1. Initiating and Sustaining Mental Health Services in Primary Care Neil Korsen, MD, MSc Mary Jean Mork, LCSW April 16, 2009

2. Outline  Getting Started  Leadership buy-in  Practice level  Support  Supervision, marketing, relationships  Financial Sustainability  Shared responsibility  Tracking the work  The Grid  The Value of a Work Group  Impacting policy and regulations – state and national level

3. Objectives 1.Identify steps for starting an integrated practice 2.Describe barriers to financial sustainability and methods of working within and around those barriers 3.Obtain tool for tracking reimbursement 4.Learn strategies for advocacy

4. Getting Started

5. Aim for Buy-in at Every Level  Leadership  Need to engage organizational leaders and front line leaders  Organizational leaders provide support and resources to the teams working on integration  Front line leaders champion the change and provide energy and momentum.

6. Aim for Buy-in at Every Level  Practice  Importance of champion(s) – clinical and administrative  Involve representatives of all groups affected by integration  Plan for spread within a practice

7. Getting Started – the Practice Level Pieces

8. Pre-”Hire”  Preparation with Practice Staff  Contract  Hiring (Identifying) MHP  Licensing, credentialing, insurance  Supervision  Billing

9. Orientation and Pre-Patient  Space  Staff support  Registration and scheduling  Shadowing  Consents  Documentation

10. Ongoing Support to MHP and Practice  Marketing  Integration efforts  Community connections  Supervision  Reimbursement  Relationships

11. Supervision and Support  “Hiring” the right person for integrated work  Ongoing availability of clinical and administrative supervision– Surprises will happen  Marketing –  Start-up and access – the balance  If you build it, they may, or may not come”  “Spreading” the resource – when and how

12. “Hire” someone who:  Is dissatisfied with specialty MH  Is intrigued with the idea of helping a patient “function” better  Thinks it’s better to spend 10 minutes with a patient than zero  Is comfortable with noise and rooms with sinks (and uncomfortable furniture)  Has training in behavioral and brief interventions  Is willing to help a patient of any age  Wants to take a team approach to patient care

13. Financial Sustainability Our Goal Outcome Driven, Sustainable Integrated Practice Model for Patients and Providers

14. The Problems with Integrated Care  No one seems to know how to get paid  Mental Health regulations and licensing expectations don’t fit the primary care setting  Confidentiality vs. “shared records”  Lack of clarity and understanding about present practices  Complicated licensing and reimbursement rules without accessible experts

15. Concerns about Carve Outs… Carving out Behavioral Health means:  Different systems  Different reimbursement streams Potential for barriers to integration

16. Understanding the Big Picture  Medicare - Regional Fiscal Intermediaries  Medicaid – States vary  Flexibility in defining covered mental health services  Some limit procedures, providers and/or practices  Commercial – Inconsistencies  Lack of clarity around covered services  Difficulty finding “experts”  Carve outs

17. Understanding Potential Reimbursement “The Grid”

19. Components within “the Grid”  Coding Category  Coding number for service  Discipline of Provider allowed to bill for service  Codes by insurer  Psychiatric Services by type of license  Practice site able to bill for code, funding source, provider and license

20. Where to begin  What is the discipline of your mental health practitioner?  What service will they deliver and what code will be used?  Under what license?  Where will the service be delivered?  Which insurance will be billed? What are the rules for that insurer?

21. Tracking the Work

22. Why track billing data?  To provide rapid feedback on financial aspects of integration  Because we are increasingly able to estimate reimbursement from billing  So that teams working on integration can use data to assess whether the mix of services being provided is sustainable

23. Tracking Sheet  Records services delivered  Billable  Non-billable  Records Insurances  Assigns relative “factors”  For services - based on approximate time units  For insurances – based on general reimbursement comparisons  Multiplies Service x Insurance  Arrives at total for time period  Allows tracking in relation to budget. Shows change overtime

24. Mental Health Codes Health and Behavior Codes E&M CodesNon-Billable Activities 90801 = 4 Initial Assess 96150 = 2-4 H&B Assess 99201- 99201= 4 New Pt DI - Dual Interview with Physician = 0 90804 = 1 Ind Therapy 96151 = 1-4 H&B Reassess 99211-99215= 1-2 Established Pt PO – Parents only before 90801 = 0 90806 = 2 Ind Therapy 96152 96153 = 1-4 H&B Intervention 99401- 99404 = 1-2 Prev Med Ind Counseling C - Consult to Provider = 0 90847 = 4 Family Tx /w pt 96154 =1-4 H&B Intervention with Family & Pt 99411 -99412 = 1-4 Prev Med Grp Counseling M – Meeting = 0 MaineCare = 1Medicare = 2Commercial = 3Self Pay = 1 Tracking Sheet – Reimbursement Codes and Values DRAFT

25. Date of ServiceService Code Billed Reimbursement Factor Insurance Factor Total 3/9/0990801428 3/9/09C (Consult to PCP) 020 3/9/0990847414 3/9/09DI (Dual Interview) 030 3/9/0990806212 Total14 SAMPLE Reimbursement Tracking Sheet Primary Care Mental Health Provider ________Annette_________________ Place of Service ______MMP - Westbrook_____________

26. Questions??? Suggestions!!!

27. The Value of a Task Force on Regulation, Funding and Licensing

28. The Members  Billing and Coding Experts  Credentialing and reimbursement experts with links to licensing  Physicians  Mental Health practitioners including Psychiatrists  Administrators from mental health and primary care  Program Managers  Director of Health Information

29. Monthly Meetings  Sharing information about billing and reimbursement  Different perspectives  Clarifying, explaining, investigating, and re-clarifying  Data gathering  Shared understanding of the present landscape

30. Task Force Strategies  Understand the current rules  Identify opportunities and barriers that affect sustainability  Use understanding of current rules to:  Recommend most effective way to organize services  Maximize reimbursement for integrated care  Target barriers with highest priority and/or are most likely to be able to change

31. How it really feels during the meetings…

32. …and then there are those moments!

33. Impacting Policy and Regulations at the State Level

34. Workgroup Participants  DHHS Leadership  Licensing and Regulation – licensing rules  Funding – Medicaid Rules  State Psychiatric Medical Directors  Other Mental Health Providers  Other Hospital Providers  Maine Health Access Foundation

35. Workgroup Activities  Agree on Goals  Agree on Standard Elements of integrated care  Compare present Medicaid rules with what is needed to support integrated care. (“We don’t need an ICU at the front door”)  Define outcome measures  Support financial incentives

36. Our Next Steps  Gather reimbursement information  Seek input from other organizations in our state doing integrated work  Involve employers, insurers and state government  Compare and link to other Regions  Advocate for change

37. We’re optimistic about the Future of Integrated Mental Health and Primary Care