2017 CMS physician fee schedule important step toward achieving population health

On Nov. 2, 2016, the 2017 Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule was finalized, reflecting, among other changes, an emphasis on primary care efforts to drive enhanced care management and behavioral health integration, all with the aim of better care, smarter spending and healthier people.

Specifically, four new codes were added to the Schedule with the intent to "improve payment for care management services provided in the care of beneficiaries with behavioral health conditions (including services for substance use disorder treatment) through new coding, including three codes used to describe services furnished as part of the psychiatric collaborative care model and one to address behavioral integration more broadly."1

The potential impact of primary care settings addressing both their patients' medical and behavioral (mental health and substance abuse) conditions in an integrated approach cannot be overstated. With the simple addition of a collaborative care model and four new codes for reimbursement, the 2017 CMS Physician Fee Schedule will be breaking dramatic new ground for truly achieving population health.

The integration of primary care and behavioral healthcare, particularly for those populations with chronic medical conditions and/or chronic behavioral conditions, has long been challenging practitioners. Anxiety or depression among individuals with chronic medical conditions is not a new concept for most specialists and primary care practitioners. Nationally, more than 80 percent of patients with behavioral health conditions seek care in medical (primary and specialty) settings.2 Of these patients, 60 to 70 percent receive no behavioral treatment3, and the 11 percent who do receive treatment, fewer have interventions that impact their symptoms.4 The behavioral health treatment community has known for years that their patients facing the most serious mental health conditions die, on average, 25 years younger than the general population5, primarily due to untreated medical conditions. Stigma, fear, ignorance and lack of funding for the services of behavioral professionals have all contributed to limiting the availability of patient services and the patients' access to care.

Chronic medical diseases—any of them—can take a toll on an individual's mental health. The demands of treatment regimens can be rigorous and draining. The juggling of appointments, pharmaceuticals, health benefits, labs, exercise, diet, family and work are tedious and often challenging, even among patients who are highly committed to their treatment

For example, this is especially true for the estimated 20 percent of the adult population with diabetes.6 The prevalence of depression ranges from 11 to 28 percent among adults with diabetes and varies dramatically by type and severity of diabetes, gender, age, economic status, race and ethnicity.

According to the Mayo Clinic, co-occurrence of diabetes and depression can be associated with a worsening of both conditions:
• "The rigors of managing diabetes can be stressful and lead to symptoms of depression.
• Diabetes can cause complications and health problems that may worsen symptoms of depression.
• Depression can lead to poor lifestyle decisions, such as unhealthy eating, less exercise, smoking and weight gain—all of which are risk factors for diabetes.
• Depression affects your ability to perform tasks, communicate and think clearly. This can interfere with your ability to successfully manage diabetes."7

While the frequency and impact of co-occurring diabetes and depression is significant, it is important to note that depression is unrecognized, undiagnosed and untreated in more than two-thirds of patients with both conditions.8

As such, it is not surprising that health care costs for this population are higher than their non-comorbid counterparts, and are likely understated for those patients whose depression has not been identified. Specifically, patients with diabetes and depression have higher ambulatory care use, fill more prescriptions, have more hospitalizations and incur total health care expenses that are 4.5 times higher than expenses for diabetics without depression.9

So, what was the impetus for these new codes?

Pressure on providers and regulators to promote better care, lower costs, and improved access as part of the Affordable Care Act and MACRA, in concert with big data availability, has likely opened the eyes of policymakers and healthcare leadership. While it follows logic that serious illness impacts medical and behavioral well-being, we now have the data, incentives and evidence-based treatment models to drive integration.

Specifically, the changes to the codes incorporate better access to integrated care in those primary care offices which adopt a collaborative care approach, utilizing primary care and behavioral professionals who, in turn, will now get reimbursed for providing better care.

Collaborative care approaches to chronic care management began to take hold in the early 1990s, evolving around several key concepts:
• Patient-centered care teams,
• Population-based care,
• Measurement-based "treat to target,"
• Evidence-based care, and
• Systematic quality improvement and accountability for outcomes.10

The University of Washington led the development of the collaborative care model with an integrated care team comprised of primary care and behavioral professionals. They generated and documented significant treatment progress by simultaneously addressing both diabetes and depression, resulting in reduced morbidity and costs. The elevation of this collaborative care model to an evidence-based practice in multiple locations nationally is a key component and driver to the PFS 2017 focus on integrated primary care teams—they work!

The key constructs of the collaborative care model CMS is adopting for the changes to the codes are:
• Payments will be made for services delivered to Medicare and/or Medicaid fee-for service beneficiaries, not Medicare Advantage or Medicaid Managed Care patients.
• Patients must have a diagnosed psychiatric disorder requiring behavioral health assessment.
• The services provided will include:
o Establishing, implementing, revising and monitoring a care plan for each patient;
o Providing brief interventions; and
o Care directed by the primary care team and inclusive of structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate.
• The primary care team participants will include:
o Primary care providers, e.g., primary care physician or nurse practitioner;
o An employed behavioral health care manager;
o A psychiatrist consultant; and
o Employed psychologists and/or social workers for brief interventions.

While the collaborative care model and the accompanying codes will be new to many primary care practitioners, the need and demand for integrated care is not. The opportunity for health systems to dramatically improve care, reduce costs and have an impact on population health in community accessible settings will take a major step forward in 2017.
Susan C. Sargent is founder and president of Sargent Healthcare Management Advisors, and a senior fellow at The BDO Center for Healthcare Excellence & Innovation.

1 Federal Register/Vol. 81, No. 136/Friday, July 15, 2016/Proposed Rules, page 46201.
2 Reilly, S., Planner, C., Hann, M., Reeves, D., Nazareth, I., & Lester, H. (2012). "The Role of primary care in service provision for people with severe mental illness in the United Kingdom, PloS, 7(5).
3 Kessler, R.C., Demler, O., Frank, R.G., Olfson, M., Pincus, H.A., Walters,, E.E., Zaslavsky, A.M. (2005). "Prevalence and treatment of mental disorders, 1990-2003," New England Journal of Medicine, 352(24), 2515-2523.
4 Wang, P.S., Demler, O., Olfson, M., Pincus, H.A., Wells, K.B.,, & Kessler, R.C. (2005). "Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 629-640.
5 Parks, J., Svendsen, D., Singer, P., Foti, M.E., Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors, October 2006.
6 Centers for Disease Control and Prevention, "Rate per 100 of Civilian, Noninstitutionalized Population with Diagnosed Diabetes, by Age, United States, 1980-2011," September 16, 2014.
7 Mayo Clinic, "Diabetes and depression: Coping with the two conditions," July 24, 2014.
8 Katon, Wayne J., MD, "The Comorbidity of Diabetes Mellitus and Depression," American Journal of Medicine, November 2008, 121(11 Supplement 2), S8-15.
9 Egede, Leonard E., MD, MS, et al, "Comorbid Depression is Associated with Increased Health Care Use and Expenditures in Individuals with Diabetes," Diabetes Care Journal, March 2002, vol. 25, no. 3, 464-470
10 Vanderlip, Erik R., MD, MPH, "Depression and Diabetes: Improving Outcomes Through Collaborative Care," Psychiatric Times, May 29, 2015.

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