Because of abundant evidence that integrating behavioral health into primary care reduces costs and improves population health, the federal government wants mental health professionals trained to support at least 140,000 primary care practices across the country.
In October 2016, CMS (Center for Medicare and Medicaid Service) awarded the American Psychological Association (APA) $2 million to train about 6,000 clinicians, including psychologists and social workers, over the next three years to work in primary care.
Practitioner enrollment began in July 2017 for the free training that provides six hours of CE credits that include introductory webinars, course work designed by Division 38 (Health Psychology) and a course in contracting and payment models.
Enrollees have free access for two years to APA’s new registry for quality reporting and connections to a learning community of practices nationwide.
As of January 2018 only 300 psychologists had finished the training and another group of 120 recently enrolled, according to William Douglas Tynan, Ph.D., director of APA’s Office of Integrated Care.
The American Psychiatric Association began a training program about two-and-a-half years ago using a collaborative care model after CMS awarded the organization $2.9 million dollars over four years to train 3,500 psychiatrists in the skills needed to support primary care practices.
Anna Ratzliff, M.D., director of the University of Washington’s AIMS (Advancing Innovative Mental Health Solutions) Center, said over 1,900 psychiatrists completed the training.
Psychiatrists receive seven online training modules through the center and in-person training at annual conferences and district branch meetings. In the proposal to CMS, the psychiatric association planned to have the first cohort completing the program to serve as trainers for later ones.
Barry Jacobs, Psy.D., director of behavioral sciences for the Crozer-Keystone Family Medicine Residency Program, speculated why such small numbers of psychologists have signed up for the free rudimentary APA-CMS training opportunity.
He said that although APA has been beating the drum for psychologists to be involved with primary care in recent years, some psychologists are intimidated to work with physicians or do not like being part of health care teams. Many experience culture shock. “Working in primary care is an exotic enterprise to some,” he said.
Jacobs said over the past five to six years the momentum for primary care behavioral health has picked up with the rise of value-based care and changes in the Medicare codes. He said instead of being limited to Veteran’s Administration hospital clinics or federally qualified health centers, every large health system is providing some type of mental health services within primary care.
“I have three times as many psychology doctoral students applying for practicums in primary care behavioral health,” Jacobs said.
Not a passing fad
According to Alexander Blount, Ph.D., co-director of the Center for Behavioral Health Innovation at Antioch University New England, it is obvious that health care in the United States is going in the direction of integrating behavioral health into primary care. “All branches of the federal government are committed to it, and numerous states have committed to it.”
In 2014 CMS adopted a Chronic Care Management (CCM) code, 99490 (billed for 20 minutes per month for patients with two or more chronic conditions), for care coordination services.
In 2016 two more CCM codes were added for use with complex patients who require more clinical staff time.
Although these codes are usually billed by a physician, other inter-professional team members such as social workers can have their time included for activities such as phone communication, review of records and self-management education and support. Bonnie Ewald, a grant writer and public policy adviser at Rush University Medical Center in Chicago, said the addition of these codes is a significant breakthrough for CMS in recognizing the value of services not provided face-to-face with the patient.
Rebecca Lahey, LCSW, manager of Mental Health and Collaborative Care in the Department of Social Work and Community Health at Rush, said the CCM codes are used when providing services to 13 primary care practices if patients screen positively for depression.
In January 2018, CMS adopted three new CPT codes (99492, 99493, 99494) that promote behavioral health services integrated in primary care through a collaborative care medicine (CoCM) model that stemmed from the research of psychiatrist Jurgen Unutzer, M.D., at the University of Washington.
The AIMS Center website states the consultant must be a licensed psychiatrist or psychiatric nurse practitioner. Consultation is typically done remotely with no face-to-face contact.
The APA views CoCM as not allowing psychologists to work at the top of their license because social workers, licensed mental health counselors or nurses may also work as care managers, which may result in lower reimbursement rates for psychologists.
Instead, APA promotes the Primary Care Behavioral Health (PCBH) model in which psychologists work alongside the physician as doctors and members of the health care team.
A new general behavioral health integration code, CPT 99484 that can be billed on a monthly basis by a physician and/or non-physician practitioner, can be used in this model, adding about $50 per patient per month to the practice. Psychologists cannot bill for this code but can bill separately for psychotherapy or health and behavior services.
Ewald said it has taken much effort to operationalize the use of the CCM codes so Rush University Medical Center decided to focus only on those fee-for-service codes for the time being.
Even the AIMS Center that developed the CoCM model has minimal experience with implementation of the collaborative codes. “We’re in the early adopter stage,” said Ratzliff.
Workforce training needs
An issue often debated by health care administrators is how to fill current and future workforce needs. In an email interview, Ben Miller, Psy.D., chief strategy officer of Well Being Trust, said, “We need clinicians who get mental health spread out throughout the health care system as well as the community. While we undoubtedly will still want specialty providers to take care of those with more severe needs, we need generalists who are able to apply their skills more broadly to help us improve population health. We really must think outside of our traditional training paradigms to come up with novel solutions to our workforce needs.”
Nicholas Cummings, Ph.D., former APA president and creator of the Doctorate in Behavioral Health degree, said after conducting research early in his career in the 1960s at Kaiser Permanente he concluded that traditional mental health services parachuted into a medical setting do not result in savings. Cummings said clinicians in primary care settings need to be well trained in brief focused interventions.
Psychiatrist Anna Ratzliff, M.D., agrees that brief evidence-based interventions are an important element of effective CoCM.
According to Blount, a lesser trained person can provide manualized approaches to many patients’ behavioral health problems as long as there is someone to help when the protocol does not work. He envisions the future role of the doctoral-trained clinician as a trainer and supervisor to the “care enhancer,” such as a medical assistant, care manager or care coordinator.
The amount of training needed to prepare the psychologist for the primary care setting is not clear. Blount recommends one day a month of online workshops for a semester long course.
Tynan agrees that six hours of CE courses are not sufficient to prepare the psychologist thoroughly to be effective in primary care but the new online program is a basic and necessary introduction. For more information on the Integrated Health Care Alliance, go to: APA.ORG/IHCA.
Other more extensive training programs in integrated primary care are:
*The Arizona State University Doctor of Behavioral Health and Master of Integrated Health Care programs: https://chs.asu.edu/programs/
*Certificate course on Integrated Primary Care, UMass Medical School: https://www.umassmed.edu/cipc/
Paula Hartman-Stein, Ph.D., is a geriatric mental health consultant, public speaker and educator. She taught at both the ASU DBH program and a UMass Med School certificate program. Currently, she provides consultation to psychology practices on Medicare compliance and offers seminars on the ethics of Medicare billing. Her website is: www.centerforhealthyaging.com.
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