APA is partnering with other health care organizations and members of industry to promote new hybrid payment models that will shift reimbursement from fee-for-service to value-based models with flexibility and incentives to meet patients’ needs.
APA is doing part of this work as an active executive member of Primary Care Collaborativeopens in new window. PCC is a multistakeholder membership organization that brings together more than 60 organizations that include groups of health care providers, patient and consumer organizations, health plans, employers, industry, quality organizations, health systems, and many others to build consensus on policy solutions to achieve comprehensive high-performing primary care.
Susan McDaniel, PhD, the 2017 past president of APA, currently serves on the PCC board of directors and has been on the board since 2017. Staff from APA’s Office of Health and Health Care Financing and Advocacy are engaged closely with the PCC in the shared commitment to team-based primary care and the promotion of advanced payment models to support behavioral health integration.
The PCC recognizes the importance of behavioral health as an integral part of the primary care team. They promote scaling behavioral health integration through the most widely used fee-based payment methods, while testing new ways to integrate behavioral health into primary care value-based payment models. The traditional model for payment, fee-for-service, is where reimbursement is only based on what services are provided. But in value-based care, reimbursement depends on the quality of care provided and is tied to patient outcomes.
There are four main types of value-based care models:
- Performance-based payment: Provider organization receives an additional payment based on achievement of certain metrics or completion of certain activities.
- Bundled payment: Health care providers cut back on services that are usually bundled together. A plan bundles payment for services linked to a particular condition, procedure, or service. This allows patients to customize their care and avoid services they do not need, and providers can keep the money it saves.
- Shared savings and risk model: Under shared savings arrangements, providers are paid a portion of any savings that are generated when the total spending is lower than the financial target. Under shared risk arrangements, providers must also pay back a portion of any loss that is generated when total spending is higher than the financial target.
- Capitation: A provider organization receives a fixed payment (e.g., per-person, per-month), intended to pay for all individuals’ care, regardless of what services they use. Capitation can help reduce the health care provider’s financial burden while ensuring patients receive quality care.
The National Academies of Science, Engineering, and Medicine issued a report on implementing high-quality primary careopens in new window stating that we should “pay for primary care teams to care for people, not doctors to deliver services.” The report recommends a shift towards a hybrid model of payment; part fee-for-service and part capitated (per-member, per-month) as the default method to pay prospectively for interprofessional, integrated, team-based care rather than the fee-based system that undervalues the work reflected in primary care and behavioral health services.
The advocacy efforts by the PCC focus on promoting new hybrid payment models that shift reimbursement from fee-for-service to value-based models with flexibility and incentives to meet patients’ needs. PCC works closely with policymakers, government agencies, and leaders to drive health system reform to advocate for these population-based prospective payment models that would help scale behavioral health-primary care integration.
Recent advocacy work includes:
- PCC’s submitted position on behavioral health integration codes in hybrid payment (Submitted Testimony to the Senate Finance Committee) (PDF, 287KB)opens in new window.
- PCC joined more than 800 health care associations, accountable care organizations, medical practices, and health systems to urge Congressional leaders to extend incentive payments.
- PCC’s Better Health-NOW Campaign submitted comments to CMS for policy changes that reform how much is invested in primary care as well as how it is paid for.
- The PCC sent a Behavioral Health Integration Recommendation Letter to HHS/CMS to support behavioral health integration in federal primary care payment.