Consultation psychiatry in the medical home and accountable care organizations: achieving the triple aim

We are in a time of increasing concern about unsustainable increases inhealth care costs toMedicare, Medicaid, employers and individuals. At the same time, more than half of patients with mental health needs do not receive care in any given year [1], and untreated mental disorders can be important drivers of high health care costs. As in the rest of health care, we are challenged with achieving the “triple aim” of improving access to care while at the same time improving quality and outcomes of care and reducing total health care costs [2]. To achieve this triple aim, psychiatrists of the future will have to shift professional roles. In addition to traditional consultation liaison activities focused on individual patients in outpatient clinics or hospital settings, psychiatrists should have important roles in monitoring behavioral health needs, treatments and treatment outcomes for defined populations of patients and providing supervision and guidance to interdisciplinary teams of primary care and behavioral health providers caring for a defined panel of patients. Two important concepts that are being advocated to improve patients’ experience and satisfaction with care as well as the quality and cost-effectiveness of medical care are primary care-based patientcentered medical homes and accountable care organizations (ACOs). The principles of the medical home are aimed at enhancing the potential benefits of primary care by emphasizing access to care, long-term relationships with health care providers, and coordination and comprehensiveness of care [3]. These principles also emphasize the importance of health care teams using evidence-based approaches and effective quality improvement methods [1]. Payment systems are being developed to provide financial incentives for primary care practices to transform their practices into medical homes and to make “meaningful use” of electronic medical record systems and other health information technology to improve coordination, quality and outcomes of care. The National Committee for Quality Assurance (NCQA) has established criteria for levels of adaptation of practices to the medical home concept, with increasing payments for higher levels of development [4]. These criteria include the capacity to care for patients with behavioral health conditions. Federal and state payers are also developing criteria for quality of care including behavioral health care for populations that will gain insurance coverage under health care reform [5]. Accountable care organizations are built on the concept of physicians, nurses and other allied health professionals working as a team to provide the most efficient and cost-effective care of patients across different care settings [6]. The concept of ACOs assumes that primary and specialty care systems and hospitals will work closely together, often as single governing units [6]. Electronic records will integrate outpatient and inpatient systems and other information technologies such as patient registries are seen as key tools in improving the continuity and effectiveness of practice. ACOs will share with the federal government financial savings the organizationmay produce in medical costs to the population they are responsible for [7]. Given the changes in health care systems and the emphasis on improving quality of care and decreasing costs, what are the potential roles of consultation