Financing Behavioral Health Integration: The State of Oregon

Financing Behavioral Health Integration: The State of OregonJason Kroening-Roche, MD MPH, Resident, OHSU Family MedicineDeborah Cohen, PhD, Associate Professor, OHSU Dept of Family MedicineJennifer Hall, MPH, Research Associate, OHSU Dept of Family MedicineRuth Rowland, MA, Research Associate, OHSU Dept of Family MedicineDavid Cameron, Bachelors, Research Assistant, OHSU Dept of Family MedicineCollaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

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Collaborative Family Healthcare Association 12th Annual ConferenceLearning ObjectivesAt the conclusion of this session, the participant will be able to:

Discuss the CCO behavioral health integration financing landscape, including the impact of legacy organizational structures

List 3 financing barriers to integration commonly encountered by organizations

Identify 3 models of behavioral health integration and the ways in which they impact integration financingInclude the behavioral learning objectives for this sessionCollaborative Family Healthcare Association 12th Annual ConferenceReferences

Davis, M., et al. (2013). "Integrating behavioral and physical health care in the real world: early lessons from advancing care together." J Am Board Fam Med 26(5): 588-602.Blount, F. A. and B. F. Miller (2009). "Addressing the workforce crisis in integrated primary care." J Clin Psychol Med Settings 16(1): 113-119.Kathol, R. G., et al. (2008). "Financing mental health and substance use disorder care within physical health: a look to the future." Psychiatr Clin North Am 31(1): 11-25.Kessler, R., et al. (2014). "Mental health, substance abuse, and health behavior services in patient-centered medical homes." J Am Board Fam Med 27(5): 637-644.Monson, S. P., et al. (2012). "Working toward financial sustainability of integrated behavioral health services in a public health care system." Fam Syst Health 30(2): 181-186.

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This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.Collaborative Family Healthcare Association 12th Annual ConferenceIntroductionBehavioral health integration addresses the Triple Aim of improving outcomes, patient satisfaction, and lowering cost

Integration is a cornerstone of Oregons vision for coordinating care while lowering costs

Efforts to understand how to finance integration are underway

Our research adds to this work in Oregon and around the country

Behavioral health integration has been shown to address the Triple Aim of improving outcomes, patient satisfaction, and lowering costThis integration is a cornerstone of Oregons vision for coordinating care while lowering costsDespite the energy and momentum to integrate care, it remains challenging on many fronts, including how to finance this care modelEfforts to both understand and address these barriers are underwayOur research adds to this work in Oregon and around the countryBackground2011: CCO legislation passed in Oregon

July 2012: CCOs began enrolling Medicaid patients

Jan 2014: Oregon awarded $27 million in Transformation Funds to all CCOs; 23 of 120 projects focused on behavioral health integration

Today: 16 CCOs are operating with global budgets, responsible for all physical, behavioral, and oral care for Medicaid patients

2011: CCO legislation passed in Oregon, with the goal of addressing the triple aim through coordination of careJuly 2012: CCOs began enrolling Medicaid patientsJan 2014: Oregon awarded a total of $27 million in Transformation Funds to all CCOs to promote care coordination; 23 out of 120 projects focused specifically on behavioral health integration projectsToday: 16 CCOs are operating with global budgets, responsible for all physical, behavioral, and dental care for Medicaid patientsOur work: Survey of CCOs to better understand the environment of behavioral health integration in Oregon

Methods5 of 16 Oregon CCOs surveyed

33 semi-structured interviews with CCO stakeholdersCCO leadershipBehavioral health and primary care clinicians

Data analyzed by a multi-disciplinary team using crystalization-immersion approach

Findings shared with representatives from other CCOs

Study protocol approved by the Institutional Review Board at Oregon Health & Science UniversitySample included five of 16 Oregon CCOs, about six respondents per CCOData collection occurred from August to November 201433 semi-structured interviews were conducted with CCO stakeholders. Key stakeholders included both CCO leadership and behavioral health and primary care clinicians.Interviews were professionally transcribed, de-identified, and entered into Atlas.tiData were analyzed by a multi-disciplinary team using crystalization-immersion approachFindings were shared with representatives from other CCOsStudy protocol was approved by the Institutional Review Board at Oregon Health & Science University

Did we reach saturation? Did the themes we saw analytically repeat?Because the programs were small, themes did repeat within the CCOs.Across CCOs is slightly different. Dan went to a lot of other CCOs and found very similar results.We shared our findings with groups from other CCOs, and there was quite a lot of agreement and some refinement based on those results.I think you could just say some of the things i removed from this slide

Talk about variation across CCOs, about the attributes on which they vary.CCOs were chosen with OHA to maximize variation on variables including size, geography, and past experience with integrationNote the county structure of CCOs. Some CCOs span multiple counties while some overlap with others in the same county.I will talk more in later slides about why the county structure matters.

Eastern Oregon CCO: spans 12 counties, most geographically diverseTrillium CCO: Lane county, Eugene and SpringfieldPrimaryHealth CCO: Josephine county (overlaps with AllCare CCOYamhill CCOFamily Care CCO: Multnomah, Washington, and Clackamas counties

FindingsTerminologyBarriersFinancing structuresBillingCredentialingLicensingDocumentationModels of integrationState support for integrationDefinitionsMental Health Care is a broad array of services and treatments to help people with, and those at risk of developing, mental illnesses

Substance Abuse Care is services, treatments, and supports to help people with addictions and substance abuse problems of all kinds

Behavioral Health Care is often used as an umbrella term for care that addresses behavioral health problems bearing on health, including:Patient activation and health behaviorsMental health conditionsSubstance useLexicon for Behavioral Health and Primary Care Integration AHRQ Publication No.13-IP001-EFPrimary Care is the provision of integrated, accessible health care services to address a large majority of personal health care needs

Lexicon: created by a group of national expertsCame from AHRQ funded work led by CJ Peek, National Integration Academy

Primary Care is the provision of integrated, accessible health care services to address a large majority of personal health care needs

We dont know if there is widespread use of this across the countryFindings: TerminologyRespondents asked to define mental health and behavioral health

Mental health was often defined as care for patients with diagnosed mental illness

Behavioral health was often defined as mental health, substance abuse treatment, and behavior change

The distinction was made along billing lines (i.e. MH billed using DSM diagnoses, BH billed in primary care) or by provider typeOur terminology: mental health is traditional MH diagnoses, whereas behavioral health incorporates MH, substance abuse, and behavior change

Terminology was then clarified and used for the remainder of the interviewFindingsTerminologyBarriersFinancing StructuresBillingCredentialingLicensingDocumentationWhile all CCOs studied are working on integration projects, they are often doing so despite unsustainable financial models.This unsustainability is a result of multiple factors, including legacy financing structures, licensing, credentialing, billing, and documentation.Barriers: Financing StructuresFinance drives development. And that has to happen statewide. - CCO QI Director

Were doing what we think is the right thing to do. And we are trusting that the system is going to[sic]get aligned to fully support the work that were doing. Community Mental Health Agency Executive Director

The financing of behavioral health integration was consistently identified as the primary area where changes were needed to foster integration.These quotes demonstrate the varied thinking on how best to respond to these financial barriers.Finance drives development. And that has to happen statewide.Were doing what we think is the right thing to do. And we are trusting that the system is going to[sic]get aligned to fully support the work that were doing.In our CCO scan we saw CCO leadership often aligned with the first quote, hoping for state level change to facilitate integration, while providers and practice administrators aligned more often with the second quote, aiming to do what was necessary and right in the current environment, and hoping all the while the system would support them eventually.Barriers: Financing StructuresCCOs have global budgets and are now responsible for:Physical healthMental healthSubstance use servicesOral health

Despite these global budgets, in most cases money does not flow much differently in the current CCO era than it did priorGo through slide firstThis was true at the time of our study and is due to many reasons.Global budgets dont necessarily change the reality on the ground.Some of this can be explained by the speed at which CCOs were required to form. Many maintained similar contract relationships, county agencies, etc as were in place within counties previously.Block grants also limit funding flows, and this is a federal budgetary restriction.Centers for Medicare and Medicaid Services gives funds to Oregons Medical Assistance Program (OMAP) for Medicaid physical health dollarsSubstance Abuse and Mental Health Services Administration (SAMHSA) gives a block grant to Oregon Addictions and Mental Health (AMH) for mental health.While the new structure for Oregon CCOs combines OMAP and AMH funds into global budget, this does not mean that the way the money flows out of the CCO can differ much from the way it flowed previouslyPrevious OHA Financing StructureOregon Health AuthorityChemical Dependency & Substance Use DisorderHospitals, ClinicsSubstance Abuse and Mental Health Services Administration (SAMHSA)Centers for Medicare and Medicaid Services (CMS)Mental Health AgenciesPhysical Health (OMAP)Mental Health (AMH)CCO OHA Financing StructureOregon Health AuthorityPhysical Health (OMAP)Mental Health (AMH)Chemical Dependency & Substance Use DisorderHospitals, ClinicsSubstance Abuse and Mental Health Services Administration (SAMHSA)Centers for Medicare and Medicaid Services (CMMS)CCOMental Health AgenciesSome of the mental health funding comes from federal block grants from SAMHSA, which flow through AMH.These funds must be used according to certain rules, which makes changing financing difficult.Where CCOs can make changes, such as opening up more BH codes on the physical health side, they have made some change. Ill talk about that in a bit.

Talk about county organizational structure, where the dollars were still flowing along

Mental HealthPrimary CareBilling Code ABilling Code BBarriers: Billing and LicensingLicensed BHCs can bill in the PC setting using Billing Code A if:They have a MAP numberThe CCO makes these codes availableUnlicensed providers can only bill using Billing Code B if:They work for an organization (i.e. CMHC) with a Certificate of Approval (COA) from Addictions and Mental Health (AMH)COAPrimary Care and Mental Health use different billing codes:Billing Code A: CPT codes (which includes HBAI codes)Billing Code B: Healthcare Common Procedure Coding System (HCPCS) with CPT codes and modifiers

Many CCOs were not aware they could make these billing codes available to licensed providers. Additionally, we were often told these codes did not reimburse at a level required to support the work of these licensed BHCs

Unlicensed providersQualified Mental Health AssociatesCertified Alcohol and Drug CounselorsPeer Support SpecialistsQualified Mental Health Professionals

This is a sentiment we heard as respondents discussed the various financial barriers they faced. In this case, this BHC is lamenting the fact that they are able to bill for their work in an agency with a Certificate of Approval, such as a Community Mental Health Agency, but they cannot bill when working in a primary care office. While this sounds unjust, there is another side to this argument. Unlicensed folks are often not trained to the level of licensed folks, and may not be trained to the level that is needed when working in a primary care setting. In a CMHA they are required to be overseen by a licensed practitioner and thereby have some degree of supervision.

18Barriers: Licensure and TraineesBarriers exist for recently trained BHCs to enter the workforceLicensed Clinical Social Workers (LCSW)Licensed Psychologists

Licensure and credentialing require supervised hours

Resident BHCs are prevented from billing during this period and practices cannot be reimbursed

Other states have made billing possible in a manner similar to medical residents

The absence of such reimbursement was seen to deter practices from hiringThis next slide will report our findings about licensure and trainees.

These individuals have often been Trained specifically to work in a BH integrated practice.These internship or training hours happen post-graduation.Licensure and credentialing are necessary for reimbursement by payers but require a certain number of supervised hoursResident BHCs are therefore prevented from billing during this period and practices cannot be reimbursedOther states have made billing possible in a manner similar to that for medical residentsThe absence of such reimbursement was seen to deter practices from hiring this group because they could not pay, and practices risked losing this workforce to other agencies.Other agencies that could pay were those with a COA who could use unlicensed providers

Barriers: DocumentationFor PC practices contracting with agencies with a COA, the required CMS mental health documentation must be followed

This documentation includes:Patient assessment (often 1-2 hours in length)Mental health diagnosisFormal treatment plan

Such requirements often prevented practices from using BHCs for integrated practices such as warm handoffs, brief interventions, and quick EMR documentationAlthough many practices found ways to move forward with these more integrated activities, but this sometimes required non-reimbursed activities, dual documentation, and the likeWell, Im technically non-licensed. Im a QMHP [Qualified Mental Health Professional] from the state. And thats a little problematic becauserequiring licensure, to me thats all about payment from certain payers. And were trying to get away from payment. Were trying to have this be part of the provision of primary care. - Behavioral Health Clinician

Barriers: Licensing, Billing, and DocumentationAnd now for a quote. Read it.This quote demonstrates how fluidly these financial issues were discussed in our survey. Licensure and billing are intertwined. Credentialing and documentation are close behind. So while we have broken them up one by one, they were often talked about in this sort of inter-connected way, as this BHC has done.A major barrier is the complexity of this problem, which is poorly understood

Most respondents identified credentialing and billing as issues but did not understand the details

Licensing and credentialing barriers were almost always framed as billing limitations, rather than the other way aroundi.e. Billing needs to change to fit licensing realities

These issues are constantly shifting, a barrier in itselfBarriers: Licensing, Billing, and DocumentationA major barrier is the complexity of this problem, which is poorly understoodMost respondents identified credentialing and billing as issues but did not understand the detailsIn a number of cases, when fact checked, responses were wrong. This is evidence of the confusion that is out there.Licensing and credentialing barriers were almost always framed as billing limitations, rather than the other way aroundie. Billing needs to change to fit licensing realities (rather than people getting licensed up to meet billing requirements)These issues are constantly shifting, a barrier in itselfLeads to significant complexity and confusion

These barriers:Create challenges to removing siloes between primary care and behavioral health

Foster a reliance on short-term grants to bypass this reimbursement system entirely

Limit the efficient use of recent graduates

Prevent BH integration for all payers and patientsBarriers: When CombinedDiscussion of E&M and CPT codes and requirements to be able to bill under these codes in the physical health spaceDiscussion of H codes and the Certificate of Approval (COA) in the mental health space which allow un-licensed mental health providers to be reimbursed for their services, but only when they document in ways required by AMH (and cumbersome to brief interventions)Describe the two possible options for Oregon CCOs to secure BH integration reimbursementWork with AMH sponsored CMHCApply for a COA and ask behavioral health practitioners to apply for MAP numbersHighlight how this financing complexity both hinders integration, and encourages reliance on grants to fund integration effortsDiscuss low reimbursement for HBAI codesPayer mix challenges

24FindingsTerminologyBarriersFinancing StructuresBillingCredentialingLicensingDocumentationModels of IntegrationWhat models exist within these limitations?

Mental HealthPrimary CarePC clinic provides physical workspaceBHC bills according to AMH rules under COA with supervisor off siteOften cannot use EHR due to HIPAACan only bill MedicaidNo reimbursement for warm handoffs and in many cases these arent achievable due to time restrictions and documentation requirementsDegree to which the BHC participates in PC clinic life varies widelyIntegration Models: Co-locationBHC located in PC site but under AMH rules and regulationsCOAOpen the possibility for co-located person doing warm handoffs, and caring for the SPMI population.26Integration Models: Other funding

Mental Health

Primary CareBHCPC clinic provides physical workspaceBHC often does not bill as they are funded outside FFS modelUse the PC Clinic EHRSee all patients in the practice regardless of insurance status/payerFree to do warm handoffs without diagnosis or documentation requirementsDegree to which the BHC participates in PC clinic life can still vary widelyIn this scenario, the PC practice now employs the BHC through Advanced Payment Methods, grant funding, or out of pocketPC clinic provides physical workspaceBHC often does not bill as they are funded outside FFS modelBilling: Remember they are able to bill Medicaid using Billing Code A if they are licensed, have a MAP number, and the CCO has made the codes available. This reimbursement was often described as too low to cover costs of providing the care.Use the PC Clinic EHRSee all patients in the practice regardless of insurance status/payerFree to do warm handoffs without diagnosis or documentation requirementsDegree to which the BHC participates in PC clinic life varies widelyMany of these practices have maintained relationships with CMHC for SPMI population.The way CCOs made this happen was through grant funding, APM, out of their global budget

Mental HealthPrimary CareIntegration Models: Bilateral IntegrationNP/PA embedded within MH agencyCMHC provides physical workspacePC provider bills without licensure or credentialing barriers via FFS modelOften face barriers to documentation due to inadequacies in the MH EHR system for physical healthSee all patients in the practice regardless of insurance status/payerChallenges exist in finding the right balance of access to make this service valuable for members and utilization to make it financially viable for CMHCsIn this model the CMHC hires or enters a contractual relationships with the providerViewed as friendlier to the SPMI population who often identify the CMHC as their health home for both mental health and physical health needsTwo CCOs surveyed had such arrangements with one providing nearly full time primary care access during business hours

Go through the slideCMHC provides physical workspacePC provider bills without licensure or credentialing barriers via FFS model using physical health codesOften faced barriers to documentation in the MH EHR due to inadequacies of the system for physical healthSee all patients in the practice regardless of insurance status/payerChallenges exist in finding the right balance of access to make this service valuable for members and utilization to make it financially viable for CMHCs28FindingsTerminologyBarriersFinancing StructuresBillingCredentialingLicensingDocumentationModels of IntegrationState support for integrationHow can states better support innovation toward integration?Technical assistance

Provide education and guidance to payers and practices about payment strategies and billing/licensing rules

Address regulatory hurdles that present barriers

Promote attitude shifts toward innovation

Consider incentive payments/metrics for BH integration

Technical assistanceProvide guidance to payers and practices about various payment strategies to successfully finance integration, including alternative payment methodologiesProvide clarity around billing, licensing, credentialing and documentation, in Oregon this includes new MAP integration codesHelp encourage attitude shifts among providers to support innovationConsider incentive payments/metrics for BH integrationEducate payers and providers about the benefits of BH integrationRemove financial barriersAddress the regulatory hurdles that exist; most see this as the states roleWe found these barriers were often Federal as well, implying that State help with advocacy is neededEncourage alignment of reimbursement among Medicaid and commercial insurance plans to allow BH integration for all patients in a practiceCreate a residency for psychology graduates modeled after medical residencies whereby trainees are able to reimburse for their work

The Transformation Center should further assist by encouraging CCOs to utilize MAPs newer billing codes for integrationthe 96150 series. This could include spreading awareness to CCO leadership about these new billing codes and encouraging CCOs to pay clinicians for using them. These codes can be used for group health, telehealth, health coaching, and peer support

Many believed that with better information about the benefits of integration, specifically studies demonstrating improved outcomes and lower costs, that momentum for integration among insurers and providers would increasei separated into two slides--make sure to check your notes. How can states better support innovation toward integration?Create residency programs for psychology graduates

Advocacy

At the Federal level to remove barriers dictating state financial flows

Encourage alignment of reimbursement among Medicaid and commercial insurance payers

DiscussionFinancing behavioral health integration is complicated, creating confusion among CCOs and practices

Historical financing structures limit innovation

The devil is in the details: billing, licensing, credentialing, documentation, and models of integration

Small steps are being taken to address barriers but these solutions are not well known among CCOs

BH integration models span a broad spectrum and each present unique challenges at each level of the system

Ron Stock should join us.David is going through the bill to pull out more details of what it is about.

Behavioral health integration is a state-wide focus in Oregon and all CCOs are working to implement integration projectsThe financing of behavioral health integration is complicated, creating much confusion among CCOs and practicesHistorical financing structures continue to promote siloes that limit potential behavioral health integration innovationThe devil is in the details: billing, licensing, credentialing, and documentationSmall steps are currently being taken to address barriers but these solutions are not well known among CCOsBH integration models span the spectrum from co-location to integration to behavioral health homes and each present unique challenges at each level of the system

Addressing regulatory roadblocksState-levelMAP activation of CPT codes to allow credentialed BH counselors to be reimbursed for services within physical health clinicsIntegrated provider license for clinics and professionals that allows one to bill for all service types (physical, mental, and substance)CCO-levelIntroducing new codes or paying for other current codes at the CCO-levelCapitated payments to support non-billable services (integration, case management, etc)

Collaborative Family Healthcare Association 12th Annual ConferenceLimitationsCCOs and state policies and regulations evolve quickly

Sample Did not include all CCOsMost interviews were conducted at the leadership levelSubstance use leaders were not included and details about these organizations did not emergePatients were not included

The extent to which these findings are generalizable to other states is unknownCCOs evolve quickly, as do state policies and regulations surrounding BH integration, making any effort to describe these entities quickly out of dateThe sample:- Did not include all CCOs, however we purposefully selected CCOs for variation along several lines to obtain a representative sample and findings were shared with key informants and additional CCOs, who endorsed our findings- Most interviews were conducted at the leadership level and may not reflect the views of most PCPs in the state- Substance use disorder leaders were not included in the sample and details about these organizations did not emerge, suggesting that these services remain in separate siloes from primary care but more investigation is needed- Patients were not included in the sample

The extent to which these findings are generalizable to other states is unknown, although many of our findings align with work that has been done in this area.This is an area for more research.Collaborative Family Healthcare Association 12th Annual ConferenceConclusionsWithout meaningful changes to financing barriers, there is a risk of losing momentum when current grant funding runs out

Opportunities for state assistance abound in areas of technical assistance, advocacy education, regulation change, and advocacy at the Federal level

New state solutions should encourage a transition from grant funded programs to a self-sustaining modelWithout meaningful changes to financing barriers, there is a risk of losing momentum when current grant funding runs outOpportunities for state assistance abound in areas of technical assistance, such as regulation change, guidance, and program creation, as well as for advocacy for payer alignment and Federal level advocacy to a align financial flowsNew state solutions should encourage a transition from grant funded programs to a self-sustaining model

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