Noting that payment models that sustain behavioral health integration with primary care remain underdeveloped, the Primary Care Collaborative recently brought together clinicians, payers, and purchasers to discuss how to build more robust payment models that support behavioral health integration.
Alin Severance, M.D., medical director of behavioral health services for UPMC Health Plan in Pennsylvania, began by noting that there are three CPT codes designed explicitly for collaborative care model services.
“The nice thing about these codes is that they support clinical work by the primary care doctor and the care team that under the old status quo CPT codes are not reimbursable or they're very poorly reimbursed,” Severance said.
UPMC sees many health disparities in Pennsylvania regarding behavioral health — rural versus urban, and among ethnic minorities. It is not easy to find a psychiatrist or a therapist, he said.
“Collaborative care is a great strategy to narrow those gaps, but we've seen extremely low utilization of these codes. I've actually had several practices approach me for guidance on billing and documentation,” Severance added. “I know several practices that have been self-funding collaborative care for years. We’re motivated to help them be compensated for providing high-quality care because it allows them to sustain and hopefully expand their programs. But that's really hard in a multi-payer environment. We have competitor plans that are not reimbursing for collaborative care codes, so a clinic really has to think hard if they can take that financial risk, knowing that not all of their patients are going to be able to be covered for what they're doing.”
Even so, Severance added, “when you talk to providers, everybody feels like this is the right direction to go. They all want more integration. They want better access to resources. The question is how do you get from here to there. They don't have the knowledge, the resources, or the time to begin their implementation journey. Having the codes turned on is just not enough, even if all plans do it. We've been taking a more proactive role in promoting collaborative care, connecting clinics that are actually doing this with other clinics that are doing it so they can compare notes.”
Severance noted that if you just have co-location, where you have physical health and behavioral health under the same roof, it doesn't guarantee meaningful care coordination. “If you have separate documentation, separate billing, separate contracting, treatment tends to be siloed. Also, there's no reimbursement for actual team-based care. They might share the same office, they might be down the hall, but they might not actually talk to each other. And that's not the direction that we want to be going.”
“We have put a stake in the ground from a purchaser perspective,” said Mike Thompson, president and CEO of the National Alliance of Healthcare Purchaser Coalitions. “It is not an advanced primary care model if it does not have behavioral health integration. And behavioral health integration, as Alin said, is not simply having people in the same office. That's not integration. It requires systematic screening and treatment and follow-up to confirm that progress has been made and treatment is modified accordingly and appropriate triage when things are more serious than can be handled by the primary care practice.”
“That team-based model is fundamental, and frankly, we know we need to pay more, but it will more than pay for itself,” Thompson said. “We know that practices that have implemented integrated behavioral health — at least the ones I've talked to — have said we will never go back once we experienced what this looks like. We realize it's better for patients in a big way, and frankly, it's better for the practice. We just have a change management and a leadership challenge in front of us to move it forward. And yes, let's make sure we're paying for these high-value services for practices to adopt.”
Judy Zerzan-Thul, M.D., is chief medical officer for the Washington State Health Care Authority, which covers close to 2.4 million Washingtonians. She said some primary care practices in Washington do collaborative care, but not very many. In talking with primary care practices about why there is not more behavioral health integration, they say it takes a lot of time. “It is hard to figure out how to do this,” she said. “It takes a lot of time and resources to do and then the second thing is the startup costs to the practice. They find that it's really expensive to start this. Once they get it going, once they're in a groove, billing for the codes, it keeps sustaining them, but it takes a little while to get there, so that initial investment can be a little challenging.”
Kevin Wheeler, M.D., is medical director for practice transformation and value-based contracting strategy at the AmeriHealth Caritas family of companies, which has Medicaid plans in 11 states. He noted that one trend they are seeing involves hybrid provider/vendors — for-profit companies that are acting as providers with a behavioral health focus, but also saying they have a care integration focus and they have primary care services that they are also bringing to the table. “These offerings are compelling,” he said. “They very often come with a fairly aggressive savings target that sometimes we have our issues with, but at the same time, the concept is there. They very often have a digital platform. We're exploring these partnerships pretty aggressively — always with the idea of maintaining local resources as the first priority.”
Wheeler added that people are often focused on the short-term revenue cycle. “That is an unfortunate fact of all of our lives,” he said, “but the investment that we're talking about is necessarily many orders of magnitude longer than any one of our revenue cycles. As an industry and as a group of peers, we have to take risks together and understand that despite what a short-term profit and loss might look like, despite what the short-term contract cycle might look like, the investment in the future has to be upfront. It has to be aggressive. It has to be investing in residency programs and graduate programs, all of those things, and as much support as we can have from our regulatory partners in taking that risk, the better.”
“What I've frustratingly observed is a lot of the time, we're spending more time debating what the model is and not enough time actually executing,” Thompson said. “I think we ought to just get away from labels and talk about what we need, right? We need to systematically be assessing, need to systematically be triaging short-term treatment, and then measuring and monitoring progress. It doesn't need to be co-located. It can be virtual.”
He said there are pockets of progress. “There's a major effort to facilitate behavioral health integration in primary care in Texas. I think it's called the Lone Star project. There is a major activity in Michigan, with Blue Cross and Michigan. Of course, they have a dominant market share in the state of Michigan, but Blue Cross is actually making the investment. I think the federal government has stepped in and led with investment because this pays for itself. There is so much cost of poor quality in ignoring behavioral health and that's largely what our system does today.”
“In Washington state we are thinking about multi-payer and payment change as things that need to accelerate,” said Zerzan-Thul. “We have started in small pockets and need to keep going. In Washington, we have a primary care transformation model that we've been having a number of different convening forums on. Where it started was with the payers and Washington State agreeing they wanted to support primary care and in particular, that integration and how we get better behavioral health to folks because what we're doing now isn't working.”
She said that as part of the transformation, the state has 10 accountabilities for practices, including things like whole person health and behavioral health screening for every patient. “Part of how we measure that is through an integrated care assessment that Medicaid has fully adopted, and we are hoping to spread statewide,” Zerzan-Thul said. The integrated care assessment tool that we're using was originally developed in New York State, and one of the handy things is there's an assessment for primary care, and there's an assessment for behavioral health settings because, I think, to get integrated primary care, it's not just about primary care. Some people are more comfortable getting the majority of their care from mental health or substance use providers. How do we meet people where they are and have the integration go both ways? It does take a whole village to figure this out, and to have good communication, back and forth.”
“Judy's last point about integration happening in both directions is often forgotten. The collaborative care model was designed for primary care, but you can bring physical health resources into the behavioral health space,” UPMC’s Severance said. “Our Medicaid subsidiary has done exactly that. We published on a model called Behavioral Health Home Plus, where we bring in physical health resources to methadone clinics, to residential psychiatric residential treatment facilities, to places where people with serious mental illness or fairly severe substance use disorders are getting care. This is a population that often doesn't get much in the way of physical health maintenance. There are value-based payment arrangements to sustain these programs, and the outcomes have been terrific. So bringing primary care into the behavioral health space is a is a needed strategy, too.”