Shmerling Alison C, Gold Stephanie B, Gilchrist Emma C, Miller Benjamin F
Department of Family Medicine, University of Colorado Denver, Denver, CO, USA.
Eugene S. Farley, Jr. Health Policy Center, University of Colorado, Denver, CO, USA.
Transl Behav Med. 2020 Aug 7;10(3):648-656. doi: 10.1093/tbm/ibz026.
The objective of this study was to characterize financial barriers and solutions for the integration of behavioral health in primary care at the practice and system levels. Semi-structured interviews were conducted March-August of 2015 with 77 key informants. Initially a broad thematic coding approach was used, and data coded as "financing" was further analyzed in ATLAS.ti using an inductive thematic approach by three coders. Themes identified included the following: fragmentation of payment and inadequate investment limit movement toward integration; the evidence base for integration is not well known and requires appropriately structured further study; fee-for-service limits the movement to integration-an alternative payment system is needed; there are financial considerations beyond specific models of payment, including incentivizing innovation, prevention, and practice transformation support; stakeholders need to be engaged and aligned to support this process. There was consensus that the current fragmented, fee-for-service system with inadequate baseline reimbursement significantly hinders progression toward integrated behavioral health and primary care. Funding is needed both to support integrated care and to facilitate the transition to a new model. Multiple suggestions were offered regarding interim solutions to move toward an integrated model and ultimately global payment. Payment, in terms of both adequate amount and model, is a significant obstacle to integrating behavioral health and primary care. Future policy efforts must focus on ensuring stakeholder collaboration, multi-payer alignment, increasing investment in behavioral health and primary care, and moving away from fee-for-service toward a global and value-based payment model.
本研究的目的是在实践和系统层面描述初级保健中行为健康整合的财务障碍及解决方案。2015年3月至8月，对77名关键信息提供者进行了半结构化访谈。最初采用广泛的主题编码方法，对编码为“融资”的数据，由三名编码员在ATLAS.ti中使用归纳主题方法进行进一步分析。确定的主题包括：支付碎片化和投资不足限制了向整合的推进；整合的证据基础尚不为人所知，需要进行适当结构化的进一步研究；按服务收费限制了向整合的推进——需要一种替代支付系统；除了特定的支付模式外，还有财务方面的考虑因素，包括激励创新、预防和实践转型支持；利益相关者需要参与并保持一致以支持这一过程。大家一致认为，当前碎片化的、按服务收费且基线报销不足的系统严重阻碍了向综合行为健康和初级保健的进展。既需要资金来支持综合护理，也需要资金来促进向新模式的过渡。就向综合模式及最终向全球支付迈进的临时解决方案提出了多项建议。在金额和模式方面，支付都是行为健康与初级保健整合的重大障碍。未来的政策努力必须集中在确保利益相关者合作、多支付方协调一致、增加对行为健康和初级保健的投资，以及从按服务收费转向全球和基于价值的支付模式。
