BACKGROUND
Specialty mental health support services are underprovided despite ample evidence supporting their use 1 2 and ongoing efforts to encourage adoption.3 Team based support services such as assertive community treatment, supported employment, and family psychoeducation have been shown to improve outcomes and reduce hospitalizations among individuals with serious mental illness. 4 5 6 Accountable Care Organization (ACO) contracts may facilitate access to such services by contracting with behavioral health providers that provide these services, adopting technology or policies to facilitate data sharing, or by pursuing informal referral arrangements with providers that do offer such services.7,8,9 Because ACO contracts may yield savings (or losses) to provider organizations based on total cost of care and quality, these organizations have incentives to facilitate access to such services for individuals with serious and persistent mental illness.10 Furthermore, understanding whether ACOs, early adopters of payment and delivery reforms, have the ability to refer patients to specialty mental health services may shed light on barriers and facilitators to accessing these services.
METHODS
Data
We conducted a cross-sectional analysis of the 2017–2018 National Survey of ACOs (NSACO) described elsewhere. 11,12,13 This fourth wave survey of organization leaders asked about ACO organizational characteristics, data sharing capability, and ability to refer to specific evidence-based mental health support services14 (Table 1). In this fourth wave of the survey, questions were tested using three cognitive interviews, and survey wording was revised when necessary for clarity. Earlier waves of the survey underwent extensive cognitive testing and piloting, and many questions related to ACO characteristics are overlapping. We fielded web and paper versions of the instrument to improve response rate. Although the paper version contained a subset of questions, most respondents (80%) completed the survey online (eFigure1). The Dartmouth College Committee for the Protection of Human Subjects approved the survey protocol.
Table 1:
Relevant survey questions, NSACO 2017–2018
|
Information
sharing We are interested in sharing of patient information regarding behavioral health treatment. Do behavioral health clinicians and non-behavioral health clinicians participating in the ACO share patient information (e.g., through consultation or through an EHR)? (yes/no) • Behavioral health diagnoses • Behavioral health prescriptions • Information related to physical health |
|
Access to specialty mental health
services Can clinicians in your ACO offer or refer patients with serious mental illness to the following support services? (yes/no)* • Supported employment (vocational services for serious mental illness) • Assertive community treatment (ACT) • Integrated Dual Disorder Treatment (e.g., for co-occurring mental illness and addiction) • Family psychoeducation • Illness Management and Recovery Services |
|
Treatment for first episode
psychosis Do clinicians in your ACO have a standardized process for identifying patients with first episode psychosis or schizophrenia? Please select one response. • Yes, most or all clinicians • Yes, some clinicians • No, no clinicians Do clinicians in your ACO have a referral or tracking process for patients with first episode psychosis? Please select one response. • Yes, works well • Yes, needs improvement • No We categorized ‘some clinicians’ or ‘most or all clinicians’ (or ‘Yes, works well’ or ‘Yes, needs improvement‘) as an affirmative response. A single three-level variable was created indicating processes: 1) for both identification and referral or tracking; 2) for identification only; or 3) no process for identification, tracking or referral. |
| For each type of provider organization, are
any of the following participating in your largest ACO contract?
(yes/no)† • Community mental health centers • Other behavioral health groups |
Notes
Question not asked in paper survey.
Question also included participation by two treatment providers not included in this study: Addiction treatment providers; Federally Qualified Health Centers.
Additional information about the NSACO survey is available online https://sites.dartmouth.edu/nsaco/
Measures
We considered whether behavioral health and non-behavioral health clinicians participating in the ACO shared patient information regarding behavioral health prescriptions, diagnoses and physical health treatment information. We then assessed the ability of providers to refer to five evidence-based specialty mental health services: assertive community treatment; family psychoeducation; illness, management, and recovery services; integrated dual disorder treatment; and supported employment. 15 16 17 18 19 20 Service definitions and evidence supporting their efficacy is in eTable 1. In most cases we did not provide specific definitions for these services in the survey question(Table 1), allowing respondents to assess based on their knowledge of these programs. Because the paper survey excluded the referral question, the sample size for these questions is slightly smaller. Finally, we assessed whether ACOs reported having a standardized process for identifying and tracking patients with first episode psychosis (FEP). For all outcomes, we categorized missing data as a negative response – this affected 14–21 (3–6%) respondents. All correlation results are robust to coding these responses as missing or positive.
Organizational characteristics studied included size (large, or ACOs in the top quartile for number of physician full time equivalents), whether the ACO was physician-led (versus those led by hospitals, joint hospital-physician group, coalition-led, or led by state-region or county), Census region, whether the state where the largest number of ACO beneficiaries reside expanded Medicaid by 201721 and whether the ACO reported including community mental health centers (CMHCs) or behavioral health provider groups as participating providers.
Methods
Weights applied matched the sample to the sample frame of ACOs and adjusted for survey nonresponse. Frequencies were calculated and χ2 tests were performed with statistical significance set to p<0.05 (2-sided).
RESULTS
Of 862 eligible organizations, 478 ACOs (55%) returned a survey. We omit the 59 ACOs that did not answer at least half of predefined core questions noted in eFigure 1 (complete rate=49%22) and the 7 ACOs that did not answer the questions related to services for those with serious mental illness, yielding 412 ACOs for analysis.
In the analysis sample, about half of ACOs were physician-led (52%), 37% of ACOs served states in the South and 63% served Medicaid expansion states. About one quarter (28%) included either a CMHC or a behavioral health provider group (Table 2).
Table 2.
Characteristics of Study Sample (weighted %) (N=412)a
| Full Sample (weighted %) | |
|---|---|
| Full sample | 100% |
| Organization Characteristics | |
| Size, number of physicians, % in: | |
| Top quartile (757 or more physicians) | 27.5% |
| Not top quartile (under 757 physicians) | 72.5% |
| Physician led | |
| Physician led | 51.5% |
| Not physician led b | 48.5% |
| Region | |
| Northeast | 19.6% |
| South | 37.2% |
| Midwest | 23.0% |
| West | 20.3% |
| Medicaid expansion state (as of 2017) c | |
| Medicaid Expansion state | 63.2% |
| Not Medicaid expansion state | 36.8% |
| Providers participating in ACO contract | |
| CMHC | |
| Yes | 12.1% |
| No | 87.9% |
| Behavioral health provider group | |
| Yes | 22.2% |
| No | 77.8% |
| Either a community mental health center or a behavioral health provider group | |
| Yes | 27.6% |
| No | 72.4% |
ACOs were omitted if relevant questions had missing data. Physician led, n=417, Providers participating in ACO contract, n=407.
Not physician led includes ACOs who were led by hospitals, led by a joint hospital-physician group, were coalition-led, were led by state-region or county, or other.
State determined by whether the state served by the ACO expanded Medicaid by 2017
Table 3 indicates most ACO respondents reported sharing patient information between behavioral and non-behavioral health clinicians including: behavioral health prescriptions (66.0%), behavioral health diagnoses (67.0%), physical health treatment (73.9%). Information sharing was more common among large and physician-led ACOs.
Table 3:
Information sharing (weighted %)
| Behavioral Health Prescriptions (N=412) | p-value | Behavioral Health Diagnoses (N=412) | p-value | Physical Health Treatment (N=412) | p-value | |
|---|---|---|---|---|---|---|
| Full sample | 66.0% | 67.0% | 73.9% | |||
| Organization characteristics a | ||||||
| Size, number of physicians, % in: | .04 | .12 | .047 | |||
| Top quartile (757 or more physicians) | 75.8* | 74.2 | 82.5* | |||
| Quartiles 1, 2, or 3 (under 757 physicians) | 62.3 | 64.2 | 70.6 | |||
| Physician led | <.01 | <.01 | .03 | |||
| Physician led | 59.4** | 59.5** | 68.6* | |||
| Not physician led b | 73.1 | 75.0 | 79.4 | |||
| Region (%) c | ||||||
| Northeast | 67.4 | .82 | 70.0 | .62 | 75.8 | .74 |
| South | 56.0*** | <.01 | 54.6*** | p<.001 | 65.3** | .01 |
| Midwest | 72.9 | .13 | 75.5 | .06 | 80.0 | .14 |
| West | 75.2 | .08 | 76.9 | .06 | 81.0 | .14 |
| Medicaid expansion state (as of 2017) | .02 | .01 | .13 | |||
| Medicaid Expansion state | 70.6* | 71.9* | 76.7 | |||
| Not Medicaid expansion state | 58.0 | 58.5 | 69.0 | |||
| Providers participating in ACO contract | ||||||
| Community mental health center | .17 | .21 | .011 | |||
| Yes | 78.0 | 78.0 | 93.0* | |||
| No | 65.5 | 66.6 | 71.3 | |||
| Behavioral health provider group | .02 | .03 | .005 | |||
| Yes | 79.7* | 79.7* | 88.9** | |||
| No | 63.4 | 64.6 | 69.8 | |||
| Either a community mental health center or a behavioral health provider group | .003 | .005 | P<.001 | |||
| Yes | 81.3** | 81.3** | 90.4*** | |||
| No | 61.5 | 62.9 | 69.0 |
p-values indicate results from chi square tests of differences between rows (within ACO characteristic)
p<.001
p<.01
p<.05
Not physician led includes ACOs who were led by hospitals, led by a joint hospital-physician group, were coalition-led, were led by state-region or county, or other
p-values indicate results from chi square tests of whether the percent of ACOs that shared information in the noted region was different from percent that shared information in all other regions combined (eg, Northeast versus not in Northeast).
Providers had the ability to offer or refer to specialty mental health services in about half of ACOs, with integrated dual disorder treatment most commonly offered (57.1%) and illness, management, and recovery services least likely to be offered (41.0%); Table 4. The most common predictor of offering services, inclusion of CMHCs or behavioral health provider groups as participating ACO providers, was positively associated with four of the five services studied.
Table 4.
Ability to offer or refer patients to mental health support services (weighted %) (N=328)
| Supported employment (N=328) | p-value | Family Psycho-education (N=328) | p-value | Integrated Dual Disorder Treatment (N=328) | p-value | Assertive Community Treatment (N=328) | p-value | Illness, Management, and Recovery Services (N=328) | p-value | |
|---|---|---|---|---|---|---|---|---|---|---|
| Full sample | 46.3% | 49.1 | 57.1 | 46.8 | 41.0 | |||||
| Organization characteristics | ||||||||||
| Size, number of physicians, % in: | .15 | .04 | .02 | .17 | .08 | |||||
| Top quartile (757 or more physicians) | 54.5 | 61.3* | 69.8* | 54.6 | 51.0 | |||||
| Not top quartile (under 757 physicians) | 43.4 | 44.8 | 52.6 | 44.0 | 37.5 | |||||
| Physician led | .17 | .19 | .24 | .63 | .81 | |||||
| Physician led | 42.2 | 45.2 | 53.6 | 45.3 | 40.3 | |||||
| Not physician led | 50.9 | 53.5 | 61.0 | 48.4 | 41.8 | |||||
| Region | ||||||||||
| Northeast | 46.5 | .98 | 52.9 | .57 | 65.0 | .22 | 42.2 | .48 | 47.1 | .35 |
| South | 39.2 | .08 | 48.1 | .81 | 54.7 | .55 | 44.1 | .50 | 40.7 | .93 |
| Midwest | 52.5 | .26 | 43.6 | .32 | 49.8 | .17 | 51.5 | .39 | 36.1 | .36 |
| West | 52.8 | .34 | 53.6 | .51 | 61.8 | .48 | 51.6 | .48 | 40.9 | .98 |
| Medicaid expansion state | .35 | .97 | .53 | .41 | .79 | |||||
| Medicaid Expansion state | 48.5 | 49.0 | 58.6 | 48.7 | 41.7 | |||||
| Not Medicaid expansion state | 42.5 | 49.3 | 54.6 | 43.3 | 40.0 | |||||
| Providers participating in ACO contract | ||||||||||
| Community mental health center | .011 | .14 | .51 | .007 | .03 | |||||
| Yes | 71.7** | 63.9 | 63.8 | 72.7** | 61.7* | |||||
| No | 43.5 | 47.5 | 56.5 | 43.7 | 38.6 | |||||
| Behavioral health provider group | .32 | .015 | .04 | .92 | .39 | |||||
| Yes | 53.4 | 65.8* | 71.3* | 46.2 | 46.9 | |||||
| No | 44.9 | 45.1 | 53.7 | 46.9 | 39.7 | |||||
| Either a community mental health center or a behavioral health provider group | .03 | .004 | .012 | .29 | .09 | |||||
| Yes | 59.9* | 66.5** | 72.0* | 53.1 | 51.1 | |||||
| No | 42.3 | 43.7 | 52.5 | 44.8 | 37.9 |
p-values indicate results from chi square tests of differences between rows (within ACO characteristic)
p<.001
p<.01
p<.05
Not physician led includes ACOs who were led by hospitals, led by a joint hospital-physician group, were coalition-led, were led by state-region or county, or other
p-values indicate results from chi square tests of whether the percent of ACOs in the noted region was different from percent in all other regions combined (eg, Northeast versus not in Northeast.
Although most ACOs (55.3%) reported identifying first episode psychosis patients, only 37.7% reported tracking or referring these patients (Table 5). No organizational characteristic studied was significantly correlated with the presence of these programs.
Table 5:
Standardized process for identifying and tracking individuals with first episode psychosis (weighted %)(N=412)
| Report process for identification (55.3%) | Report no process for identification or tracking | p-value | ||
|---|---|---|---|---|
| Report process for referral or tracking | No process for referral or tracking | |||
| Full sample | 37.7% | 17.6% | 44.7% | |
| Organization Characteristics a | ||||
| Size, number of physicians, % in: | .888 | |||
| Top quartile (757 or more physicians) | 35.7 | 17.3 | 47.0 | |
| Not top quartile (under 757 physicians) | 38.5 | 17.8 | 43.8 | |
| Physician led | .972 | |||
| Physician led | 37.6 | 17.2 | 45.1 | |
| Not physician ledb | 37.8 | 18.1 | 44.2 | |
| Region c | ||||
| Northeast | 33.1 | 22.5 | 44.4 | .56 |
| South | 35.0 | 21.0 | 43.9 | .45 |
| Midwest | 39.2 | 11.5 | 49.4 | .23 |
| West | 45.4 | 13.7 | 41.0 | .37 |
| Medicaid expansion state (as of 2017) | .76 | |||
| Medicaid Expansion state | 38.6 | 16.5 | 45.0 | |
| Not Medicaid expansion state | 36.2 | 19.6 | 44.2 | |
| Providers participating in ACO contract | ||||
| Community mental health center | .53 | |||
| Yes | 46.9 | 12.8 | 40.4 | |
| No | 37.0 | 18.1 | 45.9 | |
| Behavioral health provider group | .72 | |||
| Yes | 41.6 | 18.4 | 40.0 | |
| No | 37.2 | 17.2 | 45.6 | |
| Either a community mental health center or a behavioral health provider group | .51 | |||
| Yes | 43.3 | 17.2 | 39.5 | |
| No | 36.2 | 17.6 | 46.2 | |
Respondents were asked, “Do clinicians in your ACO have a standardized process for identifying patients with first episode psychosis or schizophrenia?” Respondents answering affirmatively were asked, “Do clinicians in your ACO have a referral or tracking process for patients with first episode psychosis?”
p-values indicate results from chi square tests of differences in distribution between rows (within ACO characteristic)
Not physician led includes ACOs who were led by hospitals, led by a joint hospital-physician group, were coalition-led, were led by state-region or county, or other
p-values indicate results from chi square tests of whether the distribution of ACOs in the noted region was different from distribution in all other regions combined (eg, Northeast versus not in Northeast)
DISCUSSION
Most prior evaluations of alternative payment models and behavioral health characterize quality of depression treatment.23 In this study, we consider evidence-based structural outcome measures related to support services 24 25 26 27 28 29 recommended by the Substance Abuse and Mental Health Services Administration (SAMHSA) that are likely to benefit patients with serious mental illness. Fewer than half of ACOs reported that providers have the ability to either offer or refer patients to specialty mental health support services. That relatively few providers were able to refer patients to these services is disappointing, although rates may be even lower among non-ACO providers. It may be that nearby behavioral health providers do not offer these services and ACOs are unlikely or unable to induce centers to offer these programs due to high startup costs and because these programs are likely to help relatively few ACO-attributed patients.
One consistent predictor of the outcomes studied is a formal relationship with a behavioral health provider group or CMHC, although only 27.6% of ACOs report such a relationship. One reason for the lack of formal relationships may be the strong incentives faced by capitated providers or commercial insurers to create provider networks limiting those specialties (behavioral health, oncology) likely to attract expensive patients for whom savings may be hard to achieve.30 Even among ACOs with formal relationships with specialty mental health providers, ability to refer to the services studied ranges from 51.1% to 72.0%.
Limitations of this study include that we do not directly observe services offered by the ACO, response bias may reduce generalizability, survey questions were not formally validated, the availability of a single wave of data, and possible changes in services offered since the data were collected in 2017–2018.
CONCLUSION
Linkages to specialty mental health support services are limited, even among organizations likely to lead innovations in population health, ACO participants. Complementary payment models to encourage formal relationships with specialty mental health organizations may be needed, in addition to incentives or resources to encourage adoption of support services.
Supplementary Material
Funding:
This research was funded by the National Institute of Mental Health (R01MH109531 and R01MH106635). Contents are solely the responsibility of the authors and do not necessarily reflect the views the National Institute of Health.
Footnotes
Authors have no competing interests to report.
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Contributor Information
Susan H Busch, Yale School of Public Health, Department of Health Policy and Management, 60 College Street; Suite 300B, New Haven CT 06520.
Marisa Tomaino, Geisel School of Medicine at Dartmouth College.
Helen Newton, Yale School of Public Health.
Ellen Meara, Harvard TH Chan School of Public Health; Geisel School of Medicine at Dartmouth College.
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