Behavioral Health in the PCMH: Making it Work in Small and Medium Sized Independent Practices Lori...

Behavioral Health in the PCMH: Making it Work in Small and Medium

Sized Independent Practices

Lori Zeman, PhD, Licensed PsychologistDirector of Behavioral Health Integration,

MedNetOne Health [email protected]

Michigan Primary Care Consortium Symposium 4/29/14

Objectives

• Define why it is important to integrate behavioral health into the PCMH

• Discuss ways behavioral health and physical health can be integrated to improve care

• Identify important considerations and implementation strategies for your setting

Join the Conversation:

Behavioral Health CategoriesWarranting Attention in Primary Care

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• Mental Health and Substance Use Disorders• Health Behaviors• Psychological factors that do not meet criteria for

mental heath diagnoses but exacerbate physical symptoms and impact health behaviors

Prevalence of Mental Health Conditions in Primary Care

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Psychiatric disorders prevalence

• Major Depression 10 to 24%

• Panic Disorder 6 to 16%

• Other Anxiety Disorders 7 to 21%

• Alcohol Abuse 7 to 17%

• Any Psychiatric Diagnosis 28 to 52%

• 50% of all life-time MH disorders start by age 14

• 90% of all substance addictions start in the teens

• First symptoms of MI typically occur 2 to 4 years before full-blown disorder

• Despite effective treatments, the average delay between onset of symptoms and interventions is 8 to 10 years

Trajectory of Mental Illness

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50% of people with major depression do not get detected• 40 to 60% of those get minimal guideline

concordant care for antidepressant dose and duration

• <10% get empirically validated psychotherapy 67% with any behavioral health disorders do not

get treatment (Kessler et al, 2005)

Behavioral Health Needs Are Not Adequately Addressed

Primary Care Clinic

Mental Health Clinic

Low Follow Through to MH Referrals

Patients who refuse referral tend to be high utilizers with unexplained physical symptoms


People Access Mental Health Care in Primary Care

• 49.6% of people getting MH treatment get it in primary care • National Comorbidity Survey-Replication, Kessler et al,

2005

• 92% of all elderly patients receive MH care from PCP• PCPs prescribe:

• ~67% of all psycho-tropics

• ~80% of antidepressants

• More than 80% of all children and 70% of adolescents see a physician at least once each year, and more than 50% have routine health visits

• 23% of pediatricians and family physicians routinely screen their adolescent patients for MH disorders• When pediatricians rely on clinical judgment 40 to 80% of

children with developmental or MH problems are missed

Missed Opportunities

• x

x

10 Most Common Complaints in Adult Primary Care

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Chest Pain Fatigue Dizziness Headache Back Pain

Swelling Insomnia Abdominal Pain Numbness Shortness of

Breath10 to15% had identifiable organic basis

Kroenke & Mangelsdorf (1989) Am J Med;Strosahl et al. (1998); Kaiser; APA

Common Chronic Medical Conditions that Have Significant Behavioral Health Components

• Pain• Hypertension• Asthma• Diabetes• Sleep disorders

• HIV• Cardiovascular Disease• Irritable Bowel Syndrome• Obesity• Sexual Dysfunction

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Health Behaviors

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Behaviors or Unhealthy Behaviors

•Smoking25%

•Poor Diet30%

•Sedentary lifestyles 50%

•Non-Adherence20 to 50%

•Risky sexual behavior

•Poor sleep hygiene

High Costs of Unmet BH Needs and Fragmented Care

• BH disorders account for half as many disability days as “all” physical conditions (Merikangas et al., Arch Gen Psychiatry. 2007)

• Untreated mental disorders in chronic illness is projected to cost commercial and Medicare purchasers between $130 and $350 billion annually (Hertz et al, 2002)

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Annual Medical Expenditures for Adults with and without a MH Condition

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Cost without mental health condition

Cost with mental health condition

All adults * $1,913 $3,545Heart condition 4,697 6,919High blood pressure 3,481 5,492

Asthma 2,908 4,028Diabetes 4,172 5,559

*-Refers to all adults with and without chronic conditions. .

Information from U.S. Department of Health and Human Services. The 2002 and 2003 MEPS. AHRQ, Rockville, Md.

• HERO study in Birmingham Alabama• Study of 46,000 workers at several major US

companies

•Medical costs 70% higher among individuals with untreated depression

•Medical costs 46% higher among individuals reporting uncontrolled and untreated stress

Impact of Psychological Factors on Overall Health:

Top 10 Health Conditions Driving Costs for Employers (Med + Rx + Absenteeism + Presenteeism)

Costs/1000 FTEs

Depression

Obesity

Arthritis

Back/N

eck PainA

nxiety

GER

D

Allergy

Other C

ancerO

ther Chronic Pain

Hypertension

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

$400,000 PresenteeismAbsenteeismDrugMedical

Loeppke, et al., JOEM. 2009.

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Improved Outcomes and Lower Costs With BH Integration

• Medical use decreased 15.7% for those receiving behavioral health treatment while controls who did not get behavioral health medical use increased 12.3% (Chiles et al., Clinical Psychology)

• Depression treatment in primary care for those with diabetes $896 lower total health care cost over 24 months (Katon et al., Diabetes Care. 2006)

• Depression treatment in primary care $3,300 lower total health care cost over 48 months (Unützer et al., Am J of Mgd Care )

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The Affordable Care Act

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Requires mental health and substance abuse coverage as one of the 10 essential health benefits

Integrated Behavioral Health Helps Meet PCMH Core Principals

Whole Person Orientation: majority of personal health care in primary care

Coordinated Integrated Care: Personalized care across acute and chronic problems, to include prevention and focus on the physical, social, environmental, emotional, behavioral and cognitive aspects of health care.

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Integrated Behavioral Health Helps Meet PCMH Core Principals

Enhanced Access: Time to third available appointment and same day access to the range of health care needs the patient has to include addressing in primary care by the team mental/behavioral health and health behavior change.

Payment for Added Value Enhance evidence-based screening, assessment and intervention for mental/behavioral health, substance misuse and abuse and health behavior change, that improves acute and long-term outcome, patient and provider satisfaction, decreases monthly cost for enrolled population, decreases ER visits, and prevents/decreases hospitalizations (i.e. medical and psychiatric).

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Join the Conversation: 23

NCQA PCMH High-Level Goal for 2014: Further Integrate Behavioral Health

Element 2E delineates unhealthy behaviors and conditions related to mental health or substance abuse and evaluates capability to provide care reminders and use clinical decision support.

Element 1E asks practices to communicate the scope of services available including how behavioral health concerns are addressed.

Element 4B (Referrals) includes specific factors on establishing relationships with behavioral health providers.

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Roles for BH Providers in Primary Care

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• Screening and/or follow-up assessment (should have good diagnostic skills)

• Program development: evaluation, treatment and follow-up protocols

• 2-way coordination with community resources, schools, specialty mental health

• Develop referral resource book• Brief interventions


• Patient education/Anticipatory guidance • Handouts• Workshops

• Consult to medical providers• Address health behaviors • Help medical providers around engagement with

patients and families• Quality improvement initiatives

Roles for BH Providers in Primary Care (continued)

Integrated Care Models

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• Identify partners• Preferential referral relationship• Referrals followed by phone calls and ongoing

collaboration• Effort to reduce barriers• Shared information

Enhanced Referral (PCMH-N)

• Specialist serves as consultant via telephone or video-conferencing

Telehealth

• Formalized screening• PCP training• Patient education• Follow-up care• Care manager • Psychiatrist consultant/supervisor

Disease/Care Management

.

Colocated

• BH and PC offer services in same physical location.

• PCPs typically refer to BH.

• Each has own traditional practice patterns, separate administrative and record systems.

• BH and primary care providers are considered part of the same team, not specialists within a clinic

• Care is co-managed

• Shared appointments, treatment plans

Fully Integrated: Primary Care Behavioral Health (PCBH)

If you have seen one integrated care program … you have seen one integrated care program

One size does not fit all – Understand factors important for

integration success in YOUR setting

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AAP Mental Health Practice Readiness Inventory

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What does your practice

do well?

What does your practice

do not so well?

http://pediatricmentalhealth.files.wordpress.com/2011/11/a8-mh-practice-readiness-inventory.pdf


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• What do you want to accomplish?• Who is your target population?

• How will they be identified?• Perform a needs analysis • Determine available financial mechanisms

Considerations


Business Arrangements With BH Provider

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• Independent contractor (e.g., an individual or an organization such as a clinic or a PO)• Formal business agreement • Can be billed under separate Tax ID or same Tax ID with BH

provider paid via collections or flat hourly fee

• Employed member of practice • Billed under same Tax ID

• Partner model• Share risk• Same Tax ID


How Will BH Provider Be Compensated?

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• Percent of collections• Hourly rate• RVU/productivity• Share of P4P


Funding Streams

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• Fee-for-service• Capitation• Pay for Performance• Flexible infrastructure support• Case rates to cover prevention and care management of

chronic conditions• Grants/Demonstration projects• Carve-ins versus Carve-outs• Increased physician productivity (BHP frees up PCP time)


Fee-For-Service Options

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• Traditional mental health codes - 90791-92, 90832, 90834, 90837, 90833, 90836, 09838, 90839, 90840, 90846, 90847, 90849, 90853 –psychiatric evaluation, psychotherapy, and psychological testing

• Health and Behavior codes (H & B) - 96150-96155• Chronic Care Management Codes – T1015, T1019, G-

codes• Interdisciplinary team conference codes – 99366-99368


Fee-For-Service Options (continued)

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Screening and Brief Intervention (SBI) for Substance Use Payer Code Description 2012 Fee

Commercial

Insurance

99408

structured screening and brief intervention services; 15 to 30 min

$33.41

99409

structured screening and brief intervention services; >30 min

$65.51

Medicare

G0396

Structured screening and brief intervention services; 15 to 30 min

$29.42

G0397

Structured screening and brief intervention services; >30 min

$57.69

Medicaid

H0049

Screening $24.00

H0050

Brief intervention, per 15 min $48.00


Fee-For-Service Options (continued)

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• Incident-to physician billing• Optimizing physician E & M coding

• Other – Medicare Advantage Hierarchical Condition Category (HCC) Payment Methodology • HCC Code 55 (Depression) adds ~ $300 to monthly payment• Not implemented yet in Michigan


Billing Challenges

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• Covered codes vary by payer• PCP and BH not always on same insurance panels • Carve-outs: disincentive for BH to address medical • Multiple co-pays at same visit• Some payers won’t cover 2 visits on same day• Prior authorization


Considerations

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• What performance metrics do you want to impact?• Financial implications

• Target your resources to priority areas• Select evidence based strategies• Determine appropriate metrics to evaluate success• Use of patient registry • Amount of BH provider time needed

Logistics: • Space, • Scheduling, • Patient flow – referral process• Information sharing

Confidentiality, consent Skill set of medical and BH staff

• Who is your optimal partner?• Training needs

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Considerations

Desirable Characteristics of MH Providers in Primary Care Clinics

Flexible, adaptable to fast pace, unpredictable schedulesComfortable with ambiguity, think on their feetEnjoy teamworkComfortable in brief, sometimes one-session interventionsStrong diagnostic skills; Trained in EBTUnderstand BH problems common in primary care

(somatization, chronic pain, non-adherence, lifestyle changes necessary for comorbid chronic illnesses)

Naturally gravitate towards Motivational Interviewing


Implementation Tips

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• Identify integration champion(s)• Solicit input from people in all roles• Solicit patient/family input• Assess current practices• Build on strengths


Implementing Tips (continued)

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• Map the workflow

• Establish tracking system - goals



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• Conduct staff orientations• Engage all staff• Inform patients and families

• scripts

• Start small, pilot first• Address obstacles• Modify as needed



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• Review progress on regular basis• Integration is an ongoing process – it does not happen

quickly• Evaluate success of initiative• Acknowledge achievements!


Resources

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• AIMS Center (Advancing Integrated MH Solutions)• PCPCC (Patient-Centered Primary Care Collaborative)• AHRQ (Agency for Healthcare Research and Quality)• SAMHSA –HRSA Center for Integrated Health Solutions


Conclusions

• Behavioral and physical health integration has unique challenges but the payoff is worth it!• Improved access• Improved quality• Improved satisfaction (patient and provider)• Improved outcomes• Lower costs or cost neutral

• What are your challenges?• What are your successes?• What will your next steps be?

Behavioral Health in the PCMH: Making it Work in Small and Medium Sized Independent Practices Lori...

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