Although Kristine McVea, MD is an internist at OneWorld Community Health Centers Inc. in Omaha, Neb., she’s also often a “surrogate psychiatrist,” titrating and prescribing psychiatric medications for patients with anxiety, depression, and other mental health problems daily. These patients need access to psychiatric services. However, it’s not uncommon for them to wait months or longer to see a psychiatrist.
The good news is that, as of Jan. 1, 2018, financial incentives exist for physicians and psychiatrists to collaborate when caring for patients with behavioral health disorders. In its 2018 Medicare Physician Fee Schedule, CMS created a new Psychiatric Collaborative Care Model that enables physicians to generate revenue when they co-manage patients with a psychiatrist or some other professionals trained in behavioral health and provide ongoing care management support.
With psychiatric collaborative care management, the primary care physician bills Medicare monthly when the care team delivers services that meet or exceed a time threshold defined under the billing code. The internist then pays the behavioral healthcare manager (usually employed by the practice) and psychiatric consultant directly.
Collaborating for better outcomes
The collaborative care model is important because it underscores the connection between physical and mental health, says Seth Bernstein, Ph.D., executive director of the Institute for Behavioral Health Integration in Corvallis, Ore. Bernstein cites the example of depression that fuels diabetes. By addressing the underlying mental health issue, physicians may improve physical health outcomes as well. Internists and primary care physicians are well-positioned to address these concerns because of their long-standing relationships with patients, he adds.
Thomas Weida, MD, a primary care physician at University Medical Center in Tuscaloosa, Ala., says primary care physicians are among those most qualified to spot the mental health conditions that drive some physical health symptoms. He provides the example of sleep disturbances that may be related to anxiety—a problem he often treats in his practice.
In a collaborative care model, Weida, who plans to bill psychiatric collaborative care management this year, says he can work with a psychiatrist to identify the most appropriate medication without requiring patients to see an additional provider, and get paid for doing so.
Weida says the new collaborative care model will take some of the burden off physicians trying to care for patients with behavioral health conditions. “We see a huge number of the walking wounded—those with depression and anxiety. Having some additional expertise is helpful,” he says.
Addressing operational challenges
Although psychiatric collaborative care may improve outcomes, it may create operational challenges—specifically, the need for practices to create a care team that includes a behavioral healthcare manager and psychiatric consultant.
According to CPT guidelines, the behavioral healthcare manager must have a masters or doctoral degree-level education or specialized training in behavioral health. The psychiatric consultant must be a medical professional who is trained in psychiatry or behavioral health and qualified to prescribe the full range of medications.
Neither are required to be practice employees, but it might be most cost-effective for small practices to hire someone to serve as a full- or part-time behavioral healthcare manager if that individual can also perform chronic care management (CCM), transitional care management (TCM) and other clinical services, says Charlie Hutchinson, CPA, chief financial officer at InSync Healthcare Solutions LLC in Tampa, Fla.
Likely candidates include social workers as well as physician assistants or nurse practitioners with specialized training in behavioral health techniques (e.g., motivational interviewing and behavioral activation).
Weida says his practice employs a full-time social worker to serve as the behavioral healthcare manager. Another option is for practices to jointly hire a behavioral healthcare manager and share his or her time, he adds.
McVea’s practice hired a licensed marriage and family therapist to serve as the behavioral healthcare manager. Though the clinic hasn’t yet billed for psychiatric collaborative care management, McVea says OneWorld essentially began performing the service a year and a half ago, most frequently for patients with depression, anxiety, and schizophrenia.
“In terms of increasing access to psychiatric care, the program has been amazing,” says McVea. Since implementing the program, she says, the clinic has reduced the waiting list for psychiatric care from 300 patients to zero.
Weida’s practice plans to contract with a psychiatrist on an hourly basis. He suspects that the psychiatrist’s time will be minimal because the behavioral healthcare manager will do the majority of the work assessing patients and following up with them. Practices that employ the behavioral healthcare manager directly would therefore retain most of the revenue that the program generates, he adds.
Another option for the psychiatrist’s contract is to simply split the total revenue, says Mike Strong, MBA, CPC, bill review technical specialist at SFM, a worker’s compensation consulting firm in Bloomington, Minn. A 70/30 split in favor of the internist or primary care physician makes the most sense.
“Ultimately, it’s the [primary care physician’s] license on the line because they’re the ones prescribing the medication,” he says. “They’ll be the ones held accountable if it’s prescribed inappropriately.”