Where health services, policy and cost issues, and the needs of underserved people intersect, you’ll often find Mark Gritz, PhD, head of the University of Colorado Department of Medicine’s Division of Health Care Policy and Research.
And so, when officials at the Colorado Department of Health Care Policy and Financing (HCPF) needed information to draft recommendations to the state legislature on best practices for sustaining integrated-care models – integrating primary care and behavioral health care at a medical practice – it’s no surprise that they called on Gritz and his research colleagues.
Integrated care “has been shown not only to improve quality of care for patients, but also to bend the total cost of care curve that our country deals with day after day,” Gritz says.
The CU Health Care Policy and Research division’s mission is to design and conduct health services research and policy analyses, and to evaluate health care innovations and programs from multiple perspectives, including performance, quality, and value. It has a particular focus on services involving Medicaid and Medicare, long-term and post-acute care services such as nursing homes and home health providers, and hospice and palliative care.
Gritz notes that his division is “relatively small” within the CU Department of Medicine. “We’re a research-only division, no clinical operations, focused on being a resource for quantitative health services research. We’ve built up capability for data informatics, statistics, and health economics, not only for own projects in the division, but also to support other divisions within the department and across the campus. We’re collaborators as well as principal investigators.”
Warm handoffs
Research shows that integrating primary and behavioral health care in a single practice can mean improved access to behavioral care, fewer visits to hospital emergency departments, and reduce costs.
Integrated care “is a whole-person approach to providing primary care, where you have primary care physicians at a clinic working alongside behavioral health professionals to address low-acuity types of behavioral health issues and health behavior changes,” Gritz says.
“The advantage for patients is, if they come in for a primary care visit and they have an acute behavioral health issue – maybe they had a death in the family and they’re feeling anxious and depressed – they can get assistance immediately without going somewhere else,” he says. “We call that a warm handoff.”
Colorado SIM advanced integrated care
Under a four-year, $65 million federal grant awarded in 2014, state health leaders worked to implement a Colorado State Innovation Model (SIM) project advancing integrated care. The project led to an estimated $179 million in health cost savings for Medicaid as well as commercial insurers through the end of 2017, and also produced improved care quality.
But the Colorado SIM project ended in 2019 when the grant ran out, slowing progress on integrated care. In May 2022, the Colorado legislature passed House Bill 22-1302, which allocated $31 million in federal COVID-19 pandemic stimulus funds to restart expansion of integrated care across the state.
Under the legislation, the state’s HCPF department – which oversees Colorado’s Medicaid program, a key funder of integrated-care programs – was tasked with submitting a report to the legislature recommending best practices for sustaining integrated care in the state.
Integrated care “makes sense for patients. It makes sense for payors. But does it make sense from a provider perspective? That’s a big, unanswered question,” Gritz says. “After our SIM grant ended, although not formally studied, anecdotal evidence suggested that practices and health systems struggled to make integrated care financially sustainable for themselves.”
Time-driven activity-based costing
Gritz has a longstanding collaborative relationship with HCPF. He worked with his colleagues at the Farley Health Policy Center, where Gritz is director of operations, on cost estimates for delivering integrated care that would inform the agency’s report. Their work was supported under an umbrella interagency agreement between the CU School of Medicine and HCPF.
In addition to reviewing available research on integrated care costs, Gritz’s team visited and collected data from 11 Colorado primary care practices that are delivering integrated care. The researchers assessed direct and indirect costs using “time-driven activity-based costing,” a method of translating the amount of time spent on various activities into a cost estimate.
As a result, they estimated the annual cost of providing integrated care in a typical practice at between $360,000 and $475,000, depending on practice size and the types of behavioral health clinicians employed. That estimate will inform the work of policymakers as they develop a sustainable funding structure for integrated care, which could include seed funding and grants for clinics as well as reforming systems of provider reimbursement under Medicaid and other payer programs.
Gritz is a Colorado native and an economist by training who spent years in the private sector before returning to Colorado in 2013, joining CU to work on health policy issues involving lower-income people and other underserved groups.
“I came back to Colorado to work with our state Medicaid agency and other state agencies, and look at how we can improve the life circumstances of people served by those programs – health, human services, education, training, and so on,” he says. “As a society, we need to do a better job at integrating services and programs for those populations. They end up way too siloed. If I had my druthers, we’d work collaboratively across health and human services sectors to coordinate these programs and make them work better together.”
