Countdown to health care reform
By Communications staff
April 11, 2013—“You are going to be valued to the extent that you can bring value to the big challenges facing our country,” Mark B. McClellan, MPA, MD, PhD, senior fellow, director of the Engelberg Center for Health Care Reform and Leonard D. Schaeffer chair in Health Policy Studies at the Brookings Institution told participants at the opening session of the 30th annual State Leadership Conference in Washington, D.C., on March 9.
The opening session, which featured an introductory address from APA Executive Director for Professional Practice Katherine C. Nordal, PhD, along with the keynote speech from McClellan, marked the beginning of four days of advocacy training, education and networking focused on health care reform and the critical need for psychology to get engaged. Nearly 500 psychology leaders from throughout the U.S. and Canada participated in this year’s conference, sponsored by the American Psychological Association Practice Organization (APAPO) and APA.
Many of the challenges in the health care system are about achieving better care at lower cost, said McClellan. Health care spending continues to drive general gross domestic product (GDP) spending, and McClellan predicts the best approach to addressing health care cost challenges involves moving away the traditional approach of reducing payment rates and limiting coverage.
McClellan sees a “lack of alignment between where psychological practice can… get to making a difference in our health care system in terms of better outcomes at a lower cost, and where we are now.” In order to achieve “aligned financing,” practitioners will need to help identify ways to reduce overall costs while improving patient outcomes.
McClellan believes leadership from clinicians and a move toward coordination of care are part of the solution. There is growing evidence that integrated primary care and mental health care, along with specialty mental health care, can help achieve better overall health and avoid costly complications. According to McClellan, more individualized patient processes and diverse services like group therapy, distance services, focused interventions and working with teams of practitioners in mental health care settings can create a pathway to real health care reform that the public will support.
Educating the American public about being better partners with their providers and taking personal responsibility for their health outcomes also will be key.
McClellan highlighted four issues related to reform:
Data, measurement and evidence. “Measurement is the foundation for many of these reforms,” said McClellan. Collection of data such as number of office visits and recidivism rates through basic screening and submitted claims is evolving into clinical measures like depression screening to track additional expenditure and resource use, and finally longitudinal outcome measures that report condition-specific outcomes such as functional status or change in risk factors. Though mental health outcomes are harder to measure, better measures will support better reforms, says McClellan.
Provider payment. Once adequate measurement is established, the system will start paying providers based on achieving better results at a lower cost, rather than volume and intensity of services. This will be implemented through a step-by-step approach that identifies measurable opportunities for clinical improvement and builds on it year after year.
Benefit design. When given the option, most people choose a tiered structure of benefits. The challenge is building that structure into benefit designs to promote growth and provide more access to mental health services.
Insurance choice. McClellan noted the importance of patient choice. Part of ensuring choice will involve allowing for risk adjustment for people with high expected costs. McClellan predicts that new health insurance plans won’t have high enrollment right off the bat. So there will need to be incentives for insurance companies — such as risk adjustment — to provide better mental health coverage.
Several obstacles to reform exist. State regulatory barriers include corporate practice of medicine laws that prohibit multidisciplinary practice formation. Another barrier is inadequate or no payment for services in an era of tightening resources. Finally, McClellan noted limited evidence to date on system-wide savings from better mental health care.
Further, public opinion could also stand in the way of rapid reform. According to McClellan, the public is anxious about health care reforms that reduce cost or cause changes in benefits. Rather than trusting government or insurers, McClellan said, “The people they trust are you: psychologists, physicians, nurses and others involved in care.”
Though there are numerous obstacles, McClellan believes clinician leadership could provide vision for real reform that public will support. “It is a very challenging environment,” said McClellan. “The reason I’d be optimistic about this is there is so much unmet medical need and so much opportunity for improving health outcomes while lowering costs as a result of getting mental health services more effectively integrated into the delivery of care.”
Nordal’s speech also addressed continuing challenges to practice in the changing landscape of the health care system. Increasing demands for cost containment coupled with declining levels of reimbursement and limits on service delivery, stricter regulatory requirements that drive up the cost of maintaining a practice, and more competition in the psychotherapy marketplace from growing numbers of masters-level mental health providers all present challenges for practitioners.
In order to meet these challenges and be active participants in emerging integrated care systems, Nordal stressed that psychologists will need to promote the “value-add” they bring to the system. “We are a highly educated and talented discipline,” said Nordal. “We need to identify and create opportunities to make others aware of the skills and strengths we can contribute to health care.”
Katherine C. Nordal, PhD, discusses challenges and opportunities in the current health care reform environment
Mark B. McClellan, MPA, MD, PhD explains how the economics of health care will drive system changes and how psychologists will be affected