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The American Journal of Accountable Care December 2014
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A. Mark Fendrick, MD Co-editor-in-chief, The American Journal of Managed Care, Professor of Medicine and Health Management and Policy, Schools of Medicine and Public Health, University of Michigan, An
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Sustainable Lifelines: Supporting Integrated Behavioral Health Services for Children and Adolescents in the Accountable Care Era
Amy M. Kilbourne, PhD, MPH; Jane Spinner, MSW, MBA; Anne Kramer, LMSW; Paresh D. Patel, MD, PhD; Katherine L. Rosenblum, PhD; Richard Dopp, MD; Liwei L. Hua, MD, PhD; Maria Muzik, MD, MS; and Sheila M
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Thomas D. Doerr, MD; Herbert B. Olson, FSA; and Deborah C. Zimmerman, MD
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Melanie Applegate, MSN, FNP; Glen B. Taksler, PhD; Negin Hajizadeh, MD, MPH; Kate lyn Milavsky, BS; Catherine Ekeleme, MPH; Angela Fagerlin, PhD; Lauren Uhler, BA; and R. Scott Braithwaite, MD, MS, FA
For ACOs Large and Small, Sharing Ideas With an Open Mind
Mary K. Caffrey

Sustainable Lifelines: Supporting Integrated Behavioral Health Services for Children and Adolescents in the Accountable Care Era

Amy M. Kilbourne, PhD, MPH; Jane Spinner, MSW, MBA; Anne Kramer, LMSW; Paresh D. Patel, MD, PhD; Katherine L. Rosenblum, PhD; Richard Dopp, MD; Liwei L. Hua, MD, PhD; Maria Muzik, MD, MS; and Sheila M
A reimbursement strategy for collaborative care models is presented to enhance access to integrated behavioral healthcare for children and adolescents from underserved areas.
ABSTRACT
Objectives: Debundled payment mechanisms, such as those proposed to be used in the accountable care organization (ACO) structure, have the potential to promote integrated behavioral health and general medical care, notably by supporting services such as collaborative care that are not routinely available or covered under traditional fee-for-service. However, to date, bundled payment mechanisms have only been applied to adult populations. We present current efforts to develop a reimbursement model to provide behavioral healthcare for children and adolescents who are primarily seen in primary care settings with limited access to psychiatrists. The Michigan Child Collaborative Care (MC3) program has components similar to many other state-based initiatives that are designed to increase access to behavioral healthcare, notably through telepsychiatry, but adds components of the evidence-based Collaborative Care Model (CCM) to promote sustainability through enhancing the capacity of primary care physicians to provide behavioral health treatment on-site.

Despite increased demand, sustainability of MC3 is challenged due to the lack of reimbursement for CCM-related services, including phone-based consultation with primary care providers, outcomes assessment, and care coordination with families. We describe a potential strategy to financially sustain MC3 that builds upon existing fee-for-service reimbursement frameworks as well as emerging bundled payment mechanisms for integrated care, to ultimately improve access to behavioral health services for vulnerable children and youth in Michigan and across the United States.
One in 10 children and adolescents in the United States has a behavioral health condition (eg, anxiety, depressive disorder, attention-deficit disorder) but fewer than half receive effective treatment, 1-4 resulting in increased chances of morbidity and lifelong social dysfunction.5,6 Most children with behavioral health problems present to primary care first7,8 due both to perceived stigma associated with seeking help for mental illness and to a shortage of behavioral health professionals with pediatric or adolescent specialties. Increasingly, pediatric primary care physicians and providers (PCPs) are interested in improving behavioral healthcare for their patients,9,10 and in most cases mild and moderate forms of behavioral health problems can be diagnosed, treated, and monitored within primary care.11-13

However, PCPs in pediatric practices report gaps in training and knowledge in behavioral health, and they are less comfortable managing certain conditions such as depression.14 PCPs also may lack the resources and training to detect and address these conditions,15,16 and they often are unable to refer patients to behavioral health specialists in the community, especially where there is variation in insurance policy coverage17-22 and in access to local behavioral health providers. Even when trained behavioral health specialty care providers are involved in pediatric patients’ care, administrative barriers to sharing health information data hinder the ability of the PCP to monitor patients’ progress and treatment effectiveness. Hence, children with very complex behavioral health issues, especially in rural and underserved areas, are not receiving the treatment that they need, leaving them at risk for a lifetime of poor outcomes including incarceration, declining health, aggression and violence, suicide, or homicide.

One promising approach to improve access to behavioral health services in underserved communities is telepsychiatry. Telepsychiatry has been found to be effective at identifying psychopathology in youth through increased rapport between doctor and patient similar to that established in traditional face-to-face evaluations.23 Relatively inexpensive to deliver, telepsychiatry operates by connecting patients seen in primary care settings with a behavioral health specialist via video interfacing. Currently, a major national initiative—the National Network of Child Psychiatry Access Programs (www.nncpap.org)—is promoting the use of telepsychiatry for children and adolescents served in community-based primary care practices with limited access to behavioral health specialists. More than 30 states have initiated telepsychiatry through this initiative as of 2014, and it has been associated with improved access to care in at least 2 states where it was rigorously evaluated.24-26

Nonetheless, evidence suggests that telepsychiatry requires coordination of services beyond the video encounter in order to improve behavioral health outcomes.26-28 Moreover, additional effort is needed to set up and maintain the video interface between pediatric practices and behavioral health providers, provide additional treatment guidance to PCPs, and, for children in particular, provide further education of treatment options for parents and other family members.

Collaborative Care Models (CCMs) are evidence-based and provide care management, clinical decision support, and clinical information systems in a proactive manner that enhance physician encounters and patient activation. They have been widely used to integrate behavioral health services within primary care settings27 and have been shown to promote the use of telepsychiatry and subsequently improve behavioral health outcomes in adults.28 More recently, CCMs have been shown to improve child behavioral health outcomes in primary care settings.29 However, these additional CCM components, while vital for enhancing access to behavioral healthcare, are currently not reimbursable within the fee-for-service model used by most healthcare payers, or are inadequately reimbursed by Medicaid. While strategies have been proposed to reimburse CCM components to provide integrated behavioral health services in primary care for adult populations,30 to date no such reimbursement model exists for children with behavioral health problems. Moreover, emerging payment models under Accountable Care Organizations (ACOs), such as bundled payments for care management, have not been fully developed for providing integrated behavioral healthcare for adults or children.31

In the wake of healthcare reform and proliferation of shared savings programs that have the potential to provide bundled payment for CCM-related services,30 there is an urgent need to develop similar reimbursement models to support community-based providers who deliver needed behavioral health services for children. We describe the Michigan version of a telepsychiatry collaborative care program (Michigan Child Collaborative Care; MC3), as well as barriers to supporting MC3 and similar programs. Based on emerging payment models for adult populations, we propose a reimbursement mechanism for MC3 that is consistent with the principles of accountable care, which could potentially be applied to improve access and outcomes for children with behavioral health problems elsewhere.

MC3 is Michigan’s version of the Child Psychiatry Access Program, enhanced to include components of the CCM27,28 and to provide access to remote behavioral health specialty care for children, youth, and perinatal women seen in Michigan community-based primary care practices, particularly those from underserved urban and rural geographic settings. MC3 was initiated by a coalition of clinician investigators from the University of Michigan, community-based providers from regional community mental health (CMH) centers, as well as pediatricians, family medicine physicians, and other PCPs from private practices and federally qualified health centers from rural and urban underserved areas (eg, Detroit, Wayne County). The president of the Michigan Chapter of the American Academy of Pediatrics was also involved and served a statewide leadership and advocacy function in this project.

MC3 relies on technology available through the University of Michigan Comprehensive Depression Center, which permits telepsychiatric consultations from CMH centers and clinical care offices to University of Michigan child psychiatrists based in Ann Arbor. As of fall 2014, MC3 has been implemented in primary care clinics in 17 counties throughout Michigan which serve children and high-risk childbearing women with psychiatric symptoms; all are from rural or underserved urban counties who do not have access to psychiatrists. Expansion to an additional 16 counties is planned in the upcoming year.

MC3 provides coordinated services including telepsychiatry for patients across Michigan via a team of child and adolescent psychiatric providers (CAPs). The MC3 CAP team includes a child psychiatrist, a perinatal psychiatrist, and a developmental psychologist. Collaborative Care model components added during the start-up and maintenance of the telepsychiatry program including PCP consultation provided by the CAP team (decision support), care coordination (care management), and outcomes assessment (clinical information systems) (Table 1).

PCPs access the MC3 program by ordering a comprehensive evaluation through the CAP team, who then schedule a remote session (typically 50 to 90 minutes, depending on need) to see the patient and family members by video. The CAP team also provides treatment consultation by phone (not video) to PCPs so that they are able to make diagnosis and treatment decisions, particularly involving medications and referral decisions to CMH centers if necessary. Each telephone consult with a PCP can take about 15 minutes, which is more time-efficient than a traditional 90-minute psychiatric interview (with patient present). Hence, in most cases, the PCP determines the treatment plan and is the principal prescriber of psychotropic medications, with back up consultation from the psychiatrist.

As with other Collaborative Care Models,27,28 MC3 includes care management support primarily to help coordinate telepsychiatry encounters and additional services between patients, PCPs, the hub MC3 behavioral health team, and behavioral health providers at CMH centers (Table 1). In MC3, care managers are referred to as liaison coordinators; they are master’s-level behavioral health specialists with expertise in behavioral health symptoms and treatment options, and work out of CMH centers within the same county as the primary care practice. The liaison coordinators also play a vital role before and during the telepsychiatric consultation by obtaining necessary outcomes assessments; explaining the process to families and supporting them during their consultation; and serving as a referral and treatment engagement liaison after the initial telepsychiatry encounter (Table 1).

In collaboration with the State of Michigan Department of Community Health, the MC3 team operationalized intermediate and long-term measures of success (Table 1). These metrics corresponded to major healthcare reform initiatives, including the Medicare shared savings program,30 as well as to evidence suggesting that psychotropic mediations are overused in children.31 Key outcomes included appropriate prescribing of psychotropic agents in children (including use of generic vs brand name medications which are more costly)32 and reduced preventable emergency department (ED) visits or hospitalizations. The expectation is that MC3 will lead to greater cost efficiency through use of generic as opposed to brand name medications, as well as reduced preventable hospitalizations of ED visits, and limiting medication use when psychotherapeutic or behavior-based treatments are more appropriate. In addition, it is expected that greater access to outpatient behavioral healthcare will result in reduced ED visits or hospitalizations30; it is also expected to reduce other costly services such as incarceration and involvement of child protective services. MC3 is also tracking, over time, the knowledge and confidence PCPs have in treating behavioral health problems among children as the program continues. Challenges in Billing for MC3

 
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