1. Financing Behavioral Health Integration: The State of Oregon Jason Kroening-Roche, MD MPH, Resident, OHSU Family Medicine Deborah Cohen, PhD, Associate Professor, OHSU Dept of Family Medicine Jennifer Hall, MPH, Research Associate, OHSU Dept of Family Medicine Ruth Rowland, MA, Research Associate, OHSU Dept of Family Medicine David Cameron, Bachelors, Research Assistant, OHSU Dept of Family Medicine Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Proposal # 5805792 / Session # D2a in Period 2 October 16, 2015

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months

3. Learning Objectives At 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 financing

4. References 1.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. 2.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. 3.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. 4.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. 5.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.

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. Introduction Behavioral health integration addresses the Triple Aim of improving outcomes, patient satisfaction, and lowering cost Integration is a cornerstone of Oregon’s 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

7. Background 2011: 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

8. Methods 5 of 16 Oregon CCOs surveyed 33 semi-structured interviews with CCO stakeholders CCO leadership Behavioral 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 University

10. Findings Terminology Barriers – Financing structures – Billing – Credentialing – Licensing – Documentation Models of integration State support for integration

11. Definitions Mental 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 behaviors Mental health conditions Substance use Lexicon for Behavioral Health and Primary Care Integration AHRQ Publication No.13-IP001-EF

12. Findings: Terminology Respondents 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 type

13. Findings Terminology Barriers – Financing Structures – Billing – Credentialing – Licensing – Documentation

14. Barriers: Financing Structures “…Finance drives development. And that has to happen statewide.” - CCO QI Director “We’re 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 we’re doing.” – Community Mental Health Agency Executive Director

15. Barriers: Financing Structures CCOs have global budgets and are now responsible for: Physical health Mental health Substance use services Oral health Despite these global budgets, in most cases money does not flow much differently in the current CCO era than it did prior

16. Previous OHA Financing Structure Oregon Health Authority Chemical Dependency & Substance Use Disorder Hospitals, Clinics Substance Abuse and Mental Health Services Administration (SAMHSA) Centers for Medicare and Medicaid Services (CMS) Mental Health Agencies Physical Health (OMAP) Mental Health (AMH)

17. CCO OHA Financing Structure Oregon Health Authority Physical Health (OMAP) Mental Health (AMH) Chemical Dependency & Substance Use Disorder Hospitals, Clinics Substance Abuse and Mental Health Services Administration (SAMHSA) Centers for Medicare and Medicaid Services (CMMS) CCO Mental Health Agencies

18. Mental HealthPrimary Care Billing Code A Billing Code B Barriers: Billing and Licensing Licensed BHCs can bill in the PC setting using Billing Code A if: – They have a MAP number – The CCO makes these codes available Unlicensed 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) COA

19. Barriers: Licensure and Trainees Barriers exist for recently trained BHCs to enter the workforce Licensed 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 hiring

21. Barriers: Documentation For 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 diagnosis Formal treatment plan Such requirements often prevented practices from using BHCs for integrated practices such as warm handoffs, brief interventions, and quick EMR documentation

22. “Well, I’m technically non-licensed. I’m a QMHP [Qualified Mental Health Professional] from the state. And that’s a little problematic because…requiring licensure, to me that’s all about payment from certain payers. And we’re trying to get away from payment. We’re trying to have this be part of the provision of primary care.” - Behavioral Health Clinician Barriers: Licensing, Billing, and Documentation

23. 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 around – i.e. Billing needs to change to fit licensing realities These issues are constantly shifting, a barrier in itself Barriers: Licensing, Billing, and Documentation

24. Leads 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 patients Barriers: When Combined…

25. Findings Terminology Barriers – Financing Structures – Billing – Credentialing – Licensing – Documentation Models of Integration

26. Mental HealthPrimary Care -PC clinic provides physical workspace -BHC bills according to AMH rules under COA with supervisor off site -Often cannot use EHR due to HIPAA -Can only bill Medicaid -No reimbursement for “warm handoffs” and in many cases these aren’t achievable due to time restrictions and documentation requirements -Degree to which the BHC participates in PC clinic life varies widely Integration Models: Co-location BHC located in PC site but under AMH rules and regulations COA

27. Integration Models: Other funding Mental HealthPrimary Care BHC -PC clinic provides physical workspace -BHC often does not bill as they are funded outside FFS model -Use the PC Clinic EHR -See all patients in the practice regardless of insurance status/payer -Free to do “warm handoffs” without diagnosis or documentation requirements -Degree to which the BHC participates in PC clinic life can still vary widely

28. Mental HealthPrimary Care Integration Models: Bilateral Integration NP/PA embedded within MH agency -CMHC provides physical workspace -PC provider bills without licensure or credentialing barriers via FFS model -Often face barriers to documentation due to inadequacies in the MH EHR system for physical health -See all patients in the practice regardless of insurance status/payer -Challenges exist in finding the right balance of access to make this service valuable for members and utilization to make it financially viable for CMHCs

29. Findings Terminology Barriers – Financing Structures – Billing – Credentialing – Licensing – Documentation Models of Integration State support for integration

30. How 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

31. 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

32. Discussion Financing 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

33. Limitations CCOs and state policies and regulations evolve quickly Sample Did not include all CCOs Most interviews were conducted at the leadership level Substance use leaders were not included and details about these organizations did not emerge Patients were not included The extent to which these findings are generalizable to other states is unknown

34. Conclusions Without 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 model

35. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!