Payment for Collaborative Care Part of 2017 Medicare Fee Plan

The collaborative care model—which puts primary and behavioral health care under one roof—would get a boost from Medicare under the 2017 Physicians’ Fee Schedule (PFS) proposed Thursday.

Collaborative care, which puts psychiatrists or other mental health providers, behavioral health care managers, and primary care physicians within a single practice, can involve services that extend “beyond the scope of an office visit,” according to a blog post by CMS Acting Administrator Andy Slavitt and CMS Acting Deputy Administrator and Chief Medical Officer Patrick Conway, MD, MSc.

“This model, increasingly used by primary care practices, has demonstrated benefits in a variety of settings to improve patient outcomes,” they wrote, adding that CMS, “is also proposing to pay for other approaches to behavioral health integration.”

Paying for collaborative care in Medicare is part of a wide-ranging PFS proposal that Slavitt and Conway said would steer an estimated $900 million into primary care, mental health, and care coordination. But in the long run, targeting funds to better manage patients with multiple chronic conditions and mental health issues could save money—by keeping them out hospital beds and emergency rooms.

Patients with multiple conditions and a mental health problem may be small in number but account for disproportionate shares of healthcare spending. Work by Jeffrey Brenner, MD, in Camden, NJ, first coined the term “superutilizer” to identify patients who frequently ended up in the emergency department because they failed to properly access the healthcare system elsewhere, often for lack of coverage but not always.

A July 2013 Medicaid bulletin found, for example, that the top 1% of the beneficiaries accounted for 25% of the spending, and the top 5% accounted for 54% of the spending. Among the top 1% in spending, 83% had 3 chronic conditions and 60% had 5 or more.

The concept of collaborative care was pioneered at the University of Washington Medical School by the late Wayne Katon, MD, whose first paper on the topic appeared in JAMA in 1995. In interviews with The American Journal of Managed Care, Katon said that most people referred for a behavioral health visit won’t go because of the stigma, but that fear eases when the provider is within the primary care office. It’s also easier on the clinicians to share information on a patient, and for case managers to barriers to care.

Katon’s work found that collaborative care increased medication adherence, reduced clinical inertia, and increased the likelihood that physical causes of depressive symptoms are discovered, and vice versa.

Studies have found that patients with diabetes and depression who received care this way showed improvements in both their clinical indicators for diabetes and their mental health. But at scientific meetings where this model has been discussed, clinicians frequently ask: how do we bill for it?

The proposed PFS seeks to address this, Slavitt said in a statement. The proposals “are intended to give a significant lift to the practice of primary care and to boost the time a physician can spend with their patients listening, advising, and coordinating care,” he said. “If this rule is finalized, it will put our nation’s money where its mouth is by continuing to recognize the importance of prevention, wellness, and mental health and chronic disease management.”