Alternative Payment Structure May Support Integrated Care


Oregon’s Alternative Payment Methodology (APM) model may be a promising approach to financing and sustaining behavioral health (BH) integration efforts, suggests Deborah Cohen, PhD, in an April, 2015 blog post in Health Affairs Blog entitled “Addressing Behavioral Health Integration with Payment Reform.” Dr. Cohen, an Associate Professor in the Department of Family Medicine at Oregon Health & Science University, is part of the team evaluating the Oregon APM model. Based on her experiences with over 25 integrated care clinics throughout the country, she explains that “integrated care is comprehensive primary care.” Integrated care is designed to address both medical and behavioral patient concerns within one setting, allowing for whole-person primary care (PC).

Despite growing interest in integrating BH and PC, several financial barriers make integration difficult to achieve. The author highlights three barriers:

  1. Inability of many practices to afford a BH clinician.
  2. Lack of funds to pay for necessary clinic renovations to provide space of BH providers to see patients within the PC clinic, rather than having an off-site office.
  3. The traditional 50-minute therapy session and payment structure for BH providers, which means that BH providers are inaccessible for warm hand-offs and that hiring enough providers to see patients would be cost prohibitive.

If health providers (PC and BH providers) are paid in a fee-for-service model, surmounting these barriers is very difficult.  

The APM pilot is testing the notion that a per-member-per-month (PMPM) fee structure can support the provision of comprehensive care. For some clinics, the APM pilot has allowed for “experimentation” with integrating BH into the PC team. Dr. Cohen explains that:

“While APM is not specifically funding primary care-behavioral health integration, it is freeing up practices to look more broadly at how they treat their patients. The practices in the APM pilot do not have requirements for how to they spend their PMPM fee. Therefore, instead of needing to generate a high number of physician-patient primary care visits, they now have the flexibility to spend some of their fees on behavioral and mental health services. As long as the net effect is budget-neutral, they can treat patients in new ways and with new combinations of providers.”

The APM model may bring the health care system one step closer to a payment structure that allows PC clinics to integrate BH services in a way that is financially sustainable. In addition to initiating a payment structure that makes integrated care financially feasible, the author notes that for comprehensive, integrated PC to become “common place will require leadership to push further on paying for services that are central to comprehensive primary care, align payment across payers to reduce complexity, and support system-wide practice change.”