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Policy initiatives can improve both physical and mental health care quality and outcomes for those with serious mental illnesses.
People with serious mental illnesses (SMIs) like schizophrenia, bipolar disorder, and major depressive disorder pass away 10 to 20 years prematurely relative to the overall population.1,2 This excess mortality is driven by cardiovascular disease and other medical conditions including cancer, liver disease, chronic lung disease, and HIV/AIDS. The high burden of these conditions among people with SMI is driven by multiple factors, including the metabolic adverse effects of psychotropic medications. Social risk factors for chronic disease include poverty, unemployment, housing instability, and criminal justice involvement-all of which are overrepresented among people with SMI.3 Cognitive and communication impairments experienced by some people with SMI, as well as low social support, can present challenges for patient-provider communication, shared decision-making, and navigation of complex health care systems.
Effective interventions to address medical conditions in the population with SMI exist. Evidence-based screening, diagnosis, and treatment of chronic medical conditions is largely the same for people with versus without SMI, and tailored behavioral interventions have been shown in clinical trials to support weight loss and tobacco smoking cessation in SMI.2 Clinical trial evidence also shows that supportive employment and housing programs tailored to SMI can reduce unemployment and housing instability, important social determinants of chronic disease among people with SMI and the overall population. Many people with SMI, particularly the 70% covered by Medicaid, do not receive guideline-concordant medical care.3 Moreover, tailored health behavior and supportive employment and housing interventions have not been widely implemented in the US.
The role of state and federal policy
State and federal policies have a key role in scaling up evidence-based interventions to prevent and treat the medical conditions driving premature mortality in SMI. Policies at multiple levels, ranging from federal laws to clinic-level policies, delineate the rules by which interventions are financed and delivered. In this article, we focus on federal and state-level policy initiatives.
To date, federal and state policy efforts have predominantly focused on supporting integration of primary care and specialty mental health services for people with SMI. The collaborative care model of integrated care can improve both physical and mental health care quality and outcomes. Collaborative care is a primary care-based model in which primary care physicians collaborate with a mental health care manager and a psychiatric consultant to proactively identify, treat, and monitor mental illness.4 The evidence supporting collaborative care is strongest for depression, although findings from limited clinical trials suggest this model may also benefit people with schizophrenia and bipolar disorder.5 Specialty mental health-based integrated care models that operate in a manner conceptually similar to collaborative care but with the specialty mental health program as the locus of care, have the potential to improve quality of medical care and physical health outcomes for people with SMI.
Insurance reimbursement challenges have been cited as a major barrier to adoption of integrated care models.6 Three federal and state policy initiatives are designed to address insurance reimbursement challenges: Centers for Medicare and Medicaid (CMS) behavioral health integration billing codes, the Affordable Care Act Medicaid health home waiver, and removal of same-day billing laws (Table).
CMS behavioral health integration billing codes
CMS introduced four new billing codes for behavioral health (mental health and substance use) integration services in 2017. Three of these codes reimburse services provided within the collaborative care model and the fourth code reimburses services provided under other integrated care models. These codes can be billed by primary care or other general medical clinicians. To be eligible to bill the collaborative care codes, practices must be able to demonstrate that they have implemented the core elements of the collaborative care model.
The elements of the model include: a care team consisting of a general medical clinician, a behavioral health care manager, and a psychiatric consultant; use of validated instruments to identify and monitor mental illness; measurement-based treatment that uses a registry to monitor and track adjustments to patients’ care; and regular case reviews.7 To bill for care management that is not embedded in collaborative care, practices must demonstrate that their integrated care model includes systematic patient assessment and monitoring using validated instruments and behavioral health care planning, monitoring, and coordination.
These behavioral health integration billing codes have been adopted by Medicare and some state Medicaid and commercial plans. However, Cross and colleagues8 found that only 0.1% of Medicare beneficiaries with a mental health or substance use disorder diagnosis received behavioral health integration services billed with these codes from 2017 to 2018. The majority of behavioral health integration codes were billed for general care management services as opposed to collaborative care services. While use of these codes may increase over time, these findings suggest that the primary care and other general medical practices allowed to bill these codes face challenges meeting the staffing, infrastructure, and workflow requirements, particularly for the intensive collaborative care model.
ACA Medicaid health home waiver
The Patient Protection and Affordable Care Act (ACA) of 2010 included a provision that allowed state Medicaid programs to apply for a waiver to use Medicaid funds to create health homes. The homes were for high-cost, high-need subpopulations of Medicaid beneficiaries, including but not limited to people with SMI. In practice, this waiver allowed states to bill Medicaid for 6 previously non-billable services: comprehensive care management; care coordination; health promotion; transitional care; individual/family support; and referral to community and social support services.
As of November 2019, 17 states and the District of Columbia had used the waiver to implement health home programs for people with SMI. Of these 18 total programs, 10 are specialty mental health care-based and 8 allow either primary care or specialty mental health settings to implement health homes for Medicaid beneficiaries with SMI.9 Early research on waiver-established health homes suggest limited benefits. For example, Maryland’s waiver was associated with increased rates of cancer screening but had no effects on receipt of guideline-concordant cardiovascular care for participants with SMI.10,11
Same-day billing laws and requirements
The federal 21st Century Cures Act of 2016 clarified that federal law does not prohibit organizations or individual clinicians from billing Medicaid for both primary care service(s) and mental health service(s) delivered to a single patient on the same day. Prior to this clarification, the federal Medicaid statute was frequently interpreted as prohibiting same-day billing. Despite the clarification at the federal level, the same-day billing prohibition persists in many state laws.
In the most recent comprehensive assessment of state Medicaid laws that was conducted in 2015, 24 state Medicaid programs prohibited same-day billing by some or all settings and provider types.12 Since the clarification to federal law in 2016, some states have introduced and passed legislation to do away with the same-day billing prohibitions in state Medicaid laws. Medicaid is the largest payor of mental health services in the US, and same-day billing prohibitions have been cited as an important barrier to delivery of integrated care for people with SMI. No studies have assessed the effects of eliminating same-day billing requirements on care quality or health outcomes among people with SMI.
Federal and state policy gaps and next steps
To date, federal and state policies have focused on insurance billing for integrated care. However, new behavioral health integration billing codes have had low uptake and early research shows that the Medicaid health home waiver had limited effects on quality of physical health care for people with SMI. These findings suggest that the existing billing policies are insufficient to support adoption and high-fidelity implementation of the complex integrated care models that improved the physical health conditions driving premature mortality in SMI as shown in clinical trials.
There are many challenges to implementing integrated care for patients with SMI. One-sided financial incentives, lack of accountability, and carved-out financing of general medical and specialty mental health services are barriers to implementation. The behavioral health integration billing codes and most Medicaid health home waivers reimburse only one side of the general medical/specialty mental health duo. For example, the entire reimbursement for the collaborative care billing codes goes to the billing general medical provider, despite the central roles of the behavioral health care manager and psychiatric consultant on the care team.
Alternative financing arrangements, such as bundled payments or hub-and-spoke models, may alleviate this issue. Lack of accountability for physical health outcomes in SMI among either medical or mental health providers may impede care integration. Accountability could be improved through models tying payment to performance metrics, particularly models such as accountable care organizations, which can be structured so that both general medical and specialty mental health providers are subject to the same incentives.
Finally, carve-out of mental health insurance benefits so that such benefits are administered by a different organization than general medical benefits may obstruct delivery of integrated care. Carve-outs are particularly common in Medicaid, and many states are considering policies to integrate, or carve-in, mental health and general medical benefits. The effects of such policies on quality of care and health outcomes among people with SMI have not been rigorously studied.
In addition to these financing challenges, insufficient health information technology (IT) infrastructure and provider training have been identified as barriers to integrated care in multiple studies. Shared electronic medical records across general medical and specialty mental health care providers as well as electronic patient registries that track patients’ health indicators and needed/used services are core components of effective integrated care models but lacking in many settings. Policy models, such as the federal HITECH Act, could be used as the basis for new policies specifically focused on incentivizing health IT infrastructure for integrated care. Siloed primary care and specialty mental health training could be addressed through policies requiring incorporation in medical, nursing, and social work training curricula.
Critically, better integration of specialty mental health and general medical care for people with SMI is not enough to reduce premature mortality in the SMI patient population. Policies must also support delivery of effective health behavior interventions and address social determinants of health.
Obesity is a major driver of excess mortality in SMI, and tailored behavioral interventions have been shown to lead to clinically significant weight loss in this group. Financing strategies to support the weight management and group exercise sessions included in such interventions are needed. Medicare’s reimbursement strategies for its Diabetes Prevention Program sets a precedent for coverage of weight loss interventions that could be adapted.
Accreditation policies could be used to require health care or other types of organizations (eg, psychiatric rehabilitation programs) to have an on-staff trainer certified to deliver tailored behavioral weight loss interventions for SMI. Policies addressing the social determinants contributing to premature mortality from cardiovascular disease and other medical conditions in SMI are also needed. While some policies could be society-wide (eg, expansions of federal cash assistance or nutrition benefits policies) other policiess could target SMI specifically. For example, federal and state laws can allocate resources to evidence-based supportive housing and employment programs.
Dr McGinty is Associate Professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, and Associate Director, Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness; Dr Daumit is Professor, Division of General Internal Medicine, Johns Hopkins School of Medicine, and Director, Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness, Baltimore, MD. The authors report no conflicts of interest concerning the subject matter of this article.
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