APA Protests Exclusion of Psychiatry From Primary Care Designation in ACOs

APA wants the government to reconsider its method for assignment of patients to primary care providers within accountable care organizations (ACOs) under the Medicare Shared Savings Program and to include psychiatrists among those physicians designated as primary care physicians.

The Shared Savings Program is designed to facilitate coordination and cooperation among clinicians; eligible physicians and hospitals participate in the program by creating or participating in an ACO.

In a February 6 letter to the Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner, APA CEO and Medical Director Saul Levin, M.D., M.P.A., said psychiatry is frequently the point of first contact for persons with undiagnosed conditions.

“Many patients will present with nonpsychiatric disorders that become manifest through psychiatric symptoms,” Levin wrote. “Differential diagnosis is a core skill and function of the specialty. The psychiatrist generally establishes a treatment plan for all presenting medical conditions and assumes the role of care manager/supervisor with the required team of health care professionals. This includes provision of care for mental health/substance use disorders as well as medical comorbidities. … Simply put, psychiatrists are often responsible for ensuring that patients are properly diagnosed and triaged and for securing all needed services even if they do not provide all of them themselves.”

More broadly, Levin expressed APA’s concern about how the administration’s methodology for designating primary care will affect where people with serious mental illness—and especially “dual-eligible” individuals who qualify for both Medicare and Medicaid—are treated.

Levin said the administration needs to “carefully examine how the assignment rules affect accountability for beneficiaries with mental health and substance use disorders.” He added that the methodology currently used by the administration “could have a negative and avoidable impact on access to appropriate care coordination for disabled and elderly beneficiaries with psychiatric disorders who often suffer from multiple co-occurring medical conditions.”

Levin’s letter was in response to a December 8, 2014, proposed rule by CMS designating certain physicians as primary care providers on the basis of a two-step assignment process by which Medicare beneficiaries are assigned to an ACO.

The first step in this process assigns a beneficiary to an ACO if the beneficiary receives the plurality of his or her primary care services from internists, general practitioners, family practitioners, or geriatric medicine practitioners within the ACO (or from a physician in a federally qualified health center or rural health clinic included in the attestation provided by the ACO as part of its application).

Beneficiaries not assigned in the first step are assigned to an ACO in a second step if they receive a plurality of primary care services from specialist physicians and certain nonphysician practitioners within the ACO.

But in the December 8 proposed rule, CMS excluded psychiatry from consideration in the second step of the assignment process. The proposed rule is part of an ongoing effort by the government to reform the way physicians are reimbursed in public programs; last month, CMS announced it will accelerate the movement toward “value-based payment” of physicians (see box).

The administration apparently excluded psychiatry from among physicians designated as primary care providers in the second step of the assignment process on the basis of several criteria. These include recommendations by CMS medical officers about the services typically performed by physicians and nonphysicians, the number of services provided by psychiatrists under codes included in the definition of primary care services (CPT codes 99201–99215, 99304–99340, 99341–99350), and a determination that psychiatrists are not typically the only physicians who a beneficiary sees.

In the letter to Tavenner, Levin questioned all three criteria. “We believe the decision to [exclude psychiatry] may have been based on common misperceptions rather than on how patients actually receive care, especially the care provided to dually eligible individuals with psychiatric and/or substance use disorders and medical comorbidities,” he wrote.

He said there are a number of reasons why most people with serious mental illness would rather see their psychiatrist than a traditional primary care provider. For example, primary care physicians have been found to be uncomfortable providing care for those with serious mental disorders; people with cognitive deficits often have limited ability to navigate the health care system and access care in nonspecialty settings; and exacerbation or improvement of psychiatric disorders often affects behavior and the medical treatment of other systems of the body.

Regarding calculations of primary care service codes, Levin said APA has conducted its own rank-order claims analysis by volume and found that psychiatry consistently ranks higher than many of the specialties denominated as primary care by CMS. For example, he said a review of claims for codes 99211–99215 (Evaluation and Management–Established Patient) shows psychiatry ranked higher than many specialties that received designation under the second step of assignment.

Moreover, he said the highest-volume claim, CPT 99213, shows psychiatry ranked sixth in total volume, less than only cardiology among those specialties otherwise designated for second-step assignment.

For those codes designated as primary care services for nursing facility services, psychiatry ranks in the top five of volume, Levin pointed out.

Finally, Levin said a solid experiential base, predicated on numerous discussions with psychiatric physicians who provide care to individuals with serious mental illness in specialty-sector settings, indicates that these patients are very likely to see only their psychiatrist for all of their health care, medical and behavioral.

“The psychiatrist in turn performs most, if not all, of the core primary care functions …,” Levin wrote. “Derivative of this reality, system transformation in the mental health/substance abuse (MH/SA) specialty sectors has led to a number of care innovations that bring the requisite primary medical care to the specialty-sector sites as well as specialty psychiatric care to primary medical care settings that would otherwise be without the ability to address MH/SUD conditions.” ■

Levin’s letter to CMS can be accessed here. Additionally, a summary of the 2015 fee schedule released by CMS in December, which outlines rules regarding value-based payment and physician quality reporting, is also on the APA website.