Care Access Merits Top Priority as a Multidimensional Goal
Our field’s track record for providing access to care is dismal. Efforts to rectify this are underway, but it is a complicated issue. We know that factors such as stigma and cost have long suppressed access. Yet access should not be discussed in isolation from concerns about the quality of care. We should endeavor to ensure access to affordable, high-quality outpatient clinicians.
It is not clear if our field can achieve this multidimensional objective, but we have not really tried. Our system was not developed with this as its main goal. Cost became a leading priority with managed care’s rise in the 1990s. Quality has long been a focus, but resistance to measurement-based care has hindered progress. Access to affordable, quality clinicians has not been embraced as a cohesive priority.
It Starts With How Care Delivery Is Organized
One key to achieving this complex goal may be changing how we organize care delivery. Might some delivery models better ensure success? For the sake of clarity, it is best to focus discussion on two archetypal models—the staff or clinic model versus the contracted network model of independent clinicians (i.e., staff vs. network). Each model is well-represented today.
Distinct funding streams and delivery systems drive government-funded and commercially funded care. Public systems rely more on clinics, while private systems favor a network model. The staff model is easy to understand in any context. Groups of clinicians practice together for various personal and professional reasons. Mutual support and problem-solving helps everyone do a better job.
Networks of independent clinicians are quite different. They have typically been organized by or for the payers of care. The goal is to establish predictable costs for the payer, often for large coverage areas. Contracts include discounted fees and certain clinical and quality protocols. Payers use accreditation by NCQA to promote quality improvement, and measurement-based care is not a requirement.
Payers have been building provider networks for decades with a central goal of ensuring timely access in every location. Yet many network clinicians are disengaged and ready to end their contracts. This threat is real judging from the volume of “phantom” clinicians. They resent reimbursement rates more than anything. Network rates seem to degrade access at the same time they reduce payer costs.
It is important to prevent a key misunderstanding on this point. The managed care organizations that drove the national expansion of networks have tried diligently to ensure access to affordable, quality clinicians. The problem is that their well-intended tactics conflict with their leading financial priorities. A multifaceted, cohesive vision of care access will never be achieved as a secondary goal.
Is the network model broken beyond repair? The original intent was for discounted network rates to be appealing as a trade-off for a greater volume of clients. Except for some isolated geographies with few clinicians, this is not possible. Re-negotiating network rates to be similar to prevailing private rates would require a massive investment. Payers have shown little interest to date.
Economic forces created these networks, and they may also bring their demise. Networks may be increasingly irrelevant as consolidation transforms healthcare. As healthcare companies acquire behavioral businesses, clinicians may find equitable salaries their new focus. Signs of this shift can be seen in how health plans have acquired provider groups and are focused on owning key elements of care delivery.
Leadership Matters
Our success improving access and quality may ultimately boil down to the accountability of the staff model. Clinics have real leaders, while networks have remote administrative managers. This is not to say clinic leaders always know what to do, but their leadership can produce meaningful results.
Quality is an example. Studies show that outcomes for clinicians form a bell curve. A small tail of outliers have results well below average. Staff model clinics should be able to identify this small group and either help them improve or replace them. The training to do this is available. Quality is achievable.
Our poor access rates are not really a quality improvement issue. Access is a macro issue, not a discrete QI goal. We should stop setting access goals without creating the conditions needed for meeting them. Timely access depends on basic financial and structural changes that will define our field for generations. Consider a few goals that are critical stepping stones on the way to better access:
- Budgeted allocations for our specialty (made by the healthcare companies that will increasingly own our services) must meet all clinical needs in a population without waiting lists
- Client cost-sharing must be low (presuming health plan benefit designs are relevant) so that non-insured or out-of-network services are never needed to provide timely or urgent care
- Clinicians and administrators must embrace measurement-based care to ensure high quality
- Wages for behavioral clinicians must be roughly on par with comparable medical professionals
Access will improve when financing supports it and when accountability exists from top to bottom, from the chief executive to the clinic leader.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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