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Change the payment, change the

Michigan Psychological Association

Ben Miller

on 4 June 2015

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Transcript of Change the payment, change the

the fundamentals
the what
healthcare landscape
why ingratiation
the colorado story
what you can do

fragmentation fighters
perpetuating fragmentation?
How well do you know your payment models?
the colorado story
it could be your story, too
Sustaining Healthcare Across integrated Primary care Efforts

A partnership between Collaborative Family Healthcare Association, Rocky Mountain Health Plans, Colorado Health Foundation, and University of Colorado School of Medicine Department of Family Medicine

To test an alternative payment model to sustain behavioral health in primary care

musings for the future
-clarify billing and reimbursement strategies across payers
-know your baseline cost (how else will you know what's sustainable?)
-Establish relationship with payers and discuss options beyond fee for service
-assess downstream cost-savings; make your case
payment reform 101
supporting integration: a twofold approach
Workarounds and creativity in an imperfect world.

Make your own case and what to do with these data.

Change the payment, change the
care: The role of payment reform and
comprehensive primary care

Benjamin F. Miller
Eugene S. Farley, Jr. Health Policy Center


Community expectation

Payment /financing

Clinical delivery

Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.
The care that results from a practice team of
primary care and behavioral health clinicians
, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization.

Value of Integration
Physical/Behavioral Integration is good health policy and good
for health.


DeVoe JE, Dodoo MS, Phillips RL Jr, Green LA. Who will have health insurance in the year 2025? Am Fam Physician. 2005 Nov 15;72(10):1989.
is coordination the answer?
Kessler, R., Miller, B. F., Kelly, M., Graham, D., Kennedy, A., Littenberg, B., Pace, W. D. (2014). Mental Health, Substance Abuse, and Health Behavior Services in Patient-Centered Medical Homes. The Journal of the American Board of Family Medicine, 27(5), 637-644. doi: 10.3122/jabfm.2014.05.140021
Cunningham, P. J. (2009). Beyond parity: Primary Care Physicians' Perspectives on Access to Mental Health Care. Health Affairs, 28(3), w490–w501.
Accountable Care Organizations
Providers are accountable for total per capita costs
Patient Centered Medical Home
Supports better coordination between providers
Bundled payments
Promotes efficiency and care coordination within an episode
Partial capitation
Combines FFS and prospective foxed payment up front providing payments that can be used to enhance infrastructure and processes
Full capitation
Provides up front payments and makes providers accountable for per-capita costs
Since 2008 the Colorado Health Foundation has awarded more than 40 grants to support the delivery of integrated primary care and behavioral health services.

Grantees report difficulty financially sustaining integrated care due to reimbursement limitations and challenges.

Current grants are focused on addressing clinical improvements and staff/infrastructure needed to facilitate integrated care delivery.

Sense of urgency to identify policy fixes, but recognition there is considerable confusion among providers and advocates about billing and reimbursement for integrated care services.
Based on Medicaid payment rate for code 90804 for behavioral healthcare service for same-day treatment using fee schedule effective 7/1/11.
Service cost equivalents based on retrospective 2008 average Medicaid claims levels for each service category.

Budget Neutrality – Integrated Care Visits on Same Day

Pursue same-day billing codes for physical health and behavioral health services.

Recommendation #1

Based on estimates of Medicaid payment rates for Health and Behavior codes 96150-96155, developed from the 7/1/11 rate schedule and relative value units (RVUs) and an average distribution of individual Health and Behavior visits.
Service cost equivalents based on retrospective 2008 average Medicaid claims levels for each service category.

Budget Neutrality – Health & Behavior Codes

Examine viability of paying for Health and Behavior Assessment codes(CPT 96150-96155) under insurance.
Recommendation #2

Determine a plan to implement a standardized statewide data collection system to document clinical, financial, and operational elements
Clarify current billing regulations and train integrated care sites to optimize use of existing revenue sources to provide cost efficient, medically necessary care.
Test and analyze the viability of global funding strategies to financially sustain integrated care models.
Recommendation #3

Recommendation #4
Recommendation #5
Behavioral health providers bill only for the services that are reimbursed (predominately co-located specialty services)
fee for service workarounds
Behavioral health providers make use of “Health and Behavior Assessment and Intervention Codes” - 9600 series
Collaborative visits with physician and behavioral health provider; Medical provider may be able to change the level of their visit if they add another level of service with the behavioral health provider (medical provider must be in the room and a part of the visit)
Calculating numerators and denominators
Who is in your denominator?
Attributing patients to the intervention
Which patients received what intervention
Process measures are not a bad thing
% identified
% treated
% improved
Tracking patients and matching utilization patters
Unique identifiers and claims connection
make your own case
Do you know your cost?




The commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem

Collective Impact

Disconnected brilliance
Limited ears to listen
Lack of policy traction
Letting our patients experience integration and then take it away

The risks we take without uniting
Full transcript