Among adults enrolled in an integrated health care system, receipt of primary care at integrated team-based care practices compared with traditional practice management practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system, according to a study appearing in the August 23/30 issue of JAMA.
Limited evidence is available to support the utility of medical home and accountable care integration with mental health and primary care teams. Brenda Reiss-Brennan, Ph.D., A.P.R.N., of Intermountain Healthcare, Salt Lake City, and colleagues assessed the association of integrating physical and mental health over time in team-based care (TBC) practices with patient outcomes and costs. The study included adult patients who received primary care at 113 Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and traditional practice management (TPM) practices.
Of the 113 practices observed over the study period (2010- 2013), 102 practices were classified annually as TBC (n = 27) or TPM (n = 75). The analysis included 113,452 patients (average age, 56 years; women, 59 percent). The researchers found that patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46 percent for TBC vs 24 percent for TPM), adherence to a diabetes care bundle (25 percent for TBC vs 20 percent for TPM), and documentation of self-care plans (48 percent for TBC vs 8.7 percent for TPM), lower proportion of patients with controlled hypertension (85 percent for TBC vs 98 percent for TPM), and no significant differences in documentation of advanced directives (9.6 percent for TBC vs 9.9 percent for TPM).
Rates of health care utilization were lower for TBC patients compared with TPM patients for emergency department visits, hospital admissions, ambulatory care sensitive visits and admissions, and primary care physician encounters, with no significant difference in visits to urgent care facilities and visits to specialty care physicians.
Payments to the delivery system were lower in the TBC group vs the TPM group ($3,401 for TBC vs $3,516 for TPM) and were less than investment costs of the TBC program.
"The study suggests the value of coordinated team relationships within a delivery system emphasizing the integration of physical and mental health care," the authors write.
Editorial: Integrated Behavioral and Primary Care -- What Is the Real Cost?
"This study has several important implications. Integrated TBC is clearly superior to TPM for patients with complex mental illness and chronic medical disease, consistent with the increasing recognition that this type of care is best applied to higher-risk patients with substantial disease burden," writes Thomas L. Schwenk, M.D., of the University of Nevada, Reno, in an accompanying editorial.
"However, practicing in an integrated, value- and outcomes¬ based model but continuing to be reimbursed in a traditional, volume-based system is costly. The investigators note that the investment cost of the program was lower than the reduction in reimbursement, but both are, in fact, a reduction in the bottom line for practices large and small, and therein lies the most important implication of this study."
"The results of the study by Reiss-Brennan et al document the value of an integrated model of mental health and chronic disease care that likely can only be provided to patients who receive their care in large, integrated health systems. The most significant consequence, however unintended, of outcomes-based medical care and value-based reimbursement may be a profound change in the fundamental structure of the U.S. health care delivery system."
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