Examining the Impact of Payment Reform on Coordination with Behavioral Health Providers Among Ambulatory Physicians

Background: Behavioral health and physical health conditions often co-occur, and can increase an individual’s risk for negative outcomes, including reduced symptom remission and premature mortality. Regular coordination between physicians and behavioral health providers helps protect against these adverse outcomes, and is now recognized as an essential component of quality care. Alternative payment models (APMs), such as Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs), have been a leading strategy to incentivize care coordination by providing financial rewards for providers and organizations that deliver high quality and cost effective care. There has been research evaluating the impact of these models on clinical quality and outcomes, but less on how these models change clinical practice, specifically in terms of enhancing care coordination between physicians and behavioral health providers. Further, given the diversity in the structure and design of APMs, even less is known about whether this variation has an impact on provider behavior. This study sought to examine the role of APM models on care coordination with behavioral health providers among ambulatory physicians.

Methods: The data source was pooled data spanning four years (2015-19) of the National Electronic Health Records Survey (NEHRS; n= 8,898). NEHRS is a nationally representative survey of ambulatory physicians and focuses on their use of electronic health records. The dependent variable of interest was behavioral health (BH) care coordination, measured using a binary self-reported indicator of whether providers electronically send patient health information to behavioral health providers. Multivariate logistic regression was used to test (1) the effect of any APM participation on BH coordination and (2) the effect of specific payment reform models on BH coordination using a categorical indictor of ACO, Patient-Centered Medical Home, or other APM participation. Provider and clinic level variables were use as covariates in the fully adjusted model.

Results: Overall, only 17% of providers reported engaging in BH care coordination. Overall, participation in any payment reform was associated with an increase in BH care coordination (OR=2.98, p<.001). The next step in analyses showed significant increases in the odds of BH care coordination were found only among physicians participating in ACOs (OR=1.91, p<05) and Patient-Centered Medical home models (OR=3.36, p<.001). Participation in other APMs did not affect the odds of BH coordination.

Conclusions: In this nationally representative sample, less than a fifth of providers sent information electronically to behavioral health providers. This suggests that communication between medical and behavioral health providers remains infrequent, and understanding barriers to this practice is critical. APMs can improve this practice among ambulatory physicians, but the effect varied by program type, with The Patient-Centered Medical Home model having the greatest impact on BH coordination, followed by the Accountable Care Organization models. Future work can build on these findings by identifying the specific components of ACOs and Patient-Centered Medical Homes that uniquely enhance BH care coordination.