Lisa Eramo, MA, is a contributing author for Medical Economics.
Physicians understand the connection between mental and physical health, yet many don’t feel equipped to address patients’ behavioral health problems.
Physicians understand the connection between mental and physical health, yet many don’t feel equipped to address patients’ behavioral health problems. They also don’t have the time, says Bonnie T. Jortberg, Ph.D., RD, associate professor of the department of family medicine at the University of Colorado School of Medicine. “Severe depression and anxiety isn’t something you can address effectively during a 15-minute visit,” she adds.
Yet talking about behavioral health is critical-particularly when physicians are increasingly held accountable for patient outcomes under value-based care models. For example, screening for depression, evaluating risk of opioid misuse, and screening for unhealthy alcohol use-all of which are billable-can help physicians increase reimbursement under the Merit-based Incentive Payment System.
Providing behavioral health-related services can also help providers hit quality benchmarks, bill for new and/or higher-level services, and even address social determinants of health such as food insecurity, housing instability, and health literacy.
Behavioral health integration care management, another billable service that focuses on care coordination between a care manager and behavioral health specialist, pays approximately $49 for 20 minutes of services each calendar month.
Aside from the revenue implications, incorporating behavioral health into a primary care practice also can help patients achieve better outcomes-both physical and mental.
“This isn’t just about someone’s mood-it’s about addressing physiologic problems that affect patients’ health,” says Allen Y. Tien, MD, MHS, president and chief science officer at mdlogix, a software company that develops cloud-based solutions to help practices streamline behavioral health screening, care coordination, and outcomes reporting.
In some cases, a mental health problem is the root cause of the physical ailment, says Tien. Depression fueling diabetes is one example. If physicians don’t treat the depression, they likely won’t improve the diabetes, he adds.
Creating a one-stop shop for addressing patients’ needs
Experts agree that embedding a behavioral health specialist in the practice can potentially boost revenue and take pressure off physicians by serving as a resource for patients. Doing so makes sense because primary care physicians already have a rapport with patients, making it more likely that patients will follow through with behavioral health referrals, says Coley Bennett, CMM, CHA, practice manager at A Plus Medical, P.C., an independent primary care practice in Tacoma Park, Md.
Earlier this year, A Plus Medical hired a certified registered nurse practitioner to focus on billable mental health services such as smoking cessation counseling and intensive behavioral therapy. As in many communities, there’s a growing need for these services because many providers don’t accept Medicaid, and there aren’t enough outpatient mental health centers to accommodate timely appointments.
In addition, Takoma Park is a culturally diverse city with many undocumented immigrants. Trust plays a large role in whether patients ultimately decide to seek any kind of treatment and particularly behavioral health services for which there continues to be a stigma, says Bennett. Once they find a provider they trust, they tend to want to stay within the practice for as many services as possible, she adds.
Last year, Matthews-Vu Medical Group, a multi-specialty group in Colorado Springs, Colo. integrated an adult psychiatrist, a pediatric psychiatrist, and five licensed clinical social workers (LCSWs)after physicians had difficulty finding providers who would accept Medicaid patients, says Debbie Chandler, MBA, CMPE, chief executive officer at the practice. Even with these providers, Chandler says, there’s frequently a waiting list for patients requesting services.
Despite the benefits of behavioral health integration, experts agree that hiring a specialist requires a financial risk that isn’t easy for small independent practices to take.
“The model that typically works best is the primary care physician employs an LCSW or team of LCSWs that internally handle the majority of behavioral health care and then contracts with a psychiatric consultant for services that require advanced expertise,” says Toni M. Elhoms, CCS, CPC, consultant at Alpha Coding Experts LLC in Orlando, Fla. “LCSWs are a lot more affordable than psychologists and psychiatrists.”
According to Payscale.com, the average national salary for an LCSW is approximately $57,000, whereas a psychologist earns about $76,000, and a psychiatrist earns approximately $202,000. Local and regional salaries may vary.
Physicians need to determine what services the behavioral health specialist will perform and whether revenue from those services will pay for that provider’s salary, says Chandler.
For example, if physicians don’t routinely screen for anxiety and depression, these should be among the most common services the behavioral health professional renders, says Tien. Many of these screenings can be completed electronically on a tablet while patients wait to see the physician in a fraction of the time it takes administer them face-to-face, he adds.
However, specialists can also focus on more intensive therapies (e.g., for obesity) and generally spend more time with patients discussing advanced care planning, smoking cessation, and other mental health concerns.
A behavioral health specialist can also perform and bill for general behavioral health integration care management for patients with a behavioral health condition (including substance abuse) who require at least 20 minutes of face-to-face or non-face-to face services each calendar month, says Elhoms. This service is appropriate for patients who require ongoing care coordination similar to chronic care management, though the documentation requirements are not nearly as onerous, she adds.
Behavioral health specialists can also bill for this service during the same calendar month as the patient receives chronic care management, creating more revenue for the practice while helping patients with chronic conditions obtain the added layer of behavioral health services when needed, she says.
Another consideration is how much additional revenue the primary care physician can generate as a result of increased productivity. For example, a planned 10-minute visit could easily become a 45-minute encounter when a physician tries to manage the patient’s anxiety or depression.
By saving 35 minutes, physicians could potentially see an additional three patients. The SAMHSA-HRSA Center for Integrated Health Solutions has published a guide, The Business Case for Behavioral Health Care, that can help physicians calculate a more specific return on investment.
If employing a full-time specialist isn’t realistic, another option is to hire one on a contractual basis with a financial split. The CRNP at A Plus Medical, for example, is a contractor who receives a percentage of each fee-for-service amount billed.
Under this model, there’s less financial risk for the practice because the specialist is paid based only on the revenue she generates, says Bennett.
However, “Bringing the behavioral health specialist on as an employee changes the financial game,” she adds. “It means their schedule must be full, and you’re also going to need to actively market those behavioral health services as if you’re building a business from the ground up.”
If neither of these are feasible, practices could consider co-locating a behavioral health specialist in the practice, says Chandler. The primary care physician could refer patients to the specialist, who rents space within the office-but there are no financial ties or formal care coordination.
This arrangement gives physicians an option when behavioral health issues arise, but it doesn’t offer the full suite of benefits that comes with truly integrated care, including the ability to bill for their services, she adds.
Consider these six tips to ensure a successful integration of behavioral health and primary care:
1. Use a “warm handoff.”
At A Plus Medical, for example, patients complete relevant screenings, then, depending on the results, there’s a “warm handoff” between the physician and CRNP. During these handoffs, Bennett says, physicians tell patients they reviewed the screening and feel the patient could benefit from talking with someone else in the practice to get the help they need. Then they introduce the patient to the CRNP, who schedules the patient to come back for an appointment.
Matthews-Vu follows a similar workflow; however, it also has a process in place for crisis management. If a patient presents in crisis, or a crisis develops during a medical appointment, a behavioral health specialist is always available to speak with that individual.
Practices may want to consider using a daily huddle to identify patients who might benefit from behavioral health services, says Jortberg. For example, have any patients been on depression medication long-term? Do any patients have a history of substance abuse? Flag these patients in the EHR for a warm handoff to the specialist for a brief check-in after meeting with the physician, she adds.
2. Hire a behavioral health specialist with diverse experience.
Depression and anxiety are common; however, behavioral health providers may have varying degrees of experience with trauma, post-traumatic stress disorder, eating disorders, substance abuse, post-partum depression, and pain management, says Chandler. Identify specific needs within the population, and hire someone who can address those needs, she adds.
3. Develop a plan to address coding, billing challenges.
Practices may need more specialized administrative support when hiring a behavioral health specialist, says Chandler. Matthews-Vu, for example, hired a certified medical coder with behavioral health experience to address coding and billing challenges.
Alternatively, a practice could pay for existing staff to obtain training in this field. A Plus Medical trained staff on how to obtain prior authorizations for initial assessments and subsequent visits, though Bennett says there are ongoing challenges. For example, some payers will approve psychotherapy for depression but not for anxiety.
4. Make sure your EHR vendor can accommodate documentation requirements.
The SOAP note works well for primary care; however, behavioral health providers must also perform a mental status examination that should be included in an EHR template, says Bennett. To provide effective care, these providers also need access to comprehensive assessment tools that go beyond the standard Patient Health Questionnaire (PQH)-2 and PQH-9, she adds.
5. Invest in an e-prescribing module.
A module that integrates the state’s Prescription Drug Monitoring Program (PDPM) database into the EHR streamlines the process of prescribing controlled substances, says Bennett. In Maryland, providers prescribing these medications are required to check the state’s PDPM before prescribing because many mental health drugs are controlled substances. Forty-one states have this type of mandate, though the specific requirements vary.
6. Require the specialist to sign a business associate agreement (BAA).
This only applies if the practice intends to provide access to protected health information without employing the behavioral health specialist directly, says Tien.