1 Boring Old Man

APA Urges Creation of Payment Codes Specific to Collaborative Care Model

PsychiatricNews

by Mark Moran

September 24, 2015

Separate codes should be created for the care-management and psychiatric-consultation components of the collaborative care model. Appropriate payment codes need to be developed to reflect the work of physicians — including psychiatrists — participating in collaborative care models treating patients with mental illness in primary care settings, said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a letter last month to the federal Centers for Medicare and Medicaid Services.

The 18-page letter was in response to CMS’s Proposed Rule for Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016. The letter addresses a range of issues raised in the proposed rule — including improving payment accuracy for primary care and care management services, chronic care management and transitional care management services, the Physician Quality Reporting System, electronic health records, and the Medicare Access and CHIP Reauthorization Act. But the bulk of APA’s comments in Levin’s letter focused on payment and coding issues around reimbursement for the collaborative care model [CoCM]. The model, developed by leaders in integrated care at the University of Washington, involves a primary care physician, a care manager, and a psychiatric consultant.

“The lack of reimbursement for key components of this model has been the principal barrier to its widespread implementation,” Levin stated. “Although there may be other treatment models that engage primary care clinicians and behavioral health specialists, the specific Collaborative Care Model [referenced in the proposed rule] is the only model that has compelling scientific data supporting its effectiveness. Over 80 randomized, controlled trials have shown the CoCM to be more effective than care as usual. … In addition to the robust research evidence for the value of collaborative care, there is also substantial practice experience with this model of care from the Medicaid-funded Mental Health Integration Program in Washington State, the commercially funded DIAMOND program in Minnesota, and similar programs in several other states.”

The letter continued, “[T]he development of codes and requirements to be used for collaborative care for behavioral health conditions must be specific to the CoCM to enable its clinical approach and processes. To create codes that would facilitate any or all of the clinical roles or transactions embedded in the model [such as co-location of a care manager and screening mechanisms] without being tied to the other elements of the model [such as measurement-based care maintained in a registry with psychiatrist oversight] will not realize the substantiated results of the model’s utilization: that is, better quality patient care and outcomes and cost efficiencies”…

^{[click image for description]}

It remains hard for me imagine that anyone takes Collaborative Care as it is being presented seriously or would willingly participate. It begins [top version] with a Primary Care Provider who sees the patient and "Makes initial diagnosis and prescribes medication." So right out of the gate, the model is based on the premise that a symptomatic diagnosis of mental illness should lead to a medication prescription. The patient then gives symptom updates  to the Primary Care Provider and the Case Manager. At some point, the Case Manager discusses the patient’s progress with the Psychiatrist, and the Psychiatrist makes treatment [medications] recommendations. In the second version, there are provisions for the Psychiatrist or other Behavioral Health Clinicians to have infrequent interactions with the patient.

We’re further down that yellow brick road than we used to be.  We know that none of the current psychiatric drugs are benign and that their efficacy is nowhere near what has been widely advertised. We also know that these medications are grossly over-prescribed and many, if not all, can have a withdrawal syndrome that can be problematic. The majority of people who come to a clinic complaining of psychiatric symptoms have some problem in their life, and could benefit from a talk with someone who understands people [I work in such a clinic, and I’m impressed that one can get a lot done even with short and infrequent visits].

• keep the Primary Care Provider from using the medications as badly as they are currently being used
• certify that the patient is receiving psychiatric care