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Wendell Potter is a former Cigna executive turned whistle blower. This from an essay in the Center for Public Integrity.
When you’re shopping for health insurance, wouldn’t it be great if you could find out every insurer’s claim denial rate? And how much each one spent on lobbying and advertising — and how much they paid their CEO?
You can now find all of that information and more if you live in Vermont, thanks to a law that was enacted last year at the urging of the Vermont Public Interest Research Group.
In compliance with that law, the insurers that do business in Vermont have just disclosed data they’ve been able to keep secret for years. And that information should come in handy when Vermonters begin shopping for coverage at the state’s online health insurance exchange in October.
With just 626,000 residents, Vermont is the second smallest state in terms of population (only Wyoming has fewer people), and it has only three major health insurers — Blue Cross Blue Shield of Vermont, MVP Health Care and Cigna, the company I used to work for.
Blue Cross Blue Shield of Vermont is by far the biggest and the only one based in the Green Mountain State. MVP is headquartered in New York, and Cigna, the for-profit company among the three, is based in Connecticut.
Which of the trio do you think denied the most claims on a percentage basis in 2012?
If you guessed the for-profit company, as I did, you would be right. But even I was shocked to see how Cigna compared with its competitors, especially Blue Cross.
Of all the claims submitted to it last year by health care providers and policyholders, Blue Cross denied 7.6 percent. Cigna denied 21 percent. MVP was in the middle at 15.5 percent.
Since Vermont is a pretty small state, chances are pretty high that all three companies have the same doctors and hospitals in their provider networks. One would have to wonder why Cigna felt it necessary to deny more than one of every five claims submitted by those doctors and hospitals while Blue Cross denied only one of every 13.
Most of the claims denied by all three companies were categorized as “administrative,” meaning they were denied because a provider presumably used an incorrect procedure code or made some other clerical error when submitting their claims for payment. It defies reason to think that the doctors and hospitals in Vermont submitted inaccurate claims to Cigna at almost three times the rate they did to Blue Cross.
One of the things you need to know about the private health insurance business is that insurers make a lot of money when they delay paying a claim. I would be willing to bet that many — if not most — of the claims the Vermont insurers denied were eventually paid. When an insurance company delays paying a claim by days, weeks or months, it can take advantage of “float.”
The longer you can delay paying a claim, the more investment income you can make on the premiums you take in from your policyholders. And investment income is especially important to for-profit insurance companies because it contributes significantly to the bottom line. Shareholders and Wall Street financial analysts like that, even though much of the money on which the investment gains were made should have been paid to health care providers.
The data reported by the insurers is consistent with recent claim denial rates in California. A California Nurses Association analysis of 2010 data submitted by insurers to the California Department of Managed Care showed that Cigna’s claim denial rate was 39.6 percent. Aetna’s denial rate, by contrast, was 5.9 percent.
The Vermont disclosures showed that Blue Cross and MVP spent far more money lobbying state officials last year — $258,347 and $55,366, respectively, than Cigna, which spent only $9,141. But Cigna spent much more lobbying federal officials: $1.59 million. MVP spent $160,000 lobbying in Washington. Blue Cross of Vermont spent nothing, although the Chicago-based Blue Cross Blue Shield Association, which represents all of the country’s Blues plans, spends a lot on lobbying every year, as does America’s Health Insurance Plans, of which Cigna and MVP are members.
Cigna, a much bigger company than the other two, reported paying its CEO $3,970,833 in total compensation last year, compared to $1,250,000 for the CEO at MVP and $587,184 at Blue Cross. And Cigna was especially generous in paying its nine board members: $3,199,855. Board members at Blue Cross earned a combined $246,632. MVP did not pay its board members anything.
The one area in which Blue Cross Blue Shield of Vermont spent much more than the others was advertising and PR. The company spent $743,968 for marketing last year in Vermont, compared to $516,358 for MVP and $66,849 for Cigna.
Cigna notified the state earlier this year that it would not seek to sell policies to individuals and small businesses on Vermont’s exchange, leaving that part of the marketplace to Blue Cross and MVP. But Cigna will still have at least one big client in Vermont — the state of Vermont. Cigna has had a contract for several years with the state to provide coverage to state employees. If I were one of them, I would ask for an explanation of those high claim denial rates.
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A variety of forces are reshaping how behavioral healthcare is delivered in the US. These changes are due to a host of forces, among them:
-The Affordable Healthcare Act (more patients for behavioral clinicians)
-Parity (better reimbursement for behavioral clinicians)
-Focus on population based medicine
-Recognition that primary care is the de factor mental health system in America, i.e. the place where most behavioral healthcare is delivered
-That medical illness comes with much higher rates of depression and other psychiatric sequelae
-That behavioral interventions can assist patients better cope with chronic illness
-That costs can be contained through care coordination between behavioral and medical clinicians.These changes are behind the movement toward a new model of behavioral healthcare delivery: integrated behavioral care. Integrated care involves the close collaboration and coordination of care by the healthcare team to address physical and behavioral needs of the patient. It recognizes the central role of the primary care (called the patient’s medical home), the need for behavioral interventions to treat not only psychiatric conditions but also to support and facilitate medical treatment as well, and the focus on populations at risk. The big change in the delivery system in behavioral care is not so much where the care is delivered as how: integrated care means close and ongoing coordination between medical and behavioral clinicians. Integrated behavioral care takes clinicians out of their silos and situates them squarely on the healthcare treatment team.
Integrated behavioral care portends the end of the psychiatric “carve out” whereby mental health services are managed (and funded) separately from medical services. As behavioral health services are “carved in” to the delivery system via integrated care, the culture of mental health service delivery will more closely resemble that of other areas of medicine and will become more standardized, accountable and outcomes driven.
What does this mean for behavioral clinicians? It means that behavioral clinicians will transition from a primarily silo model where psychotherapy is largely outside the mainstream healthcare delivery system, to one in which it is fully integrated. It means that clinicians will have to expand their repertoire of services to include addressing medical illness issues, e.g. compliance, lifestyle coaching, etc. And it means that the electronic medical record (EMR) will become the clinician’s workbench: communication with the treatment team, documentation, outcomes and accountability will derive from this technological platform.
Is this new model a challenge to behavioral clinicians. Yes. In the current mental health silo model, the clinician is sovereign and practices with a great deal of privacy. In the world of behavioral integration, clinicians will be thrown into a healthcare fishbowl—their work will be visible and their and results will be measured and public to the treatment team and the funders of care. Psychiatric EMRs will largely automate integration by automatically communicating with other treatment providers via the Continuity of Care Document (basically a Diagnosis and Problem list), and by routinely collecting data for standardized reporting and outcomes tracking. In short, behavioral healthcare will become accountable as never before.
In the next several years behavioral clinicians will need to figure out how they relate to the behavioral integration movement. Some will want to work in larger medical systems as employees. However, many, perhaps most, clinicians will want to integrate with the medical system without losing their independence. Co-location is one option for behavioral clinicians, but probably not feasible on a widespread basis. Remote collaboration is the more likely outcome with behavioral clinicians serving as virtual treatment team members.
So what to do? In my view, behavioral clinicians ought to consider coming together to establish affiliation groups. These affiliations would be multidisciplinary groups that cover all behavioral sub-specializations. The groups would provide a one-stop shop for medical groups and payers. They would use a common cloud-based, ONC certified behavioral health EMR. The behavioral EMR would insure that confidential patient information that goes beyond the needs of the medical treatment team was kept strictly confidential and did not “leak” into the larger medical record. The behavioral EMR would also, of necessity, be cloud-based so that interoperation (communication) between medical and behavioral clinicians could be accomplished remotely, thereby enabling behavioral clinicians to be members of the treatment team, albeit virtually. A referral widget could be provided to medical practices so that with one click a physician could quickly identify a suitable referral source, i.e. clinician within a geographical area with the right sub-specialization, insurance panelling, etc.
The model I am describing is not organizationally top heavy. External inspection and control management—the model of the carve out—is replaced in the behavioral integration model with internal management via information feedback and best practices. As a result more funding goes to care, less to costly administration.
It is not too soon for clinician’s to begin to build the behavioral healthcare system of tomorrow. Replacing behavioral health 1.0, the “carve out” model, with a “carve-in” model—behavioral health 2.0—is long overdue. Already initiatives such as I have described are being created.
Update:
For a good summary of integrated care see this website for a comprehensive overview of integrated behavioral care see http://ibhp.org -
Here is an article that underscores the revolutionary potential of emrs to improve the efficiency and quality, i.e. value, of healthcare services. Were emrs incorporating automated outcomes systems implemented, there would be a knowledge explosion in the field that would change practice and better serve clients. The technological infrastructure is now in place to make this a reality. In fact, nascent Practice Research Networks (PRNs) are already moving down this path.
Here is the article:
EMR systems are improving efficiency in healthcare facilities while making medical research more comprehensive and cost-effective than ever before.
A study related to heart disease risk conducted in 1994 included a patient sample size of 26,714 participants and took 14 years to complete. An identical study published in July 2012 took three months to achieve the same results – with 959,030 individuals. The difference? Electronic medical records.A recent article in The Plain Dealer highlights the benefits of EMR systems to medical research. According to the news source, the original study, done in Norway, involved monitoring patients for 13 years. Researchers from MetroHealth Medical Center in Cleveland, Ohio were able to replicate those results, but on a much larger scale, while spending a fraction of the time and money as the Norwegian project.
Instead of having to screen and recruit participants and then employ people to track medical statuses for more than a decade, MetroHealth Medical Center researchers were able to use the “de-identified” electronic medical records database set up by Explorys. This way, valuable data was collected without patient confidentiality ever being compromised.
“There is tremendous potential to make discoveries, to improve medical outcomes,” Sharona Hoffman, professor of law and bioethics at Case Western Reserve University School of Law, told The Plain Dealer. “This allows researchers to really access millions of records very quickly, to see patients who receive care in real clinical settings with diverse demographics and diverse geographical settings.”
Hoffman does go on to say that studies conducted by using EMR databases must be done carefully in order to weed out records that are incomplete or flawed in some way so the results are not compromised.
EMR consultants have been working feverishly to help medical practices implement these systems to increase efficiency and overall quality of patient care. The federal government has encouraged digital adoption with financial incentive programs. However, the far-reaching research benefits of such systems are proving to be just as valuable.
Electronic medical records allow healthcare research to be done in a more comprehensive and cost-effective manner, potentially leading to medical advancements that would otherwise take decades to achieve.
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Here’s a good idea–a website, www.therapistoutcomes.com, created by Tony Rousmaniere, Ph.D., Associate Director of Counseling at University of Alaska. The website will contain a list of therapists who make their therapy outcome data available for prospective clients–there are no therapists listed yet. The website’s main purpose is to help clients make informed decisions when picking therapists. Right now clients who go to a directory or a review site or do a google search have no OBJECTIVE evidence as to whether a particular therapist is effective.
Rousmaniere writes that
Serious concerns have been raised about the reliability of Yelp and other therapist-review sites. These sites suffer from a “selection bias”, meaning that they only have information by clients who are motivated to write a review. These are often clients who are either very happy or very unhappy with a therapist’s performance. We think it is important to show the whole picture of a therapist’s outcomes from their entire practice.
The site does not provide a standard format for publishing a practitioner’s outcomes. It would be helpful to require certain essential data, e.g. % of patients recovered, improved, unchanged, deteriorated. Also,
-Total # of clients seen in the data set, or per year
-Client populations, diagnostic categories, etc.
-Duration of therapy for successful and non-successful cases
-% of clients who return after one visit
-% of clients who dropoutAt this point it is not clear that using outcomes routinely in practice improves effectiveness. However, knowing that a given clinician is highly effective is useful, perhaps the single most useful datum for the potential consumer of psychological services to have in order to make an informed decision about which therapist to select.
Whether this site catches on or not is up in the air. But I think it is a worthy contribution to the field and would encourage clinicians who collect outcomes to post their outcomes at the site.
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In 1985 I worked for a small health plan setting up a mental health provider network in western Massachusetts. We contracted with psychologists for $58 for 90806, the most commonly reimbursed procedure code. This was a deeply discounted rate that led to some grumbling from providers who were used to a higher rates from Blue Cross Blue Shield and other payers. No surprise that some providers refused to join for that reason.
I mention this because I read today that Humana and its wholly owned subsidiary LifeSynch have lowered reimbursement rates for 90806 to $58 for its Illinois providers.* Between 1985 and 2012 the cost of living has increased 78.2%! So if the 1985 rate had kept pace with inflation, providers today would receive about $103 for 90806.
And Humana and LifeSynch are not alone. This year:
Florida BCBS has reduced rates for the most commonly billed mental health procedure codes by 33 – 54%.
Kansas BCBS and Kansas City BCBS have reduced rates by 18-35%.
California Blue Shield reduced it’s already rock bottom rates by 9.1%–from $60 for 90806 to $55–when it changed managed care vendors.
The responsibility for reducing these rates in each instance was off loaded from the health insurer–Humana, Florida BCBS and Kansas BCBS, Kansas City BCBS, and California Blue Shield–to a carve out managed care company–LifeSynch (Humana), New Directions (Kansas BCBS and KC BCBS), or Magellan (California Blue Shield.)
Better that the carve out company take the brickbats than the parent company!
These reductions hit clinicians hard. But they hit them even harder when you factor in that the actual claims paid rate achieved by managed care companies tends to be significantly lower than for parent health insurance company. But more about this in my next post when I present a data analysis of several hundred thousand mental health claims.
*I just ran our reimbursement data for Magellan (n=7778) for 2011 and found that their mean payment rate for 90806 nationally was $58.65, with a mean payment for all codes of $48.12.
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Parity has made it politically incorrect to discriminate against mental health. External barriers such as different limits, etc are no longer tolerated. So what is a health plan to do to lower treatment costs? The answer: put up internal barriers. Humana has done just that.
Humana’s mental health treatment/claims are handled by a subsidiary called LifeSynch. LifeSynch, unlike other major healthcare companies, does not accept electronic claims through the standard channels, i.e. clearinghouses. A Humana mental health clinician can either go to the LifeSynch internet portal, which is cumbersome and time consuming, or, more likely, send claims in paper format via a HCFA 1500 form.
If the clinician makes the mistake of sending the claim to Humana, rather than LifeSynch, Humana often does not send them on to LifeSynch. As one provider remarked to me recently, “I send the claims electronically to Humana and they acknowledge receiving them, but they do not forward them to LifeSynch for reprocessing. Lifesynch never gets them.”
Humana has, then, erected, internal barriers that make it difficult for clinicians to send in claims and get paid. What’s more, their paper claims submission system guarantees higher denial rates, lower claims costs, and a longer turn around time. The use of standard national clearinghouses would insure quicker, more accurate claims processing which would benefit clinicians greatly. The obvious benefit to Humana, of course, are lower costs. But their claims policy also sends a signal to clinicians–this is a plan to steer clear of. This can translate in the marketplace to: avoid Humana if you have mental health issues and are in the market for a health care plan, a message, I’m sure, Humana is happy to get out.
As noted, it is likely that Humana engages in this practice because it saves them money: the capitation to LifeSynch reflects the lower claims costs due to the higher denial rates. But there may be an even bigger reason: Humana may be able to use the entire capitation paid to LifeSynch to count toward their health plan’s medical loss ratio. The medical loss ratio is the amount of the premium dollar that goes to actual medical care as opposed to administrative overhead. In fact, as much as 50% of the capitation to LifeSynch may go to administrative overhead (due to duplicate systems, inefficiencies of paper claims processing, oversight, etc). But the whole amount may be counted as health care expense. Obamacare calls for health plans to have an 85% medical loss ratio and, if passed, this accounting gimmick would help Humana reach that threshold. Even if Obamacare does not pass, health plans can market their services better if they are able to show higher medical loss ratios.
Humana could provide more care if they followed industry standard claims practices. Instead, they appear to have chosen to put a disproportionate amount of the the mental health care dollar into administrative cost to the detriment of patients and providers, but not, it would seem, to their bottom line.
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WHY OUTCOMES FAILED
Despite the expenditure of tens of millions of dollars and scores of outcomes initiatives over the last 20 years, there are few viable outcomes programs in operation.
Most have failed. Some examples from the private insurance market:
–Aetna/HAI’s ambitious nationwide outcomes initiative implemented in the 1990s
–VRIs multistate initiative also implemented in the 1990s.
–Pacificare Behavioral Health’s nationwide program which was terminated around 2004
–Humana’s behavioral health internet based outcomes and behavioral disease management project ended after a year in 2001
–Massachusetts BCBS statewide outcomes program terminated around 2007A variety of states also initiated ambitious outcomes projects, such as the states of Washington and Oregon, only to jettison them after a few years operation.
JCAHO made outcomes mandatory nationwide in 2000 with its ORYX project. It was ended barely two years after it began.
Companies set up to develop and implement outcomes have also collapsed. Compass, Inc had millions in investment funding in the mid 90s and developed an outcomes system based on the well regarded work of Ken Howard. The company failed after a few years of operation. A number of other outcomes companies collapsed, as well. The few that are remaining have been drastically downsized. The business model of these companies was akin to those of medical laboratories: to sell a “lab test” of mental health functioning to health plans that would enable the plans to determine the necessity and effectiveness of treatment. They reckoned that health plans would buy these services rather than build them themselves.
The outcomes projects in operation now are implemented by true believers; they are mainly financed by providers. For instance Miller and Duncan developed a feedback informed treatment system based on the Outcomes Rating Scale (ORS). It is software based and used by clinicians mainly in the US and Northern Europe. See http://www.centerforclinicalexcellence.com/ICCE. Jeb Brown, an early champion of outcomes who spearheaded the Aetna/HAI and Pacificare projects that were insourced, has a site http://www.clinical-informatics.com in which he provides outcomes tools for clinicians. He has a number of pilot projects underway. But outside of the true believers, outcomes have not gained traction in the mental health community. This despite the fact that 1) outcomes are regarded by the American Psychological Association as an evidenced based approach; and 2) controlled studies and naturalistic studies show conclusively that outcomes with feedback to clinicians improves the effectiveness of treatment.
So the question, why have outcomes failed?
I think there are a number of reasons:
1) Most outcomes systems were developed by psychologists who eschew the medical model. Their instruments (OQ 45, ORS) measure measure general distress. The dominant health care culture is simply not interested in general distress. It is interested in diseases such as Major Depression, Bi-Polar illness, Schizophrenia, and the like. Measures that are disease-specific are of interest to the medical community. That interest turns into funding. For example, CMS will now pay PCPs to administer disease specific outcomes measures such as the PHQ 9 for depression. Behavior follows funding. When mental health clinicians do the extra work involved in collecting outcomes data, they, unlike PCPs, receive no payment for that extra work. This makes sustaining outcomes difficult; only the true believers stay with it.
2) Clinicians resistance has been a big factor in torpedoing outcomes initiatives. There are a number of reasons for this. First clinicians resent the paternalism of managed care companies that have the arrogance to attempt to micromanage their clinical practices. No physician would stand for it. Incidentally, all or almost all the outcomes projects that have been implemented, excluded psychiatrists from participating in outcomes. Why? They would not comply. Also, clinicians are rightly suspect of managed care companies. As one senior executive of a managed care company said–a company that touts its committment to outcomes–”we really don’t care about outcomes.” In addition, many outcomes instruments contain questions that constitute a HIPAA violation. Take this question from perhaps the most widely used outcomes instrument in the world, the OQ 45: “I have an unfulfilling sex life.” Aetna, Pacificare, Value Options and other companies for years routinely collected this information as part of their outcomes initiatives. Third, outcomes could be used a health care company to impair the clinician’s ability to make a living. e.g. poor outcomes could lead to loss of referrals and outcomes decision support data could result in treatment being curtailed, further eroding clinician’s income. Willed ignorance on the part of clinician’s about outcomes is then fully justified. As Sinclair Lewis remarked: “It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”
3) Feasibility. Until very recently outcomes projects were expensive and cumbersome to implement–clinicians had to make an extra effort to make sure the client filled out the instrument, then it would have to be faxed to the managed care organization, etc. The lack of any tangible benefit, eg. real time feedback, contributed clinician demoralization. “Empty compliance” has often been the norm for clinicians involved in outcomes initiatives. Another factor is that clinicians involved in these projects deal with many payers. For one payer to use a procedure that is applied to, for instance, only a handful of the patient’s a clinician sees a week is rightly viewed as an unfair imposition.
Outcomes–Quo Vadis?
1.Outcomes with feedback to clinicians improves behavioral health outcomes, but it is unlikely they will be adopted if the measure is one of general distress. Psychologists who develop these measures need to get out of their silo and develop measures that the health care community is interested in. That means disease specific instruments.
2. Outcomes need to be a standard of care. PCPs do a number of routine procedures, e.g. blood pressure monitoring. They don’t do blood pressure monitoring for one health care company but not another. It is unfair to ask behavioral clinicians to use different procedures for different companies.
3. The technology still has a ways to go–outcomes ought not to burden the clinician and should be fully automated; alerts to the patient for followup assessments should be provided via e.g. email or text message. Clients should be able to complete outcomes measures on the Internet or a smart phone. Reports should include decision support and be provided instantly to the clinician. Also, outcomes must be integrated into electronic health records. Separate outcomes systems which provide e.g. monthly reports are expensive and inefficient. Naturalistic research via Practice Research Networks would be dramatically enhanced if outcomes data and a robust set of clinical data resided in the same database.
4. While outcomes data should be available to health care companies to insure that care is medically necessary, that data should not violate HIPAA, nor should it be used punitively against the clinician.
5. Clinicians need to be rewarded for providing outcomes informed care; reimbursement rates need to go up to defray the cost of implementing these systems.
6. Effective therapists should be rewarded by higher rates of reimbursement. (h/t Ed Wise, Ph.D.)
7. Less than average therapists should be offered state of the art evidence based treatment workshops. (h/t Ed Wise, Ph.D.)
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As we have written there is a strong case for behavioral clinicians to use an ONC certified EHR. The biggest reason is that it puts the behavioral clinician on the virtual clinical team. Via interop, the behavioral clinician’s clinical summary (diagnosis and problem lists) will be automatically exchanged with other members of the health care team, e.g. PCPs, etc. This will promote coordination of care and referrals.
But behavioral clinicians do not participate in Meaningful Use–which is the bonus system for clinicians who use an ONC certified application. This as I will show not all bad. Indeed, not being part of the Meaningful Use program might be an unexpected godsend for behavioral clinicians–true, they don’t get the bonus payments (which most behavioral clinicians don’t qualify for anyway), but they don’t get the hassles either.
Consider the testimonial of this physician, Michael Koriwchak, MD, an ENT specialist who is also an IT specialist:
“Well, sorry, it’s still that bad (Meaningful Use certification). It took about 150 man-hours of work to complete this project. And our EMR use, our quality of patient care and our practice efficiency is for the most part no better. In some ways it is worse. As a result of MU:
We now take blood pressures on children. This is almost never medically relevant in an ENT practice. We can’t exempt ourselves from this requirement because of our adult patients, in whom blood pressure is often relevant.
We waste volumes of paper printing clinical visit summaries that no one reads. While the concept of a visit summary is OK, the document itself must include so much extra data it is useless. Our web portal, which we are in the process of replacing, does not support this requirement so we have to use paper visit summaries for now.
Patient waiting time is increased while we process data on pneumovax status, smoking status and body mass index on every patient. In our practice these data are medically relevant for many patients, but not everyone. Doing it for everybody is a waste.To be fair, a couple of good things did happen:
Use of EMR-based prescriptions and true e-prescribing (e-Rx) improved with those physicians that were still hanging on to paper scripts and/or were not using e-Rx.
We were not maintaining true ICD-coded problem lists in the EMR before MU. We had problem lists and diagnoses of course, and we were using ICD codes for billing. But we had never combined the two processes before.The entire process is complicated, confusing, and intimidating. Not only are the guidelines themselves a mess, but also there is a surprising amount of inaccurate and misleading information out there. Even the CMS publication Attestation User Guide is missing a page compared to the actual attestation web site. After reading the User Guide I lost an entire night’s sleep thinking that the “children with pharyngitis” quality measure had been deleted because it is missing from that document. I have 17 years of medical practice experience and 37 years of IT experience. If I can’t figure this out there is something wrong.”
The view from the top of the MU Mountain looking down is no better than the view from the bottom looking up. Meaningful Use remains an expensive distraction that forces the true benefits of EMR to be overlooked in favor of regulatory compliance. MU also creates an unhealthy alliance between government and the health IT community. The government wants to own health IT just like it wants to own the rest of health care. Don’t fall for it.
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The integration of behavioral healthcare with physical healthcare is coming. In the coming years implementation of electronic health records (EHRs) that interoperate with other EHRs will enable behavioral clinicians to participate with the virtual health care team. The other development driving healthcare integration are H & B CPT codes (96150-96155). These codes enable non-medical clinicians (psychologists, social workers, nurse practitioners and others) to treat patients with a medical but not a psychological condition.
Here are the developments:
First, Medicare now routinely reimburses H & B codes nationally, with the exception of Illinois and Wisconsin. However, the number of units allowed is often restricted.
Second, private payers are following Medicare’s lead and are also now reimbursing for H & B Codes. However, most payers, with the exception of United HealthCare, pay only for face-to-face treatment, not for chart review, report writing, etc.
Third, it is often difficult to get many private payers to authorize treatment for H & B services. Mental health is often carved out by health plans and the contractual boundary between mental health and physical health is often not clear cut. The mental health carve out company, for instance, may not authorize care for treatment of a medical condition or diagnosis, and the medical insurer may not authorize care by non-medical providers. Thus, behavioral clinicians seeking reimbursement for these services are often are left having to petition the plan.
The good news is that progress toward care integration is advancing due to new technologies and reimbursement policies. The bad news is that America’s healthcare bureaucracy seems designed to make that advance as slow and difficult as possible.
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Two initiatives from Medicare–parity and incentives for early detection of Depression and Substance Abuse–will create new opportunities for mental health treatment in the elderly.
One change already taking place is the phase in of parity. Medicare is lowering the 50% co-payment for outpatient mental health services (that has been program policy since 1965) to a 20% co-pay by 2014. Most other outpatient services covered by Medicare have a 20% co-pay.
A second change, reported in American Medical News, is that Medicare will now pay physicians for the early detection of depression and substance abuse. The CMS website lists 8 depression measures, including Hamilton Depression Rating Scale, the Beck Depression Inventory and the Zung Self-Assessment Depression Scale. (The Hamilton Depression Scale is in the public domain). Because parity removes the disincentive to treat depression, the door is open for potential medication and counseling options.
While the focus of Medicare’s efforts is on incentivizing physicians to treat depression and substance abuse, the opportunity for non-medical mental health clinicians to benefit from these changes is significant. CMS requires PCPs to utilize comprehensive care supports, including case management working with the primary care physician; and planned collaborative care between the primary care provider and mental health clinicians. Both of these services–care management and collorative care–can be provided by mental health clinicians. The guidelines also (implicitly) caution against medication monotherapy and require that PCPs pay attention to patient preferences regarding counseling, medications, and referral to mental health professionals.
Clinicians who use an ONC certified behavioral EMR that shares clinical summaries with medical EMRs will be able coordinate care with PCPs and provide the counseling and progress tracking services that busy PCPs are unable to provide.
Update on Recommended Measures
Hamilton Depression Rating Scale (HAM-D)
This 20-item instrument is widely used in a 17-item version in clinical trials to measure remission and treatment response. The scale’s length limits clinical utility, but versions of varying length are available. The HAM-D is not suited to assess patients affected by cognitive impairment and requires administration by trained personnel.
Beck Depression Inventory (BDI)
This 21-question self-report was developed to quantitatively measure depression severity over time. The 1996 revision (BDI-II) occurred when the DSM-IV changed diagnostic criteria for major depressive disorder (MDD). The length of this tool limits its utility for screening; but because patients must choose a level of gravity (corresponding to a distinct definition of the patient’s condition, with reference to the previous week), the BDI lends itself to monitoring of variations in the intensity of depression over time.
Zung Self-Assessment Depression Scale (SDS)
This 20-item measure of depression severity for those already diagnosed with depression is now also used in primary care as a screening tool. The SDS is available in a number of languages and can be completed by most persons in 5 minutes.17 Disadvantages include that it does not cover symptoms of atypical depression, and that it may be less sensitive to change that other scales. Although devised to identify depression in adults in general, the SDS is also used to study depression and cognitive symptoms/disturbances in the elderly.
Center for Epidemiological Studies Depression Screen (CES-D)
This 20-item self-administered screening test, a hybrid of the Zung SDS, the BDI and the Minnesota Multiphasic Personality Inventory Depression Scale (MMPI-D), was designed to assess depression and gravity of depressive symptoms in normal elderly people.18 A concise 10-item version, whose sensitivity has proved to be only slightly lower than that of the original version, is also available.
Geriatric Depression Scale (GDS and GDS-SF)
This 30-item self-reported tool for assessment of depression in the elderly requires yes or no answers describing patients’ feelings on the day of completion.19 There is a 15-item short form version (GDS-SF) where a score >5 may indicate depression warranting follow-up and >10 usually indicates depression.
General Health Questionnaire (GHQ)
This 60-item test is an assessment of psychological well-being to detect those likely to have or be at risk for developing psychiatric disorders. It is a measure of the common mental health problems or domains of depression, anxiety, somatic symptoms and social withdrawal. Developed in the 1970s, the GHQ comes in 38 languages.20 A 28-item version is most often used.
Patient Health Questionnaire (PHQ-2 and PHQ-9)
The purpose of the 2-item Patient Health Questionnaire (PHQ-2) is not to establish a final diagnosis or to monitor depression severity, but to screen for depression in a first step approach. Patients who screen positive on the PHQ-2 require further testing and can be evaluated with the PHQ-9, a self-reported 9-question version of the Primary Care Evaluation of Mental Disorders (PRIME-MD). The PHQ-9 is a more detailed test with a scoring system based on duration/severity of particular symptoms.
Cornell Scale for Depression in Dementia (CSDD)
This 19-item scale has the best sensitivity (93%) and specificity (97%) for identifying depression in a demented population.22 In patients with severe cognitive impairments who cannot reliably answer the PHQ-9, the scale can be completed by a caregiver.
