Moving to an Integrated Medical and Psychiatric Payment Platform
In this month’s column, Roger Kathol, M.D., and David Leader, M.D., tackle one of the biggest challenges in integrated care: payment. They make the case for integrating payment by rolling behavioral health benefits into medical benefits, and they present the example of one organization that is taking important steps toward integrating both services and payment. —Jürgen Unützer, M.D., M.P.H.
Independent medical payors (managed care organizations—MCOs) and behavioral health (BH) payors (managed BH organizations—MBHOs), whether carved-in or carved-out, reimburse nonpsychiatrists and psychiatrists for services to the same patient from separate funding pools. To assure that funds from MCOs and MBHOs are used for intended services, that is, medical funds for medical treatment or BH funds for BH treatment, MBHOs require BH service delivery in separate BH clinical locations.
Sixty percent to 80 percent of BH patients, including the majority with serious mental illness and substance use disorders, choose to access services primarily in the medical sector. Most of these patients are untreated or ineffectively treated because BH services are nonexistent or provided by nonpsychiatrist practitioners with assessment and intervention limitations. Lack of treatment for comorbid medical patients is associated with medical and psychiatric symptom persistence, medical treatment resistance, increased medical complication rates, impairment, and substantially higher annual health care expenditures.
The future demands that psychiatrists provide services in the medical setting, where the majority of patients with psychiatric illness are seen. Unfortunately, segregated MBHO reimbursement prevents this, since competing medical and BH business practices are designed to protect resources from cross-disciplinary use. A logical solution in the new world of parity would be for BH benefits to roll into medical benefits such that medical and BH services could be coordinated and supported by a single integrated budget.
The MBHO industry resists an integrated budget since it makes its money by segregating BH payments. A growing number of health care stakeholders, however, understand the negative health and cost impact of segregated reimbursement. For instance, several state Medicaid agencies have combined medical and BH Medicaid budgets. There are also commercial insurer demonstration projects attempting to consolidate payment procedures.
Advocate Health Care (AHC), the largest health system in Illinois, provides an interesting example of a delivery-level system introducing financially sustainable value-added BH care in the medical setting. Based on an assessment of health and cost outcomes of AHC’s own medical/surgical patients with concurrent BH issues, AHC is piloting a hub-and-spoke model in the South Chicago market with a full systemwide launch by late 2015. This model places psychiatrists, psychologists, social workers, therapists, and nurse practitioners on site, either physically or via telehealth, for 24/7 proactive screening, treatment planning, and treatment initiation in systemwide medical emergency departments (EDs), inpatient general hospital settings, and outpatient primary care and specialty medical clinics.
The program is intended to treat chronic and refractory medical patients with unmet BH needs. It links medical physicians and BH specialists by embedding BH personnel in the medical setting, uses proactive BH screening for undetected psychiatric comorbidity, and helps primary and specialty care clinicians institute best practices with background support from on-site BH professionals. More-complicated comorbid patients will have access to direct on-site BH personnel services or easier referral to specialty BH sector interventions.
Introduction of BH personnel is designed to improve health and cost outcomes of treatment-resistant medical patients who currently have little access to “traditional” off-site psychiatric care provided in AHC settings. Through this initiative, AHC anticipates increasing the number of its patients exposed to effective BH care and improving medical outcomes. From these, a reduction in BH-related ED visits, medical inpatient admissions and readmissions, average lengths of hospital stay, and total health care service use becomes possible.
AHC’s integration model poses direct professional reimbursement and program payment challenges. While face-to-face medical setting consultations are often reimbursed by payors, albeit with coding and submission hassles and at low payment rates, telehealth consultations, BH screening, “curbside” consultations, and integration of other BH services in medical settings generally are not. Nevertheless, AHC has chosen to move forward since it sees current losses experienced due to excess medical service use by medical patients with BH comorbidity as a greater risk and expense to its future contracting competitiveness than the anticipated shortfall in BH professional reimbursement.
To address its financial challenges in the short term, AHC is developing direct partnerships with established BH community agencies and BH providers through preferred-provider agreements. Using this approach, it can define standards for access, communication, safety, and quality of BH care in its medical settings without being hampered by MBHO demands for segregated BH service delivery. Contracted BH providers will follow designated accountable care organization (ACO) metrics, including outcome measures, to ensure that BH services add clinical and economic value to patients in AHC’s medical settings.
In the long term, AHC’s ACO anticipates that development of BH service capabilities in the medical setting will ultimately save money due to better health outcomes in expensive comorbid patients for which it has become financially accountable. AHC will be better able to compete for population risk-based contracts as health reform measures are implemented. Further, AHC is exploring offset to BH professional reimbursement shortfalls by sunsetting independent MBHO contracts and replacing them with MCO contracts in which BH services are paid as part of medical benefits. AHC sees this journey toward BH integration as consistent with its mission to provide holistic care and its focus on population health management, confident that doing the “right thing” is achievable in a high-quality and cost-effective fashion. ■
Biographies
Roger Kathol, M.D., president of Cartesian Solutions Inc., is a health complexity and integrated care specialist who assists care delivery systems, health plans, government agencies, and large businesses to create value-added total health programs that meet clinical and fiscal needs in a changing health care environment. David Leader, M.D., is a medical director at Dreyer Medical Clinic and a medical director of the Behavioral Health Service Line at Advocate Health. Jürgen Unützer, M.D., M.P.H., is an internationally recognized psychiatrist and health services researcher. He is a professor and chair of psychiatry and behavioral sciences at the University of Washington School of Medicine, where he directs the Division of Integrated Care and Public Health and the AIMS Center, dedicated to “advancing integrated mental health solutions.”
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Published online: 2 December 2014
Published in print: November 22, 2014 – December 5, 2014
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