In an ideal world, value and price would be closely aligned. This alignment doesn’t occur, however, when the value of a service or good isn’t understood. One only has to look at the huge disparity between the salaries of teachers compared with entertainers and sports figures to appreciate this incongruity; or between compensation in the financial-services industry and medicine. For too long, this has especially been the case for psychiatric services. Mental illness is a health care disparity, and mental health care has been stigmatized and undervalued, as have been the physicians who provide it. The result has been inappropriately low reimbursement rates for psychiatric treatment and a corresponding lack of access to mental health care for too many patients.
But now, thanks to the hard work and effective efforts of the volunteer members of APA’s Committee on RBRVS, Codes, and Reimbursement and APA staff, we have strong evidence this situation is changing. Last November, APA won a significant victory on behalf of psychiatrists from the Centers for Medicare and Medicaid Services (CMS), the institution responsible for setting reimbursement values for Medicare coverage.
This victory was possible because of the support psychiatry had from the AMA/Specialty Society’s Relative Value Update Committee (RUC). The RUC, an AMA-convened multispecialty committee of physicians and other professional health care providers that makes recommendations to CMS on the relative value of all medical services, voted to recommend an increase in the work values for all of the most commonly provided psychiatric services. This is the panel of physicians who make recommendations to CMS on the relative value of all medical services by CPT code, so the support of the RUC was a necessary first step. APA members are represented on the RUC by Dr. Ronald Burd, chair of the RBRVS, Codes, and Reimbursement Committee, and Allan Anderson, a member of the committee.
Their high bar for support required APA to present a strong and persuasive case, which was based on survey data gathered from practicing psychiatrists and other mental health professionals. APA’s RUC advisor, Dr. Jeremy Musher, worked tirelessly and collaborated with other mental health specialty advisors, members of the Committee on RBRVS, Codes, and Reimbursement, and APA’s Office of Healthcare Systems and Financing to craft recommendations to the RUC. Dr. Musher led the joint presentation, convincing the RUC that an increase in the values for most of the psychiatric codes was long overdue. In fact, it has been 15 years since psychiatric codes last received an increase in value.
APA’s next success was with CMS itself. CMS is not required to accept the RUC’s recommendations, and in today’s cost-cutting environment, often does so selectively. But in several years of discussion, face-to-face meetings, and letters, APA convincingly laid out our position that an increase in reimbursement rates for psychiatric services was justified. Thanks to these efforts and those of the RUC, CMS finally agreed, along with a growing number of other policymakers, that mental health services are vital and worth paying for.
So, what does this mean for our members? As the article on page 1 explains in greater detail, now that psychiatrists can code using the E/M code that actually reflects the level of medical work we do along with a more appropriately valued psychotherapy service, reimbursement from CMS will be higher than it was previously. In fact, starting this year, we estimate this will translate into $150 million in improved Medicare payments for mental health services each year.
This increase may also translate into better reimbursement by commercial insurers since many tie their covered services and rates to the Medicare fee schedule. While this is by no means guaranteed, it does give us a strong foundation for future efforts with nongovernment insurers, and APA will be aggressively pursuing these Medicare gains with other payers.
This hard-won victory would not have been possible without the extraordinary efforts of APA members who volunteer their time to work for our profession and the staff in APA’s Healthcare Systems and Financing Office. This effort was literally years in the making and represents the kind of tangible value the APA seeks to provide to its members. It also wouldn’t have been possible without you—our members—and your ongoing financial support through your membership dues. ■