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    Spencer Hutchins
    Spencer Hutchins
    Virna Little
    Virna Little, PsyD, LCSW

    Securing access to behavioral health services for patients is often difficult for primary care providers (PCPs). Behavioral health providers often have long waiting lists or do not accept public insurance. As a result, PCPs have become the providers of care and of choice for patients who have mild to moderate depression or anxiety or are suffering from substance use.

    Many of these patients often present with multiple chronic primary care and mental health diagnoses, and can prove challenging for PCPs during a standard 15-minute visit. These patients are often the ones who do not successfully manage chronic medical conditions or participate in recommended preventive care. This affects providers’ ability to successfully care for them and to excel in the practice’s quality scores and measures.

    Acknowledging PCPs’ new role in behavioral health, Medicare and several commercial payers have begun to reimburse providers for caring for this population of patients. Medicare created a series of new reimbursement codes that, for the first time, pay primary care practices to implement evidence-based behavioral healthcare management for their patients. These are the new collaborative care codes.

    Collaborative care

    Collaborative care is a systemic approach to identify and treat depression and anxiety in a primary care setting. Collaborative care has been shown to be effective across 80 randomized controlled trials and is now recognized by Medicare and multiple state Medicaid programs for reimbursement.

    Sometimes referred to as IMPACT care, collaborative care was pioneered by a group of clinicians at the University of Washington who wanted to build a stronger behavioral foundation for the medical home.

    The model (Figure 1) deploys a therapist-care manager and psychiatric consultant into the primary care team. Collaborative care has four critical components:

    1. Universal screenings: Every year, patients should be given screenings such as the PHQ9 (depression), GAD7 (anxiety) and AUDIT (alcohol), with those screening positive enrolled in collaborative care.
    2. Warm handoffs: Rather than using outside referrals, practices should have a care manager (usually with a social work or nursing background) who PCPs can introduce to patients immediately — either in person or by phone within 24 hours.
    3. Regular behavioral healthcare management: The care manager should reach out to the patient multiple times each month to reassess symptom severity (using the same screening scale) and conduct evidence-based talk-therapy interventions such as problem-solving therapy, behavioral activation or motivational interviewing.
    4. Registry review and curbside consults: The behavioral care manager should spend an hour each week reviewing the panel with a psychiatric consultant (psychiatrist or Psych-NP). The registry is an efficient way to review each patient’s record: symptom severity over time, current goals or therapy, and current medications. Together, the team can then set goals for care, and the psychiatric consultant can make medication recommendations directly into the physician’s chart. In addition to the registry time, the psychiatric consultant is available to the primary care office for curbside consults to review the recommendations or help provide guidance.

    The model is intuitive to many providers, administrators and laypeople. But numerous, high-quality, replicated studies also demonstrate its value. More than 80 randomized control studies show that collaborative care improves behavioral health symptoms over the usual care patients receive. While most of this research has looked at depression or anxiety, studies are increasingly examining additional diagnoses, such as opioid and alcohol abuse.

    Reimbursement for collaborative care

    For 2018, Medicare created three new billing codes (see Figure 2) to support physician practices interested in this care model. Dubbed collaborative care management (CoCM), Medicare’s new program reimburses practices on a per enrolled patient per month basis, assuming the criteria are met.

    Creating an action plan

    Here are four steps for implementing a successful collaborative care system: 

    1. Find champions: An “on-the-ground” champion in the practice can help with implementation and lead team and practice efforts. This can be any member of the practice team, but it’s important that the champions can call on many major disciplines in the practice, including information technology, billing, and practice and senior management.
    2. Pick the team: A critical decision involves how you build your new behavioral health team. Do you already have social workers, psychiatric nurses or psychiatrists in your group? If so, you are fortunate. If you don’t, you’ll have to decide whether to grow your team or partner with a behavioral health practice in the community.
    3. Plan for sustainability and profit: The Medicare CoCM codes are a game changer, but important decisions still need to be made. Are there other plans in your market that will reimburse for these codes? Can your practice launch with a “Medicare-only” focus before commercial plans adopt these codes? How focused is your leadership team on near-term cash-flow concerns versus long-term infrastructure and positioning? Implementation may not be successful if the implementation team and the physicians or executives who control the budget don’t see eye to eye. It’s best to get a small group operational and try to break even, and then learn how to scale from there. If you have a larger practice, you may want to hire implementation help. It can be a smart investment that pays off quickly.
    4. Develop a screening workflow: Consistent with regulatory and clinical practice guidelines, most practices have implemented a screening workflow for depression, and even for addiction, suicide risk and anxiety. While most practices screen as part of the triage process, others have modified their practices to include patient portals, kiosks or front-desk staff as part of screening. Implementing a screening workflow can help identify patients who would benefit from collaborative care.

    While strategies for implementing collaborative care will vary among medical groups, an increasing number of practices recognize the value of these programs to patient care, provider job satisfaction and a practice’s financial sustainability, both now and in the future.
    It might be time for you to consider jumping in.  

    Value of incorporating collaborative care
    • Better patient care: The research is clear: Practices that deploy collaborative care effectively do a better job supporting their patients and see better outcomes.
    • Better economics: Practices that implement collaborative care can earn direct revenue through collaborative care codes and indirect revenue through quality and value-based payment arrangements for improved measures.
    • Better value: Whether your practice opted into accountable care organizations or capitation arrangements, or you are just starting to get your head around the Medicare Access and CHIP Reauthorization Act of 2015, value-based payment models are becoming the norm. Practices should be judged by outcomes and total cost of care. But too often, they do not have new revenue streams to support the infrastructure to get there. Medicare has created that path for behavioral health, with codes that support implementation in today’s fee-for-service environment, but also allow practices to build the systems necessary to succeed in risk models.
    Spencer Hutchins

    Written By

    Spencer Hutchins

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