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Prepare Now: New Codes for Integrating Primary Care and Behavioral Health

Integrating primary care and behavioral health is a central focus in health care delivery reform for many states and payers as they work towards addressing quality and cost containment. Significant research demonstrating the effect of co-morbid behavioral health conditions on overall health outcomes, and the subsequent cost increases, has led to exploring the implementation of new models of care.

The Collaborative Care Model of integrated care was first tested at the University of Washington. With over 80 randomized controlled clinical trials showing robust results across multiple diagnoses, settings and payment groups, it has emerged as the predominant outcome changing model for treating mild to moderate behavioral health conditions in primary care settings. However, even with a remarkable evidence base and proven return on investment, widespread implementation has not occurred due to funding barriers, and implementation has languished despite being touted as a solution.

Recently CMS announced a commitment to providing a reimbursement solution to encourage implementation of the Collaborative Care Model by announcing the creation of three new codes for the distinct services in this model. The new codes will be in the 2018 Physician Fee Schedule but due to a sense of urgency to make this available sooner, CMS-designed temporary codes may be available as early as January 2017.

So why did CMS decide to fund the Collaborative Care Model? Collaborative Care is different from simply co-locating a therapist in a medical clinic and having him or her see patients who may be presenting with a behavioral health concern. Instead, a population health approach is implemented that includes utilizing validated screening tools to identify problems and tracking response to treatment with a data management tool called a registry. The registry helps make sure patients not actively participating in treatment get follow-up, and allows the team to see who is and is not improving over time. Evidence-based brief interventions proven to work in the primary care setting are used instead of traditional longer term psychotherapy. If someone is not getting better they are easily identified in the registry, and during the weekly review with a psychiatric consultant additional recommendations for treatment changes can be suggested. The model includes regular measurement of progress to identify when adjustments are needed including referral to behavioral health specialty care. Using this stepped care approach, Collaborative Care can judiciously use scarce resources (such as psychiatric input) to provide effective treatment.

Many of the tasks listed above do not include face-to-face evaluation of patients and therefore are not billable. The new codes from CMS provide a monthly bundled payment to cover the cost of the registry maintenance and data entry, psychiatric caseload review and a myriad of care management duties. It is important for health care systems to understand these codes and the required tasks and how this differs from simple co-location of behavioral health services. Specific training in the Collaborative Care Model for clinic staff will be crucial to meet reimbursement and audit standards.

Value-based payment for healthcare services is the emerging trend in healthcare, and the Collaborative Care Model is a proven means to deliver outcome changing clinical and cost containment results. Using these codes will require new workflows, staffing requirements, IT buildouts and ultimately a culture shift. It is important to prepare now, and HMA can help.

We have Collaborative Care Model experts – including a master trainer – who can help your organization position itself to take advantage of this long-awaited solution. Our value-based payment assessment tool can help your organization assess its readiness. Click here to learn more. Join us Oct. 10-12 as more than 30 industry leaders will serve as keynote speakers and panelists at our conference, “The Future of Publicly Sponsored Healthcare: Building Integrated Delivery Systems for Vulnerable Population.” Click here to learn more or to register for our Chicago event.