INTRODUCTION

One in four Americans suffer from mental disorders, and of those the majority also suffer from a co-occurring general medical condition, leading to substantial health care costs, impaired functioning, and premature mortality.1 Despite the social and economic burden experienced by people with mental disorders, only a fraction receive adequate care.2 The majority of persons with mental disorders never get to the mental health sector for treatment.2 Given that most persons with mental disorders present to primary care first,3 integrating mental health services into primary care is paramount.

The Chronic Care Model (CCM)4,5 is a particular type of integrated care model that has been shown to improve outcomes for persons with mental disorders,6,7 at little to no net healthcare cost.6 The CCM is ideally implemented with a co-located care manager (i.e., nurse or clinical social worker) within the primary care clinic.7,8 The care manager provides counseling to patients on self-management, monitors outcomes, and consults with a mental health specialist (i.e., psychiatrist) for more complex cases. The mental health specialist is either co-located in the primary care clinic or is located off-site, with a contractual arrangement to provide consultation.7,8 The CCM is also considered the cornerstone of healthcare reform, as an operational framework for the patient-centered medical home under accountable care organizations, which seek to reward providers on improved quality and care coordination.5,9

However, the CCM for mental disorders has not been widely implemented in routine practice,10,11 primarily because of the separation of physical and mental health services, and a lack of a reimbursement strategy. Current reimbursement codes for CCM components do not adequately compensate providers, and may not be known to providers in the first place.12,13 As a result, persons with mental disorders face the additional burden of having to go elsewhere for their mental health care, leading to duplication of services, increased costs, and overall poor outcomes.

To ultimately sustain the CCM, providers will need an effective reimbursement model for CCM components. Realistically, the reimbursement model should start with available fee-for-service codes, but should also be aligned with emerging health care reform initiatives, so that primary care providers can effectively negotiate with healthcare organizations to cover CCM costs. The goal of this paper is to provide a critical analysis of challenges in reimbursing CCM components in primary care settings under the current fee-for-service system, and discuss opportunities for developing a sustainable reimbursement model under current and evolving healthcare reform initiatives.

LIMITATIONS OF CURRENT REIMBURSEMENT STRATEGIES FOR CCM COMPONENTS

The fee-for-service (FFS) model is the predominant provider payment system for individuals with mental disorders.13 Table 1 provides examples of billing codes14–17,19–23 under the current FFS system that could potentially be used to reimburse CCM components; notably, self-management, care management, and measurement-based care. However, current FFS codes are inadequate for reimbursing providers for the integration of guideline-based behavioral health specialist consultation, a core CCM component. Moreover, there have been no studies in which standard FFS billing practices using current payment rules lead to financial solvency of the CCM, without making the behavioral health benefit part of the general medical benefit.18

Table 1 Billing Codes Under Current Fee-For-Service for Integrated Mental Health Care Using the Chronic Care Model
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Current FFS billing practices are also limited because of separate public and private payers and inconsistent rules regarding who can bill for what service. This artificial separation of “physical” and “mental” health care, mainly through mental health carve-outs and carve-ins, prevents primary care practitioners from billing for mental health services. Location of services and insurance type also impact reimbursement. In some states, health behavior and assessment intervention codes are reimbursable at Federally Qualified Health Centers by commercial insurance and Medicare, but not by Medicaid.17,19 Many public payers will not accept a physical and mental health billing code on the same day, impeding integrated care. Moreover, prior studies of the CCM for depression treatment in primary care settings used nurses or social workers as care managers, yet these professionals may not be able to use FFS billing codes for CCM components. There is great variability in what different payers (including states and health plans) will reimburse, how much they will reimburse, and the documentation and certification/licensure required. Even if billing codes are allowable, some payers may not have “activated” them, often out of fear that the new services will increase costs without sufficient offsets.18

Under FFS, start-up costs for establishing and maintaining key CCM components are not reimbursed, including registry development, outcomes assessment tools, and contractual arrangements with mental health specialists.20 Many primary care clinics are operating on slim margins, and would have to spend additional time and resources to implement these components. Mental health specialists would also have to agree to block consultation time in their schedules to assist primary care providers with more complex patients. Ultimately, any long-term savings achieved through these system changes tend to go to insurance companies, but not to the medical practices.

Finally, even with available FFS codes, CCM components are difficult to implement in smaller practices.24 The majority (98 %) of privately insured persons with mood disorders received care from solo or small group primary care practices.25 Even if these providers could bill for CCM components, they may not have adequate staffing to redesign their practice to incorporate essential CCM components.

EMERGING CCM REIMBURSEMENT STRATEGIES: DIAMOND

In response to these challenges, DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction)26 was initiated in 2008 with the goal of developing a bundled payment model to support the CCM for depression treatment in Minnesota. DIAMOND is based on a collaboration of commercial health plans, the Minnesota Department of Human Services, and medical providers within the state. Together these organizations agreed that improving depression care was a priority and that the current FFS reimbursement system was inadequate for primary care practices to support depression care management. A quality improvement organization in Minnesota, the Institute for Clinical Systems Improvement (ICSI), brokered an agreement to implement the CCM based on a common set of shared goals and outcomes (e.g., PHQ-9 for depression).

Under DIAMOND, primary care providers implemented the CCM for depression with the incentive of receiving a negotiated monthly bundled payment from the six major insurance companies in the state for every patient needing depression care. The bundled payment was designed to include reimbursement for costs for care managers’ salaries/benefits, as well as supervision time from a psychiatrist. While the primary care practices involved could not discuss the amount of reimbursement they negotiated with each insurance company due to anti-trust regulations, ICSI assessed CCM maintenance and startup costs for each practice and provided an average of these costs to the practices that could be used in their negotiations with the insurance company. The availability of this bundled payment mechanism was enough for many diverse practices to accept the burden of CCM startup costs (e.g., hiring care managers, registry development), due to the promise of at least breaking even if they recruited enough patients. The state also agreed to measure outcomes for depression centrally on a publically viewed website. As of the date of this publication, these insurance companies have continued bundled payments to support the CCM, and practices are exploring ways of expanding the program to other mental health diagnoses as well as for patients with complex chronic illnesses.

LESSONS LEARNED FROM DIAMOND

Overall, DIAMOND’s implementation of the depression CCM would not have been possible without the involvement of a third party (ICSI) to effectively negotiate relationships and the bundled payment mechanisms. In addition, three key lessons were learned that can inform future implementation of CCM reimbursement and sustainability strategies (Table 2).27

Table 2 Reimbursement Strategies Under Emerging Payment Structures to Promote Integrated Mental Health Care Using the Chronic Care Model
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First, participants realized that there needed to be a frank discussion of how the program benefitted multiple stakeholders. Developing the bundled payment model required a ‘what’s in it for me’ analysis from all members of the healthcare interaction (Table 3). DIAMOND had a steering committee that included patients, providers, insurance companies, and state representatives, who agreed on key benchmarks to measuring program success. The reimbursement plan was negotiated with an eye towards what was possible for insurance companies, and what was most likely feasible for practices to take the risk of redesign.

Table 3 Summary of Stakeholder Interests and DIAMOND Responses
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Second, results from DIAMOND needed to be disseminated early on in order to sustain stakeholder engagement. As a quality improvement project rather than a formal randomized study, the success or failure of DIAMOND depended on early publication of outcomes on their website, without the peer-review process.28 Initial results showed better outcomes at clinics where DIAMOND models were integrated into practice, and kept the health plans and providers enthusiastic and engaged in the initiative.

Third, the CCM needed to show a return on investment beyond clinical outcomes, notably employee productivity. Employers contracting with the health plans involved in the initiative needed to see how the program impacted their bottom line (employee productivity and costs). Hence, ICSI published a white paper highlighting the impact of the CCM on increased work productivity.28 In response to the white paper, a subsequent study was conducted showing that even mild depression was associated with significant productivity loss (including absences and impaired functioning at work), thus making a stronger business case for depression treatment among employers.29

In addition, there were also unexpected findings based on the initial implementation of DIAMOND. In contrast to chronic medical illnesses such as diabetes, the introduction of a care coordination plan for depression was not as natural for many primary care clinics. Despite wide dissemination of depression practice guidelines, primary care providers still requested specific tools to implement the CCM in their routine practice. Based on a survey when DIAMOND was initially implemented, many providers desired user-friendly tools to incorporate depression management into their practice without losing efficiencies (e.g., incorporation of pocket guidelines, standard depression diagnostic codes, self-management materials into routine workflows).30 Subsequently, these tools had to be developed during the DIAMOND initiative because they were not routinely available.

In addition, primary care practices realized that the bundled payments did not cover all of their additional start-up costs to implement the depression CCM. Additional start-up costs, such as building workflows to incorporate depression measurement-based care, specialist consultation, and care managers’ time in updating clinical registries, will need to be considered in future reimbursement models. One way to pay for these added costs would be to share any potential savings from reduced emergency department or hospital visits promised from the CCM31 with primary care practices as well as insurance companies.

SUSTAINABLE REIMBURSEMENT MODELS FOR CCM

Bundled payment strategies similar to DIAMOND have the potential to be adopted under emerging health care reform initiatives such as accountable care organizations (ACOs). Hence, it will be vital to implement a multilevel strategy to promote a sustainable CCM reimbursement model. Table 2 provides key steps for establishing a sustainable CCM reimbursement plan for primary care settings based on the lessons learned from DIAMOND.17,25,28–32 While these steps towards a sustainable CCM reimbursement model may be daunting, evolving healthcare reform initiatives could allow for opportunities to incorporate CCM reimbursement mechanisms within state health care exchanges and Accountable Care Organizations (ACOs), especially since these organizations will be benchmarked on improving coordinated care and chronic care outcomes.9

Overall, the advent of healthcare reform initiatives, notably ACOs, may facilitate the uptake of the CCM through bundled payments that reward quality rather than volume. Hence, it is vital that organizations serving primary care and mental health specialty providers who are interested in the sustainability of the CCM get involved with their state-level exchanges and accountable care organizations, to ensure that these emerging payment models are adopted to implement integrated mental health–general medical care.