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Cohort study
Team-based primary care with integrated mental health is associated with higher quality of care, lower usage and lower payments received by the delivery system
  1. Aimee F English
  1. Correspondence to : Dr Aimee F English, University of Colorado Family Medicine Residency, 3055 Roslyn St, Suite 100, Denver, CO 80238, USA; aimee.english{at}ucdenver.edu

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Context

Team-based care (TBC) is commonly seen as a foundational element of successful practice transformation.1 Mental health integration in primary care has been shown to be clinically effective, but historically limited by organisational and financial barriers.2 As a fully integrated health delivery system, Intermountain Healthcare has internally developed and implemented its Intermountain Mental Health Integration (MHI) programme since 2000. This study compares measures of healthcare quality and usage as well as actual payments received and programme investment costs for patients receiving care in TBC/mental health integration practices versus those in usual care.

Methods

This was a retrospective, longitudinal, cohort study of adult patients (n=113 452) who received primary care at Intermountain Healthcare primary care practices. Patients ≥18 years old with a continuity relationship with Intermountain (defined as ≥1 primary care visit between 2003 and 2005 and ≥1 encounter annually with the delivery system thereafter) were included. The intervention was exposure to primary care in TBC practices versus traditional practice management (TPM) practices. TBC practices (n=27) achieved level 3 NCQA recognition and 5 MHI components (assessed by internally developed scorecard). TPM (n=75) practices had no components of MHI or NCQA elements in team care. During the assessment period from 2010 to 2013, seven quality measures, six usage measures, payments to the delivery system and investment costs were compared.

Findings

Four quality measures assessed were significantly better in the intervention group, most notably self-care plan documentation (48.4% for TBC vs 8.7% for TPM; OR 5.59 (95% CI 4.27 to 7.33), p<0.001). Decreased usage was seen across four measures, most notably ED visits per 100 person-years (18.1 for TBC vs 23.5 for TPM; IRR, 0.77 (95% CI 0.74 to 0.80), p<0.001). Actual payments received were lower with intervention practices ($3400.63 for TBC vs $3515.71 for TPM; β, −$115.09 (95% CI −$199.64 to −$30.54), p=0.008). The cost of implementing the MHI programme was $9.86 per patient per year during the study period ($22.19 at full implementation).

Commentary

This study suggests there is some increased quality and decreased usage associated with a team-based model with integrated mental health. It also shows a reduction in actual payments received when performed within a fully integrated healthcare delivery system in the absence of explicitly linking payment with value. Evaluation of practice transformation initiatives is inherently complex, and overall, this study does well in addressing that complexity, for example, by measuring exposure to the intervention over the assessment period and adjusting the comparison to account for patients who received care in both practice types. What is novel about this study is its large sample size, 4-year study period, use of an internally developed MHI scorecard to assess degree of transformation (in addition to some NCQA elements)3 and the setting of a fully integrated care delivery system.

Additionally, this study shows that TBC with integrated mental health was associated with decreased usage and decreased revenue. Care coordination per member per month and quality incentive payments were only available for Intermountain health plan enrolees (1/5 of the total person-years), so this was seen as an implementation cost. A programme that included a shift towards value-based payments or one with payments for non-face-to-face encounters may see different results.

This study addresses very relevant outcomes to healthcare systems—quality, usage and cost. It would be strengthened by including measures of patient satisfaction, and staff and provider burnout. Additionally, when process measures were used to assess quality (eg, depression screening rate), the study could have been strengthened by also measuring related patient-oriented outcomes (eg, depression symptom scores).

Implications for practice

For providers, this study may increase realisation that team-based primary care with mental health integration is of value for patients. For healthcare delivery systems, this study may not spur change as payment reform that rewards value may still be needed to allow programmes such as this one to be financially sustainable.

References

Footnotes

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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