David Rettew, M.D., is an associate professor of psychiatry at The Robert Larner, M.D. College of Medicine at The University of Vermont and a child psychiatrist at the University of Vermont Medical Center. He authors a blog, titled "ABCs of Child Psychiatry" on the Psychology Today website. The blog, below, originally titled "Mental Health Care Could Look Really Different Soon (or Not)," was posted on the ABCs of Child Psychiatry blog on October 13, 2016,

My home state of Vermont is poised to be the first state in the nation to switch from a fee-for-service model of healthcare delivery to an accountable care organizational (ACO) structure, regardless of whether a person uses Medicare, Medicaid, or a private insurance company. This means that doctors, hospitals, and other providers would no longer be paid based on what services and procedures they do but instead would receive a fixed amount of money, based upon the number of participating patients, to meet the healthcare needs of that population. It also means that financial incentives will not come not from simply doing more procedures and tests but from keeping people as well as possible, especially along specific pre-defined benchmarks.

Sure versions of this have already been tried in various forms both in this country and in many others, but this remains a historic step given the inclusion of all types of healthcare providers and all types of insurance payers, public and private. Like many physicians across all specialties in our state who spend time working with patients and not studying health care policy and insurance practices, I’m not exactly sure what to make of this proposal. Just understanding what exactly it means seems like it would require a full-time job. 

Nevertheless, a couple aspects of this new “all payer” proposal could result in significant changes to our current model of mental health care that, if expanded to other states, might affect large numbers of people across the country.

1. Recognizing that health is in large part mental health.  There is increasing appreciation that many of the risk factors such as adverse childhood events (ACEs), that have traditionally been associated with risk for psychiatric disorders like major depression, are also risk factors for some of our most common non-psychiatric chronic diseases. This insight has helped bring the importance of mental health onto the radar screens of broader health policy initiatives.  For this new Vermont plan, two of the four main health outcome “targets” on which the success of the ACO will be judged are directly related to mental health and involve a) reducing the number of deaths due to suicide and b) reducing the number of deaths due to substance abuse. These are important and challenging goals and it is gratifying to see them raised to such prominence within an entire healthcare system.  At the same time, I hope that the tying of these specific goals to financial incentives doesn’t mean that we will “teach to the test” and spend inordinate amounts of resources on these two goals at the expense of other very critical needs.

2. The post fee-for-service landscape.  Just imagining this new world is challenging.  Furthermore, there is remarkable little information I can find that examines how a lack of fee-for-service pressure has or at least could alter the way mental health care is delivered.  Psychiatrists and other mental health providers will continue to be scarce resources, but if we no longer get paid based on having face-to-face visits with patients/clients, a number of possibilities emerge, some of which would likely be welcomed by the public and mental health professionals alike, others less so.

• Much more care could potentially be given outside of the office, through telephone calls, tele-medicine technology, and even emails.  In a fee-for-service world, these things have been completely uncompensated.
• There could be closer collaboration with primary care providers in their day to day care of people before and after they develop symptoms.  This could involve psychiatrists or other mental health professionals actually seeing patients but also could be in the form of simply meeting with primary care providers to discuss cases and offer guidance.  
• Greater emphasis might be taken on emotional-behavioral wellness and the prevention of psychiatric disorders.  At this point, there is strong evidence that efforts directed at things like reducing childhood abuse and adverse events, improving parenting practices, and helping families promote wellness and health promotion not only improve health later in life but also save money.
• There could be greater priority to doing group therapy versus individual work. 
• Care could become more based on teams than an individual counselor or psychiatrist.  For example, rather than having initial evaluation with a psychiatrist go for an hour or longer, much of that information gathering may first be obtained by someone else.
• For clinicians, another interesting question is how we will measure our clinical time.  Right now, our employers know we are busy clinically based upon the number and types of appointments we bill.  Under this model, we may need to develop a whole new system of time accountability. 

Of course, there also seems to be the strong possibility that things won’t really change at all, with us doing more or less the same thing before and after the implementation of the ACO model.  This seems especially plausible because some of the most glaring and obvious deficiencies in mental health care don’t come from things like prevention work but rather individuals in crisis and in need of acute intensive services and hospitalization.  How long a view an ACO administration takes also seems important here.  Even if one just focuses on the financial bottom line, what might improve that in 20 years would involve different steps than if the focus is 5 years.

If we do choose to keep things more or less as is, part of me sees that has a huge wasted opportunity when we could have made substantive improvements in how we deliver mental health care, although another part of me worries about losing some of that 1:1 time with patients and their families that I cherish.  There’s no doubt that the system is complicated, that the devil is in the details, and that the landscape ahead is full of both hazards and opportunities.  Ever the optimist, I for one will be trying to hold back my cynicism and look for creative solutions to old problems.