Improving the health of older adults by integrating behavioral health into primary care

1. Improving the health of older adults by integrating behavioral health into primary care Paula E. Hartman-Stein, Ph.D. Clinical Geropsychologist Wednesday, March 7, 2018

2. Disclaimer The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).

3. Presenter Paula E. Hartman-Stein, Ph.D. Consultant in Geriatric Behavioral Health • Clinical geropsychologist, Consultant & Educator in geriatric behavioral health • Education background • University of Pittsburgh, West Virginia University, Kent State University; Geriatric Clinician Certificate from GREC, Case Western Reserve University • Work History • Hospitals, Primary Care, Long Term Care, private practice • Medicare Correspondent, The National Psychologist newspaper • Accomplishments • Senior Fellow, University of Akron, Life-Span development & gerontology • Faculty, PCBH, Ctr for Integrated PC, Umass Medical School • Current member of CMS Technical Expert panels for depression & elder maltreatment screening measures • Member of CMS Technical expert panel for Resource-Based Relative Value Scale (1992-1993) • Lead editor, Enhancing Cognitive Fitness in Adults (2011) 3

4. Objectives • Analyze past, present & future paths to enhancing the health of older adults • Identify CPT codes for mental health (MH) services including chronic care management, collaborative care, behavioral health integration (BHI) • Analyze barriers to using new codes • Identify training opportunities for behavioral health (BH) clinicians in primary care (PC) • Ideas for models in the future to improve health of older adults • Resources 4

5. Primary Care: de facto Mental Health System in U.S. • Basic stats • 60 to 70% of PC visits are by patients with stress related physical symptoms or whose disease is complicated by psychological factors. • 30 to 50% of referrals from PC to specialty BH don’t make first appointment. • 54% of all BH is provided in PC settings. • Only half of all depressed patients seen in PC are diagnosed & treated. • 67% of all patients with BH disorders do not get treatment. 5

6. Depression and Older Adults • For older adults living at home, prevalence of major depression is between 1 and 4%. • Between 5 and 10% of older adults seen in primary care meet criteria for major depression or dysthymic disorder. • For the medically ill, prevalence of depression ranges from 10% to 43%. • Depression is major risk for suicide. Highest suicide rate is among white males, age 85 and older. 6

7. Primary Care and Mental Health Untreated BH conditions lead to avoidable suffering, increased cost of care, decreased treatment adherence, and inappropriate use of health care services. 7

8. PC is our de facto MH system • Obvious solution: combine psychological services into primary care. • Currently the federal government is committed to integrated healthcare as are numerous states. • Some states have partnerships between FQHCs and CMHCs. • Examples of current models: Co-location; Collaborative Care; primary care behavioral health (PCBH). • How new is BH integration? 8

9. Ancient Founders of Behavioral Health Integration Hippocrates Asclepius 9

10. “Healthy mind in a healthy body” Ideas from ancient Greek medicine: Provision of care included health promotion & prevention, including physical activity and good nutrition, interventions for trauma care, mental care and art, music, & drama therapy. Christos F. Kleisiaris,Chrisanthos Sfakianakis, &Ioanna V. PapathanasiouJ Med Ethics Hist Med. Health care practices in ancient Greece: The Hippocratic ideal (2014). 7, 6. Published online 2014 Mar 15. 10

11. Hippocrates • Believed to be from the lineage of Asclepius, Hippocrates placed great emphasis on strengthening and building up the body's inherent resistance to disease, i.e., prevention.  • As a holistic healing system, Hippocratic medicine treated the patient, and not just the disease. • Resource: The Science of Healing: Understanding the Mind/Body Connection, with Dr. Esther Sternberg (2009), a PBS dvd. 11

12. When did the mind/body split begin? Rene Descartes in 17th Century 12

13. Reductionism vs Psychosocial Model • Psychology was a branch of philosophy until the 1870s, when it developed as an independent scientific discipline in Germany and the United States. • Medical training and practices in the 1800s and beyond concentrated on advances in anatomy, infection control, chemistry, surgical practice etc. 13

14. Separate silos of training and practice in physical and mental health continue today. 14

15. Modern Founder of Behavioral Health Integration in PC: Dr. Nicholas Cummings 15

16. First Generation of Medical Cost Offset Research: 1960-1980 • Research by Kaiser Permanente (early HMO), in the early 1960s found 60% of PC visits were by “somatizers.” • Medical utilization was reduced by 62% over 5 years after applying brief behavioral interventions. • Reduction in costs exceeded the cost of providing the BH services. (Somatization: translation of emotional problems into physical symptoms or exacerbation of a disease by emotional factors or stress.) 16

17. Medical Cost Offset • ~1980 Kaiser Permanente had first comprehensive prepaid psychotherapy benefit. • Treatment of choice for 85% of patients with stress-related conditions was brief psychotherapy (6 – 7 sessions). • 15% needed longer MH treatment, but reduced cost of hospitalizations. 17

18. 1980 - 1990: In come the carve-outs … • Managed MH “carve-outs” reduced out-of-control psychiatric and chemical dependence treatment costs by removing them from medical-surgical delivery symptoms. • Antithesis of integration! • One benefit: Carve-outs served to prevent the dropping of MH/CD benefit from third-party payers. 18

19. Dollars and Sense:Managed Medicare Bereavement Program • 1988 Humana bereavement program in Florida • Capitated payment for 140,000 older adults, subcontracted to American Biodyne • Phone outreach by MSW to surviving spouse after spouse died offering group to help with mourning • 16% refused; house call was offered • 85% of surviving spouses entered group 19

20. Dollars and Sense:Managed Medicare Bereavement Program • Each patient was screened by MSW • 20% received individual therapy for depression, 80% referred to group • 5 to 8 patients seen in group; 2-hour sessions • 14 sessions spread over 6½ months • 15% of patients repeated the program & became peer quasi co-therapists 20

21. Dollars and Sense:Managed Medicare Bereavement Program • Goals: enhance self-efficacy, reduce helplessness, restore coherence • Content of group—psychoeducational, process of mourning, relaxation & imagery • Buddy system encouraged • In consultation with primary care physician (PCP), discontinued sleeping pills & anti-depressants 21

22. Dollars and Sense:Managed Medicare Bereavement Program Design & outcome of population-health study • Medical utilization of 323 patients compared to 278 surviving spouses in a nearby center • Followed for 2 years • Yr 1: Control group had increase in medical utilization, 2X that of bereavement group • Yr 2: control group medical utilization was 40% higher • Savings: $1400 per patient over 2 yrs. 22

23. More MH treatment is not always better After studies at Kaiser, Humana, & 7-year Hawaii Medicaid Study, Cummings concluded that traditional mental health services parachuted into a traditional setting do not result in medical cost offset. 23

24. Mental Health in Medicare • Medicare, the largest insurance program in the U.S., began in 1965. • Effective July 1990, direct payment to clinical psychologists and social workers was made available in most settings. • Psychology and social work were in the big leagues! 24

25. How is the value of MH work determined and translated to $ under FFS? Resource-based Relative Value Scale (RBRVS) determines work value for clinical procedures based upon: 1. Technical skills and physical effort 2. Mental effort and judgment 3. Stress associated with risk to the patient or others 25

26. FFS reimbursement under Medicare Payment is based upon a statistical conversion factor plus an equation developed by Harvard economist, William Hsiao, that included: • Relative value units of work • Expense of malpractice insurance • Overhead costs 26

27. Medicare FFS 1993: Mental Health services (for psychologists and social work) were studied separately from psychiatric services for their “ work value” through the Harvard RBRVS study. 27

28. FFS Mental Health intervention CPT codes used in outpatient settings Initial psychiatric evaluation (90801) Psychotherapy • 16-37 minutes for 90832 • 38-52 minutes for 90834 • 53 minutes or longer for 90837 • 26 minutes or longer for 90846 and 90847 • Codes 90832, 90833, 90834, 90836, 90837, 90838 can be reported on the same-day as codes 90846 and 90847, provided that the services are separate and distinct. Be sure to include modifier 59 to emphasize that the services are separate and distinct.  • Do not report psychotherapy codes for sessions shorter than 16 minutes.  28

29. Health and Behavior Codes In 2002 six new CPT codes that psychologists can use were introduced. These codes represent services that can be offered to patients who present with established illnesses or symptoms, who are not diagnosed with a mental illness, and who may benefit from evaluations and treatments that focus on the biopsychosocial factors related to the patient’s physical health status such as patient adherence to medical treatment, symptom management and expression, health-promoting behaviors, and health-related risk-taking behaviors. 29

30. Health and Behavior Codes • 96150 Health and behavior assessment • 96151 Health and behavior re-assessment • 96152 Health and behavior intervention Each 15 minutes, face-to-face, individual • 96153 Group (2 or more patients) (usually 6-10 members) • 96154 Family (with the patient present) • 96155 Family (without the patient present; not being reimbursed) 30

31. Alcohol Misuse Screening & Counseling Codes for PCP • G0442 Annual alcohol misuse screening 15 minutes Frequency: annual basis • G0443 Brief face-to-face behavioral counseling for alcohol misuse 15 minutes Frequency: for those with positive screens, 4 times a year For both services the co-payment/co-insurance & deductible are waived. 31

32. Prevention & Depression Screening The following clinicians are eligible to bill for the services listed below: General Practitioners; Family Practitioners; Internists; Geriatricians; Nurse Practitioners; Certified Clinical Nurse Specialists; Physician Assistants. G0402 Initial Preventive Physical ExaminationG0438 Annual Wellness VisitG0444 Annual Depression Screening, 15 minutes 32

33. A Model of PC Integration: Co-located • On-site service • Easy to refer • Communication is easier • Uses traditional FFS psych billing codes open to social work and psychology • Not collaborative care, goals are not same because it is not team-based care • Separate documentation 33

34. Primary Care Behavioral Health (PCBH) • Pace similar to PCP • No traditional psychotherapy • Interruptions are common • Brief interventions (10 to 15 min) • Psychoeducation, behavioral activation, relaxation strategies • Less dependence on psychiatry 34

35. Movement by CMS toward greater integration • Chronic Care Management (CCM) involves care planning for all health issues and includes systems for preventive services • BH Integration focuses on patients with BH issues, uses validated rating scales and does not focus on prevention • CCM requires certified EHR, BH Integration does not 35

36. Chronic Care Management • CPT 99490: 20 min per month 2 or more chronic conditions, expected to last at least 12 months; Place patient at significant risk of death, decompensation or functional decline; Establishment of comprehensive care plan • CPT 99487 (complex CCM services): 60 min per month 2 or more chronic conditions Place patient at risk of death, decompensation, functional decline, establishment of care plan; Moderate or high complexity of medical decision making; Directed by an MD or qualified health care professional CPT 99489: Each additional 30 min of clinical staff time per month Rush University Medical Center in Chicago is beginning to implement in 2018. Bonnie Ewald is contact. 36

37. Behavioral Health Integration (BHI) Code CPT 99484 Available January 2018 (formerly G0507) 20 min/month General behavioral health care management For non-facility (PC): price payment/pt/month ~$50 Used to bill monthly services through BHI models other than CoCM; includes core elements of assessment and monitoring, care plan revision for pts whose condition is not improving adequately and a continuous relationship with a designated team member. Does not involve a psychiatric consultant nor a BH care manager. 37

38. BHI Code 99484 • For patients with identified psychiatric or BH condition(s) that requires a BH care assessment, care planning, and provision of interventions. • Initial assessment or follow-up monitoring, including validated rating scales • BH care planning • Facilitating and coordinating care • Continuity of care with a designated member of care team 38

39. BHI Code 99484 (cont’d) • BHI code is billed by a physician and/or non-physician practitioner (PA, NP, CNS, CNM: Qualified health provider) usually in primary care • Can include time from clinical staff on interprofessional team (e.g., SW, RN, MA) not otherwise billable 39

40. Barriers to using codes for integration • Verbal consent is needed (obtained by billing provider, doc in EHR) • Subject to Medicare Part B’s 20% co-insurance • Collaborative Care Codes require a registry and a change in billing system. BHI is less complex than collaborative care codes but it is not a per encounter code the way FFS codes are. • All of these new codes require billing system changes. (Harder for larger health care systems than small ones.) • Advantage: first step away from Fee-for-Service (FFS) 40

41. Collaborative Care Model • Based on IMPACT studies of J. Unutzer, a collaborative care team of 3 (billing practitioner, BH care manager, psychiatric consultant) is used in this model. • Pt must be entered in a registry, track patient follow up and progress • Weekly consultation with the psychiatric consultant. Brief interventions such as behavioral activation, motivational interviewing, and other focused strategies. CPT codes 99492 (70 min) first month CPT code 99493 (60 min) per subsequent month CPT code 99494, additional 30 min per calendar month 41

42. Collaborative Care Model BH care manager role: assessment, admin rating scales, care planning, provision of brief interventions, maintains registry, consults with psychiatric consultant, available to provide services face to face with the patient; has a collaborative relationship with team members. Does not need to have requirements to be independent provider under Medicare. Psychiatric consultant: reviews clinical status of patients; advises the billing practitioner and BH care manager of discharge, resolves issue with treatment adherence and makes adjustments of plan. Can and typically is remotely located; not expected to have direct contact with the patient. 42

43. Collaborative Care Model (cont’d) • IMPACT (Improving Mood and Promoting Access to Collaborative Treatment) savings of $3365 per patient over patients receiving usual primary care over 4 years. • Patients in the IMPACT trial of depression collaborative care for older adults had lower average total health care costs than patients who received usual care over 4 year period. • Up to $6 are saved for every dollar spent, ROI of 6:1. 43

44. Competencies for MH providers in PC • Core Competencies for Behavioral Health Providers Working in Primary Care http://farleyhealthpolicycenter.org/wp-content/uploads/2016/02/Core-Competencies-for-Behavioral-Health-Providers-Working-in-Primary-Care.pdf • Competencies for Psychology Practice in Primary Care https://www.apa.org/ed/resources/competencies-practice.pdf • NASW Standards for Social Work Practice in Health Care Settings https://www.socialworkers.org/LinkClick.aspx?fileticket=fFnsRHX-4HE%3D&portalid=0 44

45. Efforts by CMS to Promote PC Integration • The Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation. • Goal: to support >140,000 clinician practices over the next four years in sharing, adapting and further developing their comprehensive quality improvement strategies. 45

46. Efforts by CMS to promote PC integration • American Psychiatric Association, a Support and Alignment Network (SAN), that was awarded up to $2.9 million over 4 years to train 3,500 psychiatrists in the skills needed to support primary care practices that are implementing integrated behavioral health programs. • will train psychiatrists in integrated care in collaboration with the AIMS Center at the University of Washington through online and live trainings. • will focus on the Collaborative Care Model (CoCM) and population health principles • Trained over 1900 psychiatrists so far (Ratzliff, personal communication, February 1, 2018) 46

47. Efforts by CMS to promote PC integration • In October 2016 the American Psychological Association received a 3-year, $2 million grant from the Center for Medicare and Medicaid Services (CMS) to help train psychologists to work within an integrated health care system. • Goal is to reach 5,000 practitioners (as of January 2018 only 420 have signed up for this free training). It is open to social workers as well. • Integrated Health Care Alliance: APA.ORG/IHCA (Tynan, personal communication, January 18, 2018) 47

48. Training in BH in Primary Care Examples of training opportunities • AIMS Center, University of Washington: https://aims.uw.edu/ • APA Integrated Health Care Alliance: http://pages.apa.org/ihca/ • Arizona State University Doctorate of Behavioral Health (DBH) and Master of Integrated Health Care: https://chs.asu.edu/programs/schools/doctor-behavioral-health • Certificate course, Integrated primary care, University of Mass Medical School: https://www.umassmed.edu/cipc/pcbh/pcbh-short-courses/ • Cummings Institute DBH program: https://cummingsinstitute.com/doctorate-of-behavioral-health/ 48

49. Concepts for the Future of Integration in Primary Care Competency, Consulting, Coordinating, Collaborating, Cost sharing, Community, Culture, Creating closeness 49

50. Future Directions in PC Integration • Current models will evolve to where BH of the patient will become the responsibility of the whole team. • “Care enhancers” will have behavioral roles in addition to medical roles such as medical assistants, care managers, community health workers, health coaches, health navigators, etc. but scope of practice can become an issue. • When BH clinicians provide training and supervision to care enhancers, scope of practice problems go away. (Blount, personal communication, February 4, 2018) 50