Are Psychiatrists Ready for Health Care Reform? Findings From the Study of Psychiatric Practice Under Health Care Reform
Abstract
Objective:
Methods:
Results:
Conclusions:
Methods
Results
Sample Characteristics
Characteristic | N | % | 95% CI | Characteristic | N | % of patients | 95% CI |
---|---|---|---|---|---|---|---|
Age (mean) | 1,097a | 56.7 | 56.0–57.4 | Practice setting (%) | 1,074a | ||
Gender | Solo office practice | 361 | 34 | 33.9–39.4 | |||
Male | 711 | 65 | 62.0–67.8 | Outpatient clinic in a public hospital or freestanding facility | 192 | 18 | 15.5–19.7 |
Female | 387 | 35 | 32.2–38.0 | Group office practice | 214 | 20 | 14.2–18.4 |
Race-ethnicity | Outpatient clinic in a private hospital or freestanding facility | 80 | 7 | 5.4–8.1 | |||
White, non-Hispanic | 776 | 82 | 79.6–84.6 | Inpatient unit in a public hospital (includes partial hospitalization) | 60 | 6 | 5.3–8.0 |
Asian | 76 | 8 | 6.6–10.2 | Inpatient unit in a private hospital (includes partial hospitalization) | 55 | 5 | 4.1–6.3 |
Hispanic | 41 | 5 | 3.4–6.2 | Otherb | 112 | 10 | 9.2–12.6 |
Black, non-Hispanic | 40 | 4 | 3.2–5.9 | Main source of patient payment (%) | 1,076a | ||
Other | 6 | 1 | .3–1.4 | Private or commercial insurance (includes managed and nonmanaged, excluding all categories below) | 317 | 30 | 26.0–29.7 |
Region | Self-payc | 239 | 22 | 23.3–27.5 | |||
West | 259 | 24 | 21.1–26.3 | Medicaid or CHIP/SCHIP (including Medicaid HMOs)d | 189 | 18 | 15.4–18.6 |
South | 239 | 24 | 21.1–26.3 | Medicare (including Medicare HMOs) | 155 | 14 | 11.5–13.7 |
Northeast | 257 | 20 | 18.2–22.8 | Other government or publice | 117 | 11 | 10.1–13.5 |
Midwest | 200 | 17 | 15.3–19.7 | No charge or uncompensated | 23 | 2 | 1.8–2.7 |
Mid-Atlantic | 144 | 15 | 12.9–17.5 | Otherf | 14 | 1 | .8–1.6 |
Primary psychiatry specialty | Don’t know | 23 | 2 | 1.2–2.8 | |||
General | 829 | 75 | 72.6–77.9 | ||||
Child and adolescent | 234 | 21 | 19.0–24.0 | ||||
Psychoanalysis | 14 | 1 | .3–.7 | ||||
Addiction | 10 | 1 | .5–1.8 | ||||
Forensic | 9 | 1 | .5–1.9 | ||||
Clinician workload in most recent typical work week | |||||||
N of patients treated (mean) | 1,080a | 45.3 | 43.2–47.5 | ||||
N of hours providing direct patient care (mean) | 1,076a | 34.3 | 33.4–35.2 |
Health Care Reform Roles
Question and response options | Currently do this | Likely or very likely to do this | Neutral or not at all likely to do this | Don’t know or missing data | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
N | % | 95% CI | N | % | 95% CI | N | % | 95% CI | N | % | 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 services | 460 | 42 | 38.7–44.7 | 94 | 9 | 7.1–10.5 | 456 | 41 | 38.5–44.4 | 89 | 8 | 6.8–10.2 |
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 clinician | 459 | 41 | 38.4–44.3 | 70 | 7 | 5.2–8.2 | 491 | 45 | 41.7–47.7 | 79 | 7 | 5.9–9.1 |
Provide consultation to primary care and mental health clinicians caring for psychiatric patients who have diagnostic or therapeutic challenges | 438 | 39 | 36.5–42.4 | 150 | 14 | 11.8–16.0 | 424 | 39 | 35.9–41.7 | 87 | 8 | 6.6–9.9 |
Provide leadership and supervision for team delivery of psychiatric and general medical care for psychiatric patients | 369 | 33 | 30.3–36.0 | 96 | 9 | 7.4–11.0 | 534 | 49 | 45.5–51.6 | 100 | 9 | 7.7–11.3 |
Oversee, track, and review care for psychiatric patients, working with practice leadership to ensure services are available, appropriate, and well managed | 225 | 21 | 18.2–23.1 | 100 | 9 | 7.6–11.2 | 625 | 57 | 53.6–59.6 | 149 | 14 | 11.7–15.8 |
Provide general medical care to psychiatric patients (for example, screening and routine preventive care) | 174 | 16 | 13.7–18.1 | 38 | 4 | 2.7–5.1 | 806 | 73 | 70.4–75.7 | 81 | 7 | 6.0–9.2 |
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 integrated | 207 | 18 | 16.3–20.9 | 92 | 8 | 6.9–10.3 | 688 | 63 | 59.8–65.6 | 112 | 10 | 8.7–12.4 |
Primary care treatment settings | 159 | 15 | 12.5–16.8 | 59 | 5 | 4.1–6.8 | 765 | 70 | 66.9–72.5 | 116 | 10 | 8.8–12.4 |
Patient-centered medical or health homes that provide patient-centered, comprehensive, team-based, coordinated care for Medicaid patients | 91 | 8 | 6.6–10.0 | 81 | 7 | 5.9–9.0 | 759 | 69 | 66.4–71.9 | 168 | 15 | 13.3–17.7 |
Accountable care organizations, which are integrated delivery systems that assume responsibility for the cost, quality, and outcomes of health care | 57 | 5 | 3.9–6.6 | 75 | 7 | 5.4–8.4 | 728 | 66 | 63.3–69.1 | 239 | 22 | 19.5–24.5 |
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? | ||||||||||||
Salaried | 469 | 42 | 39.0–45.0 | 46 | 4 | 3.3–5.9 | 508 | 47 | 43.6–49.6 | 76 | 7 | 5.7–8.8 |
Reimbursed fee for service with a potential financial bonus, receiving a financial bonus for containing costs and meeting quality standards | 42 | 4 | 2.7–5.1 | 60 | 6 | 4.4–7.2 | 817 | 74 | 71.6–76.9 | 180 | 16 | 14.3–18.7 |
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 targets | 16 | 2 | .9–2.6 | 33 | 3 | 2.1–4.2 | 859 | 78 | 75.6–80.6 | 191 | 17 | 15.2–19.7 |
Capitated or paid a per-member per-month case rate | 15 | 1 | .8–2.4 | 26 | 2 | 1.6–3.4 | 878 | 80 | 77.4–82.2 | 180 | 16 | 14.3–18.7 |
Partially capitated with payment partially fee for service and partially a capitated or fixed amount | 13 | 1 | .7–2.0 | 21 | 2 | 1.3–3.1 | 861 | 78 | 75.7–80.7 | 204 | 19 | 16.3–21.0 |
Integrated Services Delivery Systems
Payment Reforms
EHRs
Question | N | % | 95% CI |
---|---|---|---|
Please indicate your current use of EHRs or electronic medical records for clinical functions not limited to billing or practice management | |||
Currently use | 579 | 53 | 49.9–55.9 |
Plan on using within the next year | 92 | 8 | 6.7–10.0 |
Plan on using in more than 1 year | 45 | 4 | 2.9–5.3 |
Uncertain about using | 122 | 11 | 9.3–13.1 |
Do not plan on using | 257 | 24 | 21.3–26.5 |
Please indicate your participation in the Medicare or Medicaid EHR Incentive Program | |||
Currently participate | 228 | 21 | 18.3–23.2 |
Plan on participating | 59 | 6 | 4.4–7.3 |
Uncertain whether I will participate | 278 | 25 | 22.8–28.0 |
Do not plan on participating in either program | 523 | 49 | 45.7–51.8 |
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 patients | 45 | 15 | 11.3–19.7 |
Uncertain about meeting all the program requirements | 67 | 23 | 18.4–28.3 |
Do not know enough about the program | 178 | 63 | 56.7–68.0 |
Other | 75 | 26 | 21.6–32.0 |
Factors Associated With ACA Readiness and Receptivity
Characteristic | N of responses | Practice in a primary care or other integrated settingb | Assume ≥1 role central to services integrationc | Engage in salaried arrangementsd | Participate in risk-sharing paymentse | Use an EHR or participate in the Medicare or Medicaid EHR Incentive Programf | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Yes | No | p | Yes | No | p | Yes | No | p | Yes | No | p | Yes | No | p | ||
Physician characteristic | ||||||||||||||||
Mean age | 1,097 | 55.7 | 57.2 | .039 | 55.6 | 59.6 | <.001 | 53.7 | 59.1 | <.001 | 54.1 | 56.8 | .085 | 53.4 | 61.9 | <.001 |
Mean % female | 1,097 | 34 | 35 | .753 | 36 | 34 | .574 | 38 | 32 | .033 | 24 | 36 | .075 | 36 | 33 | .420 |
Mean % non-Hispanic white | 939 | 77 | 85 | .008 | 80 | 88 | .006 | 77 | 86 | .001 | 75 | 83 | .293 | 76 | 93 | <.001 |
Practice setting | 1,074 | |||||||||||||||
Mean % of patients in solo practice | 19 | 41 | <.001 | 26 | 58 | <.001 | 9 | 54 | <.001 | 17 | 35 | <.001 | 17 | 65 | <.001 | |
Mean % of patients in group practice | 15 | 22 | .005 | 19 | 23 | .210 | 16 | 23 | .009 | 27 | 19 | .265 | 22 | 16 | .047 | |
Mean % of patients in public outpatient clinics | 27 | 13 | <.001 | 22 | 4 | <.001 | 32 | 7 | <.001 | 15 | 18 | .548 | 25 | 4 | <.001 | |
Work characteristic | ||||||||||||||||
Mean N of patients treated in most recent typical work week | 1,080 | 44.1 | 45.9 | .389 | 44.8 | 46.6 | .562 | 43.8 | 46.5 | .200 | 51.3 | 45.0 | .218 | 48.5 | 39.7 | <.001 |
Mean N of hours providing direct patient care in most recent typical work week | 1,076 | 34.0 | 34.4 | .665 | 34.0 | 35.1 | .329 | 32.5 | 35.7 | <.001 | 37.9 | 34.1 | .150 | 34.7 | 33.5 | .185 |
Patient payment source | 1,076 | |||||||||||||||
Mean % of patients with private insurance | 25 | 32 | .001 | 28 | 35 | .002 | 23 | 35 | <.001 | 34 | 29 | .308 | 27 | 35 | <.001 | |
Mean % of self-pay patients | 12 | 28 | <.001 | 17 | 37 | <.001 | 8 | 34 | <.001 | 11 | 23 | <.001 | 14 | 38 | <.001 | |
Mean % of Medicare patients | 16 | 14 | .077 | 15 | 13 | .108 | 17 | 13 | .002 | 19 | 14 | .048 | 16 | 11 | <.001 | |
Mean % of Medicaid patients | 24 | 14 | <.001 | 21 | 6 | <.001 | 27 | 10 | <.001 | 20 | 17 | .512 | 24 | 6 | <.001 |
Discussion
Participation in ACA Services Delivery Models and Roles
Payment Reform Participation
EHR Adoption
Conclusions
References
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