May 27, 2021, 4:08 p.m. News Staff ― The latest installment in the FPM journal’s supplement series on value-based payment ― “Innovative Care Delivery: Behavioral Health Integration and Home-based Primary Care” ― draws a direct line between VBP’s focus on increasing physician engagement in risk-based payment models to achieve the “quadruple aim” (i.e., better patient population health, better patient satisfaction, lower cost of care and greater primary care team satisfaction) and reliance on flexible care delivery models to provide what the AAFP calls the “quadruple right” (i.e., delivering the right care to the right patient at the right time in the right location).
“To achieve the quadruple right, the goals of VBP should be inherently aligned and rely on implementing innovative care solutions,” the supplement notes, pointing to behavioral health integration and home-based primary care as two examples of such solutions.
Statistics from the National Institute of Mental Health reveal that the prevalence of mental illness among U.S. adults in 2019 was nearly one in five, and evidence suggests that up to 70% of primary care visits in the United States are related to behavioral health needs.
Moreover, according to a recent blog post from the American Psychiatric Association, “as many as 40% of all patients seen in primary care settings have a mental illness, and the presence of psychiatric comorbidities translates not only into suffering due to the psychiatric illness, but also worsens outcomes for the other illnesses afflicting the patient.”
Clearly the ability to integrate behavioral health services into primary care can greatly benefit patients. But given the accompanying need for adequate financial support, resources, time and staff, that’s not always a good fit in a fee-for-service practice setting. Fortunately, the move toward VBP can allow primary care practices to leverage the care delivery and payment flexibilities available to them through alternative payment arrangements.
Indeed, flexibility is the key to successful BHI. Essentially a patient-centered approach in which primary care and behavioral health physicians and other clinicians collaborate with patients and their caregivers to improve patients’ physical and mental health, BHI is highly individualized from practice to practice and evolves to meet patient and practice needs.
The supplement lays out a BHI spectrum that comprises three distinct categories:
Most BHI is currently supported through FFS, the supplement notes, although as primary care practices move along the VBP continuum, opportunities for them to further integrate care will likely open up as they are able to take on VBP contracts with aligned payments and increased flexibility in care delivery.
Ideally, alignment of BHI with primary care VBP models would include prospective payment arrangements sufficient to support BHI at a level commensurate to the patient’s needs, as well as much-needed administrative simplification.
According to Blue Cross Blue Shield Association statistics, the total annual cost of health care in the United States tops $3 trillion, with medical care accounting for 90% of that total. The cost of care is especially high at the end of life; about 25% of Medicare payments occur in beneficiaries’ final year.
Moreover, between the aging of the American population and the rising prevalence of chronic health conditions among patients of all ages, a growing number of patients face mobility issues. Given that a 2015 report from the National Academy of Medicine found that adults with both chronic conditions and functional limitations accounted for 56% of total U.S. health care expenditures in 2011, such an increase promises to hike overall health care costs.
Fortunately, the types of innovative delivery models with payment incentives to address rising costs that characterize VBP offer a way forward. Home-based primary care has been suggested as one such possible solution.
Roughly defined as primary and palliative care provided in the home to high-risk or medically vulnerable patients, preventive services offered in an HBPC setting (i.e., in-home monitoring, care management and proactive interventions) are intended to avoid unnecessary emergency department utilization and hospital admissions.
Ultimately, HBPC permits identification of patients who would most benefit from home-based integrated care and provides the right set of services to meet patient needs.
Given that one of the goals of VBP is to keep health care costs in check, being able to accurately predict those costs is key. CMS implemented hierarchical condition category coding in 2004 to respond to that need.
Originally designed as a risk-adjustment model that would allow the agency to estimate future costs for Medicare Advantage plan beneficiaries, HCC coding has drawn renewed attention as interest in VBP has risen.
As a reminder, a previous AAFP News story that discussed HCC coding and risk adjustment noted physicians use ICD-10 codes to report specific diagnoses. Certain types of ICD-10 codes, in turn, map to an HCC.
Each HCC is assigned a weight/score proportional to the relative costs associated with its constituent diagnoses. Patient demographic factors are also assigned individual scores. The HCC and demographic scores are added together to calculate the patient’s risk-adjustment factor score. Finally, insurers use algorithms to predict health care costs based on the patient’s RAF score.
Visit the AAFP’s Hierarchical Condition Category Coding webpage for more on this topic, including examples of how to calculate RAF scores.
Because that RAF score is instrumental in calculating a patient’s total expected annual health expenditures, it has a keen effect on establishing capitation rates for MA plans as well as benchmarks for certain shared savings programs. That translates to major financial implications for physicians and practices.
In the AAFP’s newest Practice Hack video, Kansas AFP President-elect Jennifer Bacani McKenney, M.D., of Fredonia, Kan., explores using team-based strategies to optimize risk adjustment and ensure success in VBP. Here are four strategies she recommends.