Weaving Together Mental and Physical Health Care Outside the Safety Net MAY 2020 AUTHORS Muriel LaMois and Melora Simon, California Quality Collaborative Contents About the Authors 3Introduction The California Quality Collaborative (CQC), 4Background a program of the Pacific Business Group on Health (PBGH), is dedicated to advancing the 5How Did We Get Here? Policy and Market quality and efficiency of the health care deliv- Developments in California ery system in California. CQC creates scalable, measurable improvement in the care delivery 6How Current Policies and Market Arrangements system important to patients, purchasers, Create Barriers to Integration providers, and health plans. PBGH leverages Provider Participation the purchasing power of the country’s largest Coordination and Communication and most influential private employers and Reimbursement and Risk public purchasers to scale market innovations that lower costs and increase quality, trans- 9Seeking Solutions form care delivery, and influence policy. Screening At the time of the interviews, Melora Simon Coordination was senior director, California Quality Telehealth Collaborative and Care Redesign, and Muriel Employer-Sponsored Innovations LaMois was a research consultant, at the Pacific Business Group on Health. Practice Change Through the Collaborative Care Model 12Recommendations for Multipayer Alignment: About the Foundation Next Steps The California Health Care Foundation is 13Conclusion dedicated to advancing meaningful, measur- able improvements in the way the health care 14Appendix delivery system provides care to the people of 15Endnotes California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. California Health Care Foundation www.chcf.org 2 Introduction Mental health issues commonly present in primary This paper focuses on opportunities to support prac- care. Twenty percent of primary care visits relate to tice change in primary care to deliver integrated care mental health,1 and 79% of antidepressants are pre- outside the safety net. It is the result of research and scribed by primary care providers (PCPs).2 However, interviews conducted between February and May of many PCPs do not have the time and expertise to 2019 with 15 people at different types of entities, diagnose and treat mental illness.3 Depression, for focused on both challenges and strategies for integra- example, is one of the most common conditions PCPs tion outside the safety net. see, but half of patients with depression are not prop- erly diagnosed and less than 1 in 10 is appropriately Interviewees included payers (commercial, Medicare, treated.4 In addition, only 3% of psychiatrists and psy- and Medi-Cal plans), managed behavioral health chiatric nurse practitioners coordinate care with PCPs.5 organizations, and physical and behavioral health providers (independent practice associations, medi- A growing body of evidence shows that integrating cal groups, and integrated delivery systems). (See mental health into primary care services can increase appendix for complete list.) The paper was also mental health care access and coordination, improve informed by three provider interviews conducted patient outcomes, and reduce health care costs, partic- in late 2018 about adoption of the PHQ-9 depres- ularly for those with co-occurring chronic conditions.6 sion screening questionnaire, as part of developing Traditional safety-net providers have made strides a standardized measure set in partnership with the toward offering mental health services in tandem with Integrated Healthcare Association. physical health services. In part this integration has been supported by payment systems. Yet most people The Collaborative Care Model, an evidence-based care covered by Medi-Cal, California’s Medicaid program, model, came up in many of the interviews, and is thus receive care outside the safety net where integration one focus of this paper.8 Notably, this paper does not has not yet taken hold. discuss the integration of primary care into specialty mental health care clinics, nor the integration of financ- ing of specialty mental health care into managed care. INTEGRATED CARE Integrated care is a widely used term that can mean a host of different things. The framework from the SAMHSA-HRSA Center for Integrated Health Solutions helpfully distinguishes between coordinated, colocated, and integrated care.7 As noted above, this paper focuses on practice change in primary care to deliver integrated care (levels 5 and 6 below). Six Levels of Collaboration/Integration COORDINATED COLOCATED INTEGRATED Key element: Communication Key element: Proximity Key element: Practice change Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Minimal Basic Basic Close Close Full collaboration collaboration collaboration collaboration collaboration collaboration in a transformed/ at a distance on-site on-site with approaching merged integrated some system an integrated practice integration practice Source: Bern Heath, Kathy Reynolds, and Pam Wise Romero, A Review and Proposed Standard Framework for Levels of Integrated Healthcare, SAMHSA-HRSA Center for Integrated Health Solutions, March 2013, www.integration.samhsa.gov. Weaving Together Mental and Physical Health Care Outside the Safety Net www.chcf.org 3 make it difficult for providers to standardize care and Background invest the money and resources necessary to build Mental health conditions disproportionately impact out integrated care capabilities. New reimburse- people with low incomes,9 and Medi-Cal, California’s ment mechanisms such as the Centers for Medicare Medicaid program, pays for a significant portion of & Medicaid Services’ (CMS) collaborative care codes mental health care in the state.10 provide new avenues for reimbursing coordinated services in a fee-for-service context, and commercial Many Medi-Cal enrollees receive primary care from plans have largely adopted these codes. However, traditional safety-net providers – here defined as they do not provide a solution for California’s capi- Federally Qualified Health Centers (FQHCs) and FQHC tated medical groups, many of whom serve Medi-Cal Look-Alikes, Rural Health Clinics, community health patients. centers, and public hospital systems. California’s tradi- tional safety-net providers have made some progress in offering mental health services alongside primary Developing reimbursement mechanisms care services, with 29% growth in patients receiving mental health services from 2015 to 2017.11 As of 2018, to support integration outside the safety 194 of 200 California FQHCs and Look-Alikes offered net is critical to aligning incentives for mental health services.12 This expansion of colocated and, in some cases, integrated services has been bol- behavioral health integration between stered by the FQHCs’ per-visit prospective payment public and private health care and system, which pays more than the Medi-Cal fee-for- service fee schedule, and ensures the same level of expanding the use of collaborative care payment regardless of payer type. This progress has beyond the safety net and large, well- also been supported through an influx of public and resourced health systems. private grant funds to support integration.13 Fifty-nine percent of the Medi-Cal population, includ- Research for this paper shows that, outside of the ing those with behavioral health issues, receive primary traditional safety net, behavioral health integration care outside the traditional safety net.14 This is par- is rare. Among interviewees, it was limited to aca- ticularly true in Southern California, where safety-net demic centers, Kaiser Permanente, and pilots or clinics care for only 33% of the Medi-Cal population complex care management programs, usually based — compared to 75% in Northern California.15 Primary around a grant-funded project or an accountable care care providers outside the safety net do not have the organization (ACO). An ACO is a group of hospitals, benefit of the universality of the FQHCs’ prospec- physicians, and other providers who take respon- tive payment system. Instead, if a practice wants to sibility for the quality and cost of care for a patient offer integrated behavioral health services, it needs to population using a shared-savings model built on a ensure financial viability across multiple payers, look- fee-for-service architecture. Unlike FQHCs, providers ing at the reimbursement practices of many different outside the traditional safety net must reconcile the insurers across commercial, Medi-Cal, and Medicare different payment policies and mechanisms that flow lines of business. from Medicare, Medi-Cal, and commercial payers. Developing reimbursement mechanisms to support Finding sustainable methods for funding remains one integration outside the safety net is critical to aligning of the greatest barriers to integrating physical and incentives for behavioral health integration between behavioral health outside the safety net. Significant public and private health care and expanding the use variation between payers in the processes for, and of collaborative care beyond the safety net and large, level of reimbursement for, behavioral health services well-resourced health systems. California Health Care Foundation www.chcf.org 4 To meet the requirements of these parity laws, while How Did We Get Here? still controlling spending on behavioral health care, Policy and Market health plans began to delegate behavioral health services to specialized managed behavioral health Developments in organizations (MBHOs) that administer behavioral health benefits on their behalf. These MBHOs built California specialized networks and brought expertise in man- Unlike some states, California does not have a single aging and administering mental health benefits, from dominant payer; there are 73 distinct health insurers. outpatient therapy to residential treatment. They Kaiser Permanente’s closed integrated system has reimburse almost exclusively on a fee-for-service basis about 25% of covered lives,16 and no other payer cap- in order to encourage access. tures more than 18% of the insured market.17 On the physical health side, provider organizations responded The dependence on MBHOs has meant that respon- to the managed care wave of the mid-1990s and sibility for behavioral health is excluded, or “carved California’s multipayer reality by becoming delegated out,” of the contracts of risk-bearing delegated pro- medical groups, taking on financial risk along with vider organizations.22 For example, a contract between many health plan functions.18 Even in a fragmented a health plan and a medical group that delegated pro- payer landscape, this has simplified the physical fessional risk would include the costs associated with health workflows for clinicians, as they predominantly all primary care and physical health specialists, but seek prior authorization and reimbursement through would not include the costs of psychotherapy or a visit their medical group, rather than from multiple payers. to a psychiatrist. A full-risk contract would include pro- fessional and hospital costs for medical treatment but In both commercial and public systems across would exclude psychiatric hospitalization. In addition California, physical and behavioral health care financ- to splitting patients’ needs and costs between differ- ing is fragmented. Medi-Cal is even more fragmented ent accountable entities, such carve-outs also create between Medi-Cal (physical) managed care plans, complexity for clinicians and their office staffs, who county mental health plans, and county substance now needed to follow the processes of and coordinate use disorder plans. This fragmentation of financial and with multiple payers for utilization management and administrative responsibility has severe consequences: care coordination of behavioral health. By contrast, as In addition to limiting and complicating access, frag- discussed above, delegated medical groups manage mentation hinders incentives for each entity to invest these processes themselves, creating a single process in prevention and early intervention, inhibits coordina- for frontline clinicians that is health plan agnostic. As tion, and creates disruption in care that leads to poor the marketplace has evolved, many health plans have patient outcomes and increased costs.19 acquired or built internal MBHOs and developed pro- cesses to coordinate closely within the health plans. The 1996 passage of the federal Mental Health Parity However, from the perspective of a delegated, risk- Act (P.L. 104-204) marked the beginning of systemic bearing provider organization, behavioral health change for mental health care benefits, which were benefits remain carved out, creating a significant bar- not historically covered health plan benefits.20 The rier to integration of services in primary care practices. 2008 Mental Health Parity and Addiction Equity Act (P.L. 110-343) and the 2010 Patient Protection and These developments in the commercial sector came Affordable Care Act (ACA) went further, requiring later to Medi-Cal with the implementation of the health plans to provide mental health and substance ACA in 2014. Since 1995, Medi-Cal specialty mental use disorder benefits comparable to medical and sur- health services have been provided under a federal gical benefits.21 Medicaid Section 1915(b) freedom-of-choice waiver titled “Medi-Cal Specialty Mental Health Services.” Weaving Together Mental and Physical Health Care Outside the Safety Net www.chcf.org 5 Until 2014, this waiver required enrollees to access state’s population.28 The workforce shortage is likely to almost all mental health services through county worsen, as 45% of psychiatrists and 37% of psycholo- mental health plans (MHPs), which provide specialty gists are over age 60 and are likely to retire or reduce mental health services for adults and for children their work hours within the next decade.29 and youth who meet certain diagnostic, impairment, and intervention criteria. Consistent with the Early and Periodic Screening, Diagnostic, and Treatment mandate, California requires MHPs both to use less How Current Policies and stringent medical necessity criteria, and to provide a broader array of services to enrollees under age 21.23 Market Arrangements Create Barriers to Until 2014, Medi-Cal managed care plans (MMCPs) were only responsible for ensuring that their PCPs Integration offered mental health services that were within the Stakeholders interviewed for this report repeatedly normal scope of their practice (e.g., brief therapy, mentioned the same frustrations in achieving inte- writing prescriptions). The ACA required the inclu- gration related to the policy and market structures sion of behavioral health care as an essential health described above, especially in these areas: benefit for Medicaid Alternative Benefit Plans and $ Provider participation qualified health plans.24 As a result, in California, MMCPs became responsible for the delivery of non- $ Coordination and communication specialty mental health services to enrollees age 21 $ Reimbursement and risk and over with behavioral health conditions catego- rized as “mild to moderate.”25 (However, specialty mental health services must be provided by the MHP Provider Participation to children under age 21, when medically necessary, Because of the chronic and serious shortage in the without respect to any severity test or screening tool behavioral health workforce, many behavioral health employed by the MMCPs and MHPs.26) Although this specialists are at capacity and are not taking new change expanded the overall mental health benefit in patients, creating a gap between “paper access” as Medi-Cal, it further fragmented financing and coordi- measured by network adequacy requirements and nation of care, requiring recipients to move between a patient’s experience in getting an appointment. plans based on the severity of their illness. In addi- In addition, many professionals in California’s urban tion, rollout happened quite quickly, and many plans areas, in high demand and frustrated by low reim- turned to MBHOs to administer the benefit. MBHO bursement and payer administrative requirements, networks often differed dramatically from those of the opt out of insurance altogether, creating access and MHPs, adding further complexity. As a result, there are affordability challenges across payer types.30 MBHOs county-specific processes for referral and coordination have responded, often paying well in excess of the fee and significant variation in interpretation of the divid- schedule for Medi-Cal and Medicare. For example, ing line between the services covered by managed one medical group leader reported that a psychiatrist care plans and the specialty system administered by is paid $275 for a 20- or 30-minute visit for commer- the counties.27 cial and managed Medi-Cal patients, while Medicare pays only $70. Even with these higher reimbursement Underlying this market complexity is a severe short- rates, access is challenging. Primary care providers age of behavioral health providers. California had interviewed for this paper described their patients’ over 80,000 licensed behavioral health professionals difficulties in finding in-network mental health provid- in 2016, but these professionals are unevenly spread ers with availability, and MBHOs similarly described across the state and do not reflect the diversity of the extensive efforts to help patients find appointments California Health Care Foundation www.chcf.org 6 with their network mental health providers, many of patients are successfully connected to care and to whom are not accepting new patients. share treatment plans to better improve coordination efforts. Coordination and Communication MBHOs also expressed frustration at the current state Payers’ behavioral health networks can be difficult for of communication between behavioral health special- PCPs to navigate. Each health plan has different pro- ists and PCPs. They described having to “badger” cesses around behavioral health, and while most have PCPs for medical data, including prescriptions, lab eliminated prior authorization, the perceived com- tests, and physicals required before transcranial mag- plexity of referring patients is a barrier for busy care netic stimulation, for example. Conversely, MBHOs teams. that mandate that behavioral health specialists sub- mit treatment plans to PCPs reported that a majority Some PCPs said that carve-outs have damaged exist- of PCPs did not even look at the treatment plans ing informal referral networks. Before the rise of included in their chart notes. MBHOs in the 1990s, some PCPs in delegated enti- ties described having a sense of connection to the Some payers and MBHOs ended up facilitating com- behavioral health providers in their area, including munication between primary care clinicians and knowing which specialists were currently accepting behavioral health clinicians with successful results. new patients, or who might be a good match for a However, the payers described feeling caught in the particular patient’s needs. Now, PCPs often feel they middle and said they would prefer that the clinicians have lost that connection: Instead of sending patients communicate directly with each other. All parties to a named colleague, they refer patients to an anony- acknowledged that the traditional fee-for-service mous provider directory that may not be accurate or (FFS) reimbursement system does not provide an easy to the number of a call center on the back of an insur- way to get paid for communication and coordination ance card. between providers. Further, referral frequently does not lead to care. Interviewees described tension between concern One MBHO reported that only about 50% of patients for patient privacy and effective coordination. Much referred by a PCP for behavioral health care end up of the tension stems from differing interpretations of making an appointment. Because many providers are federal and state legislation around patient privacy not accepting new patients, making an appointment between PCPs and behavioral health specialists, but may require dozens of phone calls. Some of the refer- also between payers and MBHOs, even with the same ral “leakage” may also be due to stigma and lack of corporate parent. Some interviewees said that require- follow-through by patients, who may not perceive a ments of privacy laws including the Health Insurance need for specialty care. Portability and Accessibility Act (HIPAA)31 and rules to protect the confidentiality of substance use disorder Limitations in communication were among the most treatment records have contributed to communica- commonly cited frustrations among all stakeholders. tion challenges between MBHOs, behavioral health Trying to normalize regular communication between providers, and PCPs, adding compliance concerns to entities that historically have not shared informa- the cultural divide between behavioral health provid- tion has proved challenging. Primary care providers ers trained to focus on preserving patient privacy and frequently described MBHOs as “black boxes” and PCPs trained to share information in service of effec- did not see any differentiation in service among the tive coordination. Several initiatives across California MBHOs or by payer type. These providers described have sought to improve data sharing between physical difficulty in getting MBHOs and their network pro- and behavioral health providers.32 However, different viders to acknowledge receipt of referral to ensure requirements around gaining patient consent to share Weaving Together Mental and Physical Health Care Outside the Safety Net www.chcf.org 7 data persist based on how individual legal counsel Interviewees said that fragmentation of financial risk interpret consent requirements, and provider comfort limits the incentives for each entity to invest in pre- around data sharing without first obtaining consent.33 vention and early intervention across the continuum of needs.34 In particular, the Knox-Keene Act (1975) was referenced as a barrier to improving coordination Reimbursement and Risk and integration for one particular type of organization, Insufficient funding and fragmented financing were the behavioral health independent practice associa- common sources of frustration for providers. They tion (IPA). The act regulates and licenses managed noted that many of the activities required for inte- care plans under either “full service” or “specialized” grated care (e.g., consults between providers, care licenses. Specialized licenses are issued to entities management by a social worker) are not currently providing only a single health care service, such as reimbursed under the FFS system used by MBHOs. behavioral health.35 These are limited to professional WHAT’S A CARVE-OUT? Three distinct but related “carve-outs” result from the Medi-Cal’s mental health and substance use disorder policy and market developments described above, and carve-outs. In Medi-Cal, responsibility for behavioral make it more difficult to integrate physical and behav- health benefits is divided based on type of service and ioral health care both inside and outside the safety net: medical necessity. “Specialty” mental health services are provided through county mental health plans Physical and behavioral health insurance carve-out. (MHPs), while non-specialty services — including indi- Health insurance companies often delegate or “carve vidual and group psychotherapy; psychological testing; out” responsibility for mental health benefits to an outpatient drug therapy monitoring; outpatient labora- internal or external MBHO. That entity develops its tory, drugs, supplies, and supplements; and psychiatric own provider network and has its own processes for consultation — are the responsibility of Medi-Cal man- claims, utilization management, and care coordination. aged care plans. (These plans have only very limited Such delegation recognizes that mental health services responsibility for substance use disorder [SUD] treat- require specialized knowledge and focus, but also com- ment services; the SUD benefit in Medi-Cal is provided plicates coordination for people who have both physical through a separate county system, Drug Medi-Cal.) and mental health needs. Fragmentation: An Extreme Example Capitated contracts that exclude behavioral health. One interviewee described the case of a Medi-Cal California’s health plans often delegate financial risk enrollee whose care coordination required interaction to provider organizations in the HMO market. In the with six distinct entities: provisions of these capitated contracts — known as $ Thecounty specialty mental health system that the division of financial responsibility — behavioral health is often excluded, with the health plan retaining provided crisis services responsibility rather than delegating it to the provider $ The Medi-Cal managed care plan’s MBHO vendor groups. As a result, PCPs in delegated groups who do for outpatient therapy following the resolution of not typically have to interface with health plans for prior the acute crisis authorization of physical health services face a different $ A delegated medical group for primary care situation when it comes to behavioral health services. $ Thecounty Drug Medi-Cal Organized Delivery In addition to bearing the financial costs of unmet System for outpatient SUD treatment behavioral health needs, which can result in expensive $ Medi-Calfee-for-service system for psychotropic physical health crises, these groups have to develop workflows for interfacing with each payer’s MBHO, a medications substantial and complex undertaking in California’s $ The Medi-Cal managed care plan for durable fragmented health plan market. medical equipment California Health Care Foundation www.chcf.org 8 risk only, however, and thus prevent a behavioral care coordination for their medically complex popu- health IPA from taking on hospital risk to align revenue lations. Typically, this was done without incremental and incentives: This barrier is significant because the revenue, with medical groups capturing cost savings greatest savings potential in behavioral health man- through improved health outcomes and reduced agement is in reducing hospital admissions and length acute utilization. of stays. Telehealth Almost all of those interviewed expressed strong Seeking Solutions interest in expanding their telehealth efforts but face In interviews, stakeholders expressed interest in behav- challenges around reimbursement, including differing ioral health integration as a strategy to improve quality geographical restrictions, and regulations on when and patient satisfaction while reducing physician burn- the remote practitioner or the originating site or both out and excess medical costs. They described the may be reimbursed. Potential telehealth applications following activities taking place in their organizations. included psychiatric evaluations, therapy, patient edu- cation, and medication management.38 Services can be synchronous, allowing for live discussions, or asyn- Screening chronous, also known as “store and forward,” which Almost all provider organizations interviewed rec- includes the use of eConsults.39 Telehealth can also be ommended that their PCPs implement universal used for remote patient monitoring, either by direct depression screening, but outside those that had video monitoring or via review of tests and images implemented integrated care, few were able to collected remotely.40 Importantly, telehealth can help identify the degree to which it was happening and address access issues stemming from uneven distribu- many discussed an unwillingness on the part of PCPs tion of the behavioral health workforce, especially in to screen without a reliable means of connecting rural areas. patients to care after screening. Patient data from the Patient Assessment Survey administered by the Pacific Business Group on Health from 2013 to 2015 shows Employer-Sponsored Innovations that primary care screening for anxiety and depression Interviews with payers said that some purchasers (e.g., has been increasing, albeit from a low base, with one large employers) recognize the potential for improved in three patients reporting being asked about anxi- behavioral health access to lower their health care ety and one in four being asked about depression.36 costs and improve their employees’ health and pro- These rates may have increased following the US ductivity. A few innovative arrangements have sprung Preventive Services Task Force’s 2016 “B” recommen- up as part of employers’ directly contracted account- dation of screening for depression among adolescents able care organizations, in which a group of hospitals, and adults who “receive care in clinical practices that physicians, and other providers take responsibility for have [cognitive behavioral therapy] or other evidence- the quality and cost of care of a patient population based counseling available after screening.”37 This using a shared-savings model built on a fee-for-ser- recommendation requires payers to reimburse and vice architecture. The service expectations in these waive patient copayments for depression screening. innovative payment arrangements sometimes explic- itly include behavioral health integration for a limited population. These arrangements support a variety of Coordination activities, including embedding behavioral health spe- Several provider organizations discussed implement- cialists in primary care settings, releasing authorization ing aspects of care integration such as hiring licensed for data sharing, and supporting case management clinical social workers to facilitate warm handoffs and and care coordination. One example is Boeing’s ACO Weaving Together Mental and Physical Health Care Outside the Safety Net www.chcf.org 9 pilot program with MemorialCare.41 Interviewees who do not show clinical improvement.44 The CoCM described targeted impact on hospital and emergency has been shown to be not only an effective treatment department utilization as well as provider satisfaction approach but also cost-effective for common mental and retention and the patient experience, recognizing disorders such as depression across diverse practice that the business case for these services is not based settings and patient populations.45 In California, the solely on the revenue they generate. CoCM has been implemented in multiple care set- tings, including in the safety net, Kaiser Permanente, In addition, employers are expanding teleconsultation academic medical centers, and by a few pioneering outside of traditional practices, embedding behavioral delegated medical groups. Importantly, colocation is health specialists into on-site primary care locations, not a requirement of the CoCM, and telehealth has arranging for specialized access through employee proven to be an effective option for practices to deliver assistance plans, and testing digital therapeutics, such the CoCM, especially where colocation is impractical as computerized cognitive behavioral therapy. These or infeasible.46 innovations are often paid for outside of traditional health plan contracts and may be paid on an encoun- Figure 1. Collaborative Care Team Structure ter basis, a cost-plus basis, or a per employee per month charge. In the most novel payment arrange- ment, two employers, one payer, and a medical group described piloting a digital platform in which payment is based on outcomes, as measured by the patient’s self-reported response. Practice Change Through the Collaborative Care Model What Is the Collaborative Care Model? Based on interviews, the Collaborative Care Model (CoCM) has emerged as the dominant evidence- based approach to integrating physical and behavioral health services in primary care. All interviewees who had undertaken integrated care incorporating prac- tice change described their approach as being based on the CoCM. Other models, such as Primary Care Copyright ©2017 University of Washington. All rights reserved. Behaviorist, were not discussed.42 In CoCM, developed by Wayne Katon and colleagues Making the Economics Work at the University of Washington in the mid-1990s, a In 2017, CMS began making payments for services care team composed of a PCP, a behavioral health provided to patients receiving collaborative care care manager, and a consulting psychiatrist work services through traditional Medicare or Medicare together to provide care, monitor patient progress, Advantage plans.47 These CoCM codes are billed by and adjust treatment plans.43 It includes (1) care coor- the primary care provider and cover the costs of the dination and care management, (2) regular, proactive primary care provider, the behavioral health care man- monitoring and treatment to target with validated ager, the consulting psychiatrist, and the population clinical rating scales, and (3) regular, systematic psychi- health registry infrastructure for treatment to target atric caseload reviews, and consultation for patients using validated rating scales. CoCM codes may be California Health Care Foundation www.chcf.org 10 used for patients with any behavioral health condition One particular challenge with the CoCM being addressed by the treating provider, including substance use disorders.48 A modeling simulation that code implementation in California lies looked at likely revenues and costs associated with in the adoption of the codes by medical staffing and related infrastructure for delivery of inte- grated care under the CoCM codes showed positive groups operating under delegated net revenue in both FQHC and private practice set- arrangements that exclude behavioral tings when adopted by multiple payers.49 There has been significant uptake of these codes among payers health. While these arrangements often including Aetna, Anthem, Beacon, and United/Optum specify that all activities that occur in in California, and by 13 state Medicaid agencies, primary care are included, the exclusion though it is by no means universal.50 As of the time of publication, the authors were not aware of any MMCP of mental health and substance use that had adopted the codes. disorder services leaves CoCM services The CMS CoCM codes are imperfect. The workflow — by definition billed by PCPs — in a changes required, including tracking cumulative treat- gray area. ment minutes and monthly code entry, were described in interviews and in the literature as challenging and arduous to implement.51 Depending on the particular That said, Medicare’s CoCM codes have spurred electronic health record (EHR) system, some organi- action for some provider groups, who correctly antici- zations described laborious workarounds in order to pated that commercial insurers would follow. Not use the CoCM in their EHR. In addition, the codes surprisingly, staff and foundation model groups with represent a challenge in California’s delegated medi- employed physicians have been the earliest adopters, cal groups, where capitation and behavioral health as they can aggregate volume from multiple practice carve-outs are the norm. As a result, providers have sites and spread the costs of behavioral health staff negotiated letters of agreement or contracted with across all payer types. MBHOs for FFS payment of behavioral health services delivered outside their delegated arrangements. Interviewees cited Medicare Advantage as the most common starting point for CoCM pilots, in part One particular challenge with the CoCM code imple- because delegated arrangements are more likely to mentation in California lies in the adoption of the include behavioral health and in part because the codes by medical groups operating under delegated downstream health savings are likely to be greater arrangements that exclude behavioral health. While due to the higher prevalence of chronic conditions these arrangements often specify that all activities among older adults. that occur in primary care are included, the exclusion of mental health and substance use disorder services In interviews, both payers and providers expressed leaves CoCM services — by definition billed by PCPs excitement about these delivery and payment models. — in a gray area. Some interviewees described a However, these arrangements are not yet common. solution where behavioral health clinicians were cre- Multipayer alignment and standardized payment dentialed by the MBHO and billed services delivered models are critical to overcoming barriers to integrat- under the Collaborative Care Model to the MBHO. ing care at scale. This ensured that collaborative care services gener- ated incremental revenue to the practice to cover the costs of the additional mental health clinicians. Weaving Together Mental and Physical Health Care Outside the Safety Net www.chcf.org 11 for behavioral health services, but face chal- Recommendations for lenges around reimbursement. A standard set of Multipayer Alignment: approaches for telehealth reimbursement would help improve communication and access issues.52 Next Steps $ Implement payer-agnostic hub-and-spoke mod- The following opportunities for multipayer alignment els for services with very limited supply. Providers across lines of business to support the implementation expressed interest in a payer-agnostic method to of the CoCM emerged from interviews: access behavioral health from primary care. The hub-and-spoke model used in California’s safety $ Adoption of Collaborative Care Model codes by net to treat opioid use disorder53 has demon- payers and MBHOs outside of capitated contracts. strated impact in connecting PCPs to behavioral Widespread multipayer adoption of the CoCM health specialists and helping PCPs better meet codes at Medicare rates would ensure sufficient the behavioral health needs of their patients.54 revenue for providers to make the investment in Similarly, the Massachusetts Child Psychiatry Access integration for all their patients. Project provides telephonic child psychiatry consul- $ Development of standard payment mechanisms for tations and specialized care coordination support Collaborative Care Model in capitated, delegated to over 95% of the pediatric primary care providers contracts. These might include: in Massachusetts, through six regional hubs, each of which has one full-time equivalent child psychia- $ A monthly capitation rate for CoCM that is trist, licensed therapist, and care coordinator.55 A incremental to professional or full-risk arrange- similar model is being implemented in rural areas ments that exclude behavioral health. While in San Diego County and has been suggested as the amount may vary based on the needs of the a potential method to expand capacity by enhanc- population and be established through expe- ing the skills of primary care physicians, improve rience, an industry-wide agreement that the coordination and communication, and address CoCM goes beyond the scope of primary care colocation challenges for small practices.56 and requires additional compensation is neces- sary, as are studies that determine where savings $ Standardize consent forms and processes, and accrue for shared-risk contracts. data-sharing rules. Collective action by industry groups to standardize patient consents and nor- $ Monthly CoCM payments by MBHOs to PCPs malize interpretation of HIPAA, 42  CFR Part 2, providing team-based integrated services. and corresponding California statutes would be a While MBHOs do not typically hold contracts powerful tool to improve coordination. Once com- with primary care providers, they could begin mon standards are in place, educating payers and credentialing and reimbursing practices offering providers on these standards may be needed to collaborative care using the CoCM codes, even ensure universal adoption. if the practice is capitated for primary care. $ Move toward accountability for outcomes. Payers $ Other value-based arrangements that reward should consider offering additional reimbursement outcomes and cost savings. in exchange for providers reporting outcomes data in mental health. Paying for reporting will help pro- In addition to recommendations specific to the CoCM, vide an understanding of how integrated services interviewees also made the following requests for are impacting patient outcomes and can serve as multipayer alignment: an important first step in moving toward paying for $ Standardize and expand reimbursement for tele- outcomes. health when specialty services are needed. Many interviewees are working on expanding telehealth California Health Care Foundation www.chcf.org 12 Conclusion Outside of California’s traditional health care safety net and a few large, well-resourced health systems, integration of mental health into primary care remains rare. The experience of California’s FQHCs and a few other pioneers demonstrates what is possible with practice change support and standardized, near-uni- versal reimbursement. Spurred in part by Medicare reimbursement, providers have come together around an evidence-based model, but a fragmented payment landscape makes sustainable financing one of the greatest barriers to integrating physical and behavioral health in primary care. Multipayer align- ment of payment mechanisms would accelerate adoption of integrated care for all patients. This is particularly true among smaller practices that could be supported in integration activities through their IPAs. These practices serve many Medi-Cal patients and face a challenging and complex reimbursement environment. On the current course, market movement in California will lead to integrated systems in the safety net, aca- demic centers, Kaiser Permanente, and well-resourced foundation models that are historically closed to new Medi-Cal patients. But without collective action by payers, either voluntarily or as a result of legislative or regulatory activity, most primary care practices — including those serving a significant component of the Medi-Cal population — will be unlikely to undertake the practice change needed to provide truly inte- grated care.57 This research points to potential next steps to build on the momentum created by pioneer- ing providers and payers and create the foundation for the multipayer alignment needed to achieve wide- spread behavioral health integration. Weaving Together Mental and Physical Health Care Outside the Safety Net www.chcf.org 13 Appendix. California Organizations Interviewed Medical Groups Brown and Toland Medical Group, Oakland HealthCare Partners Medical Group, El Segundo Heritage Provider Network, Northridge Kaiser Permanente, Oakland MemorialCare Health System, Fountain Valley Providence St. Joseph Heritage Healthcare, Anaheim River City Medical Group, Sacramento Sharp Rees-Stealy Medical Group, San Diego Payers Blue Shield of California, Oakland CalOptima, Orange Cigna HealthCare of California, Glendale Health Net, Woodland Hills Behavioral Health Providers Community Psychiatry, Sacramento Windstone Health Services, Santa Ana Managed Behavioral Health Organizations Beacon Health Options, Cypress Cigna Behavioral Health of California (as part of Cigna interview), Glendale MHN (as part of HealthNet interview), San Rafael Additional organizations interviewed as part of Integrated Health Association-Pacific Business Group on Health Commercial ACO Measurement & Benchmarking Initiative Humboldt IPA, Eureka University of California at Davis University of California at Los Angeles California Health Care Foundation www.chcf.org 14 Endnotes 1. 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