Policy Changes Help Integrate MH Services in Primary Care

While more than 40 percent of Americans turn to primary care clinicians when they are concerned about mental health problems, those clinicians may not provide the help publicly insured beneficiaries need because of the current payment structure for those patients.

Primary care physicians and allied health care workers, in fact, have the ability and tools to provide better mental health care than they have had in the past for publicly insured patients, although many may not realize it.

To address deficiencies in access and understanding of mental health diagnosis and treatment, federal mental health officials are calling for implementation of several initiatives and policy changes.

An examination of the current reimbursement structure for publicly funded insurance programs found numerous obstacles to provision of better mental health care in primary care settings. Officials from the Substance Abuse and Mental Health Services Administration (SAMHSA), Health Resources and Services Administration (HRSA), and Centers for Medicare and Medicaid Services (CMS) concluded in a report released in July that seven major changes can improve mental health care access.

“The actions identified in this study are practical as well as achievable,” said SAMHSA Administrator Terry Cline, Ph.D., in a written statement about the federal report. “Improving access to timely and targeted mental health services in primary care settings can improve patient health and compliance with treatment.”

The effort stems from one of the goals set by the 2003 report of the President's New Freedom Commission on Mental Health, which was to increase screening for mental disorders in primary health care “across the life span and connect [patients] to treatment and supports.”

A long-standing financial obstacle to providing mental health care in primary care settings is lack of awareness by physicians and allied health professionals that a range of payment mechanisms is available to cover mental health services. The report also found that some public insurance programs have mental health carveouts that do not include or allow for payment of primary care or school-based providers in practitioner networks. Other financial barriers include public insurance programs' limiting payment to a small number of visits and low reimbursement rates for mental health services.

Federal officials also identified access barriers that often prevent screening, diagnosis, and treatment, such as patients' lack of access to primary care providers, closed provider networks, and misunderstanding by physicians and allied health care workers of covered services and reimbursement rules.

A dearth of clinicians in some rural or inner-city areas and lack of payment for the key components of the collaborative-care model for providing care also were identified as access barriers by the federal officials.

The report's authors, Danna Mauch, Ph.D., and Cori Kautz, M.A., researchers at Abt Associates Inc., and Shelagh Smith, M.P.H., a government project officer at SAMHSA, recommended seven actions to improve access, including increased collaboration among federal and state policymakers in Medicare, Medicaid, primary care, and mental health “to ensure clarity in policies, rules, and procedures, and to promote the provision and reimbursement of mental health services in primary care settings.”

Other needed changes include better dissemination of clearly written descriptions of federal and state policies and procedures to patients, payers, providers, and care managers. More technical assistance and better education on the array of mental health services that are covered in various public-insurance programs also are needed for states, providers, and managed care organizations. The report recommended that CMS officials encourage flexibility in state Medicaid benefit design to cover mental health services in primary care settings, using approaches that have proven effective is states that received Medicaid waivers.

The report also called for increasing reimbursement amounts for professional services by nonphysician practitioners under Medicare and Medicaid, particularly in underserved rural and urban areas. Other rural-focused recommendations included a call for “appropriate reimbursement of telemedicine services.”

The final recommendation called for reimbursement of mental health prevention and screening services.

“Actions identified in this report can help improve reimbursements for health centers and other safety-net providers that deliver mental health services in primary care settings, such as community health centers, which is important to our grantees,” said Elizabeth Duke, administrator of HRSA, in a written statement.

David Shern, Ph.D., president and CEO of Mental Health America, said that millions of Americans do not get needed mental health treatment because“ wrongheaded policies and practices” discourage provision of mental health care in primary care settings

“Improving integration of mental health and primary care will not only result in better clinical care, but will also lower medical costs,” Shern said in a written statement. “We commend SAMHSA, HRSA, and CMS on their report and call on them to implement its critical recommendations.”

At least one of the obstacles to mental health care access in the primary care setting already has been addressed: the higher patient copayment required for outpatient mental health services under Medicare, compared with other types of care. Congress passed the Medicare Improvements for Patients and Providers Act (HR 6331) in July to phase in lower mental health copayments until they reach the 20 percent level required for all other covered services (Psychiatric News, August 1).

“Reimbursement of Mental Health Services in Primary Care Settings” is posted at<http://download.ncadi.samhsa.gov/ken/pdf/SMA08-4324/SMA08-4324.pdf>.▪