Welcome to the first edition of the CFHA News and Research Column, a new series of posts that highlight recent developments in the field of collaborative and integrated care. Check back each month for additional reports.

NEWS

Reimbursement Codes

A new bill introduced by U.S. Senator Debbie Stabenow (D-MI), U.S. Senator Barbara Mikulski (D-MD) and Congresswoman Barbara Lee (D-CA) aims to help older individuals with mental illness by changing the way Medicare reimburses clinical services performed by social workers. According to Congresswoman Lee, a psychiatric social worker herself, “social workers are not adequately reimbursed for the vital services they provide”. The bill was introduced in the Senate on October 8^th, 2015 and is now moving through the Committee on Finance.

The new bill, called Improving Access to Mental Health Act of 2015, would align Medicare payments for licensed clinical social workers (LCSW) with that of other non-physician providers like nurse practitioners and physician assistants. Specifically, this means that LCSW’s would be allowed to deliver and bill for Health and Behavioral health services (codes 96150 – 96155) that are presently restricted to clinical psychologists only by Medicare. An LCSW would not need to use a mental health diagnosis but could instead use the medical provider’s diagnosis and focus on behavior change. This may especially help improve chronic disease management and expand behavioral health services to older patients.

ACO for SNFs has Positive Outcomes

Collaborative care works for Medicare beneficiaries in skilled nursing facilities (SNF), according to data from a joint venture by the Atlantic Accountable Care Organization (AACO) and Optimus Healthcare Partners. In 2014, ACOs in New Jersey started working with SNF leadership to improve collaboration and performance outcomes (e.g., length of stay, lowered hospital admissions). Within six months, there was significant improvement across all performance measures as well as a reduction in nursing home costs for sub-acute care patients. Sub-acute care is for patients who require more intensive skilled nursing care, but not hospital acute care.

How did they do it? The ACOs worked with administrators and leaders from each of the 61 participating SNFs to review facility performance and collaboratively revise or design new protocols and processes. Managers then worked with clinical staff to provide training and ongoing support to implement the new ideas which included great patient and family engagement. The success of the new network of SNFs is attracting other facilities in the state of New Jersey to join.

According to Poonam Alaigh, M.D., corporate consultant to the Atlantic ACO, “these results are proof that when you remove silos and work collaboratively across the health care continuum reduced costs are possible, while improving the quality of care.”

Global Payments for Behavioral Health Integration

A new report from the SHAPE pilot study in western Colorado suggests that global payments for primary care and integrated behavioral health services results in lower total cost per patient. “We are pleased, but not really surprised by these findings,” says Patrick Gordon, MPA, associate vice president, Rocky Mountain Health Plans. According to Benjamin Miller, director of The Eugene S. Farley, Jr. Health Policy Center at the University of Colorado, “This is about changing the rules of the game to allow for seamless, unfettered access to behavioral health care in the setting where patients most often present with behavioral health issues.”

Fixed-dollar payments for patient care, otherwise known as global payments, are nothing new to healthcare. The goal of global payments is to reduce costs while also not punishing providers for treating sicker patients. Instead, providers act as stewards over limited resources; they must deliver good outcomes while also eliminating waste. Historically, there has been less data for global payment systems compared to traditional payment systems like fee-for-service. The SHAPE study provides important analysis for determining the effectiveness of a fixed-dollar payment for integrated behavioral health services.

The SHAPE project is funded by the Colorado Health Foundation and supported by the Collaborative Family Healthcare Association (CFHA). Stay tuned for more information about this project in the future.

RESEARCH

·         A case example from the University of Washington demonstrates the effectiveness of treating serious mental illness in a primary care setting using a collaborative care model. Primary care physicians consulted with on-site psychiatrists to successfully reduce symptoms and increase functioning for a 36-year-old patient. Click here for more information.

·         In the past, there has not been much research available on the effectiveness of integrated behavioral health services for pediatric populations. Now, a systematic meta-analysis from researchers at UCLA suggests a significant advantage for integrated care interventions relative to usual care on behavioral health outcomes (d = 0.32; 95% CI, 0.21-0.44; P < .001). The strongest effects were seen for treatment interventions that targeted mental health problems and those that used collaborative care models. Check out the additional commentary from David Kolko at the University of Pittsburgh. He considers this type of research a “national priority” and praises the researchers for their methodological rigor.

·         Several studies suggest that collaborative care is especially effective for chronic disease management. A recent systematic literaturesearch from the Tilburg University in the Netherlands examines the relationship between context, mechanisms, and outcomes for thirty-two studies of integrated care and type 2 diabetes. The researchers concluded that most barriers to implementation are related to the organizational context level, including workflow changes, logistical barriers, and staff turnover or limited staff capacity. They also concluded that most facilitators for implementation occur at the social context level, which include involvement of staff in decision-making and planning, the ability to find committed staff and generate staff buy-in, and good leadership and intra- and inter-practice resource-sharing and cooperation.

·         Finally, researchers from the Mayo Clinic in Rochester, Minnesota conducted a retrospective cohort study of 7340 patients with depression to see if collaborative care management (CCM) was superior to usual care (UC). They compared the two treatments using (9-item Patient Health Questionnaire [PHQ-9] score <5) and persistent depressive symptoms (PDSs; PHQ-9 score =10) as end points. The results show that the median time to remission was 86 days for the CCM group versus 614 days for the UC group. Likewise, median duration of persistent depressive symptoms was 31 days for the CCM group versus 154 days for the UC group. The researchers conclude that patients enrolled in CCM have a faster rate of remission and a shorter duration of PDSs than patients choosing UC.