Medicare embraces chronic care management and creates opportunities for behavioral health providers

Medicare’s Chronic Care Management (CCM) program does not specifically reimburse non-physician practitioners, and thus, seemingly excludes much of the behavioral health community. The program has enjoyed success since its 2015 introduction and was expanded in 2017, which presents some unique and exciting opportunities for behavioral health providers.

Along with the expansion of the CCM program, the Centers for Medicare and Medicaid Services (CMS) also introduced an expanded code set for the psychiatric Collaborative Care Model (CoCM) and Behavioral Health Integration (BHI) programs. As of January 1, 2017, CMS began directly reimbursing clinicians who coordinate care for patients with behavioral health conditions. Although reimbursements in these models still favor primary care practices, they are yet another small, but positive step on the journey to more tightly integrate the general medical and behavioral health communities.

The programs encourage primary care providers (PCPs) to coordinate patient care with a trained behavioral health practitioner, and in many cases, a consulting psychiatrist. Historically, uptake for BHI has been low because of unclear reimbursements, but industry experts believe that the anticipated coordination within the BHI program will have a substantial impact on reducing the costs of care and improving its quality.^[1]

Reimbursement for care coordination

Prior to the creation of the CCM program, there was an obvious problem: Patients were less likely to receive collaborative and coordinated care from a variety of providers because there was no way for practices to bill for this service. Lack of coordination often meant unnecessary and potentially harmful prescriptions, tests and costs. 

When CMS rolled out the CCM program (CPT code 99490) in 2015, it did so while still being uncertain if the program would truly lower costs within the system. Likewise, providers weren’t sure how to appropriately staff for coordination services, which requires that a clinician spend 20 minutes per month communicating and coordinating with the patient and other members of the care team.

Fortunately, CMS’s big bet paid off. While some studies discovered that initial costs would rise for certain patients under CCM, long-term savings would be worth the upfront expense. The program translates into savings of $15,000 to $80,000 per quality-adjusted life year^[2].

Although CCM is exclusively for physical health, the new codes added through CoCM and BHI are allowing those in the mental health community to take part as well. These programs allow care coordination services for behavioral health patients, and requirements for the care manager are specific to mental health.

How behavioral health providers can position themselves

While behavioral health providers now have a greater opportunity to be involved in a patient’s collaborative care, it’s the responsibility of the providers themselves to ensure they are set up for success in these situations.

1. Practice what they preach

Exclusion from collaborative care in the past naturally drew out complaints from mental health providers who believed they were unfairly and incorrectly excluded from a patient’s holistic healthcare.

While that may be true, now that behavioral health is being included in CMS’s care management programs, this is a crucial time for mental health practitioners to practice what they preach.

Whole patient healthcare consists of more than just the patient’s behavioral health. For mental health providers, it needs to be about creating solutions to bridge the gap between mental health and PCPs and reach across the aisle to truly bring collaborative care to their patients.

2. Embrace healthcare technology

Many physicians in the medical community now coordinate on care via their EHR systems. Bolstered by meaningful use payments, the physician community has already embraced healthcare technology, while mental health providers were largely excluded from these incentives. As a result, there’s a huge disparity in technology use between the two groups. Various policy proposals were introduced to remedy this issue, though none have succeeded in becoming law.

For care coordination to work, it is imperative that mental health providers are also utilizing EHR and practice management software capable of sharing patient records pertinent to care coordination. Implementing software will not guarantee the involvement of behavioral health practitioners in care coordination, but it will certainly increase the possibility of participation if a PCP is able to easily send and receive records, notes and requests with a behavioral health practice’s own system.

Technology that allows for a longitudinal patient record will be important as the behavioral health community becomes more integrated into whole patient care and better aligned with the general medical community.

3. Be advocates for change

In the past year, the behavioral health community has experienced great progress from a government perspective as well. Thanks to state parity laws, the 21st Century Cures Act and BHI programs, mental health providers are beginning to gain the voice they’ve long deserved in helping to shape the country’s healthcare.

However, it’s not enough to wait for change to happen. There is work to be done at multiple levels to truly achieve equality for behavioral health.

Breaking down barriers

Without question, progress has been made in favor of the mental health community and its role in patient care. The expanded programs and new codes for CMS reimbursement are positive steps, but this is a long game. The behavioral health community needs to continue to enhance its voice, push innovation forward and work to coordinate on behalf of patients in need. 

With more integration, the barriers between the mental and physical health communities will continue to deteriorate, resulting in greater cost savings, more positive clinical outcomes and optimal care collaboration in all aspects of patient care.

Charlie Hutchinson is the chief financial officer of InSync Healthcare.