Using Payment Policies to Support Primary Care – Behavioral Health Integration in Medicaid

Many states are developing and implementing strategies for integrating behavioral health with primary care. Integrated care improves patients’ access to behavioral health services, attendance at scheduled appointments, satisfaction with care, and adherence to treatment. Minority populations in particular are more likely to seek mental health treatment from primary care practitioners than from mental health specialists. Medicaid payment policies, including reimbursement for behavioral health screenings, management, and referrals in primary care settings, can facilitate this integration.

States are pursuing behavioral health and primary care integration in a variety of ways, including:

  • Providing mental health and substance abuse screenings at primary care visits and providing prompt referrals to treatment as needed. For example, as of 2010, 14 states allow reimbursement for Screening, Brief Intervention, and Referral to Treatment (SBIRT), an approach where primary care staff assess patients’ substance use risk and refer to appropriate treatment.
  • Providing integrated behavioral health (either mental health services, substance abuse treatment services, or both) and primary care services at one clinic site, allowing patients to see multiple providers during the same visit. Co-location also facilitates ‘warm handoffs’ – in-person introductions between referring providers – which have been shown to improve patient attendance at follow-up appointments.*

Missouri’s two Health Home initiatives focus on behavioral health and primary care integration. Several different payment strategies support providers in delivering integrated services in the health homes:

  • Behavioral health screenings are currently included in the monthly care management fee for primary care practices serving as health homes.
  • Missouri is developing fee-for-service payments for screening and assessment of mental health and substance abuse needs, and for brief behavioral health interventions in primary care settings.
  • Individual physicians or psychiatrists are allowed to bill for more intensive evaluation and management procedure codes if they deliver behavioral health services during the same visit as primary care services.

Dr. Joe Parks, director of the MO HealthNet Division (the state’s Medicaid agency), says that these payment strategies are important tools to support behavioral health integration. “Payment methodologies should be designed to support the delivery system transformations needed to improve access to and quality of care. Payment methodologies should be seen by payers as tools to shape and guide the delivery of care and not as technical constraints that care must adapt itself to accommodate,” Parks said.

There is increased federal attention to expanding safety net providers’ capacity to provide primary care and behavioral health services to patients in a single location, as evidenced by new HRSA funding that will support 221 health centers to improve and expand their behavioral health services. According to a survey conducted by the National Association of Community Health Centers (NACHC), 24 state Medicaid programs allowed federally qualified health centers to bill for multiple visits in the same day, allowing a patient to receive medical services and some combination of same day behavioral health, dental, or other services in 2011. The SAMHSA-HRSA Center for Integrated Health Solutions’ most recent billing and financial worksheets outline opportunities in all 50 states, including when two services in one day are billable at a Federally Qualified Health Center (FQHC). In Michigan, the Medicaid agency and Michigan Primary Care Association (MPCA) worked together to develop a policy allowing reimbursement for both primary care and behavioral health encounters on the same day. Rebecca Cienki, MPCA Chief Operating Officer said that this policy has been important in helping health centers provide integrated care, and that there might be further opportunities to use reimbursement as a lever for integration, particularly in relation to payment for substance abuse services.

States may want to review their Medicaid payment policies – including in relation to billing for multiple services provided on the same day – to see how they might remove barriers and facilitate behavioral health integration. Medicare has recently revisited this issue with respect to Part B and re-affirmed the ability of providers to bill for multiple services provided on the same day. Medicare’s new Prospective Payment System for FQHCs (effective October 2014) also establishes a method for health centers to bill separately for physical and mental health services that occur on the same day.

If you would like to learn more, the SAMSHA-HRSA Center for Integrated Health Solutions provides a variety of resources on payment policies to support integration, and NASHP’s website includes many useful resources for states on behavioral health integration.

*A 2000 study in a family medicine practice with co-located behavioral health providers found 76% of that patients attended their first visit with a behavioral health provider when scheduled after an introduction by their primary care physician as compared to 44% attendance when appointment was scheduled without introduction.

This work was made possible by the Health Resources and Services Administration (HRSA grant number UD3OA22891).

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