Bringing Psychiatric Services to Primary Care with the Collaborative Care Model
By Art Kelley, MD
Chief Medical Officer | Emtiro Health
Ask any primary care clinician and they will tell you that their practice is a de facto mental health clinic. Over half of individuals who receive mental health services in any given year receive those services in medical settings. For example, primary care practitioners write the majority of prescriptions for antidepressants in the United States. There are many drivers of this phenomenon. Despite significant work by many, there remains a stigma among patients to seek mental health care. And some people who could benefit from mental health care do not think they need it. The inadequate size of the mental health workforce, particularly that of psychiatrists, and the concentration of that workforce in more urban areas creates significant access issues for many patients. Access is further diminished by the fact that low reimbursement rates for mental health services have driven many providers of mental health care to a cash-only practice model.
Because they have received little psychiatric training in residency, many primary care clinicians are uncomfortable with the role of mental health provider but, doing the right thing, they accept that role-often reluctantly. The lack of robust screening for mental disorders in primary care and less than optimal treatment regimens often lead to under-treatment.
The current landscape is unlikely to change. Primary care practices will continue to provide mental health treatment to significant numbers of patients. However, the importance of better screening and treatment of mental disorders by the primary care clinician will substantially increase as the healthcare system continues its move from fee for service to value based contracting. Here’s why: those patients with multiple chronic medical conditions who have a co-morbid mental disorder (particularly major depression) have significantly higher medical costs –sometimes double. In value based contracting, improving the quality of care and “bending of the cost curve” will be paramount as clinicians seek incentive payments based on these parameters. And these metrics become even more important as advanced practices take on risk- based contracts.
Fortunately, the collaborative care model offers a way to deliver psychiatric services in a primary care practice that helps achieve higher quality treatment of psychiatric illness while lowering the medical treatment costs of patients who because of their chronic illnesses are high utilizers of medical services and who, because of their psychiatric disorder often are not able to commit to disease self-management. This model adds two members to the primary care treatment team: a behavioral health care manager and a consulting psychiatrist. Allow me to describe the work flow of this process using depression as an example. Using a robust screening process with the PHQ-9 to identify those who appear to be suffering from depression, the primary care clinician confirms the diagnosis and refers the patient to the care manager who evaluates the depression further, places the patient in a registry, and begins to monitor the treatment progress with serial PHQ-9s and frequent contacts (usually every two weeks for the first twelve weeks) with the patient either face to face and telephonic. The care manager has a weekly discussion with a consulting psychiatrist to discuss patient progress and ask treatment questions he/she, primary care provider or the patient may have. Recommendations are made by the psychiatrist, particularly for those patients who are not improving or where the diagnosis becomes unclear. These treatment recommendations are quickly forwarded to the primary care physician who remains responsible for all treatment. The psychiatrist functions as a caseload consultant not a face to face treater. This allows a leveraging of a precious resource (psychiatrist time and expertise) to address the treatment needs of a population of patients with major depression. Research shows up to 60% of patients treated within this model achieve remission or at least a 50% improvement. And other research has demonstrated that $6.00 in medical costs are saved for every $1.00 invested in the model.
Until recently, paying for this model has been difficult because payers were not reimbursing for care management and consultation time that occurs outside of a direct patient encounter. Much of the current work is self-funded by organizations that see its value or through grants. This is changing. Since the beginning of 2017, the Centers for Medicare and Medicaid (CMS) has been reimbursing a group of collaborative care G-codes covering the non-face to face time necessary for its success. Beginning in 2018, these codes will be given official CPT codes. There is now growing expectation that other payers will soon be reimbursing these codes as well. This should create a revenue stream for practices that will further the adoption of this model to the benefit of patients and practices.
Emtiro Health is working diligently on making a collaborative care service available to primary care practices. One that will help practices address mental health disorders is a way that benefits patients and providers and is financially sustainable. We believe strongly that this service should be available virtually. Having an internet-based system will enable Emtiro to offer this service to rural practices large or small, increasing access to evidence-based psychiatric care to those who have had limited access. Of course, we will provide this service to those practices who have the capacity to embed care managers in their practices.
Matthew J. Press, M.D., Ryan Howe, Ph.D., Michael Schoenbaum, Ph.D., Sean Cavanaugh, M.P.H., Ann Marshall, M.S.P.H., Lindsey Baldwin, M.S., and Patrick H. Conway, M.D., Medicare Payment for Behavioral Health Integration, Matthew J. Press, M.D., Ryan Howe, Ph.D., Michael Schoenbaum, Ph.D., Sean Cavanaugh, M.P.H., Ann Marshall, M.S.P.H., Lindsey Baldwin, M.S., and Patrick H. Conway, M.D. The New England Journal of Medicine, Downloaded from nejm.org on January 26, 2017.
C. Huffman, M.D., Shehzad K. Niazi, M.D., James R. Rundell, M.D., Michael Sharpe, M.D., Wayne J. Katon, M.D. Essential Articles on Collaborative Care Models for the Treatment of Psychiatric Disorders in Medical Settings: A Publication by the Academy of Psychosomatic Medicine Research and Evidence-Based Practice Committee, Psychosomatics 2014:55:109–122