Telepsychiatry: Solutions to Integrated Care Jessica Estes, DNP, APRN-NP

Objectives At the end of this presentation the participants will be able to: Discuss practicality of using telepsychiatry to provide integrated services. Discuss the value Telepsychiatry adds to clinics and provides resources to areas that are underserved. Identify the consultative codes for behavioral health integration and how telepsychiatry can be used for those codes, as well as the best practices for the provision of telepsychiatric services.

Impacts Of Behavioral Comorbidities Increasing acuity with significant co-morbid medical issues and associated poly-pharmacy: Patients with treated MH/SUD cost 2-3 times more ($400 PMPM compared to $1,000 PMPM) Most of the added cost is in facility-based costs (ER and inpatient) for medical care Only 14% of individuals with insurance are receiving treatment for mental health or substance abuse disorders American Psychiatric Association. (April 2014). Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry. Denver, CO: Milliman. Retrieved from http://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care. SOURCE: American Psychiatric Association. (April 2014). Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry.

Behavioral Health Disorder Impact on Primary Care In 2010, 20% of all visits to primary care physicians included at least one of the following mental health indicators: depression screening, counseling, a mental health diagnosis or reason for visit, psychotherapy, or provision of a psychotropic drug. The percentage of mental health–related visits to primary care physicians increased with age through age 59 years and then stabilized. Approximately 6% of visits for children aged <12 years and approximately 31% of visits for adults aged ≥75 years were associated with mental health care.

Integrated Care What is integrated care? “Integrated care is the systematic coordination of general and behavioral health. Integrating mental health, substance abuse and primary care services produces the best outcomes and proves the most effective approach to caring for people with multiple healthcare needs.” -SAMHSA-HRSA Center for Integrated Health Solutions, www.integration.samhsa.gov

Making the Case for Integration People with mental health diagnoses die earlier than their counterparts and have more comorbid physical problems 68% of people with mental health diagnoses have physical problems 1 in 5 adults have a co-occurring substance use disorder

Cost of Mental Health in Primary Care MEDICAID BENEFICIARIES WITH DISABILITIES: 45% have 3+ chronic conditions 50% have a psychiatric illness 35% have a chronic mental health/substance use disorder (MH/SUD) 60% of those with MH/SUD also have other chronic physical conditions & report fair or poor health Healthcare spending is 60-70% higher for beneficiaries with MH/SUD and chronic physical conditions; 4-5 x more likely to be hospitalized for the top 5 most common chronic conditions (asthma/COPD, congestive heart failure, coronary heart disease, diabetes & hypertension)

Psychiatry & Primary Care Consultative model Sees patients in consultation in his / her office – away from primary care. Co-located model Sees patients in primary care Collaborative model Responsibility for a caseload of primary care patients and works closely team of PCPs and behavioral health providers.

Extending Psychiatric Expertise to Larger Populations Caseload-focused psychiatric consultation supported by a care manager Better access PCPs get input on their patients’ behavioral health problems within a days /a week versus months Focuses in-person visits on the most challenging patients. Regular Communication Psychiatrist has regular (weekly) meetings with a care manager Reviews all patients who are not improving and makes treatment recommendations More patients covered by one psychiatrist Psychiatrist provides input on 10 – 20 patients in a half day as opposed to 3-4 patients. ‘Shaping over time” Multiple brief consultations More opportunity to ‘correct the course’ if patients are not improving SOURCE: Raney, L. (June 2014). The Evolving Role of Psychiatrists in the Era of Healthcare Reform.

Collaborative/Consultative Care Model Telepsychiatry visits VIA a HIPPA complaint platform Telepsychiatry Provider bills for the service

Basic Principles of Billing and Reimbursement CPT Codes (Current Procedural Terminology) Evaluation and Management Codes (E&M) Is generally billed by an FQHC or Medical Facility and must have a physical health diagnosis Health & Behavior Assessment Codes (HAB) Can only be billed by an FQHC or Medical Facility and must have an accompanying physical health diagnosis Used to identify the psychological, behavioral, emotional, cognitive and social factors important to the prevention, treatment, or management of physical health problems. The focus is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments. Depending on the state the E&M and HAB codes can be billed on the same day

Basic Principles of Billing and Reimbursement (con’t) CPT Codes (Current Procedural Terminology) Behavioral Health Counseling Codes 90833 series (MH & SU) Traditional behavioral codes by an acceptable licensed and credentialed practitioner for that state and setting (Physician, Nurse Practitioner, Masters Social Worker, PhD Psychologist) Telemedicine (usually the same code as face to face service with a modifier) (usually GT) Typically these services are billable by an acceptable licensed and credentialed practitioner for that state and setting Case Management Can only be billed by an acceptable licensed and credentialed practitioner for that state and setting Generally a CMHC service Healthcare Common Procedure Coding System (or HCPCS) is a set of health care procedure codes based on CPT. It was designed to provide a standardized coding system in order to describe specific items and services that are provided when health care is delivered. It is a necessary form of coding for anyone who carries Medicare, Medicaid, and other health insurance programs in order to ensure that insurance claims are processed efficiently. Read more: Difference Between HCPCS and CPT | Difference Between | HCPCS vs CPT http://www.differencebetween.net/science/health/difference-between-hcpcs-and-cpt/#ixzz28Wq8efVD

Tips/Opportunities for Billing Interim Financing Solutions for Integrated Healthcare Worksheet Two Services in One Day Paying for Case Management 96000 Series of Codes Screening Brief Intervention & Referral to Tx (SBIRT)

SAMHSA Interim Financing & Billing Worksheets Designed to help agencies understand billing for integrated health services using the public safety net system. Type of Agency (FQHC, CMHC) Funding Source (Medicare, Medicaid) CPT Code Diagnosis Practitioner Discipline & Credential The worksheets are posted on the CIHS website under Finance https://www.integration.samhsa.gov/ The Texas billing worksheet was created in collaboration with Mental Health America-Greater Houston & the Hogg Foundation

Collaborative Care Models

Psychiatric Collaborative Care Codes

How do I know who can bill for services? SAMHSA provides state-by-state in depth looks at CPT codes and provider levels who can bill https://www.integration.samhsa.gov/financing/billing-tools#billing worksheets

The Value Behind Telepsychiatry Avoid inappropriate admissions by reducing psychiatric onboarding in emergency departments Shorten wait times and reduce length of stays Staff difficult cases with a telepsychiatrist or get timely determinations for most appropriate treatment, whether hospitalization or community-based Meet standards of patient care for boarding times Follow-up after hospitalization capacity by expanding community-based capacity with direct-to-consumer models Empower onsite staff to handle psychiatric patients by having a specialist available for consult or assessment when needed – less tangible but actionable A place to also mention positive impacts to HEDIS metrics http://insighttelepsychiatry.com/value-telepsychiatry-ed-6-benefits-cutting-psychiatric-boarding-telemedicine/ https://www.ahcmedia.com/articles/134483-states-leverage-telepsychiatry-solutions-to-ease-ed-crowding-accelerate-care

Telepsychiatry Specialty Service Challenges Technology Specifications Recruiting Credentialing State Licensing Reimbursement Geographic Limitations Unique Needs

The Value Of Telepsychiatry Provide Care When, Where Needed Reduce Travel Costs Address Workforce Shortages

Telemedicine Coverage Commercial Commercial plans may or may not cover telehealth if there is no parity law More private insurers are adopting “virtual care physician visits” – UnitedHealthcare, WellPoint Medicare 2016 bundled-payment program waives geographic limitations of telemedicine providing incentive for use Medicaid States can choose to cover under Medicaid Requires submission of State Plan Amendment (SPA) 48 States have some type of coverage for telehealth Medicaid.gov. Telemedicine. Retrieved from http://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/telemedicine.html.

Principles Of Effective Care Patient–Centered Care: this includes team based care with effective collaboration between PCPs/nurses/care managers and the telepsychiatrist; Population-Based Care: behavioral health patients tracked in a registry to ensure no patients fail to connect to care; Measurement-Based Treatment to Target: measureable goals and outcomes defined and tracked for each patient. Treatment plans are actively changed until the clinical goals are achieved; Evidenced–Based Care: all treatments utilized are evidenced-based and practiced-based; Accountable Care: providers are accountable and reimbursed for quality care, clinical outcomes and patient satisfaction, not simply volume or fee-for-service based compensation; Improvement of Clinical Outcomes: this is for acute and chronic conditions through coordinated triage, population management, outcomes tracking and review of quarterly data.

Jessica Estes, DNP, APRN-NP Clinical Director – Nurse Practitioner Services jessica.estes@intelpsych.com