Expense of Behavioral Health and Primary Care Integration
Expense of Behavioral Health and Primary Care Integration
Purpose: Provide credible estimates of the start-up and ongoing effort and incremental practice expenses for the Advancing Care Together (ACT) behavioral health and primary care integration interventions.
Methods: Expenditure data were collected from 10 practice intervention sites using an instrument with a standardized general format that could accommodate the unique elements of each intervention.
Results: Average start-up effort expenses were $44,076 and monthly ongoing effort expenses per patient were $40.39. Incremental expenses averaged $20,788 for start-up and $4.58 per patient for monthly ongoing activities. Variations in expenditures across practices reflect the differences in intervention specifics and organizational settings. Differences in effort to incremental expenditures reflect the extensive use of existing resources in implementing the interventions.
Conclusions: ACT program incremental expenses suggest that widespread adoption would likely have a relatively modest effect on overall health systems expenditures. Practice effort expenses are not trivial and may pose barriers to adoption. Payers and purchasers interested in attaining widespread adoption of integrated care must consider external support to practices that accounts for both incremental and effort expense levels. Existing knowledge transfer mechanisms should be employed to minimize developmental start-up expenses and payment reform focused toward value-based, Triple Aim–oriented reimbursement and purchasing mechanisms are likely needed.
The integration of behavioral and primary care services has become a relatively common element of recent efforts to transform basic health care provision. The Advancing Care Together (ACT) program is 1 example of this effort, supporting integrated care interventions across a number of practice sites in the state of Colorado. New interventions, such as behavioral health and primary care integration, require investments to initiate the intervention and incur ongoing expenses to implement them. Published information on the level and type of expenses incurred in undertaking the transformation to integrate primary and behavioral health care is extremely limited, despite a widespread understanding that financial support is a critical barrier to widespread and sustainable adoption. Practices that have made this transformation or are considering it have little basis to understand or anticipate the expenses they might incur. Similarly, payers and policy makers that may be interested in supporting such interventions have limited information to assess the likely extent or nature of reimbursement change that may be necessary to provide sufficient incentives and support to make the transition to behavioral health and primary care integration. The ACT program presented an opportunity to provide a descriptive case study of start-up and ongoing expenses across a variety of specific behavioral health and primary care integration interventions.
Practical expenditure data on health care interventions generally is extremely sparse in the academic literature. Expenditures, where reported, are often provided as part of cost effectiveness or related evaluations. As such, they typically do not isolate practice expenditures, include start-up expenses, or report expenditures in categories relevant to typical practice activities. One study that is unique in this respect reported practice start-up and ongoing incremental expenses for primary care practices incorporating health behavior change services targeting at-risk drinking, healthy diet, physical activity, and smoking in primary care as part of the Prescription for Health (P4H) program. The P4H expenditure study developed a credible, standardized tool for capturing intervention-related expenditures at the practice level. This tool was applied with modest modifications to the practices in the ACT program to attain credible estimates of the incremental and effort expenses incurred to start-up and deliver these behavioral health and primary care integration interventions. Table 1 lists the types of expenses that were collected and reported for the study with definitions and examples.
Incremental expenses reflect expenses tied to new resources acquired and used to start up and deliver new interventions. This expense perspective provides practices with estimates of the amount of capital needed for start-up and the additional, net expenses of ongoing implementation. They also reflect estimates of the type of expenses that would typically feed into fee-for-service-type reimbursement calculations. Effort expenditures for start-up and delivery incorporate intervention expenses related to both new and existing resources. This expense perspective captures a more complete picture of the effort practices undertake to implement the intervention. Differences between effort and incremental expenses elicit important information that payers and policy makers must take into account in considering reimbursement policies that can provide meaningful incentives and support for these types of interventions. Thus, the purpose of this study is to report credible estimates of the start-up and ongoing effort and incremental practice expenses for the ACT behavioral health and primary care integration interventions in a manner that is informative to practice implementers as well as payers and policy makers.
Abstract and Introduction
Abstract
Purpose: Provide credible estimates of the start-up and ongoing effort and incremental practice expenses for the Advancing Care Together (ACT) behavioral health and primary care integration interventions.
Methods: Expenditure data were collected from 10 practice intervention sites using an instrument with a standardized general format that could accommodate the unique elements of each intervention.
Results: Average start-up effort expenses were $44,076 and monthly ongoing effort expenses per patient were $40.39. Incremental expenses averaged $20,788 for start-up and $4.58 per patient for monthly ongoing activities. Variations in expenditures across practices reflect the differences in intervention specifics and organizational settings. Differences in effort to incremental expenditures reflect the extensive use of existing resources in implementing the interventions.
Conclusions: ACT program incremental expenses suggest that widespread adoption would likely have a relatively modest effect on overall health systems expenditures. Practice effort expenses are not trivial and may pose barriers to adoption. Payers and purchasers interested in attaining widespread adoption of integrated care must consider external support to practices that accounts for both incremental and effort expense levels. Existing knowledge transfer mechanisms should be employed to minimize developmental start-up expenses and payment reform focused toward value-based, Triple Aim–oriented reimbursement and purchasing mechanisms are likely needed.
Introduction
The integration of behavioral and primary care services has become a relatively common element of recent efforts to transform basic health care provision. The Advancing Care Together (ACT) program is 1 example of this effort, supporting integrated care interventions across a number of practice sites in the state of Colorado. New interventions, such as behavioral health and primary care integration, require investments to initiate the intervention and incur ongoing expenses to implement them. Published information on the level and type of expenses incurred in undertaking the transformation to integrate primary and behavioral health care is extremely limited, despite a widespread understanding that financial support is a critical barrier to widespread and sustainable adoption. Practices that have made this transformation or are considering it have little basis to understand or anticipate the expenses they might incur. Similarly, payers and policy makers that may be interested in supporting such interventions have limited information to assess the likely extent or nature of reimbursement change that may be necessary to provide sufficient incentives and support to make the transition to behavioral health and primary care integration. The ACT program presented an opportunity to provide a descriptive case study of start-up and ongoing expenses across a variety of specific behavioral health and primary care integration interventions.
Practical expenditure data on health care interventions generally is extremely sparse in the academic literature. Expenditures, where reported, are often provided as part of cost effectiveness or related evaluations. As such, they typically do not isolate practice expenditures, include start-up expenses, or report expenditures in categories relevant to typical practice activities. One study that is unique in this respect reported practice start-up and ongoing incremental expenses for primary care practices incorporating health behavior change services targeting at-risk drinking, healthy diet, physical activity, and smoking in primary care as part of the Prescription for Health (P4H) program. The P4H expenditure study developed a credible, standardized tool for capturing intervention-related expenditures at the practice level. This tool was applied with modest modifications to the practices in the ACT program to attain credible estimates of the incremental and effort expenses incurred to start-up and deliver these behavioral health and primary care integration interventions. Table 1 lists the types of expenses that were collected and reported for the study with definitions and examples.
Incremental expenses reflect expenses tied to new resources acquired and used to start up and deliver new interventions. This expense perspective provides practices with estimates of the amount of capital needed for start-up and the additional, net expenses of ongoing implementation. They also reflect estimates of the type of expenses that would typically feed into fee-for-service-type reimbursement calculations. Effort expenditures for start-up and delivery incorporate intervention expenses related to both new and existing resources. This expense perspective captures a more complete picture of the effort practices undertake to implement the intervention. Differences between effort and incremental expenses elicit important information that payers and policy makers must take into account in considering reimbursement policies that can provide meaningful incentives and support for these types of interventions. Thus, the purpose of this study is to report credible estimates of the start-up and ongoing effort and incremental practice expenses for the ACT behavioral health and primary care integration interventions in a manner that is informative to practice implementers as well as payers and policy makers.
