Below is the HillCo client report from the October 21 Behavioral Health Integration Advisory Committee meeting.
- The advisory committee is beginning to collect Phase II recommendations
- Received very positive feedback from Commissioner Janek on the Phase I report
- The final Phase I report is posted on the internet
- Phase II recommendations should be finalized in 2015
General Updates
- The SB 58 carve in that happened on September first went very smoothly for both providers and consumers
- Majority of the providers are LMHAs
- A committee member told the group that she had been advised not to take managed care patients because the reimbursement process takes too long
- Suggested a PR even promoting the system when the claims process is more seamless
The Advisory Group discussed the following 73 initial recommendations for Phase II that resulted from a survey of stakeholders and committee members:
1. Use peer specialists as wellness coordinators to work with consumers to track physical health and mental health well-being.
2. Train peer specialists to work with consumers using the SAMHSA Shared Decision Making Tool to assess leading health concerns (i.e. weight gain; Use peer specialists as wellness coordinators to work with consumers to track physical health and mental health well-being) to determine which anti-psychotic is least likely to cause that health concern.
3. Allow for multiple billable services within a single day.
4. Set up a preferred provider designation for integrated care providers with expedited authorizations and/or credentialing.
5. Add a billable service for care coordination activities within an integrated BH/physical health setting .
6. Ensure CMS guidelines have been implemented in HHSC contracts with MCOs
7. Establish a network of specialty providers in the community for referring non-insured patients.
8. An inclusive EMR.
9. Training, support for early screening and identification activities (Family docs, ER docs, pediatricians, teachers, law enforcement, etc.).
10. Research on and application of existing research on the relationship of mental and physical health. This research should focus on social and economic benefits, emphasizing broadly defined social cost effectiveness.
11. Expand availability of providers by increasing reimbursement, access to training and support for continuing education.
12. Adjust financing for better support co-location and local coordination.
13. Have one common billing system so that mental health and physical health providers can utilize the same system which promotes efficiency and integration of services.
14. Allow for family practitioners to diagnose behavioral health conditions. Eliminate "carve outs".
15. Have a common EHR so that all care is documented within the EHR.
16. Connect psychiatric care providers within the health care home concept.
17. Have mental and physical health services provided in the same location.
18. Develop innovative ways to incentive co-management of patients by primary care and behavioral health providers. Strategies may include incentives for primary care and behavioral health providers to share office space and electronic medical records and to meet regularly to discuss mutual patients and care planning.
19. Ensure that technology is used to its full potential to allow better communication and information sharing between providers caring for the same patient.
20. Investigate and widely disseminate information on evidence-based "best practices" regarding integration of behavioral health and physical health to stakeholders and MCO's. Incentivize adoption of these "best practices."
21. Ensure billing guidelines allow for a psychiatrist or BH APN to deliver an E&M code on the same day as a primary care E&M code.
22. Expanded use of Telemedicine. Texas has made significant progress in its rules and regulations to allow for expanded use of telemedicine and telehealth services. This provides an opportunity to expand access to care for individuals with mental illness. The rule defining an allowable medical site still prohibits the use of telemedicine and telehealth in the home and other non-traditional settings such as in a police car or under a bridge. These issues must be considered for specialty populations. In addition, the scope of telehealth should go beyond counseling services to include mental health rehabilitative services and substance use disorder services.
23. Develop one stop locations for patients to get MH/PH services along with how to get housing, employment and socialization opportunities.
24. Allow billing codes that recognize the additional time to coordinate care and collaborate with other professionals.
25. Move treatment toward being patient centered and patient valued. Involve patients in all aspects of treatment and therapy. Use other models of health care to compare the quality of patient centered care (e.g., cardiac care).
26. Encourage holistic treatment and care including diet, exercise, life-style, medications, and spiritual formation.
27. Access to common information about patient treatment, outcomes and on-going communication with patient and care-givers. Use a Patient Portal to encourage consumer management of treatment/therapy and goals.
28. Require an individual's medication list from physical health and behavioral health prescribers are accessible.
29. Ensure that billing guidelines are adjusted to allow for integration of behavioral health and physical health services.
30. Ensure individuals receiving behavioral health medications receive an annual physical.
31. Billing guidelines and billing codes are adjusted to allow for integration of behavioral health and physical health services.
32. Encourage and pay for behavioral health screening and when indicated, assessment on all clients in the system. Screening tools should be evidence based.
33. Require and pay for physical health screening on all behavioral health clients and for a more complete physical exam when is done when screening indicates that would be appropriate.
34. Encourage commitment to cross agency collaboration and make sure you've provided for an adequate provider network to address the complex health needs of this population.
35. Establish specific continuity of care requirements to make sure beneficiaries retain access to out of network providers during periods of transition or when a service is needed and an in-network provider is not available.
36. Data about patient visits needs to be easily accessible to providers (e.g. child psychiatrists and primary care providers both need access to growth charts).
37. All providers should have an easily accessible list of resources available for services including psychiatric emergency hotline numbers, substance abuse treatment centers, CPS.
38. Interdisciplinary Inter- professional Team Approach needs to be the norm. The team may consist of (but not be limited to) PCPs, medical specialists, nurses, pharmacists, dieticians, social workers, behavioral health providers, peer support specialists, chiropractors, licensed complementary and alternative medicine practitioners, and physician assistants.
39. Real team collaboration, not just co-location. Team building and implementation support must be provided. This must also include provider training, ongoing support, and assessment.
40. The system and the services must be patient-centered. This includes patient and family education, and self-management support. Patient preferences, needs and strengths are incorporated.
41. A patient registry is a key component to make sure patients don't fall through the cracks by ensuring continuity of care. This is a critical tool for the care coordinator.
42. A flexible Stepped Care approach is critical to continuity of care and to minimize unplanned transitions. Also, individual and caseload summaries as part of a Stepped Care approach facilitate measurement-based practice/ treatment-to-target.
43. Care Management Functions need to include systematic outreach, structured templates which facilitate efficient I effective clinical encounters, and close follow-up and monitoring to prevent relapse.
44. Outcomes-based Feedback and Quality Improvement is key to ensuring provider accountability and to reinforce cultural and linguistic skills and/or services.
45. Ensure billing guidelines reflect what the physician is doing, and to allow for psychiatrists to bill for 'medical' service and internists to bill for 'psychiatric' service.
46. Make sure there are available 'med-psych' hospital services (ie, most free standing psychiatric hospitals are not equipped, and do not accept, patients with severe medical complications).
47. Ensure for ease of communication between general medical physicians and psychiatric physicians.
48. The state should ensure funding and support learning collaboratives to disseminate pediatric best practices in the integration of behavioral health and physical health services.
49. Barriers to the appropriate prescribing of psychotropic medications (lack of transparency and complexity re: preferred drugs and clinical edits) and lack of access to therapy for children and parenting dyad therapy are significant in limiting integrated health care.
50. Ensure there are no barriers (payment, agency rule, statute, etc.) that would prevent behavioral health services and physical services from being offered at the same location.
51. In an effort to encourage integrated healthcare services, provide clarity on the scope of mental health billing codes that can be used by a primary care physician across all MCOs and the appropriate credentialing processes when working with BHO subsidiaries
52. Integration needs to allow for parent visits for therapy, intervention and teaching without the child present, since often the parent needs to be the focus. Also, every test, screening tool, and education session in primary care should be billable even if it's shared since both providers need to assess information and use it. It's difficult to sustain integration without billing for shared visits, nurse coordination, phone management, triaging and assistance to prevent hospitalization, and care coordination among community specialists. Integration should be physically co-located when possible, but virtual for rural providers. Providers who do care coordination, education, and triage save the state money, but eat the cost of providing that type of care. This becomes a disincentive to on-going integrated care models.
53. Texas LPC's should be able to bill insurance and Medicaid for assessment procedures which they are trained and licensed for, such as IQ, achievement, cognitive and emotional tests. The license board prohibits LPC's only from administering projective measures such as the Ink Blot test and Thematic Apperception Test.
54. LPC's who are trained and licensed to perform appropriate cognitive measures should be allowed to be preform services for the Texas Department of Disability and Rehabilitative Services in disability determination. As a matter of course TDDRS frequently uses
our private assessments as treating providers as the basis for disability claims but not for independent assessment by the State which slows disability claims processing due to the poverty of psychologist will the accept the low rates that the State pays.
55. LPC's should be names primary mental health service providers as is already the case in many other states.
56. LPC's are fully competent to perform fitness for surgery assessments as required for many surgical procedures (e.g., gastrointestinal and pain management procedures).
57. Medicaid rates for LPC and LMFT should be commensurate with psychologists as we are independently licensed, represent the largest professional group providing mental health services and providing the same services as psychologists.
58. The full Medicaid carve-in model of the future must blend physical health services with BH services that promote and sustain recovery. This type of system transformation requires innovation. Innovation flourishes best when all stakeholders have opportunities to influence and own decisions. Therefore, no single entity (governmental or private) should have control over local decision-making. A model, wherein decision-making is shared increases community ownership, responsibility and accountability. This is particularly relevant, as we require the input and participation of the physical health community/providers to create an integrated system of care. Participants in this model may include: Local Mental Health Authorities, primary care entities such as Federally Qualified Health Centers, Judicial/Criminal Justice, Housing Authorities, local Government, Health Care Districts, private and public health care systems, payers and consumer voices such as peer specialists, National Alliance on Mental Illness (NAMI), Recovery Oriented Systems of Care (ROSC), etc. Leadership for this entity should be vested with those local organizations that have primary responsibility for providing physical as well as behavioral health services. This would promote the broadest and most pragmatic representation of both the behavioral health and physical health communities. The local community is best positioned to: 1) Define the scope of services needed; 2) Monitor and improve access across the continuum; and 3) Define clinical, process and financial outcomes.
59. Comprehensive services must include treating the whole person and should include wellness programs, stress management, anger management, coping skills training, and educate the consumer and the MCO's staff about the links among mental and physical health.
60. Consider alternative payment models that are more conducive to integrated service delivery and team-based care (e.g., more global payments as opposed to fee-for-service).
61. Provide funding mechanisms that allow for staff such as care managers who are key to ensuring true coordination/integration of care.
62. Provide funding mechanisms that allow for peer-based services (e.g., peer support specialists in primary care settings as part of care integration).
63. Development of workforce competencies so that all providers become PHBHI competent within their own scopes of practice. Consider creating requirements around such competencies for provider education programs.
64. Provide supplemental support for behavioral health Medicaid providers not "billable" under Medicare (LPCs, etc.).
65. Encourage LMHAs to both staff in-house primary care providers and dentists, or coordinate offsite primary care services for clients.
66. Ensure that LMHAs are creating personalized primary care plans for consumers with the assistance needed to implement them.
67. Ensure providers are incorporating behavioral and developmental screenings in required EPDST well child visits. Ensure overall provider education on EPDST benefit with resources similar to the DC HealthCheck Resource Center and appropriateness of referral to more intensive services. MCOs could pay for CME credits for providers on the EPDST benefit.
68. Continue the FREW Initiative, Services Uniting Pediatrics and Psychiatry Outreach to Texas (SUPPORT), to ensure all Medicaid primary care physicians have access to psychiatric consultation.
69. A MCO's definition of medical necessity should support the Public provision of recovery-focused mental health treatment and supports.
70. When it comes to the integration of behavioral health and physical health services we should be using the behavioral health codes and allowing providers such a psychologist to bill directly as long as they show the place of service was in an integrated system and not subservient to another provider. I'm for it and would love to work in a system where multiple specialties are truly working together.
71. Include MH screening as a standard practice of care in primary care settings. Screening for SMI should be required during an annual physical exam or any other appropriate routine check-up
72. In developing reimbursement structures, consider the special needs of the SPMI population who have a high percentage of complex psychosocial needs and comorbid chronic medical conditions and who do not access treatment (primary care) in traditional outpatient settings, i.e. primary care clinics, but are likely to either not access care at all, or to access it in sub-acute or acute settings, driving up costs and resulting in undesirable outcomes for the individual, the providers and the community. To achieve effective outcomes – improved health and functioning and reduced cost- with this population, required services must be funded to achieve these results. These include engagement and outreach; supported housing and employment services; intensive case management; wellness and prevention*; and psychosocial education* (*these services should be reimbursed for provision to family members as well as the individual.)
73. Make certain that care is actually integrated and not just the payor source.
The committee will work to consolidate recommendations by subject (ex: billing, EMR, etc.) and do research to see which recommendations are already in practice and which recommendations are not within the scope of the committee. Also, some recommendations overlap with their Phase I report recommendations so they will review to make sure there is no duplication.