It’s no secret that the US health care system is expensive and under significant change these days. One part of the system that is receiving a lot of attention in primary care. The evidence suggests that primary care is an excellent investment for payers who want better health outcomes; however, recent data shows that payers are actually DECREASING their investments in primary care.
In the midst of this confusion, innovators are pushing forward to test new clinical and financial models in primary care. One clinical model you may already know is the Primary Care Behavioral Health (PCBH) model, a team-based primary care approach to managing behavioral health problems and biopsychosocially-influenced health conditions. But does this clinical model actually fit with the movement toward value-based payment models? If so, how and what should proponents of PCBH know to push for payment reform?
The authors of a new publication identify new financing strategies are emerging which will further support the viability of PCBH integration. I reached out to Dennis Freeman, lead author and CEO of Cherokee Health Systems, to ask a few questions about their article. See the exchange below:
1). What unfavorable reimbursement policies currently exist for PCBH or behavioral health integration broadly?
The most problematic policy barriers are created when behavioral health is “carved out” from the general medical benefit in health plans. Even when health plans claim to “carve in” behavioral health they often do not modify their internal administrative structure and continue to maintain separate, isolated staff with the responsibilities for network development, contracting and providing oversight of the behavioral health services benefit. Carving out behavioral health perpetuates bureaucratic silos. When behavioral health is carved out who has responsibility of paying for integrated care– the behavioral health division who manages the behavioral health benefit or the medical division with the responsibility of overseeing primary care? Whether both or neither claim the territory it is double trouble for the integrated provider organization.
Coding of the service is another potential barrier. Behavioral health providers of more traditional specialty behavioral health care use commonly accepted psychiatric CPT codes accompanied by a psychiatric diagnosis in order to garner reimbursement for their services. Behavioral health consultants (BHCs) working in primary care have a broader scope of practice. The usual CPT codes utilized by specialty behavioral providers will fit some, but not all, of the services BHCs provide. For example, a BHC might focus on prevention, risk reduction or general health behaviors. The patient might not present with a psychiatric disorder but an intervention to promote health behaviors or cope with a chronic medical conditions is still indicated. There are CPT codes to cover these services, the Health and Behavior Assessment and Intervention CPT codes 96150 through 96155. Payers are often unaware of these codes and the provider must negotiate with the payer to assure these codes are in their contracts.
A third common barrier is a prohibition against billing two healthcare visits on the same day. Sharing care during the patient visit is core to the PCBH model. Expecting the patient to return on another day is inefficient for the providers of care and illogical from the patient’s perspective. Frequently, the patient does not return for a behavioral health visit scheduled on a different day.
Some consultation components of typical PCBH practice are not covered in a fee-for-service environment. BHC time spent in daily team huddles, hallway consultations, treatment team meetings, care coordination activities or similar activities that do not involve face-to-face time with the patient do not generally translate to an available CPT code. However, we have been able to make the case to payers these activities have value in and of themselves and contribute to the effectiveness and efficiency of care. Often we have been able to negotiate a secondary revenue stream to cover these non-revenue generating activities.
2. What does the field of PCBH need to do to leverage itself as a valued component of the future value-based healthcare payment system?
This is an easy question to answer though, quite possibly, not so easy to achieve. BHCs working in the PCBH model need to prove–with data–the presence of the behavioral health provider on the primary care team improves clinical outcomes, enhances practice efficiency and reduces total healthcare costs for the panel of patients cared for by the practice. These are team outcomes not individual behavioral health provider outcomes.
The BHC needs to know and understand the value-based opportunities available in the organization’s contracts and bring a measurement mentality to help track and improve the measures (utilization, HEDIS, cost measures) upon which value-based payments are made.
3. What can clinicians do to increase their knowledge of financing models and payment reform?
It is important for clinicians to understand why there is such an emphasis on health care reform in our country. While improving the outcomes of health services and enhancing the overall health status of US population would be sufficient reasons, the major driver of health care reform in this country is cost. The US healthcare system is the most expensive of any nation on earth, more than 50% more expensive than the next most expensive national system. Our outcomes don’t justify the cost. US healthcare expenditures are a drag on our economy and we are at a competitive disadvantage with other nations as a result. That is the “why” of healthcare reform.
Understanding the big picture helps clinicians appreciate the economic forces impacting their work. Employed clinicians should take the initiative to gain a basic understanding of the revenue sources and the financing mechanisms that support and sustain their organization. Understanding the financing helps the clinician gain an appreciation of the efforts and decisions administration is making to secure the future of the organization.
Is my wish that clinicians promptly forget all they know about the financing mechanisms when they enter the room with the patient. At Cherokee we don’t ever want the financing mechanisms or the payer source to impact the care a patient receives. We want the uninsured patient to receive the same level of excellent care as the patient with the most generous health plan. Frankly, clinicians have enough to be concerned about just focusing on delivering quality care.