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Alysia Hoover-Thompson, PsyD , Staff Psychologist

Making a Behavioral Health Program Financially Sustainable: A Look at Costs and Revenue Generation at a Fully Integrated Federally Qualified Health Center. Alysia Hoover-Thompson, PsyD , Staff Psychologist James L. Werth, Jr., PhD, ABPP, Behavioral Health and Wellness Services Director

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Alysia Hoover-Thompson, PsyD , Staff Psychologist

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  1. Making a Behavioral Health Program Financially Sustainable: A Look at Costs and Revenue Generation at a Fully Integrated Federally Qualified Health Center Alysia Hoover-Thompson, PsyD, Staff Psychologist James L. Werth, Jr., PhD, ABPP, Behavioral Health and Wellness Services Director Emily C. Stacy, PMHNP Malcolm Perdue, Chief Executive Officer Stone Mountain Health Services Session # B3 CFHA 18th Annual Conference October 13-15, 2016  Charlotte, NC U.S.A.

  2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

  3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Identify strategies for overcoming financial barriers to implementing integrated primary care. • Discuss ways that an organization can maintain a financially sustainable model of integrated care. • Define the “hybrid” model of integrated primary care.

  4. Bibliography / Reference Burke, B. T., Miller, B. F., Proser, M., Petterson, S. M., Bazemore, A. W., Goplerud, E., & Phillips, R. L. (2013). A needs-based method for estimating the behavioral health staff needs of community health centers. BMC Health Services Research, 13, 245-256. doi: 1472-6963/13/245 Davis, M. M., Balasubramanian, B. A., Cifuentes, M., Hall, J., Gunn, R., Fernald, D., Gilchrist, E., Miller, B. F., DeGruy, F., & Cohen, D. J. (2015). Clinician staffing, scheduling, and engagement strategies among primary care practices delivering integrated care. The Journal of the American Board of Family Medicine, 28, S32-S40. doi: 10.3122/jabfm.2015.S1.150087 Hall, J., Cohen, D. J., Davis, M., Gunn, R., Blount, A., Pollack, D. A., Miller, W. L., Smith, C., Valentine, N., & Miller, B. J. (2015). Preparing the workforce for behavioral health and primary care integration. The Journal of the American Board of Family Medicine, 28, S41-S51. doi: 10.3122/jabfm.2015.S1.150054 Hudgins, C., Rose, S., Fifield, P. Y., & Arnault, S. (2013). Navigating the legal and ethical foundations of informed consent and confidentiality in integrated primary care. Families, Systems, & Health, 31(1), 9-19. doi: 10.1037/a0031974 Miller, B., F. Brown Levey, S. M., Payne-Murphy, J. C., & Kwan, B. M. (2014). Outlining the scope of behavioral health practice in integrated care: Dispelling the myth of the one-trick mental health pony. Families, Systems, & Health, 32(3), 338-343. doi: 10.1037/fsh0000070

  5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

  6. Behavioral Health Integration:Support from the CEO’s Office Malcolm Perdue CEO Stone Mountain Health Services Jonesville, VA

  7. Organizational Background • Stone Mountain Health Services is a Federally Qualified Health Center (FQHC) with 11 primary care clinics and 3 respiratory care sites across seven of the Westernmost counties in Virginia • 25 medical providers across the sites • Catchment area includes three of the poorest and least healthy counties in the state • All counties have HPSA scores of 16, 17, or 18 • Primary medical care (all clinics), dental care (1 clinic), and behavioral health care (10 clinics) • Payment mix: : 20% Self-pay, 20% Medicaid, 40% Medicare, and 20% Insurance

  8. History of Behavioral Health Program • Behavioral health (BH) program started in 2001 with 3 social workers and 1 professional counselor • Salaries were grant funded from a project with Working Partners for Success and a grant from the Bureau of Primary Health Care • Four positions were filled but only two LCSWs stayed for long-term positions • Rural Workforce Development Grant (2010-2013) • Written in collaboration with East Tennessee State University and Radford University to establish Social Work and Psychology internships • 2 Social Work and 2 Psychology interns began in August 2011 • New staff hired beginning August 2012 • Funding extended to the end of August 2014

  9. Some reasons why the BH Program struggled before the recent expansion in 2011/2012: • Difficulty developing of billing sources and billable services within the medical umbrella (e.g., problems with reimbursement for same day billing) • General lack of training / understanding / shift of BH role in medical clinic setting • Medical providers, administrators, and the BH providers had difficulty determining what to do and how to do it in light of traditional mental health models • Lack of qualified practitioners to do BH work • Lack of resources in the general region for patient services and professional training

  10. Why CEOs Should be Proponents of BH Integration • Helps patients • Helps medical providers • Can help communities • Can help, or at least not hurt, organizational bottom line • Brings additional skill sets to organization • The right thing to do

  11. Building a Sustainable BH Program in an FQHC James L. Werth, Jr., PhD, ABPP Behavioral Health and Wellness Services Director Stone Mountain Health Services jwerth@stonemtn.org

  12. Current Status of the BH Program • Strong support of CEO and other Management Team members • Strong support by overall Board of Directors and local clinic Boards • Strong support by most site managers and primary care providers • Strong support by most nurses • Mixed support by front end staff

  13. Behavioral Health and Wellness Services Director • Executive Management level position • Currently filled by a Licensed Clinical Psychologist • Part-time administrative (3 days) / part-time clinical work (2) • Psychiatric Mental Health Nurse Practitioners • 2 currently on staff • Each has a nurse assigned to her • Social Workers • 2 LCSWs • 1 post-MSW working toward licensure • Bills what she can under her LCSW supervisor • 1 pre-MSW intern (most years) • Does not bill for individual service provision

  14. Psychologists • 5 additional LCPs (beyond BH&WS Director) for the fiscal year in question • 1 of whom is focused solely on psychological assessment • 1 of whom is focused on children and adolescents • 1 who had an emphasis on substance abuse and on pain management [may try to hire a replacement for this slot] • 2 of the psychologists were hired from internship so they were not licensed/credentialed for some of the year in question • 2 doctoral interns • Part of internship consortium with another intern placed at Radford University Student Counseling Services • Recently became APA-accredited for 7 years • Do not bill for individual service provision • Case/Care Manager/Coordinator • Moving toward hiring a SW to help with substance use patients and provide other support for BH providers

  15. Stone Mountain’s BH Model • “Hybrid” model • Integrated care – “warm hand-offs” / BH sessions can be interrupted • Typically, 15-30 min sessions, 1-3 times spread over several weeks • Traditional outpatient counseling (e.g., weekly, 45-60 min long) • Goal of 5 encounters per day [need to schedule 8] in addition to time for informal warm hand-offs and “curbside consultations” • Introduction to every new patient (if possible) • These do not count as encounters • Screening forms given to patients in waiting room / triage – a work in process (waiting for technology option) • Assessment position • Supervisors observe trainees (do not bill) • No show / cancellation policies (vary by provider) • Moving toward adding technology-based services – a work in process

  16. An Overview of the Financial Numbers • For FY 2015-2016, the 10 full-time BH providers and their interns had almost 9700 encounters, which placed productivity at 97% • Subtracting about 1050 unbillable intern encounters leaves approximately 8650 encounters for professional BH staff • We do not bill for warm hand-offs unless the patient consents • We had around 650 encounters billed as WH (590 were 90832WH) – no charge • For approximately 8000 billed encounters • Major CPT Codes (rounded numbers): • 90791 (Diagnostic Evaluation): 720 - 99213 (OV Est Level 3): 225 • 90832 (16-37 min): 2575 - 99214 (OV Est Level 4): 990 • 90834 (38-52 min): 1160 - 99215 (OV Est Level 5): 1160 • 90837 (53+): 500 - 96101 (Testing by Psych): 550 - 96102 (Testing by Intern): 75

  17. The charges for these encounters totaled almost $1.4M • The payments from co-pays and insurance totaled almost $480,000 • This means that our payments were only 34% of charges • Medical is 50% • Because Stone Mountain is an FQHC, services are offered on a sliding scale to patients who qualify • Approximately $390,000 was collected through the federal grant that covers the cost of care for people receiving services on the sliding scale • Note: 28% of BH patients are on sliding scale, higher than medical • Non-FQHCs would not receive this reimbursement, but they also may not see as many people without insurance or who cannot pay out-of-pocket • Adding these numbers together, the total payments were approximately $870,000

  18. For our purposes, the “cost” of the 10 full-time professional BHPs is their salary + benefits • The cost of the staff was approximately $860,000 • Thus, these BHPs generated around $10,000 in revenue • In addition, Stone Mountain received 2 grants to expand services that covered some of the salary and benefits for 3 BHPs (2 psychologists and 1 PMHNP) • The BH portion added $250,000 to the organization’s base FQHC grant

  19. Bottom Line • The BH Team broke-even / generated money • Without relying on non-sustainable grant funding • Even with “expensive” providers • Even with 3 new providers not licensed for some or all of the fiscal year • Even with the new providers not reaching 100% productivity • Even with some of the licensed providers spending time supervising interns/non-licensed professionals • Hard to measure impact on PCPs’ productivity but they report an improvement in the quality of their professional worklife • The “hybrid” model of integrated care can be sustainable

  20. Behavioral Health Integration:Costs and Revenue Generated by One Behavioral Health Provider Alysia Hoover-Thompson, PsyD, LCP Staff psychologist Stone Mountain Health Services Haysi & St. Paul, VA

  21. Weekly Schedule • Clinic 4 days/week (32 hours) • Provide services at 2 different clinics • Fridays = offsite with our doctoral level interns for training • Supervise 1 doctoral level intern (2 hours scheduled + as needed) • Total clinical hours = 30 • Cost to Stone Mountain Health Services (salary + benefits) = $90,000

  22. Scheduled Appointments vs. Patients Seen • ~60% show rate based on pre-scheduled appointments

  23. Billing Codes Used

  24. Revenue Generated: Payees

  25. Revenue Generated • Total Charges = $155,863.50 • Total Payments = $98,797.79 • Payments ($98,797.79) – Cost to SMHS ($90,000) = $8,797.79 in revenue • On average, we collect ~ $110/encounter • If I saw patients 5 days/week (instead of 4) • 5 patients/day x 45 weeks = 225 encounters @ $110/encounter = $24,750 in revenue • Actual Revenue ($8,797.79) + Potential Revenue ($24,750) = $33,547.79

  26. Psychiatric Mental Health Nurse Practitioners ExpANDINGroleS AND INTEGRATING CARE in a rural fqhc Emily stacy, pmhnp Stone Mountain Health Services Damascus, Haysi, & St. Paul, VA

  27. The Role of Nurse Practitioners“THE TIME IS ALWAYS RIGHT TO DO THE RIGHT THING” MARTIN LURTHER KING, JR. • * Profession born of necessity in 1955 (National Institutes of Mental Health) • * By 1965 more than 30 programs nationwide • * Historically served economically / socially disadvantaged populations • * Master prepared or higher, Nationally Certified, and State Licensed

  28. Statistics • * Virginia Healthcare Workforce Data (02/2016) on Licensed Nurse Practitioners • Total Licensees: 7724 • Virginia Workforce: 6505 • 18% of all NPs in Virginia work in non-Metro (which includes rural) areas • Median Salary: $90K-100K • Median Educational Debt Burden: $50K-60K • Job Satisfaction: 66% • Adult Psychiatric Mental Health Nurse Practitioners (PMHNPs): 84 • Family PMHNPs: 73 • Approximately 2.5% of NP Workforce • If the same % holds for PMHNPs as NPs overall (i.e., 18%), there are 4 PMHNPs working in non-Metro areas in Virginia

  29. Stone Mountain’s PMHNPs • * Stone Mountain Health Services • 2 PMHNPs • First hired in 2013: Case Management/Behavioral Health and Critical Care experience • Works in 2 clinics • Second hired in 2015: Oncology/Palliative Care and Critical Care experience • Works in 3 clinics • 40 hours weekly • Both are available using technology for other clinics • NHSC loan reimbursement

  30. Care Integration: Finding a Path “I HAVE LEARNED OVER THE YEARS WHEN ONE’S MIND IS MADE UP, THIS DIMINISHES FEAR; KNOWING WHAT MUST BE DONE DOES AWAY WITH FEAR” ROSA PARKS benefits Challenges We Speak Different Languages Provider Split Between Distant Sites, No Shows “You want me to do want??” Abuse, Polypharmacy $ = Better Health Cost and Quality Expected to Exceed Private Sector Developing Referral Sources Electronic Medical Records!!!!! Increased Communication Coordinated Care Disease Self Management Medications Wellness Goals Positive Effect on Cost and Quality Fostering Community Partnerships Telehealth

  31. Billing vs. Revenue “EDUCATION IS THE MOST POWERFUL WEAPON WHICH YOU CAN USE TO CHANGE THE WORLD” NELSON MANDELA • * Number of Encounters: 1226 • * Charges Billed: Approximately $250,000 • * Adjustments off Charges: Approximately $160,000 • * Payments (co-payments + insurance): Approximately $80,000 • Adjusted Charges: Around 37% of billed • Remaining $10,000 in Accounts receivable • * Income: Approximately $190,000.00 • This includes grant-related sliding scale payments in addition to the above

  32. E/M Guidelines “JUST BECAUSE YOU ARE A CHARACTER DOESN’T MEAN YOU HAVE CHARACTER.” WINSTON WOLF (HARVEY KEITEL) IN PULP FICTION • Developed by the AMA & CMS • First set released in 1995, Second set released in 1997 • Key Components: History, Physical Exam, and Medical Decision-Making • Most Commonly billed codes 99213, 99214, 99215 • 99213 - $101.00 • 99214 - $165.00 • 99215 - $237.00 • Keys are to Maximize Revenue and Streamline Documentation

  33. Example • CC: Depression, PTSD, ADHD • Interval History: The pt presents for follow up. She feels sadder than usual. • Neat, clean, alert, good eye contact • Speech is hypophonic and lacks spontaneity • Thoughts organized • Association are intact • No hallucinations or SI • Judgment and insight are intact • A&Ox3 • Attention span and concentration are impaired • Mood is anxious and depressed. Affect is congruent IMPRESSION: • Recurrent MDD • Worsening, Stable PTSD • Stable ADHD PLAN: Increase Celexa to 40mg PO QD, Continue Lamictal for PTSD, Continue Adderal for ADHD, PTSD continues to respond to intermittent exposure therapy and stress management. 16 Minutes spent on psychotherapy today above and beyond time spent on the E/M service. 99214 - $165 E/M CODE 97 WORDS - $1.70 PER WORD 90833 - $58 16 MIN. THERAPY TOTAL - $223 35%

  34. Rational Coding…(Documentation to Pass Audit & Provide Platform for Care)“Start where you are. Use what you have. Do what you can.” Arthur Ashe • Let Medical Necessity Drive Documentation • Determine Highest Ethical Level of Care • Save Time - Don’t Over Document • Will Increase Revenue and Prevent Undercoding • Eliminates E/M Code Anxiety • Focuses on Patient Care • (E/M UNIVERSITY http://www.emuniversity.com Dr. Ken Jennings)

  35. Session Evaluation Please complete and return the evaluation form before leaving this session. Thank you!

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