Integrating behavioral health and primary care

When primary care physician Dr. Karen Smith noticed that opioid abuse rates were skyrocketing in her community of Raeford, North Carolina, she decided to do something about it: She partnered with a behavioral health agency to roll out a medication-assisted treatment (MAT) program within the four walls of her practice.

Here’s how it worked: Smith screened patients for opioid abuse during the intake process. When she identified patients who could benefit from MAT, she used a warm handoff to connect them with a psychiatrist who could treat them on-site. This immediate access was a significant benefit for patients in an impoverished community where travel wasn’t easy.

Although Smith could have charged rent for the office space the psychiatrist used, she did not because she was reaping other financial benefits related to her performance in an Accountable Care Organization.

“We were actually seeing improved outcomes and a return on the back end,” she says. “We were controlling the total cost of care for those individuals. The amount we would charge for rent would be nowhere near what we would see in terms of cost control.”

When COVID-19 struck, the MAT program shifted from in-person visits to telehealth. “Patients would have otherwise fallen through the cracks,” Smith says. “With telehealth, we were able to maintain services.”

Nearly one in five U.S. adults lives with a mental illness, and the COVID-19 pandemic has only exacerbated the problem nationwide. More than 85% of primary care physicians report that the mental health of their patients has decreased during the pandemic, according to a recent survey conducted by the Primary Care Collaborative. Thirty-one percent report seeing a rise in patients experiencing addiction.

Integrating behavioral health services into primary care practices is one way to address emerging mental health challenges because it closes the gap between need and access. In October 2019, the American Medical Association (AMA) along with several other leading physician organizations established the Behavioral Health Integration (BHI) Collaborative to help primary care physicians build successful models of integration.

“We’ve been hearing about the challenges of integrating mental health because our primary care colleagues have been talking about this for years,” says Dr. Patrice Harris, practicing psychiatrist and president of the AMA. “That’s where the collaborative comes into focus. We want to continue to provide resources to maximize the potential return on investment. We want to help primary care physicians succeed.”

The collaborative is building an online compendium that includes webinars, remote learning opportunities and other resources (e.g., key steps, best practices and tools) to integrate behavioral health, engage patients and ensure billing and coding compliance.

As Smith’s experience demonstrates, BHI isn’t helpful only during COVID-19. It can also help primary care physicians move the needle on value-based care.

“Studies have shown that untreated depression can complicate the course of diabetes, hypertension, heart disease and post-surgical care,” Harris says. “It’s so important to look at the return on investment in terms of health outcomes.”

BHI: Getting started

As with any new initiative, performing a needs assessment is the first step. Depending on patient needs, there are varying degrees of integration that might be appropriate for a primary care practice.

Sean Weiss, partner and vice president of compliance at DoctorsManagement, says primary care physicians should run a utilization report for the past 30 days, then ask these critical questions:

How many unique patients had a mental health diagnosis, and what were those diagnoses? This requires asking patients to fill out Patient Health Questionnaires such as the PHQ-9, GAD-Z, PHQ-2 or EPDS.

What was the average duration of those encounters?

How often did those patients receive a referral to an external behavioral health provider?

How often did those patients receive a prescription and for which medications?

“Data is king,” Weiss says. “It’s about establishing clinical need.”

This analysis can also help physicians determine the right credentialed provider, he adds. For example, if they frequently write prescriptions, it might make sense to partner with a psychiatrist. If the majority of patients have anxiety or struggle with alcohol abuse, maybe a psychologist or social worker is the best fit.

Choosing a BHI model

The good news is that depending on the model chosen, physicians don’t need to completely re-engineer their practices, Harris says.

For example, some primary care physicians may choose to simply consult with an external psychiatrist on a case-by-case basis. This model might work well in practices with a low volume of patients with mental health diagnoses. In other models, a behavioral health specialist works on-site collaborating through varying degrees of co-created care plans and shared systems. The specialist may or may not be employed directly by the practice.

Physicians also need to think about billing implications, says Jackie Coult, CHBC, senior healthcare consultant at Eide Bailly LLP, who recently worked with a primary care practice struggling to cover an employed social worker’s wage because commercial insurance payments for the psychotherapy services she performs are relatively low.

Experts say physicians should consider these questions:

What current procedural terminology (CPT) codes will the behavioral health specialist actually bill? See the sidebar for more information. Keep in mind that state licensure requirements, payer policies and individual areas of expertise will dictate what type of provider can bill for each type of service, Coult says.

What do payers pay for the CPT codes that the specialist will most likely bill? Be sure to differentiate between Medicare, Medicaid and commercial payers (including each individual plan).

What is the anticipated service volume?

These questions can help primary care physicians determine not only whether a direct full- or part-time employment model makes financial sense, but also specifically what type of compensation structure to offer, Weiss says. Some practices use a salary while others use a lower base amount plus volume-driven bonus payments, he adds.

Telehealth considerations

During the public health emergency, the Centers for Medicare & Medicaid Services (CMS) expanded its list of telehealth-covered CPT codes to include various BHI-related services. The good news is that telehealth can help practices lower overhead costs for BHI.

“Telehealth is going to play more and more of a role in the integrated care of patients,” Weiss says. Investing in a compliant telehealth platform can help primary care physicians achieve a return on investment, he adds.

Telehealth-based BHI is something Smith hopes payers will continue to cover even after the end of the public health emergency.

“It enables access and quality care, it’s efficient, and it’s cost-effective. It meets the quadruple aim,” says Smith. “Once you address mental health problems, you’ll see an improvement in the overall health of patients.”

When it comes to BHI, she says independent primary care physicians can lead the charge. “One of the reasons I’ve been so successful is because I’m a solo physician,” Smith says. “I had the freedom to actually pursue this area of interest. When physicians are confined, that interferes with physician well-being and their desire to do what’s best for the patient.”