Payors Train PCPs to Treat Mental Health in House

More than 80 published studies have shown that the collaborative care model (CoCM) lowers the cost of care and results in better patient outcomes. Yet the barriers for primary care clinics to adopt the model are steep and implementation has been slow.

Under the model, most patients with mild to moderate mental illness can be managed at their primary care provider’s office by a treatment team along with psychiatrists who provide weekly case consultations. Why is CoCM needed? A study of claims data for 21 million patients by Milliman illustrates the problem: Half of individuals with behavioral health disorders received almost no treatment—less than $68 a year of care—for those disorders. Clinician shortages, cost of treatment, and stigma are getting in the way of patients receiving the care they need.

Medicare made CoCM billing codes permanent as of 2018, and since then, with steady advocacy work by APA and its district branches, an increasing number of Medicaid programs—now in 18 states— also reimburse for care provided using the codes. More and more commercial payors have also begun doing so.

A Michigan-based health insurance plan helping primary care practices has found that it is helping patients reach remission from depression in a fraction of the time, and physicians love it. Psychiatric News interviewed physicians from two health insurance plans that have taken the reins to help primary care practices transition to CoCM by providing training, coaching, provider incentives, and access to CoCM vendors.

Michigan Payor Trains 800 PCPs

An internal analysis of Blue Cross Blue Shield of Michigan (BCBSMI) claims data showed that it was spending two to three times more on its members with behavioral health conditions, compared with those without such disorders. In its preferred provider organization (PPO) plans, patients with primary or secondary behavioral health diagnoses made up just 24% of its member population—yet they accounted for nearly half (49%) of spending.

BCBSMI had already begun reimbursing practices in its commercial markets for collaborative care claims, and about three years ago, it began helping primary care practices adopt CoCM, starting by providing training for the largest 41 clinics. The program has since grown to include 190 practices and 800 clinicians. The idea is simple: “Insurance companies are better able to take care of people with chronic illnesses such as heart disease, hypertension, and diabetes if their behavioral health needs are met. And their health improves,” explained William Beecroft, M.D., BCBSMI’s medical director of behavioral health. “It’s a win-win for everybody.”

Roughly 10% to 15% of patients visiting a participating PCP enroll in BCBSMI’s collaborative care program—often after being seen for other somatic concerns and screening positive for depression or anxiety, Beecroft said. “They hadn’t gotten care for their behavioral health needs before. The program is a way of getting patients the correct care, not just bringing them back and doing more tests.” Their PHQ-9 and GAD-7 scores are monitored regularly. “We’re actually doing what’s been encouraged in psychiatry for the last 20 years—to provide measurement-based interventions.”

The results have been impressive: Average time for participants to reach remission from depression, defined as reducing patients’ PHQ-9 scores below 5, is just 16 weeks, compared with 52 weeks for “treatment as usual,” Beecroft said. What’s more, the program is on track to yield a two to three times reduction in medical spending for enrolled patients by the end of its first three years.

Keys to Success for Michigan Plan

BCBSMI encourages PCPs—and other physicians—to transition to collaborative care with numerous incentives and rewards, many of which are performance based. For practices, it provides free two-day intensive training through its two training partners, the University of Michigan and the Michigan Clinical Quality Improvement Systems and compensates them for closing their practice to attend. It also provides ongoing support and training throughout the first year. Physicians and practices are encouraged to participate in CoCM with enhanced reimbursements.

Another key to BCBSMI’s success has been a survey that it developed to formally assess practice and physician readiness, Beecroft said. “They have to be truly committed. This is a substantial amount of effort for practices, and if they’re not ready to make the transformation, we don’t train them.”

In addition to making sure practices are paid sufficiently to profit from this work, Beecroft said sharing in the intangible rewards of collaborative care are just as important. So physicians receive reports on patients’ average PHQ-9 scores to see how much their patients are improving.

BCBSMI has worked through various snags. More than half of patients (55%) initially refused to continue in the program once they received the first bill for a coinsurance or copayment for collaborative care. Patients enrolled in the program often already have high medical bills due to chronic illnesses, and moreover, they aren’t always aware of the “invisible” care consultations with CoCM, Beecroft explained. So BCBSMI negotiated with its self-insured employers and did away with the separate bill that patients were receiving for the service. It has had “huge acceptance with patients since then,” Beecroft said.

Participants who do not show improvement after two to three treatment trials are given referrals to psychiatrists, and they are more likely to follow through with them than patients who were never treated in collaborative care, Beecroft added. Because of this program, patients who are not candidates for CoCM, including those with psychotic disorders or severe personality disorders, are able to get access to psychiatrists more quickly, he added.

Beecroft estimates that 30 of the 36 Blue plans across the country are now reimbursing physicians for collaborative care codes in their commercial markets. “Our customers—large national employers—are now asking us about [collaborative care] and want to know which networks are participating,” Beecroft said. Next up, the health plan will be helping pediatric practices launch CoCM.

Premera Helps Clinics Transform

Spurred by a significant shortage of mental health clinicians in its vast two-state territory of Washington and Alaska, Premera Blue Cross is investing $10 million for up to 30 rural primary care clinics to implement collaborative care. The AIMS Center at the University of Washington is providing the training, coaching, and oversight for the practices. (AIMS stands for Advancing Integrated Mental Health Solutions. The AIMS Center was founded by Jürgen Unützer, M.D., M.P.H., an internationally recognized psychiatrist and health services researcher who has spent the past 20 years developing innovative integrated care models.)

“It’s the right thing to do,” Susanne Quistgaard, M.D., medical director of Provider Customer Engagement at Premera Blue Cross, said of the grants. “We care about the communities we serve.” The AIMS Center will train up to 10 practices at a time, and the first group of PCPs began using CoCM in their practices about a year ago. They have enrolled more than 1,300 patients in treatment thus far.

The program has been well received, Quistgaard said. “I do think helping primary care offices transform with a grant like we’re providing is really important, especially for small rural clinics that don’t have the resources of large provider systems.”

Premera is now preparing to launch another pilot whereby it will contract with a vendor that will provide virtual collaborative care services to PCPs. The goal is to try to increase the uptake of CoCM by reducing required training and overhead for practices. ■