Screen Shot 2014-03-26 at 12.08.48 PMby Sandra Wilkniss, PhD, and Pat Deleon, JD, PhD

Over the next five to ten years psychology will experience the steady implementation of President Obama’s landmark health care reform legislation, the Patient Protection and Affordable Care Act [PPACA]. The President’s vision is fundamentally patient-centered, rather than provider-centric, and provides the Department of Health and Human Services (HHS) and the States with considerable flexibility to meet overarching national goals. From a public policy frame of reference, we will see the revitalization of the states as “living laboratories” of social reform. It is estimated that at least 32+ million currently uninsured Americans will obtain primary care coverage by 2014, although some experts predict a significantly higher number of nearly 50 million. With an aging provider workforce and concerted efforts in the newly elected House of Representatives to repeal ObamaCare at all costs, who will be available to provide these necessary services? And, what role will psychology ultimately play?

Accountable Care Organizations: What Are They?

The Accountable Care Organizations (ACOs) concept is among the most visible health care payment and delivery system models provided for in the now one-year old health reform law [P.L. 111-148]. ACOs have the dual purpose of realigning the provider payment system and retooling performance measurement approaches to ensure accountability, thereby shifting health care practice from a volume and intensity-based system to one that supports coordinated, high quality, and cost-effective care. Specifically, this section of the federal statute focuses upon promoting accountability for Medicare beneficiaries through voluntary participation in the Medicare Shared Savings Program (which will be created before January 1, 2012), via ACOs. The law defines ACOs as provider-led organizations, which may include hospitals, that share with payers accountability for care quality and cost containment and address the continuum of care and specialty needs for a patient population (of at least 5,000). Accountability is fostered primarily through cost and quality transparency and economic rewards shared by providers and payers when costs are reduced. The initiative will be implemented in January, 2012 and the Centers for Medicare and Medicaid Services (CMS) regulations are scheduled to come out in the near future. Providers, executives, and even health insurance companies are scrambling to design and establish ACOs, but structural details are still forthcoming.

ACOs have been characterized as the elusive unicorn – everyone seems to know what it looks like, but nobody’s actually seen one. Ultimately, the shape of ACOs will likely depend on a variety of factors including proposed CMS regulations and the related financing environment, relevant statutory definitions, and, in some cases, state practice acts. High stakeholder demands for flexibility and regulation nimbleness – until we learn what works – indicate that the debate around which entities will qualify will likely be ongoing. Leading experts do agree that four general models capture the essential elements of potential ACOs: an integrated delivery system; multi-specialty group practice; physician-hospital organization; and independent practice association. Historically, whenever any complex legislation, such as PPACA, has been enacted, over the next couple of years the committees with jurisdiction will recommend bipartisan “technical fixes” in order to smooth the implementation process, based upon practical experiences. Unfortunately, in the current Congressional climate such necessary legislative oversight seems unlikely.

Exciting Opportunities For Psychology

As the nature of ACOs is still evolving, it is important for organized psychology to affirmatively enter into the policy debate, at both the local and federal level, especially in determining the fate of non-physician providers and non-physician led practices. Will the ACOs be broadly defined and horizontally-organized including behavioral health providers as equal partners (or leaders)? Or, will they take on a physician-dominated hierarchical structure? As the four models above indicate, ACOs are not necessarily physician focused. They address all facets of a patient’s condition and foster shared accountability for overall quality and costs encompassing a larger range of providers.

With respect to the quality and integration side of the equation, the opportunities for psychology are clear. First, the role of the behavioral health provider will only become more essential. Mental health and substance-use problems are the leading cause of combined disability and death of women and second highest in men in the United States. Currently, only 7% of health care expenditures go to mental health treatment. This, despite the fact that over 70% of people dually eligible for Medicare and Medicaid have mental illness. Further, we know that 67% of adults and more than 92% of people with serious mental illness do not receive effective mental health and substance-use treatment. This is due to multiple variables that affect success and acceptability of care, but these statistics highlight the type of patient who will be served in ACOs. As with health homes (or “medical homes”), the ACO concept emphasizes prevention, early identification and intervention, chronic disease management, person-centered approaches, and implies adoption of evidence-based practice. There are now several compelling examples of high value integrated care interventions targeting mental health and substance-use in elderly adults that include psychological interventions/supervision. Two examples of cost-effective models with good outcomes include the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) and the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) programs.

Second, quality care depends upon access to the well-implemented, cost-effective best practices. Psychologists can fill a knowledge and skill void here, in a number of ways. They include: a.) recruiting, training, and retraining a competent behavioral health workforce; b.) developing and studying effective implementation and service delivery models including: c.) screening and assessment technology: instrument selection and construction, administration and interpretation, training, supervision, and research; d.) bridging science and service and facilitating the dynamic, iterative learning process resulting from their interplay; e.) client- and family-centered shared decision making: intervention design, training and supervision, and basic and applied research; f.) competency in developmental psychology across the lifespan; specifically in older adults and adults with psychiatric disabilities: training and supervision, development of selection tools and interventions, and conducting and translating research; g.) developing decisional algorithms for referral to specialty services; and h.) implementing outcome-driven, culturally-informed, evidence-based intervention strategies. In addition, high quality, multidisciplinary care and cross-training is rife with interest for psychologists in both practice and research fronts. Some examples include: standardized screening; outcome measures; data collection; analysis and interpretation in the context of multiple literatures; training of staff on behavioral health evidence-based practices and process; patient engagement; and, of course, conducting research and translating findings into practice top the list of examples. Finally, coordinating communication and treatment planning across a multidisciplinary team requires appreciation for the overlapping and unique knowledge bases and skill sets of each participating discipline and managing group dynamics in the context of delivering quality-based care. Regardless of the fate (or face) of ACOs, it is clear that psychologists can and must play a critical role in their development and successful implementation. ACOs are being developed within the policy context of reports by the Institute of Medicine (IOM) that excessive costs stemming from waste and inefficiency within the nation’s health care system currently total between $750-$785 billion annually.


Sandra Wilkniss, APA/AAAS Congressional Fellow

Pat DeLeon, former APA President