Increased demand for “integration”—of care coordination, consumer data, and consumer services—is being driven by consumers and payers. For consumers, it’s a matter of the experience—a single care coordination process, all relevant information in one place, and a connection between basic medical services and specialty care. For payers, it’s a matter of value—improved health status and less inappropriate use of expensive resources. And, the pandemic has certainly shed new light on the consequences of ignoring comorbidities, as Betty Rabinowitz, M.D., FACP, Chief Medical Officer of NextGen Healthcare noted in a conversation at the 2021 OPEN MINDS Performance Management Institute (see The True Impact Of Whole Person Care).
The preference for “integrated” care has not been lost on specialty provider organizations. We’ve seen rapid adoption of the health home concept and “whole person” approaches to care coordination. And, moving beyond that, many specialist organizations are adding primary care services to their service portfolio. Our survey last fall found that 52% of specialty provider organization executives reported they have already started developing models that offer both behavioral health and primary care services. However, provider organizations have not coalesced to a preferred pathway to achieving integrated care—only 14% of the respondents have fully integrated practice models (see Intentional Approaches To Integrated Care). Twenty three percent are pursuing designation as a federally qualified health clinic (FQHC) or FQHC look-alike, 30% are pursuing designation as a certified community behavioral health clinic (CCBHC), and 14% are pursuing designation as a patient centered medical home (PCMH).
A key question for specialty provider organizations is how to make primary care service delivery work, both clinically and financially. Many of the original SAMSHA grant-funded behavioral health/primary care integration programs failed to become sustainable service lines in the long run. And executives of specialty provider organization management teams that have added primary care service lines have commented that getting to profitability has taken longer than expected.
However, the pandemic has ushered in some previously unthinkable changes to primary care—consumers have embraced virtual primary care visits. Given this shift, health plans are moving in this direction. In recent months, we’ve seen a wide array of new virtual primary care health plan offerings. And employer-sponsored health plans are embracing the virtual primary care concept. For example, health plan Oscar has an app that connects consumers to a telehealth visit with a health care professional within 15 minutes of a call and if a prescription is needed, it is sent directly to the consumer’s preferred pharmacy. Oscar’s free virtual primary care benefit includes unlimited virtual visits with Oscar primary care physicians, and free at-home vital monitors and in-home lab draws. Doctor On Demand and Community Health Choice, a managed care organization, launched a new health maintenance organization plan on the Texas Exchange centered around virtual primary care. The intent was to give Texans who do not qualify for Medicaid or Medicare a dedicated primary care provider and access to preventive care, urgent care, and behavioral health—all through convenient video visits, 24/7 support through a dedicated care team, and referrals to in-network specialists and facilities (see What Virtual Primary Care Means For Specialist Strategy).
The acceptance of virtual primary care makes it much easier for specialty provider organizations to offer primary care physician services to the consumers they serve. Another possibility is that virtual primary care professionals may want to “consult” virtually with behavioral health professionals for cases where they need an expert opinion but want to manage the treatment and consumer relationship themselves.
This move to virtual primary care will also disrupt traditional referral patterns for specialty services. Many of the new primary care platforms promote care for depression, anxiety, and chronic conditions as part of their core offerings. Professionals providing virtual primary care will not necessarily live in the same community as the consumers they are serving or know the “local” specialty provider organizations. Rather they will likely identify specialists virtually (in their virtual networks or via online information) and/or provide a “virtual warm hand off” to specialists—assuming those specialists are able to share consumer data through some interoperable real-time data exchange.
There has also been a significant increase in private equity investment in new primary care delivery systems. Among the 34 health care unicorns (privately held startup companies valued at over $1 billion) in the United States, there are three in the primary care and care coordination space. We have K Health, an app-based telehealth service that uses artificial intelligence (AI) to help users to see how doctors typically diagnose people with similar symptoms and biomarkers. Village MD offers value-based primary care at traditional free-standing clinics, at Walgreens clinics, at home, and via virtual visits. And Cityblock Health coordinates integrated social, behavioral, and medical care for high-cost, impoverished patients, through technology and face-to-face interventions.
These changes—consumer preference for convenience, payer preference for the increased value of integrated models, and the acceptance of primary care delivered by telehealth—have changed the landscape for specialty provider organizations considering adding or expanding primary care services. And in this issue of the OPEN MINDS Management Newsletter, we’re focused on organizations that are making primary care services work for the consumers they serve. What is apparent is that there is no “one size fits all” model.
In this issue we take a look at seven approaches to integrated care—the fully integrated collaborative care approach, the colocation of behavioral and physical health services, the certified community behavioral health clinics program approach, the federally qualified health center or community health center approach, the primary care/behavioral health care retail center approach, virtual behavioral health in primary care, and virtual primary care in specialty systems (see Seven Specialty Provider Organization Approaches To Providing Consumers With A “Whole Person” Integrated Care Experience). And we profile some successful programs implementing several of these approaches. Dr. Rabinowitz provides pointers for how to take on the challenges of staffing, technology, workflows, and revenue cycle management while adopting integrated care models (see Delivering Whole Person Care: Avoiding The Pitfalls Of Integrating Primary Care Into Community-Based Mental Health Centers). See how you stack up to your peers on the integration journey in Where Are You With Integration: Snapshot Of Specialty Provider Organizations. We hope this landscape assessment will be of use in your executive team discussions on how to become a “next generation” provider of comprehensive health care services.