By Evelyn Cumberbatch, MD, MPH and Douglas Olson, MD, FACP
From the Field is a series of guest blogs that offer perspectives from those working in the health care field.
Nearly every healthcare reform initiative seeks to integrate primary care (PC) and behavioral health (BH) care. This is a laudable goal, but a deep divide of practical problems exists between the ideal vision of policymakers and the current reality of delivering these services to patients.
Unfortunately, without bridging this divide, the full potential of integration will not be realized.
At our Federally Qualified Health Center, we are attempting to integrate BH care more fully into PC. Our primary care providers (PCPs) and BH clinicians routinely co-manage patients. Much communication and coordination occurs via our shared electronic health record; we now screen for depression and substance use disorders in PC; and we have some capacity for acute BH visits.
However, barriers to achieving more complete integration still remain.
Among these barriers are some regulations in BH care. Most notable is the “triad” of:
1) a full intake evaluation
2) a separate, written treatment plan
3) an insurance prior-authorization
Well-meaning tenets of medical ethics inspired these documentation requirements and authorizations are intended to manage costs, but access to timely, quality BH care that meets patients’ needs must also be a priority.
Let’s explore these requirements in more detail.
A thorough “bio-psycho-social evaluation” is required within 15 days of starting BH care. Patients must attend a longer appointment to gather the required information, and a full report must be written. While pertinent parts of a patient’s history are applicable to optimal care, requiring specific information and a substantial note within 15 days limits the ability to deliver flexible BH care.
All patients in BH care are required to have a separate treatment plan written within 30 days of the evaluation and updated every 90 days thereafter. This supposedly prevents forcing unwanted treatment on patients and encourages patient engagement. PCPs write a progress note after each visit with a plan outlining treatment. BH clinicians write a similar note and plan of care for each visit, but this is not sufficient. Having to manage separate treatment plans constrains the BH care that can be offered.
Despite much evidence showing that integration improves outcomes and that access to BH care needs to be increased and de-stigmatized, prior-authorizations for BH care are still required by many insurers. Functionally, BH care is treated as a specialty service. These prior-authorizations meet the demands of insurers but do little if nothing to improve patient care or outcomes. The cumulative effort it takes to get prior-authorizations for every BH patient creates a hurdle that hampers the better coordination of PC and BH care.
These regulations create significant administrative work that must be completed for patients to get BH treatment, impeding efforts to integrate. The time and energy that is spent meeting these regulations would be better spent treating more patients, designing creative integrated-care approaches, and improving communication with other providers in the complex healthcare system.
Many situations arise in PC that require flexible BH care. For instance, there are patients who, though agreeing they have a BH problem, won’t attend a long BH evaluation, but they would consent to intermittent short sessions during PC visits. Other PC patients won’t admit that they have a BH problem, believing it is all physical, and will only engage in creatively designed BH treatments focused on their medical problems.
With this triad of BH regulations, it is difficult to offer such flexible BH care. Some clinics have unlicensed staff doing this work and do not bill for it. However, often these situations involve very difficult clinical issues and really require licensed BH clinicians.
These regulations also make offering groups for behavioral change challenging. For example, in order for our BH clinicians to run smoking cessation groups, each patient must complete a full BH evaluation, but many patients won’t jump through this hoop. This is true for other conditions such as drug abuse, chronic pain, and obesity as well. Furthermore, running groups to help prevent certain populations from developing BH problems is also impossible as we can’t get authorizations if there is not already a BH diagnosis.
In summary, while there is pressure to integrate BH care into PC, there remain barriers to achieving this. The triad of BH regulations described above present bureaucratic road blocks to offering faster and more flexible BH treatment in PC as well as preventative BH services.
To make behavioral care a functional reality for as many patients as possible, administrative tasks that impede service delivery at a time of limited access and behavioral health crisis must be eliminated. To do otherwise is not patient-centered, and it is counterintuitive to the very tenets of integrated, accessible and high-value healthcare that we seek as a nation!
In order to change these regulations, it will take a coordinated effort at both the state and federal levels.
In Connecticut, leaders at health centers can work with state agencies, for example the Department of Social Services, to reduce the requirement for cumbersome prior-authorizations for BH care; discussing this issue with state lawmakers is one possible first step.
If this were done, the agencies managing Connecticut’s Medicaid services could then direct more resources to further identifying the truly high utilizers and working to both meet the needs of those patients and contain costs. The regulations for a thorough intake evaluation and separate treatment plan come originally from the federal level.
As a vanguard of health reform using data to drive decisions, the leadership at Connecticut’s health clinics and supporting organizations could work together and discuss this issue with our senators and congresspersons and petition the directors of CMS to change these requirements to be more in tune with the delivery of high quality integrated services.
Dr. Cumberbatch is Director of Behavioral Health and Dr. Olson is Vice President for Clinical Services, both at Fair Haven Community Health Center in New Haven, Conn. They can be reached at firstname.lastname@example.org and email@example.com, respectively.