Financial Viability and Sustainability of Integrated Care

Although we’ve learned a lot about how to deliver effective integrated care programs over the past decade, knowing how to fund them and keep them sustainable is less clear. In this month’s column, Andrew Carlo, MD, an emerging expert in this field, addresses this topic. —Jürgen Unützer, M.D., M.P.H.

For at least two decades, there have been efforts to integrate behavioral health care more seamlessly into primary care. The arguments for this have been multifold and have included growing provider shortages, pervasive stigma related to mental illness, increasingly “siloed” health care, and poor care coordination. A variety of models for care integration has been proposed and implemented throughout the country in military, general academic, specialty, and community settings. Some models, such as the Collaborative Care Model, have been repetitively validated in research studies conducted in diverse primary care and specialty care settings. However, successful implementation and maintenance of behavioral health integration have remained elusive tasks for some organizations, often due to a lack of clear pathways for sustainability. The concept of sustainability has inherent complexity and is influenced by numerous factors, none of which are more significant than financing and reimbursement.

Behavioral health integration faces unique challenges for billing and financial sustainability, particularly in fee-for-service environments. While co-located providers have not had major difficulties billing for face-to-face consultations or follow-up visits, they have generally not been reimbursed for their lunchtime question-and-answer sessions, curbside recommendations, electronic/chart review consultations, or efforts in training and supervising other primary care–based behavioral health professionals. In many cases, these less formal or quantifiable features of integrated care programs are integral—providers work together to care for patients, share elements of their specialty “cultures,” and learn from one another throughout the process. Some models of integrated care do not involve licensed professionals providing billable face-to-face services; examples include virtual care of various types and models in which primary care staff (that is, medical assistants) are part of an integrated behavioral health care team. Such practices lead to formidable billing challenges with payers that stipulate, among other things, face-to-face interaction between the patient and a licensed health care provider.

For these and other reasons, integration efforts have historically been financed through alternate payment models, such as case rates (bundled payments) and time-specified (often per annum) block grants. Some organizations have also received federal, state, or other organizational grants to implement integrated behavioral health care programs, but such grants are often time limited and can be unreliable over time as funding priorities and environments change. In recent years, a growing number of Medicaid and commercial insurance payers have begun to initiate fee-for-service reimbursement for behavioral health integration services in an effort to incentivize implementation and sustainability. Medicare notably released G-codes for collaborative care and other integrated care models in early 2017. According to recent documentation from the Centers for Medicare and Medicaid Services and other sources, these codes became CPT codes at the start of this year, and an increasing number of commercial payers are expected to provide reimbursement. Unfortunately, as is often expected with the uptake of new billing codes, implementing these new codes for care integration has had its challenges.

Depending on the specific payer, billing stipulations can make it challenging for health systems to use a new fee-for-service code, even if they have experience furnishing the associated service. In the case of collaborative care, for example, clinics and providers must be able to demonstrate through documentation that all the core components of this evidence-based practice have been performed, including care management; use of a registry to facilitate measurement-based care; and regular, systematic case review/consultation with a psychiatric provider. They must also be able to keep an accurate inventory of the amount of time that care managers and other team members spend on each patient. The associated documentation requirements can involve substantial workflow, staffing, and electronic medical record changes, all of which can be roadblocks, especially for systems with limited financial resources. For Medicare beneficiaries, additional barriers include the requirements of charging a 20 percent copayment and specifically documenting verbal consent for integrated behavioral health services in primary care.

While robust evidence now supports the effectiveness as well as cost-effectiveness of integrated care programs such as collaborative care, the financial viability and sustainability of these services are less clear. Newly available fee-for-service billing codes have both promise and limitations that remain incompletely understood; additional research and expertise in the financing of integrated behavioral health care are needed to implement and scale up these evidence-based programs in diverse primary care settings. ■