Behavioral Health Integration With Primary Care: Implementation Experience and Impacts From the State Innovation Model Round 1 States
Behavioral Health Integration With Primary Care: Implementation Experience and Impacts From the State Innovation Model Round 1 States
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DOI：
10.1111/1468-0009.12379
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发表时间：
2019-06-01
影响因子：
6.6
通讯作者：
Romaire, Melissa A.
中科院分区：
文献类型：
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作者：
Beil, Heather;Feinberg, Rose K.;Romaire, Melissa A.
政策要点：患有行为健康（BH）疾病的个人构成了一个医疗复杂的人群，他们的医疗费用高，医疗需求高。考虑到全国范围内BH提供者的短缺，初级保健提供者在识别和治疗BH病症以及向BH提供者转诊方面发挥着关键作用。各国正在越来越多地寻求解决其居民中BH状况的方法。在第一轮州创新模式（SIM）倡议下，由医疗保险和医疗补助服务中心资助的州都投资于BH整合。各国发现，在提供者之间共享数据、弥合专业鸿沟和克服BH提供者短缺是主要障碍。尽管如此，各州在整合BH护理方面取得了重大进展。除了支付模式之外，促进变革的一个关键因素是促进BH提供者和初级保健医生之间的非正式关系。基础设施投资，如通过将医院提供者与卫生信息交流联系起来促进数据共享，以及为医院提供者和初级保健提供者提供量身定制的技术援助，对于改善医院保健的整合也很重要。越来越多的州正在寻找解决居民行为健康（BH）问题的方法。自2013年以来，第一轮国家创新模式（SIM）倡议向六个州提供了财政和技术支持，以测试州政府领导医疗保健系统转型的能力。所有六个SIM国家都对BH和初级保健服务的整合进行了投资。本研究总结了各国在波黑一体化方面的进展、挑战和经验教训。此外，该研究报告了四个SIM州对BH患者的支出、利用和护理质量结果的影响。方法采用混合方法设计，利用焦点小组和关键信息提供者访谈得出实施结论，并使用医疗补助索赔数据进行定量分析，以评估影响。对于由SIM资助的三个医疗补助问责医疗组织（ACO）模型，我们使用了差异中差异回归模型来比较模型实施前后具有BH条件的模型参与者和州内对照组的结果。对于缅因州的行为健康之家（BHH）模型，我们使用了前后设计来评估模型参与者的结果如何随时间变化。非正式关系的建立、有针对性的技术援助和促进数据共享是取得进展的关键因素。实施三年后，明尼苏达州和佛蒙特州因ACO导致的BH患者每月人均支出增长分别比对照组少128美元（- 253美元，- 3美元，p < 0.10）和62美元（- 87美元，- 36美元，p < 0.001）。同样，在实施两到四年后，所有三个州的ACO参与者使用急诊科的情况都有所减少。然而，在所有三个州，ACO受益人的健康相关质量指标没有改善。虽然BHH模型的参与者在实施两年后增加了支出，但初级保健和专科护理服务的使用分别增加了3%和8%，抗抑郁药物依从性也有所改善。SIM第一轮各州在整合BH和初级保健服务方面取得了相当大的进展，所有模式都有令人鼓舞的发现。综上所述，有一些证据表明，医疗补助支付模式可以改善患有BH疾病的受益人的护理模式。
Policy PointsIndividuals with behavioral health (BH) conditions comprise a medically complex population with high costs and high health care needs. Considering national shortages of BH providers, primary care providers serve a critical role in identifying and treating BH conditions and making referrals to BH providers. States are increasingly seeking ways to address BH conditions among their residents. States funded by the Centers for Medicare and Medicaid Services under the first round of the State Innovation Models (SIM) Initiative all invested in BH integration. States found sharing data among providers, bridging professional divides, and overcoming BH provider shortages were key barriers. Nonetheless, states made significant strides in integrating BH care. Beyond payment models, a key catalyst for change was facilitating informal relationships between BH providers and primary care physicians. Infrastructure investments such as promoting data sharing by connecting BH providers to a health information exchange and providing tailored technical assistance for both BH and primary care providers were also important in improving integration of BH care. Context Increasing numbers of states are looking for ways to address behavioral health (BH) conditions among their residents. The first round of the State Innovation Models (SIM) Initiative provided financial and technical support to six states since 2013 to test the ability of state governments to lead health care system transformation. All six SIM states invested in integration of BH and primary care services. This study summarizes states' progress, challenges, and lessons learned on BH integration. Additionally, the study reports impacts on expenditure, utilization, and quality-of-care outcomes for persons with BH conditions across four SIM states. Methods We use a mixed-methods design, drawing on focus groups and key informant interviews to reach conclusions on implementation and quantitative analysis using Medicaid claims data to assess impact. For three Medicaid accountable care organization (ACO) models funded under SIM, we used a difference-in-differences regression model to compare outcomes for model participants with BH conditions and an in-state comparison group before-and-after model implementation. For the behavioral health home (BHH) model in Maine, we used a pre-post design to assess how outcomes for model participants changed over time. Findings Informal relationship building, tailored technical assistance, and the promotion of data sharing were key factors in making progress. After three years of implementation, the growth in total expenditures was less than the comparison group by $128 (-$253, -$3; p < 0.10) and $62 (-$87, -$36; p < 0.001) per beneficiary per month for beneficiaries with BH conditions attributed to an ACO in Minnesota and Vermont, respectively. Likewise, there were reductions in emergency department use for ACO participants in all three states after two to four years of implementation. However, there was no improvement in BH-related quality metrics for ACO beneficiaries in all three states. Although participants in the BHH model had increased expenditures after two years of implementation, use of primary care and specialty care services increased by 3% and 8%, respectively, and antidepressant medication adherence also improved. Conclusions The SIM Round 1 states made considerable progress in integrating BH and primary care services, and there were promising findings for all models.Taken together, there is some evidence that Medicaid payment models can improve patterns of care for beneficiaries with BH conditions.