Are Psychiatrists Ready for Health Care Reform? Findings From the Study of Psychiatric Practice Under Health Care Reform

The Affordable Care Act (ACA) holds great promise in markedly improving access to mental health and substance use treatment. More than 50 million Americans have obtained mental health coverage since its passage (1,2). The ACA seeks to significantly improve the quality and efficiency of health care delivery for millions of Americans and to have an impact on overall health outcomes for individuals who have mental and addictive illnesses (3,4). New integrated services delivery systems, payment reforms, and health information technologies are three fundamental ACA components designed to address fragmentation of services delivery, improve overall quality and efficiency of care, and reduce costs.

The ACA’s triple aim of improving health, improving health care delivery, and lowering costs (5) requires a paradigm shift in health care systems. These reforms in delivery systems offer the potential to improve care through new integrated delivery models and innovations (6), including patient-centered medical homes or health homes, which seek to provide comprehensive, accessible, patient-centered, coordinated care; and accountable care organizations (ACOs), which assume responsibility for the cost, quality, and outcomes of health care for a defined group of patients (7,8).

Central to this paradigm shift is the expectation that psychiatrists will assume new roles within the reforming health care system, moving from solo and small group practice settings to become central figures in the ACA's new integrated, collaborative care services delivery models. Within these new frameworks, psychiatrists may be members of a team-based service delivery model, supervise team delivery of psychiatric and general medical care, provide general medical care to psychiatric patients, or assume other roles beyond that of a solo practitioner (9).

New health care services delivery frameworks and expanded roles for psychiatrists also require consideration and implementation of new payment models that ensure delivery of high-quality patient care at lower costs and reward quality rather than quantity of services (10–14). Achieving the ACA’s triple aim also calls for taking advantage of health information technologies, such as electronic health records (EHRs) and telemedicine. The American Recovery and Reinvestment Act (ARRA) of 2009 included more than $26 billion in funding for physician adoption of EHRs (15) to facilitate care coordination and sharing of information, provide decision support to promote evidence-based treatment and performance monitoring, and reduce inappropriate service use (16–18).

The extent to which the nation’s health care systems and clinical workforce will be able to change to meet the expected increase in demand for services—particularly for individuals with mental and substance use disorders—is unclear. Consequently, this study aimed to describe the extent to which psychiatrists, prior to the ACA’s Medicaid and health insurance exchange expansions, reported that they were currently participating or likely to participate in various integrated care services delivery models, to assume new provider roles, to accept new reimbursement structures, and to use EHRs for clinical functions.

Methods

This study used data collected from a large probability sample of U.S. psychiatrists who took part in the Study of Psychiatric Practice Under Health Care Reform, which was fielded in the fall of 2013. A total of 2,800 physicians in the United States who self-identified as psychiatrists and listed direct patient care as their type of practice were randomly selected from the September 2013 release of the AMA Physician Masterfile. The sampling frame excluded residents and those selected in the past 24 months to participate in surveys. Those who had undeliverable addresses, were deceased, or were incorrectly identified as a psychiatrist (N=185) were excluded. Of the remaining 2,615 individuals who were invited to participate, 1,188 (45%) responded. Of these, 93% (N=1,099) reported currently practicing psychiatry and treating psychiatric patients and provided the sample for this study.

A four-page data collection instrument was mailed to the target sample with a $50 gift card to increase response. Three survey mailings were implemented at one-month intervals, followed by reminder postcards. All study procedures were approved by the American Psychiatric Association Foundation Institutional Review Board.

Weighted analyses were conducted using SUDAAN, 11.0.1, statistical software (19). The weights adjusted for the sample design, nonresponse, and physician caseload size to provide estimates that could be generalized to the target population of practicing psychiatrists in the United States. Chi-square tests for categorical variables and Student’s t tests for continuous variables were used to examine the associations between physicians’ characteristics, practice setting types, and sources of payment with the health care reform receptivity measures (that is, participate in various integrated care services delivery models, assume new provider roles, accept new reimbursement structures, and use EHRs for clinical functions).

Results

Sample Characteristics

Most participants were male (65%) and non-Hispanic white (82%) (Table 1). The most common setting for treating patients was solo office practice settings (34% of psychiatrists’ patients), followed by outpatient public clinics (18%) and group office practice settings (20%). The primary sources of payment for psychiatrists’ services were private commercial insurance (30% of psychiatrists’ patients), self-pay (22%), Medicaid (18%), and Medicare (14%).

Health Care Reform Roles

Most psychiatrists (64%) reported currently assuming at least one of the roles identified as being integral to the successful ACA implementation of health care reform; an additional 14% reported being likely or very likely to assume at least one of these roles beginning January 1, 2014. Most commonly, psychiatrists reported currently practicing as a member of a team service delivery model (42%); providing ongoing mental health treatment for a caseload of patients with more severe mental illness, coordinating with a primary care clinician (41%); providing consultation to primary care and mental health clinicians caring for psychiatric patients with diagnostic or therapeutic challenges (39%); or providing leadership and supervision for team delivery of psychiatric and general medical care for psychiatric patients (33%) (Table 2). Less commonly, psychiatrists reported that they currently oversee, track, and review care for psychiatric patients by working with practice leadership to ensure that services are available, appropriate, and well managed (21%) or that they currently provide general medical care to psychiatric patients (16%).

The mean number of health care reform roles psychiatrists reported assuming currently was 1.9 (95% confidence interval=1.8–2.0), with 15% currently assuming one role, 14% currently assuming two, and 36% currently assuming three or more.

Integrated Services Delivery Systems

Nearly one-third of the psychiatrists (29%) reported they currently practice in at least one integrated treatment setting, with an additional 13% reporting they would be likely or very likely to do so beginning January 1, 2014. Eighteen percent of psychiatrists reported currently working in an integrated treatment setting with colocated and integrated specialty mental health and primary care services; and 15% reported currently working in a primary care treatment setting (Table 2). Smaller percentages of psychiatrists reported currently practicing in patient-centered health homes (8%) or ACOs (5%). Most psychiatrists practicing in integrated treatment settings reported practicing in only one (17% of respondents); fewer reported practicing in two (7%) or three or more (5%) integrated settings.

Payment Reforms

A substantial proportion of psychiatrists reported currently receiving at least some reimbursement in the form of salary (42% of psychiatrists); an additional 4% reported that they would be likely or very likely to receive salary reimbursement beginning January 1, 2014 (Table 2). The other ACA physician payment reform mechanisms were rarely reported. Only 4% of psychiatrists reported current fee-for-service reimbursement with a potential financial bonus for containing costs and meeting quality standards; an additional 6% reported that they would be likely or very likely to participate in contracts with this type of payment beginning January 1, 2014. Even fewer psychiatrists reported currently receiving or being likely or very likely to receive the other capitated or at-risk payment mechanisms.

EHRs

Approximately half the psychiatrists (53%) reported currently using any form of EHR for clinical functions not limited to billing or practice management (Table 3). An additional 8% reported that they planned to use an EHR within the next year, and an additional 4% reported that they planned to use an EHR in more than one year. Nearly a quarter of psychiatrists (24%) reported that they did not plan to use an EHR, and 11% were uncertain about when they would use an EHR.

One in five psychiatrists (21%) reported currently participating in the Medicare or Medicaid EHR Incentive Program, and 6% were planning to participate in the future. The primary reasons reported for being uncertain regarding program participation were not knowing enough about the program (63%) or being uncertain about meeting all of the program requirements (23%).

Factors Associated With ACA Readiness and Receptivity

Most of the psychiatrist attributes examined were associated with psychiatrists’ participation in various ACA reforms (Table 4). Psychiatrists who reported current or likely future practice in primary care or other integrated treatment settings, assumption of at least one ACA role, engagement in salaried arrangements, or use of an EHR were younger, more racially and ethnically diverse, and more likely to see Medicaid and public outpatient clinic patients. Psychiatrists who reported currently participating or being very likely in the future to participate in risk-sharing arrangements were less likely to see self-pay patients or to see patients in solo office practices.

Discussion

A primary strength of this study was the use of a large probability sample of U.S. psychiatrists and their self-reported current and anticipated practices. This study was limited to psychiatrists, who treat an estimated one in five individuals who receive mental health care in the United States (20). The data are based on self-report and may be subject to response, recall, and social desirability biases. Many psychiatrists may have considered that an occasional discussion with a primary care physician or a social worker in a clinic reflected their working in an integrated treatment setting or represented one of the collaborative care roles we studied, thereby inflating our estimates. In addition, the use of simple random sampling resulted in a final sample that primarily reflected psychiatrists from more populous states. Although psychiatrists from 48 states participated in the study, no psychiatrists from Delaware or West Virginia participated.

Participation in ACA Services Delivery Models and Roles

Although a notable proportion of psychiatrists reported being currently engaged in or being likely to become engaged in new roles and integrated treatment settings, most had limited involvement in integrated treatment settings and new roles that are considered essential for health care reforms. The major barriers to psychiatrists’ assuming new roles and working in new models of care include overcoming the inertia associated with established psychiatrists’ current practices and practice settings, general workforce constraints and the limited supply of psychiatrists, economic barriers, and limited workforce development and training related to integrated treatment settings and services delivery roles.

More than half of the psychiatrists’ patients were treated in solo or group office settings. Psychiatrists in these settings, who were also more likely to treat a higher proportion of self-pay patients or those with private insurance, were less likely to be receptive to moving into new care delivery systems or models. However, they were as receptive as the psychiatrists in public outpatient clinics to assuming new roles. These findings suggest that transitioning established psychiatrists to new practice settings (for example, colocated settings) may be more challenging than engaging them in new roles. Encouraging these psychiatrists to experiment with spending at least some of their time (for example, one day a week) in integrated settings or practicing telepsychiatry may engage them in more dynamic practices with more frequent interactions with other health professionals.

As a result of the shortage in the nation’s supply of psychiatrists (21,22), it may be difficult for organized delivery systems to recruit sufficient numbers of psychiatrists to practice in integrated services delivery models. Although the ACA includes provisions to strengthen the mental health workforce, it has limited provisions to increase the supply of psychiatrists. Because these provisions are still being implemented, are temporary, and rely on discretionary funding (23), the extent to which they will be effective in increasing the supply of mental health specialists is unclear.

Engaging psychiatrists in integrated delivery systems and roles is especially challenging because traditional clinician Current Procedural Terminology payment codes are not structured to reimburse for care coordination and for many functions integral to psychiatrists’ participation in team-based services delivery. The Centers for Medicare and Medicaid Services (CMS) is currently seeking to address this limitation. The movement toward ACOs and CMS’s aggressive goals of increasing use of global, capitated payments and “merit-based” reimbursement rather than fee-for service payments may also help address this limitation (10). If successful, this paradigm shift may give health plans the flexibility and financial incentives to engage psychiatrists in salaried arrangements, helping to promote integrated treatment and offering the potential to contain or reduce health care costs, particularly for high-cost patients (24).

Until recently, there has been limited outreach, recruitment, and training of psychiatrists in integrated, collaborative care services models. Given the challenges identified in our study, there continues to be an urgent need for federal agencies to invest more efforts and resources toward workforce development to support evidence-based integrated care models (25). This includes expediting the development and implementation of effective training in the core competencies required for integrated care models for the current and future psychiatric work force (26). This will require the leadership of residency training directors, as well as the Accreditation Council for Graduate Medical Education, to develop accreditation standards to achieve proficiency in these core competencies, including training in enhanced general medical care skills, leading professional teams, setting up and participating in integrated care settings, teaching primary care providers about identifying and screening for mental and substance use disorders, and using health information technologies to support population-based, data-driven care (27,28).

To be effective, continuing education programs also need to develop and adopt evidence-based teaching approaches. This includes consideration of online technologies to replace brief lecture and workshop formats, which have little or no effect (29). In addition, significant ongoing technical assistance may be required, particularly in supporting psychiatrists in changing roles and as they form or join multispecialty group practices (26,27).

The APA has initiated a multifaceted approach to recruit and train psychiatrists and primary care providers for new collaborative roles in integrated care (30). These efforts include dissemination of a weekly newsletter, podcasts, toolkits, and resource lists, as well as offering in-person and online lectures, professional training, and continuing medical education programs (31). Recently, the APA received a CMS Support and Alignment grant to train 3,500 psychiatrists to support implementation of evidence-based, integrated behavioral health programs in primary care practices. Through this initiative, free online learning modules have been developed, in addition to live training programs offered throughout the country. Developing and evaluating these initiatives will be important in facilitating culture changes to support team-based care and health services delivery reforms.

Payment Reform Participation

Psychiatrists in general do not appear to be receptive to pay-for-performance reimbursement. Although a substantial proportion of psychiatrists reported being currently engaged in salaried arrangements, very few reported receiving other forms of payments designed to reward quality rather than quantity. Although merit-based payment mechanisms may be used more widely at the plan or group practice level, individual physicians do not appear to be commonly receiving these forms of payments or to be aware of receiving them. Given CMS’s targets of ensuring that a larger proportion of Medicare payments are in the form of global or merit-based payments, it may prove challenging to promote these payments on a clinician level to psychiatrists, given their lack of receptivity and the current shortage of psychiatrists. To address this, the APA has initiated development of a mental health clinical data registry designed in part to help psychiatrists meet CMS’s Physician Quality Reporting System requirements and maximize Medicare merit-based reimbursement while avoiding payment penalties.

EHR Adoption

Although approximately half of psychiatrists reported currently using an EHR, our measures did not distinguish between “basic use” or “meaningful use” of EHRs (32). Furthermore, because a substantial number of psychiatrists reported practicing in more than one setting, psychiatrists may have used EHRs in one but not all of their settings. The psychiatrists who reported participating in the Medicare or Medicaid EHR Incentive Program—one in five psychiatrists—provided an indication of the proportion of psychiatrists whose current EHR use met meaningful use requirements in at least one of their practice settings. These psychiatrists were more likely to work in public outpatient clinics and organized delivery systems.

Not surprisingly, psychiatrists who reported not using EHRs were more likely to treat a higher proportion of patients in solo or group office practice settings and were more likely to treat a higher proportion of self-pay or privately insured patients. Psychiatrists in solo office practice settings and smaller group settings face high fixed costs in investing in EHRs, which presents a financial barrier. They also face technical and administrative challenges in selecting and implementing EHR systems. These psychiatrists may require more technical and financial support to adopt EHRs. Although the 2009 ARRA included significant financial incentives for EHR adoption among physicians treating Medicare and Medicaid patients, physicians who primarily treat self-pay patients or privately insured patients were not included. Another barrier to EHR adoption, particularly among psychiatrists in solo and small group office settings, is privacy concerns associated with use of EHRs (33).

Notably, about one-quarter of the psychiatrists reported that they were not planning to use an EHR. Given that EHRs have been described as being “essential to almost all care delivery innovations,” including coordinating care and promoting accountability among a group of providers for a given population (34), it may prove very difficult for these psychiatrists to contribute to the ACA’s health care delivery transformation goals. These findings highlight the need for more significant resources and technical support to facilitate psychiatrists’ selection, implementation, maintenance, and use of EHRs and other forms of health information technologies that can support quality and outcome assessments essential for performance monitoring and clinical decision support to promote optimal care management.

Conclusions

Although substantial proportions of psychiatrists practicing in group and public outpatient treatment settings reported that they were currently engaged in services delivery models and roles being implemented under health care reform, our findings highlight opportunities for further workforce development, training, and technical assistance consistent with the outreach, education, and training efforts being initiated to strengthen psychiatrists’ participation in integrated care. Our findings highlight the need to help prepare psychiatrists for performance-based payment reforms and facilitate their transition to more robust use of EHRs.