What We Are Learning

INSIGHTS FROM THE REAL WORLD – REVEALING FEEDBACK FROM DIVERSE PHYSICIAN PRACTICES ACROSS THE U.S. DOING BEHAVIORAL HEALTH INTEGRATION (BHI)

The main professional body of American internists, the American College of Physicians, published a report in its July 21, 2020 Annals of Internal Medicine on a qualitative study undertaken from October 2018 – June 2019 regarding what medical and behavioral clinicians are saying about their experiences attempting to integrate mental health care into their medical practices. The insights are highly informative, giving us a snapshot view of BHI in the real world of clinical practice. NHMH summarizes the report’s findings below. Here’s what clinicians are saying:
(Source: Malatre-Lansac A, et al, Factors influencing physician practices’ adoption of BHI in the U.S., Ann Intern Med. June, 2020; 173:92-9. doi: 10.7326/M20-0132).

NEEDS: What are the biggest needs for practices to be able to do BHI?

(a) tailored, practice-specific technical support
(b) payment approaches that give the practice a feasible sustainable business case for doing BHI

MOTIVATIONS: Why do medical practices start BHI in the first place?

(a) gives practices failing to do CMS-required BH screens, a way to screen and treat the BH screen “positives”
(b) gives patients greater access to behavioral health services
(c) improves medical clinicians’ ability to respond to their patients BH needs
(d) practices see BHI as cutting-edge care that sets their practice apart from competitors

HURDLES: What are the barriers to successfully providing BH services?

(a) cultural differences between medical and behavioral professionals, such as BH clinicians acclimating to medical clinics in the collaborative
care model that features relatively brief patient interactions, and/or non-behavioral clinicians not understanding the purpose of BHI for example
(b) challenges in different communication styles of both groups of clinicians
(c) inadequate information flows between medical and behavioral clinicians, insufficient sharing of essential clinical information, and HIT platform interoperability
(d) complex, burdensome and unfamiliar billing and lack of uniformity among multiple payers reimbursing for BHI

MODELS TYPES: What was their experience of using collaborative care or co-location models of BHI?

In the study, 2/3 of practices adopted the co-location model, with its embedded BH professional, noting its congruence with preexisting practice workflows. Practices also noted their adopted BHI implementation models changed over time, even within the same parent organization. Staggered implementation was popular with practices as it continually allowed for improvement and changes in emphasis as needed.

PHYSICIAN PAYMENT: Do either the fee-for-service or valued-based APM payment systems support BHI in your practice experience?

There was no one-size-fits-all payment model that practices used to support BHI. Practices described advantages and disadvantages to both FFS and APMs payment systems. However, few reported net positive financial returns from doing BHI. Some do BHI under FFS, negotiating with commercial payers and getting CMS/Medicare BHI billing code reimbursement. Others cited APMs as critical to long-term financial sustainability of BHI. But they also reported that the net effect of BHI on practice finances was challenging to estimate under APMs because of difficulty determing what portion of any bonuses received was attributable to BHI efforts. Many felt they needed 3-4 years to calculate the financial impact of BHI in adding value to a practice. Some practices reported supporting BHI financially through internal organizational support, others used one-off grant funding. Many practices did not know, or so far had not tried to determine, the financial effects of BHI on their practices.

FAVORABLE POLICY CHANGES: What recent policy changes have helped promote BHI?

* Mental Health Parity Act of 1996 (federal statute)
* Mental Health Parity & Addiction Equity Act of 2008 (federal statute)
* Patient Protection & Affordable Care Act of 2010 (federal statute)
— expanded insurance coverage for behavioral health care
— encouraged APMs that incentivized integrated med/BH care
* 2017 Medicare New FFS Billing Codes Specifically for BHI (federal regulatory)
Some private payers and State payers are also now reimbursing those codes.

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The Destructive Impact of COVID on Americans’ Mental Health

A June 2020 national survey shows the devastating impact of the COVID pandemic/recession on American’s mental health so far (see link):

* 40.9% of American adults (100+ million persons) report experiencing at least 1 adverse MH effect as a result of pandemic
(compared with 25% of adults reporting diagnosable MH conditions in previous surveys at period without a disaster
* Reported 30.9% level of anxiety or depression
* Reported 26.3% level of significant trauma or stress reactions
* Reported 13.3% level of increased substance use (alcohol or drugs)
* Reported 10.7% level of completion of suicide
* 30.7% of unpaid caregivers reported contemplating suicide
* 25.5% of those aged between 18-24 actually contemplated suicide
* 21.7% of essential health workers, 18.6% of Hispanics and 15.1% of Blacks also contemplated suicide
* 74.9% of 18-24 yr olds reported experiencing at least 1 mental health symptom
* 51.9% of 25-44 yr olds reported experiencing at least 1 mental health symptom
* 52.1% of Hispanics reported experiencing at least 1 mental health symptom
* 54% of essential health workers reporting experiencing at least 1 mental health symptom
* 61.6% of unpaid caregivers reporting experiencing at least 1 mental health symptom

At the present time:

* Only about 6% of U.S. adults receive specialty behavioral health services
* 7-8% receive these mental health care services from primary care doctors
* Thus the total of Americans receiving mental health care is about 12% of the adult population

https://www.psychcongress.com/article/behavioral-health-pandemic-emerging

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Physicians Suffering Moral Injury in the Business of Health Care

“We also need patients to ask what is best for their care and then to demand that their insurer or hospital or health care system provide it — the digital mammogram, the experienced surgeon, the timely transfer, the visit without the distraction of the electronic health record — without the best interest of the business entity (insurer, hospital, health care system, or physician) overriding what is best for the patient.”

NHMH would add that patients need to demand that their mental health care be delivered along with their physical health care in medical settings.

https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury

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Dr. Sue Bornstein of Texas Medical Home Initiative Explains Persistence of Challenges to Integrating Medical-Behavioral Care

“It is evident that behavioral health services should be an integral part of comprehensive primary care.”
Source: Institute of Medicine, 1996 (now NASEM)

“… despite recent statutory and regulatory policy changes that may encourage adoption, behavioral health integration is still uncommon among U.S. physician practices.”
Source: Bornstein et al, AIM, June 2020

“Developing, supporting, sustaining, and growing integrated care teams is the best remedy to ameliorate cultural differences between behavioral and nonbehavioral clinicians that can serve as barriers to successful integration.”
Source: Bornstein et al, AIM, June 2020

Bornstein S, BH Integration Editorial, AIM 173, 151, 2020

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Q: According to the latest data for 2018, how many people in the U.S. suffer from mental health conditions and substance use conditions (SUDs), and critically, how many of them receive any treatment?

A: Number of Americans with BH Conditions: Results from Federal Government’s National Survey on Drug Use and Health (NSDUH) show 47.6 million Americans 18 or older suffered from a mental illness in 2018. 19.3 million citizens suffered from an apparent substance use disorder (not including tobacco). This means that substantive behavioral health disease was present in a total of 57.7 million Americans, or 23% of the adult population.

How Many Receive Treatment: Only 10.2% of individuals 12 and older with SUDs reported receiving treatment during 2018. Only 43.3% of individuals 18 and older with any mental illness reported receiving care or treatment for that mental illness.

(Source: U.S. Dept of Health & Human Services, SAMHSA, 2018 NSDUH)

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Q: Did you know that only one-third of patients with behavioral health (mental health + substance use) conditions report receiving the care they need? Would we as a society tolerate only one-third of cancer patients receiving the care they need??

A: Integrating behavioral health services into primary care will go a long way to getting MH+SUD care to patients in need of that care.

https://www.healthaffairs.org/do/10.1377/hblog20200212.952731/full/

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Thought primary care practices generally all about the same? Wrong!

How many ways can primary care practices differ? We’ve counted over 30 so far. And all of them are very relevant to the integration of mental health/addiction care. Because of this diversity in practice make-up, health policy-makers, clinicians and researchers now recognize the need to give practices as much flexibility as possible as they integrate BH into primary care while still following evidence-based approaches. Health care researchers have a goal to provide practices with a MENU of evidence-based models or approaches to integrated care and leave choice of which to adopt to them. Practices are also encouraged to organically innovate to develop their own innovative approaches that may, if proven successful, be scalable more broadly.

Primary Care Practices Variability Factors:

1) Patient population needs
2) Type of practice: independent, FQHC, hospital-linked, etc
3) Number of MDs
4) MD backgrounds, expertise, experience
5) FTE staff make-up, licensure, credentialing, training, etc
6) Administration make-up
7) Payer mix: commercial ins, Medicare, Medicaid, direct contracts, FFS, self-pay, uninsured
8) Output per physician hour
9) Revenues
10) Expenses
11) Clinical workflows, care processes, procedures, protocols, etc
12) Conditions treated in the practice
13) Number of patients, patient volume, productivity
14) Patient demographics, ethnic, cultural, linguistic composition
15) Physical locations
16) Tele-health capacity: video-conferencing, etc, partners
17) Services provided
18) Community social services linkages
19) HIT capacity: EHRs, patient registries, case management tracking tools, etc
20) If FFS: codes used for billing services, etc
21) PCMH accreditation, level
22) ACO type
23) Specialist referral inventories, arrangements, personal interactions betw PCP and BH specialists
24) Specialty (incl BH) referral management
25) Quality improvement management
26) Things in practice not reimbursable but show value
27) Staff satisfaction
28) Patient satisfaction
29) Type of data collection systems, data analytic system, data sharing system
30) Nature/type of patient engagement program
31) Staff turnover

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Disparities Accessing Behavioral Versus Physical Care Services, Milliman Report, November 2019

Q: As part of its November 2019 revealing report on stark disparities between behavioral health versus physical health access to services and provider reimbursement 2013-2017, Milliman found (p. 6) that only 1 state out of 50 in the entire country had no disparities between mental health and medical services use and reimbursement in 2017. Can you guess which one?

Milliman Research Report

A: Nebraska. Which interestingly has, along with a 1.9 million population, a nonpartisan, unicameral state legislature.

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Q: Why is Abraham Lincoln called “the father of cognitive behavioral therapy”?

A: Because he said: “We can complain because rose bushes have thorns, or we can rejoice because thorn bushes have roses.”

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Q: Is AI (artificial intelligence) coming to primary care practices?

A: We live in an era of cognitive computing (i.e. AI). And have been since 2011. Increasingly, medical doctors will be trained to deal with large datasets. Where can AI help primary care practices?

• easing the administrative burden for clinic staffs
• helping the integrated (medical and BH providers) care teams assess data
• expanding the ability of practices to manage more patients
• possibly in area of models to predict health outcomes

What would be first step bringing AI to primary care? Most likely for practices to begin to use AI to help with their administrative burden. (Source: PCPCC – Patient-Centered Primary Care Collaborative, May 2019)

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Background: Provider Networks in Commercial Health Plans: In order for consumers enrolled in commercial health plans to have adequate access to mental health/substance services, the health plan’s network of providers (i.e. primary care and specialist clinicians) needs to be adequate (have enough clinicians). If provider networks are inadequate, patients are not able to consistently access clinicians in their network in a timely fashion.

Did You Know?: That while about 95% of primary care (medical) physicians join health plan networks, only about 50% of behavioral (MH+SUD) specialists join commercial health plan networks. Why?

Cited reasons: BH professionals receive higher reimbursement when not in plan networks (i.e. when they are accessed out-of-network those clinicians may submit claims for higher payment, or get paid in cash at time of service); also many BH professionals are retiring worsening network adequacy problems. (Source: Milliman, 2017; National Alliance Healthcare Purchasers, 2018).

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