Medicare beneficiaries aren’t immune to mental illness. The CDC estimates 1 out of 5 adults over the age of 65 have depression. A study of CMS data from 2019 found that 23% of Medicare beneficiaries have a serious mental illness, such as bipolar disease, schizophrenia, or major depressive disorder, while another 8% had a common mental health disorder, defined as anxiety disorders, personality disorders and posttraumatic stress disorder. The same study found that mental illness was associated with substantially higher spending for other medical conditions.
Adding to the complexity of the situation is the reality that access to behavioral health specialists is severely limited. There is a shortage of these specialists throughout the country. According to the Kaiser Family Foundation, nationally only 27% of the need for behavioral health services is met, with 15 states meeting less than 20% of the need. The problem is even worse in rural communities. According to the American Journal of Preventive Medicine, the per capita supply of psychiatrists, psychologists and psychiatric nurse practitioners in non-metropolitan counties is substantially lower than in their metro counterparts. About one quarter of metropolitan counties lacked a psychiatrist, compared with 65% of non-metropolitan counties. For non-core counties (which is how much of rural American is classified), 80% lacked a psychiatrist.
Since 2017, CMS has allowed primary care practices to integrate behavioral health care (dubbed “behavioral health integration” or BHI) into their care management programs. Medicare makes separate payments to physicians and non-physician practitioners for BHI services they furnish to beneficiaries over a calendar month service period.
In primary care practices in rural areas of the country, “they have these patients with mental health conditions, but they often don’t have the resources at hand to direct them to,” says Faith Jones, director of care coordination and lean consulting for HealthTechS3. “Unlike another specialty, they can’t just send them to a referral. They don’t exist. But the reality is there are a lot of hoops for people to jump to get treatment for a mental illness. This program utilizes a care coordinator to help behavioral health patients jump through these hoops to get the services they need.”
There are basic BHI services (CPT code 99484), designed for patients with a mental illness diagnosis. This can be billed every month your practice carries out certain tasks associated with the care coordination of a patient’s mental health condition. The psychiatric collaboration care services (CoCM) are designed for patients whose condition is not improving. There are three CPT codes for COCM: 99492, 99493 and 99494. CoCM can kick in, typically for a month or two, when the patient needs additional support and so that the primary care practice can take the time to consult with a psychiatric care provider.
“It’s basically a higher form of BHI,” Jones says. “Medication management is probably the biggest reason to be elevating to this level of service. Lots of medications we take for our chronic conditions can interact with medications for mental health.”
Another trigger for CoCM services kicking in is rising scores on a depression screen, which BHI requires on a regular basis. “By paying attention to these things every month, the idea is that practices can be more proactive and prevent someone from getting all the way to crisis mode, when conditions can be harder to treat,” Jones says.
Like many chronic diseases, it turns out that many mental health conditions like depression and anxiety can be well-controlled by a primary care provider, in consultation with a mental health provider, without the patient needing to set up an appointment and travel long distances for a visit with a specialist. When this happens, mental health specialists can focus on the patients that they need to see, which increases access to these scarce services for both groups of patients.
“It’s just like a cardiologist doesn’t see every patient with hypertension,” Jones says. “It’s the exact same kind of scenario.”
For practices that have implemented chronic care management programs, Jones says BHI is a natural progression. In fact, she says, more and more of the practices that she’s helped implement care coordination programs are taking this next step. Some are finding their own psychiatric providers to consult with. Others are forming consortiums and sharing not only these mental health resources but also information and expertise. “A consortium can be efficient and educational,” she says.
Interested in implementing BHI and CoCM services in your care coordination program? Jones will be hosting a webinar on March 18 that will cover the basics of managing behavioral health patients in a primary care practice using collaborative care management. Reserve your spot today.