Payment for Important Work Gets Approved

More than two decades ago, in April 1995, Wayne Katon, M.D., and colleagues at the University of Washington and Group Health Cooperative of Puget Sound published the results from the first randomized, controlled trial (RCT) of collaborative care in the JAMA. Their work showed that this new model of care in which psychiatric consultants work closely with primary care providers to treat depression nearly doubled the likelihood that patients would improve compared with usual primary care.

By 2008, dozens of RCTs had replicated this original finding in different settings, with different patient populations, and with different psychiatric disorders. A meta-analysis concluded we no longer needed additional studies—it was time to move the model into practice.

But practice is slow to change. With the exception of a few pioneering, capitated health care organizations such as Kaiser Permanente, Intermountain Health Care, the U.S. military, and the Veterans Administration, the lack of a reimbursement mechanism under traditional fee-for-service payment systems has been a major barrier to the widespread adoption of collaborative care. Psychiatrists have attended presentations and courses about collaborative care and returned to their practices wondering how they could get paid for doing this important work.

All this is about to change. Earlier this year, the AMA approved a set of Current Procedural Terminology (CPT) codes that allow primary care practices to bill for collaborative care. These codes cover the work of mental health care managers in primary care clinics and the important contributions of consulting psychiatrists to such collaborative care teams.

In addition, the Centers for Medicare and Medicaid Services (CMS) recently announced that Medicare plans to begin coverage and reimbursement for “specific behavioral health services furnished using the Collaborative Care Model, which has demonstrated benefits in a variety of settings” as part of its Medicare Physician Fee Schedule rule starting in 2017. These monumental steps should increase access to evidence-based mental health care that has been proven to increase patient and provider satisfaction, improve health outcomes, and reduce overall health care costs, achieving the “Triple Aim” of health care reform.

But CMS is going well beyond simply paying for mental health care. It is shifting the focus from traditional fee-for-service payment to “value-based purchasing,” creating financial incentives for providers to improve both the quality and the outcomes of care (see the “Changing Practice/Changing Payment” series in Psychiatric News. Earlier this year, Sylvia Burwell, the secretary of Health and Human Services, announced that within a few years, more than half of health care paid for by CMS will be in “alternative payment mechanisms” that focus on quality, outcomes, and overall value.

In psychiatry and in mental health more broadly, we have lagged behind our medical colleagues in our capacity to measure the quality and outcomes of our work. A recent issue brief from the Kennedy Forum (“A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services”) summarized the tremendous potential to advance mental health care by using simple patient-reported outcome measures to track the care we provide. A number of mental health quality and outcome measures have been proposed and implemented by a wide range of health care organizations and payers. As an example, the National Committee for Quality Assurance (NCQA) recently adopted new depression measures in their 2016 Healthcare Effectiveness Data Set (HEDIS) for the accreditation of Health Plans, including two measures of depression treatment response and remission that are becoming widely used in accountable care contracts and other value-based purchasing arrangements.

With new CPT codes and CMS payments for collaborative care and a national movement toward measurement-based practice, this is an excellent time for psychiatrists to learn the skills needed to support a successful collaborative care practice. Over the past year, APA has made a substantial commitment to helping its members learn these skills. With help from a $3 million Transforming Clinical Practice Initiative grant from CMS, APA is offering free training in evidence-based collaborative care to psychiatrists through online training modules and in-person training at APA’s IPS: The Mental Health Services Conference, Annual Meeting, and district branch meetings.

I am deeply appreciative of our colleagues around the country and leaders in such organizations as CMS and the NCQA for taking important steps to make effective collaborative care available to more Americans. I only wish that Dr. Katon, who led the early research establishing the effectiveness of collaborative care and who mentored many young psychiatrists along the way, was with us to celebrate these achievements. A visionary who was well ahead of his time, he saw more than two decades ago that an effective partnership with our colleagues in primary care was a powerful way, perhaps the only way, for us psychiatrists to reach all those in need of effective mental health care. ■