BY, JD, MA
As a father and health insurance expert, I have been challenged to leverage my professional expertise to support family and friends. One of the biggest tests was watching my firstborn deal with addiction issues which pervaded her teenage years and early adulthood. A related pain point was the lack of consistent insurance coverage for her treatments even though I had full coverage through my employer. Even with training and experience as a healthcare attorney, I had to pay out-of-pocket for much of her treatment when her care should have been covered by my health plan.
The good news is that after a 10-year battle with her addiction issues (including many therapeutic interventions), my daughter began a new trajectory when she was treated in a residential treatment program that focused on her co-occurring conditions. Her anxiety and depression were driving her addiction issues, not the other way around. Once she tackled and addressed her mental health issues, her addiction issues faded away (and her physical health improved as well).
The fragmented approach taken by her treating providers earlier in her life was the equivalent of putting a Band-Aid on her alcohol and drug use as they failed to treat her as a whole person, which explains her many relapses early on. Today, she is a well-adjusted licensed nurse and is thriving.
THE NEED FOR PARITY
The historical bifurcation of insurance coverage between medical/surgical care and mental health/substance use disorders (MH/SUD) has impacted the practice of medicine in ways that can hurt patients like my daughter. The good news is, several pressure points have emerged in recent years that push for care coordination to promote a more integrated and holistic care model by leveling the clinical playing field between physical and mental health.
Two regulatory changes are helping us realize the dream of a more integrated approach to population health. One is the adoption of The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act in 2008, and the other is the Patient Protection and Affordable Care Act of 2010 (Obamacare). The former mandates that health plans offer equal coverage between the body and mind, and the latter mandates the coverage of MH/SUD services as an “essential health benefit” in most health insurance offerings.
LEVERAGING PRIMARY CARE
To take advantage of these emerging calls for integrated care, optimizing the role of primary care is one touchpoint that can make a real difference. Primary care offers a unique opportunity to evaluate the need for mental health services in addition to traditional physical health assessment.
Unfortunately, the role of a primary care provider (PCP) is often limited in most clinical settings due to time constraints, limited access to mental health professionals, and the lack of reimbursements for the wraparound services. Not surprisingly, studies have shown that 13% of people diagnosed with a behavioral health condition receive minimally adequate treatment in a general medical setting; and for substance abuse, that number drops to a dismal 5%, as highlighted by a recent Kennedy Forum Issue Brief entitled “Fixing Behavioral Health Care in America: A National Call for Integrating and Coordinating Specialty Behavioral Health Care within the Medical System.”
Health researchers evaluated ways to improve the detection and treatment of MH/SUD disorders in primary care settings for years. Their efforts initially focused on screening and diagnosis for common mental disorders such as depression, but this offers only part of the solution. After many years of research and analysis, the opportunity to optimize clinical outcomes for patients with MH/SUD conditions appears to be dependent upon an integrated delivery model.
MOVING TO COLLABORATIVE CARE
To answer the call, the “collaborative care” model was developed to treat common MH/SUD conditions in primary care settings. The traditional primary care treatment paradigm has three members: the patient, the nurse, and the PCP. Collaborative care injects two additional clinicians into the equation: a case manager and a psychiatric consultant.
As highlighted by the Kennedy Forum Issue Brief, the hallmark of a collaborative care program is made up of:
- Care Coordination. Team-based, led by a PCP with support from a case manager and consultation from an MH/SUD provider, who jointly develop and implement treatment plans
- Engagement. Patient-centered, with proactive outreach to engage, activate, promote self-management and treatment adherence, and coordinate services
- Established Clinical Pathways. Evidence-based, with demonstrated costeffectiveness in diverse practice settings and patient populations
- Outcomes Tracking. Population-based, whereby the care team uses a registry to monitor treatment engagement with measurement-based monitoring of patient-reported outcomes and other outcomes over time to assess treatment response
- Accountability. Accountable for the care provided and for continuous quality improvement to meet care goals.
THE TREATMENT TEAM
As referenced above, a collaborative care program integrates a case manager (including a clinical social worker, licensed counselor, or nurse) who supports the PCP in caring for patients with common mental health conditions. The PCP and the case manager are supported by a mental health professional who typically consults with the case manager weekly to review the treatment plan for patients who are new or who are not improving as expected. The psychiatric consultant is available to make treatment recommendations to the PCP and case manager and can see patients in person or via telemedicine if necessary.
The case manager is typically embedded in the primary care practice, whereas the psychiatric consultant consults by phone and is typically not co-located, although he/she can be. Growing evidence suggests that non-embedded case managers can also be effective.
MAKING A DIFFERENCE
The case for collaborative care is clear and compelling. Dozens of randomized controlled trials have shown this dynamic team approach to be more effective than the typical care models for common mental health conditions such as depression and anxiety. The Kennedy Forum in its Issue Brief notes:
“Several recent meta-analyses, including a 2012 Cochrane Summary that reviewed 79 randomized controlled trials and 24,308 patients worldwide, further substantiated the model. Collaborative Care has been developed in multiple settings and research protocols in the U.S. and around the world. The research is particularly strong for depression, but increasingly for other conditions as well including anxiety disorders, post-traumatic stress disorder and comorbid medical conditions such as heart disease, diabetes and cancer. Research shows Collaborative Care improves patient functioning at home and at work, reduces disability, improves clinical outcomes and increases patient satisfaction and quality of life. Although the research evidence on Collaborative Care’s ability to effectively treat substance use disorders is less extensive, people who have comorbid mental health and substance use problems can benefit from Collaborative Care. Some mature Collaborative Care programs handle a variety of substance use disorders, and alcohol screening and brief interventions are effective for decreasing alcohol use in patients with risky drinking and can be easily incorporated into Collaborative Care programs. In addition, Collaborative Care programs can engage patients in care for alcohol use disorders when they are not ready for specialty treatment.”
Up until recently, payment for collaborative care programs has been a sticking point, but this changed when the U.S. Centers for Medicare & Medicaid Services (CMS) led the way with several payment codes. The American Psychiatric Association notes today that:
“Primary care practices that are providing collaborative care services can now bill for those services using CPT® codes for Psychiatric collaborative care management services (99492, 99493, 99494). Medicare, some commercial payers, and Medicaid plans are also providing coverage—check the local coverage policies in your area to determine coverage. Federally Qualified Health Centers and Rural Health Clinics can bill for these services using HCPCS code G0512 (for the initial 70-minute or subsequent 60-minute visits).
“[CMS] has provided a fact sheet and a short list of FAQs that describe CoCM (Psychiatric Collaborative Care) services and their associated billing requirements… They have classified all of these (99492, 99493, 99494 and 99484) as Behavioral Health Integration (BHI) services on their care management site:
- Care Management—Behavioral Health Integration Fact Sheet
- CMS Behavioral Health Integration FAQs”
Although the payment codes are good news, one central challenge is to encourage primary care practices to bill under these codes. Some PCPs tend to shy away from treating their patients for MH/SUD issues due to the hassle factor of dealing with the patient in this more comprehensive manner and the potential risk management issue of not properly following up with a patient after a more detailed MH/SUD screening.
Many integration models use case managers as a key team leader, the collaborative care model being just one of them. The approach to collaborative care undoubtedly has a return on investment (ROI). Several studies have documented the clinical and financial ROI, which are referenced in The Kennedy Forum Issue Brief. I can only think about my daughter’s long-term battle with addiction issues, and how she may have responded earlier to treatment vis-à-vis a collaborative model where a PCP, case manager, and mental health professional could have identified and addressed her anxiety and depression many years earlier. If this had been the case, it would have saved my health plan and me over $100,000 in costs. But most importantly, many of her early years would have likely been given back to her to live a happy and productive life as she does now.