Collaborative Care Should Be Supported in Public Plans, Says APA

APA is supporting adoption of the collaborative care model (CoCM) of integrated care as a federal policy option for meeting the needs of individuals with chronic illness.

In a January 26 letter to Sen. Orrin Hatch (R-Utah), chair of the Senate Finance Committee, and Sen. Ron Wyden (D-Ore.), ranking member of the committee, APA CEO and Medical Director Saul Levin, M.D., M.P.A., urged the committee to take the following actions: to support plans by the Centers for Medicare and Medicaid Services (CMS) to reimburse for care delivered under a CoCM; create and support mechanisms through which practices can receive technical and other assistance needed to modify their operations to implement the model; designate the CoCM as a qualifying Alternative Payment Model under the Medicare Access and CHIP Reauthorization Act (MACRA); and consider policies to promote adoption of the CoCM for individuals who are eligible for both Medicare and Medicaid.

The Finance Committee has jurisdiction over policies related to payment for Medicare and Medicaid services. In December, the committee’s Bipartisan Chronic Care Working Group released an outline of options for improving and streamlining chronic care, titled the “Policy Options Document.”

In response to that document, Levin explained in his letter that the CoCM, a specific model of integrating general and mental health care, employs a team-based approach that includes care coordination and care management; regular, proactive outcome monitoring and “treatment to target” using validated clinical rating scales/standardized outcome measures; and regular, systematic psychiatric caseload reviews and consultation for patients who do not show clinical improvement. The model was developed by the AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington.

“Over 80 randomized, controlled trials (RCT) have shown the CoCM to be more effective than care as usual,” Levin wrote. “As a result, the CoCM has been recognized as an evidence-based best practice by a wide array of authorities, including CMS, the Substance Abuse and Mental Health Services Administration (SAMHSA), the surgeon general, the National Business Group on Health, and the Agency for Healthcare Research and Quality. In addition to the robust research evidence for the value of collaborative care, there is also substantial practice experience with this model 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.”

But Levin noted that the lack of reimbursement for components of this model is the main barrier to widespread implementation. “CMS, as part of its 2016 physician fee schedule rulemaking, initiated discussion of adopting and valuing codes to reimburse for the components of the CoCM,” he wrote. “Based on all the RCTs [randomized, controlled trials] and large-scale practice experience that has included all major payer types (Medicare, Medicaid, and commercial insurance), we believe there is no need to further study variations in payment methodology or in establishing payment amounts for the CoCM. Extensive research and practice experience with the CoCM exists to enable the development of specific codes and the appropriate valuation of these codes, and therefore we are strongly encouraging CMS to proceed in establishing payment for the evidence-based CoCM without additional demonstrations.”

Additionally, Levin urged the Finance Committee to support reimbursement for telemedicine services across all of Medicare (including in accountable care organizations and Medicare Advantage Plans) and lifting the telemedicine “originating site” requirement across the entire Medicare program. That requirement demands that patients receiving telemedicine services be in a medical facility in a region designated as a medical professional shortage area.

“The concept of an ‘originating site’ is an outmoded idea and contrary to current standard of care,” Levin wrote. “Telemedicine use in psychiatry increases access to services with positive clinical outcomes regardless of specific originating site. Medicare Advantage reimbursement for telemedicine services would be welcome as well. To ensure accurate reimbursement for actual rendered services, there should be an emphasis on physicians integrating the telemedicine technology into their tracking of delivered services and associated charges.” ■