychiatrists, economic barriers, and limited workforce development and training related to integrated treatment settings and services delivery roles.
More than half of the psychiatrists’ patients were treated in solo or group office settings. Psychiatrists in these settings, who were also more likely to treat a higher proportion of self-pay patients or those with private insurance, were less likely to be receptive to moving into new care delivery systems or models. However, they were as receptive as the psychiatrists in public outpatient clinics to assuming new roles. These findings suggest that transitioning established psychiatrists to new practice settings (for example, colocated settings) may be more challenging than engaging them in new roles. Encouraging these psychiatrists to experiment with spending at least some of their time (for example, one day a week) in integrated settings or practicing telepsychiatry may engage them in more dynamic practices with more frequent interactions with other health professionals.
As a result of the shortage in the nation’s supply of psychiatrists (21,22), it may be difficult for organized delivery systems to recruit sufficient numbers of psychiatrists to practice in integrated services delivery models. Although the ACA includes provisions to strengthen the mental health workforce, it has limited provisions to increase the supply of psychiatrists. Because these provisions are still being implemented, are temporary, and rely on discretionary funding (23), the extent to which they will be effective in increasing the supply of mental health specialists is unclear.
Engaging psychiatrists in integrated delivery systems and roles is especially challenging because traditional clinician Current Procedural Terminology payment codes are not structured to reimburse for care coordination and for many functions integral to psychiatrists’ participation in team-based services delivery. The Centers for Medicare and Medicaid Services (CMS) is currently seeking to address this limitation. The movement toward ACOs and CMS’s aggressive goals of increasing use of global, capitated payments and “merit-based” reimbursement rather than fee-for service payments may also help address this limitation (10). If successful, this paradigm shift may give health plans the flexibility and financial incentives to engage psychiatrists in salaried arrangements, helping to promote integrated treatment and offering the potential to contain or reduce health care costs, particularly for high-cost patients (24).
Until recently, there has been limited outreach, recruitment, and training of psychiatrists in integrated, collaborative care services models. Given the challenges identified in our study, there continues to be an urgent need for federal agencies to invest more efforts and resources toward workforce development to support evidence-based integrated care models (25). This includes expediting the development and implementation of effective training in the core competencies required for integrated care models for the current and future psychiatric work force (26). This will require the leadership of residency training directors, as well as the Accreditation Council for Graduate Medical Education, to develop accreditation standards to achieve proficiency in these core competencies, including training in enhanced general medical care skills, leading professional teams, setting up and participating in integrated care settings, teaching primary care providers about identifying and screening for mental and substance use disorders, and using health information technologies to support population-based, data-driven care (27,28).
To be effective, continuing education programs also need to develop and adopt evidence-based teaching approaches. This includes consideration of online technologies to replace brief lecture and workshop formats, which have little or no effect (29). In addition, significant ongoing technical assistance may be required, particularly in supporting psychiatrists in changing roles and as they form or join multispecialty group practices (26,27).
The APA has initiated a multifaceted approach to recruit and train psychiatrists and primary care providers for new collaborative roles in integrated care (30). These efforts include dissemination of a weekly newsletter, podcasts, toolkits, and resource lists, as well as offering in-person and online lectures, professional training, and continuing medical education programs (31). Recently, the APA received a CMS Support and Alignment grant to train 3,500 psychiatrists to support implementation of evidence-based, integrated behavioral health programs in primary care practices. Through this initiative, free online learning modules have been developed, in addition to live training programs offered throughout the country. Developing and evaluating these initiatives will be important in facilitating culture changes to support team-based care and health services delivery reforms.

Payment Reform Participation

Psychiatrists in general do not appear to be receptive to pay-for-performance reimbursement. Although a substantial proportion of psychiatrists reported being currently engaged in salaried arrangements, very few reported receiving other forms of payments designed to reward quality rather than quantity. Although merit-based payment mechanisms may be used more widely at the plan or group practice level, individual physicians do not appear to be commonly receiving these forms of payments or to be aware of receiving them. Given CMS’s targets of ensuring that a larger proportion of Medicare payments are in the form of global or merit-based payments, it may prove challenging to promote these payments on a clinician level to psychiatrists, given their lack of receptivity and the current shortage of psychiatrists. To address this, the APA has initiated development of a mental health clinical data registry designed in part to help psychiatrists meet CMS’s Physician Quality Reporting System requirements and maximize Medicare merit-based reimbursement while avoiding payment penalties.

EHR Adoption

Although approximately half of psychiatrists reported currently using an EHR, our measures did not distinguish between “basic use” or “meaningful use” of EHRs (32). Furthermore, because a substantial number of psychiatrists reported practicing in more than one setting, psychiatrists may have used EHRs in one but not all of their settings. The psychiatrists who reported participating in the Medicare or Medicaid EHR Incentive Program—one in five psychiatrists—provided an indication of the proportion of psychiatrists whose current EHR use met meaningful use requirements in at least one of their practice settings. These psychiatrists were more likely to work in public outpatient clinics and organized delivery systems.
Not surprisingly, psychiatrists who reported not using EHRs were more likely to treat a higher proportion of patients in solo or group office practice settings and were more likely to treat a higher proportion of self-pay or privately insured patients. Psychiatrists in solo office practice settings and smaller group settings face high fixed costs in investing in EHRs, which presents a financial barrier. They also face technical and administrative challenges in selecting and implementing EHR systems. These psychiatrists may require more technical and financial support to adopt EHRs. Although the 2009 ARRA included significant financial incentives for EHR adoption among physicians treating Medicare and Medicaid patients, physicians who primarily treat self-pay patients or privately insured patients were not included. Another barrier to EHR adoption, particularly among psychiatrists in solo and small group office settings, is privacy concerns associated with use of EHRs (33).
Notably, about one-quarter of the psychiatrists reported that they were not planning to use an EHR. Given that EHRs have been described as being “essential to almost all care delivery innovations,” including coordinating care and promoting accountability among a group of providers for a given population (34), it may prove very difficult for these psychiatrists to contribute to the ACA’s health care delivery transformation goals. These findings highlight the need for more significant resources and technical support to facilitate psychiatrists’ selection, implementation, maintenance, and use of EHRs and other forms of health information technologies that can support quality and outcome assessments essential for performance monitoring and clinical decision support to promote optimal care management.

Conclusions

Although substantial proportions of psychiatrists practicing in group and public outpatient treatment settings reported that they were currently engaged in services delivery models and roles being implemented under health care reform, our findings highlight opportunities for further workforce development, training, and technical assistance consistent with the outreach, education, and training efforts being initiated to strengthen psychiatrists’ participation in integrated care. Our findings highlight the need to help prepare psychiatrists for performance-based payment reforms and facilitate their transition to more robust use of EHRs.

References

1.
Health Insurance Coverage and the Affordable Care Act. Washington, DC, Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, May 5, 2015. http://aspe.hhs.gov/health/reports/2015/uninsured_change/ib_uninsured_change.pdf
2.
Affordable Care Act Will Expand Mental Health and Substance Use Disorder Benefits and Parity Protections for 62 Million Americans. Washington, DC, Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Feb 2013. http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.cfm
3.
Barry CL, Huskamp HA: Moving beyond parity: mental health and addiction care under the ACA. New England Journal of Medicine 365:973–975, 2011
4.
Druss BG, Mauer BJ: Health care reform and care at the behavioral health–primary care interface. Psychiatric Services 61:1087–1092, 2010
5.
Berwick DM, Nolan TW, Whittington J: The triple aim: care, health, and cost. Health Affairs 27:759–769, 2008
6.
Mechanic D: Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system. Health Affairs 31:376–382, 2012
7.
Croft B, Parish SL: Care integration in the Patient Protection and Affordable Care Act: implications for behavioral health. Administration and Policy in Mental Health and Mental Health Services Research 40:258–263, 2013
8.
Hogan MF, Sederer LI, Smith TE, et al: Making room for mental health in the medical home. Preventing Chronic Disease 7:A132, 2010
9.
Katon W, Unützer J: Consultation psychiatry in the medical home and accountable care organizations: achieving the triple aim. General Hospital Psychiatry 33:305–310, 2011
10.
Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume. Baltimore, Centers for Medicare and Medicaid Services, Jan 26, 2015. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html
11.
Ginsburg PB: Rapidly evolving physician-payment policy: more than the SGR. New England Journal of Medicine 364:172–176, 2011
12.
Davis K, Guterman S, Collins SR, et al: Starting on the Path to a High Performance Health System: Analysis of the Payment and System Reform Provisions in the Patient Protection and Affordable Care Act of 2010. New York, Commonwealth Fund, Sept 2010
13.
Orszag PR, Emanuel EJ: Health care reform and cost control. New England Journal of Medicine 363:601–603, 2010
14.
Mechanic RE, Altman SH: Payment reform options: episode payment is a good place to start. Health Affairs 28:w262–w271, 2009
15.
Recovery Act Funded Services: Health Information Technology. Washington, DC, Department of Health and Human Services, Sept 2013. http://wayback.archive-it.org/3909/20130927155711/http://www.hhs.gov/recovery/programs/index.html#Health
16.
Buntin MB, Burke MF, Hoaglin MC, et al: The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Affairs 30:464–471, 2011
17.
Blumenthal D: Stimulating the adoption of health information technology. New England Journal of Medicine 360:1477–1479, 2009
18.
Chaudhry B, Wang J, Wu S, et al: Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine 144:742–752, 2006
19.
LaVange LM, Shah BV, Barnwell BG, et al: SUDAAN: a comprehensive package for survey data analysis; in Data Quality Control. Edited by Liepins GE, Uppuluri VRR. New York, Dekker, 1990
20.
Wang PS, Lane M, Olfson M, et al: Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62:629–640, 2005
21.
Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce. Rockville, Md, Substance Abuse and Mental Health Services Administration, 2013
22.
Faulkner LR, Juul D, Andrade NN, et al: Recent trends in American Board of Psychiatry and Neurology psychiatric subspecialties. Academic Psychiatry 35:35–39, 2011
23.
Heisler EJ: Physician Supply and the Affordable Care Act. Report 7-5700 R42029. Washington, DC, Congressional Research Service, 2013
24.
van Steenbergen-Weijenburg KM, van der Feltz-Cornelis CM, Horn EK, et al: Cost-effectiveness of collaborative care for the treatment of major depressive disorder in primary care. a systematic review. BMC Health Services Research 10:19, 2010
25.
Institute of Medicine: The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC, National Academies Press, 2012
26.
Hoge MA, Stuart GW, Morris J, et al: Mental health and addiction workforce development: federal leadership is needed to address the growing crisis. Health Affairs 32:2005–2012, 2013
27.
American Psychiatric Association Board of Trustees Work Group on the Role of Psychiatry in Health Care Reform: Role of Psychiatry in Healthcare Reform. Arlington, Va, American Psychiatric Association, 2014
28.
Raney L: Integrated care: the evolving role of psychiatry in the era of health care reform. Psychiatric Services 64:1076–1078, 2013
29.
Hoge MA, Morris JA, Stuart GW, et al: A national action plan for workforce development in behavioral health. Psychiatric Services 60:883–887, 2009
30.
Raney LE: Working at the Interface of Primary Care and Behavioral Health: Integrated Care. Arlington, Va, American Psychiatric Publishing, 2015
31.
Integrated Care. Arlington, Va, American Psychiatric Association, 2015. http://www.psychiatry.org/practice/professional-interests/integrated-care
32.
Furukawa MF, King J, Patel V, et al: Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Health Affairs 33:1672–1679, 2014
33.
Grinspan ZM, Banerjee S, Kaushal R, et al: Physician specialty and variations in adoption of electronic health records. Applied Clinical Informatics 4:225–240, 2013
34.
Bowman S: Impact of electronic health record systems on information integrity: quality and safety implications. Perspectives in Health Information Management 10:1c, 2013

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services

Cover: pocket watch, by Robert et Courvoisier, 1800–1816. Silver, brass, ormuolu, enamel, and steel. Bequest of Henry Francis du Pont, Winterthur Museum, Winterthur, Del.

Psychiatric Services
Pages: 1292 - 1299
PubMed: 27524368

History

Received: 15 December 2015
Revision received: 20 June 2016
Accepted: 11 July 2016
Published online: 15 August 2016
Published in print: December 01, 2016

Keywords

  1. Mental health systems/hospitals
  2. Public policy issues
  3. Research/service delivery
  4. Service delivery systems
  5. Financing/funding/reimbursement

Authors

Details

Joyce C. West, Ph.D., M.P.P.
Dr. West, Dr. Clarke, Dr. Duffy, Ms. Barber, and Dr. Mościcki are with the American Psychiatric Association Foundation, Arlington, Virginia (e-mail: [email protected]). Dr. Clarke is also with the Division of Research, American Psychiatric Association, Arlington, Virginia. Dr. Mojtabai is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Ms. Kroeger Ptakowski and Dr. Levin are with the American Psychiatric Association, Arlington, Virginia.
Diana E. Clarke, Ph.D., M.Sc.
Dr. West, Dr. Clarke, Dr. Duffy, Ms. Barber, and Dr. Mościcki are with the American Psychiatric Association Foundation, Arlington, Virginia (e-mail: [email protected]). Dr. Clarke is also with the Division of Research, American Psychiatric Association, Arlington, Virginia. Dr. Mojtabai is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Ms. Kroeger Ptakowski and Dr. Levin are with the American Psychiatric Association, Arlington, Virginia.
Farifteh Firoozmand Duffy, Ph.D.
Dr. West, Dr. Clarke, Dr. Duffy, Ms. Barber, and Dr. Mościcki are with the American Psychiatric Association Foundation, Arlington, Virginia (e-mail: [email protected]). Dr. Clarke is also with the Division of Research, American Psychiatric Association, Arlington, Virginia. Dr. Mojtabai is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Ms. Kroeger Ptakowski and Dr. Levin are with the American Psychiatric Association, Arlington, Virginia.
Keila D. Barber, M.H.S.
Dr. West, Dr. Clarke, Dr. Duffy, Ms. Barber, and Dr. Mościcki are with the American Psychiatric Association Foundation, Arlington, Virginia (e-mail: [email protected]). Dr. Clarke is also with the Division of Research, American Psychiatric Association, Arlington, Virginia. Dr. Mojtabai is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Ms. Kroeger Ptakowski and Dr. Levin are with the American Psychiatric Association, Arlington, Virginia.
Eve K. Mościcki, Sc.D., M.P.H.
Dr. West, Dr. Clarke, Dr. Duffy, Ms. Barber, and Dr. Mościcki are with the American Psychiatric Association Foundation, Arlington, Virginia (e-mail: [email protected]). Dr. Clarke is also with the Division of Research, American Psychiatric Association, Arlington, Virginia. Dr. Mojtabai is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Ms. Kroeger Ptakowski and Dr. Levin are with the American Psychiatric Association, Arlington, Virginia.
Ramin Mojtabai, M.D., Ph.D.
Dr. West, Dr. Clarke, Dr. Duffy, Ms. Barber, and Dr. Mościcki are with the American Psychiatric Association Foundation, Arlington, Virginia (e-mail: [email protected]). Dr. Clarke is also with the Division of Research, American Psychiatric Association, Arlington, Virginia. Dr. Mojtabai is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Ms. Kroeger Ptakowski and Dr. Levin are with the American Psychiatric Association, Arlington, Virginia.
Kristin Kroeger Ptakowski, B.A.
Dr. West, Dr. Clarke, Dr. Duffy, Ms. Barber, and Dr. Mościcki are with the American Psychiatric Association Foundation, Arlington, Virginia (e-mail: [email protected]). Dr. Clarke is also with the Division of Research, American Psychiatric Association, Arlington, Virginia. Dr. Mojtabai is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Ms. Kroeger Ptakowski and Dr. Levin are with the American Psychiatric Association, Arlington, Virginia.
Saul Levin, M.D., M.P.A.
Dr. West, Dr. Clarke, Dr. Duffy, Ms. Barber, and Dr. Mościcki are with the American Psychiatric Association Foundation, Arlington, Virginia (e-mail: [email protected]). Dr. Clarke is also with the Division of Research, American Psychiatric Association, Arlington, Virginia. Dr. Mojtabai is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Ms. Kroeger Ptakowski and Dr. Levin are with the American Psychiatric Association, Arlington, Virginia.

Notes

Findings from this study were presented in part at the American Association of Medical Colleges Health Workforce Research Conference, Alexandria, Virginia, April 30–May 1, 2015.

Funding Information

American Psychiatric Foundation10.13039/100001944: New Initiative Fund
This study was funded by the American Psychiatric Association Foundation.Dr. West and Dr. Duffy are currently working on studies funded by Takeda Pharmaceuticals and Forest Laboratories. The other authors report no financial relationships with commercial interests.

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