The new CMS plan to align primary care with behavioral health

The connection between behavioral health and physical health is well-documented. Physical health is greatly affected by such behaviors as smoking, substance abuse, poor diet, lack of exercise, insufficient sleep, etc. In addition, mental health issues and social determinants of health (SDoH), such as lack of housing and/or transportation, language barriers and food insecurity, impact health.

Primary care physicians are well aware of these problems, but often are unable to do anything about them due to a lack of resources. These issues are particularly pronounced in underserved populations, such as rural Americans, for whom behavioral health support and services either are unavailable or not integrated with their primary care.

According to the National Institute of Mental Health, “Though the prevalence of serious mental illness and most psychiatric disorders is similar between U.S. adults living in rural and urban areas, adults residing in rural geographic locations receive mental health treatment less frequently and often with providers with less specialized training, when compared to those residing in metropolitan locations.”

In an effort to more closely integrate behavioral health into primary care for these populations, the Centers for Medicare and Medicaid Services (CMS) has created a primary care reimbursement model to promote a more equitable, innovative, and team-based approach. Launching Jan. 1, 2025, the voluntary ACO Primary Care (PC) Flex Model aims to address health equity and drive better outcomes for underserved populations by increasing access to higher-quality primary care, including unique services, such as behavioral health integration. CMS hopes it will grow participation in ACOs and the Medicare Shared Savings Program.

The model’s new Prospective Primary Care Payment (PPCP) option will shift reimbursement for primary care away from the fee-for-service, visit-based payment model, which should be attractive to low-revenue ACOs with Federally Qualified Health Center and Rural Health Clinic participants. 

Here’s how it works: An ACO’s PPCP rate won’t be based on the ACO’s historical spending, but on the average primary care spending in the county in which it’s located. This allows the model to pay an ACO the same rate for a specific patient in a region, before considering social and clinical risk factors. As a result, providers with patterns of inappropriately low spending for underserved areas and populations can be paid more. The PPCP also includes payment enhancements and adjustments to the county rate, providing additional resources to providers caring for underserved populations.

The ACO PC Flex Model also will help increase health equity for rural Americans and other underserved populations by:

• Increasing access to higher-quality primary care, which can include behavioral health integration  
• Incentivizing the formation of new ACOs and supporting existing low-revenue ACOs
• Increasing the number of Medicare recipients in ACOs by encouraging Federally Qualified Health Centers and Rural Health Clinics to either form or join ACOs
• Directing more healthcare dollars toward underserved populations
• Providing primary care practices with the flexible funding needed to improve care coordination and identify and address people’s unmet health-related social needs 

The PPCP option should be attractive to low-revenue rural ACOs and providers that could benefit from a flexible but predictable revenue stream and that want a better alignment between primary care providers and behavioral health services for their underserved patient populations.

Overcoming obstacles to primary care/behavioral health alignment

PC Flex and other value-based care (VBC) payment models offer a framework for collaborative, team-based care across various stakeholders, including primary care providers, clinical and behavioral health specialists, community-based organizations and payers.

Humana reports that VBC practices are hiring or partnering with behavioral health specialists and stationing them at primary care centers where they can quickly help patients in need.

Last fall, Cigna’s Evernorth Health Services launched a VBC management program for its behavioral health network that measures how well treatments produce positive outcomes. The goal is to align providers and payers on treatments that drive improvements in care, cost, and collaboration while removing administrative burdens for providers.

But integrating primary and behavioral care remains a huge challenge for some healthcare organizations, particularly low-revenue providers in rural areas. They might lack the funding or resources to fully integrate the two types of care. Another common obstacle is a shortage of qualified behavioral health professionals in the service area. 

In addition, an outdated or insufficient digital infrastructure can make aligning primary care with behavioral health services difficult or even impossible. Overcoming this requires implementing a scalable, cloud-based digital infrastructure that creates a many-to-many network of participants. 

This network could include behavioral health providers and community-based organizations, many of which have low digital capabilities but expect frictionless reimbursement. In addition, a robust analytics platform running on top of a scalable digital infrastructure can provide the performance metrics essential for the success of VBC contracts.

Conclusion

Integrating primary care and behavioral health is critical to achieving the best possible outcomes for patients. Reimbursement models that align primary care with behavioral health offer low-income provider organizations serving rural Americans and other vulnerable populations an opportunity to enhance coordination, improve outcomes, and generate badly needed revenue. 

To fully align primary care with behavioral health services, care organizations need a scalable digital infrastructure that can handle the demands of a many-to-many collaborative care network.