These new policies place primary care as the nation’s largest platform of health care delivery, and the center of a substantial health care redesign. The principles and policies of Accountable Care Organizations focus on the implementation of three key issues for behavioral health: (1) team-based care; (2) quality improvement; and, (3) cost containment. A prominent means of redesign is through the patient-centered medical home (PCMH), which offers unique opportunities for innovation for behavioral health (Barr & Ginsburg, 2006; Green, Fryer, Yawn, Lanier, & Dovey, 2001). The PCMH is both an organizational model and certification process (see Chap.3 on PCMH). PPACA policies are influencing the goals of the PCMH as a conceptual model for redesigning primary care. PCMH emphasizes the treatment of the whole person by a team of health care professionals who address a patient’s primary health care needs in one setting (deGruy & Etz, 2010; McDaniel & Fogarty, 2009). National health care policy and health care reforms align with these PCMH concepts [(American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), & American Osteopathic Association (AOA), 2007; Barr & Ginsburg, 2006; Ferrante, Balasubramanian, Hudson, & Crabtree, 2010)].

Supported By: Continuous Quality Improvement and Effectiveness

In the area of quality improvement, behavioral health could have an important role in measuring what constitutes quality health care indicators. Patient factors such as quality of life, patient engagement, depression and/or anxiety or other healthy lifestyle behaviors have a significant impact on health outcomes. But these measures are marginalized as quality indicators for patient care. Acknowledging and advocating for the role of behavioral health metrics is an open door for advancing policy initiatives in quality improvement metrics, which include integrated behavioral health factors. Currently, these behavioral health metrics are in short supply, except for screening tools such as PHQ-9, and they are rarely incorporated into quality improvement systems. The potential to add behavioral health metrics as meaningful use measures through the PPACA policy holds promise. Providers and administrators from medical and mental health contexts need to become educated on how to best incorporate and implement these measures into quality improvement efforts.

How: Team-Based Care

The area of PPACA policy centers on team-based care. Most medical administrators tend to focus on the multidisciplinary team of physicians, mid-level providers, nurses, medical assistants, and other medical support staff. However, behavioral health providers and care managers have an opportunity to be included as integral members of these teams. They play a noteworthy role and have a significant contribution in not only direct clinical care for patients, but also in helping teams work more effectively. The teams could benefit from behavioral health providers’ training and skills in group dynamics and group facilitation. These are new and untapped areas for behavioral health providers to expand and contribute to PCMH initiatives and the policy intentions of PPACA organizations.

Supported By: Business Model and Cost Containment The third area of focus for PPACA policies is cost containment. Health care systems that integrate behavioral health have shown some gains in containing expenses in care delivery. The prevalence of behavioral health issues among patients (e.g., adherence, healthy life style) in the primary care setting is well established, as is the impact of mental health comorbidities on medical outcomes (Katon & Schulberg, 1992; Kessler & Stafford, 2008; Kessler et al., 2005; Unutzer, Schoenbaum, Druss, & Katon, 2006). And the evidence for having integrated behavioral health within a primary care system has demonstrated a positive outcome on managing acute, chronic, and preventative health care needs (Butler et al., 2008; Green et al., 2001; Starfield, 1998). However, policies are often not consistent with the evidence of the importance of behavioral health in cost containment. Behavioral health is not on the forefront of cost-cutting factors in health care policy debates and standards. Currently, policies are more prohibitive of integrating care than in support of it. For example, financially sustaining integrated behavioral health care is problematic due to antiquated reimbursement policies that force behavioral health and physical health into separate billing silos (Kathol, Butler, McAlpine, & Kane, 2010; Mauch, Kautz, & Smith, 2008). These payment policies do not acknowledge an integrated team, but rather pay for “behavioral health” or “physical health” codes or services.

Another area of policy that has created confusion has been in reimbursement regulations. Policies and regulations on state and local levels can undermine integrated behavioral health care practices. For example, state policies that limit same-­day billing for medical and mental health treatment have interfered with medical and mental providers working in tandem with a patient to provide more seamless care. Policy regulations often limit continuity and collaboration, and contribute to patients’ experience of obstacles in following through with behavioral health treatments. A number of states have addressed this by allowing for same-day billing, but it continues to be a complication throughout the country. When same-day billing policies are in place, behavioral health providers are able to provide psychotherapy services and receive reimbursement for same-day billing; however, the patient must have a mental health diagnosis (http://www.samhsa.gov/healthreform/index.aspx). When behavioral health providers use health and behavior codes (e.g., CPT 95801-­4) on the same day as a medical visit to address the patient’s engagement in health-­related behavior change, many times these services cannot be reimbursed if billed on the same day of service. For example, if a physician sees an obese patient who could benefit from motivational interviewing to enhance their commitment to engaging in behavior changes for exercising, the patient would need to come back on another day rather than be seen on that same day. This policy significantly limits the continuity, efficiency, and collaboration of patient-centered care for the majority of primary care patients.