The Behavioral Health Integration Task Force in Massachusetts submitted recommendations aimed at improving health care quality and outcomes – while also controlling costs – to the state legislature and the newly created Health Policy Commission.
The task force, chaired by Department of Mental Health Commissioner Marcia Fowler, M.A., J.D., was created under Chapter 224 of the Acts and Resolves of 2012, which focuses on improving the quality and efficiency of health care delivery and payment systems – including the integration of primary care with behavioral health – as the next chapter in health care reform.
Fowler says the recommendations were submitted in July and she will meet with the Health Policy Commission (established under Chapter 224) to continue to work on key priorities from the recommendations, which offer an opportunity for early intervention and prevention of chronic mental health conditions, expanded access to treatment, prevention of early mortality from preventable physical disease and cost containment.
Elena Eisman, Ed.D., executive director, Massachusetts Psychological Association, was a member of the task force that met with key stakeholders over many months to form the recommendations. “I think one of the most important things we got in there is the broadening of the definition of behavioral health,” says Eisman, who worked to broaden the definition to include behavioral interventions in physical disease management, health promotion and/or the system of care. “We broadened it to include the work of health psychologists in the definition of behavioral health.”
Eisman says recommendations also address the need for adequate reimbursements to keep the system healthy; enforcement of parity laws; measures of success for behavioral health integration; and for medically necessary behavioral health services including collateral contacts, to be reimbursable outside of the medical/behavior health care setting (e.g., in educational, child welfare, juvenile justice and community and home settings).
Among other recommendations:
- Models for integration of behavioral health and primary care should be patient-centered, have peer supports, the use of appropriate screening tools and have care teams in integrated settings that include mental health providers.
- The task force notes the “historical failure” of the fee-for-service model and supports alternative payment methodologies, such as global payments that reimburse providers a fixed fee based on their enrolled patient panel and allows allocation tailored to the needs of the individual or family.
- Ensure reimbursement across all payers for behavioral health screening for children under 21.
- There should be no prior authorization required by insurers for admissions to inpatient psychiatric or detoxification facilities or for Clinical Stabilization Services, and the pre-approval requirement for first visits to non-emergency behavioral health services should be waived.
Recommendations also emphasize the need for provider training. “Behavioral health and primary care providers don’t talk the same language,” Fowler says. “We don’t really know about each other’s work as much as we need to and we have a shortage in the workforce. So one of the challenges we need to address is having a sufficient workforce and having a sufficiently trained and qualified workforce.”
One of the most divisive issues among stakeholders centered on privacy issues when dealing with electronic medical records. The task force recommends a tiered approach, with a set of rules governing disclosure of information within each tier, including provisions for patient choice of opt-in or opt-out of standard disclosure practices.
“There are a lot of people who are still unhappy with that,” Fowler says. “The doctors in the room weren’t happy with the opt-in language, and consumers weren’t happy with the opt-out.
“I think consumers have a right to be concerned, because they’ve experienced discrimination. Those things exist,” Fowler says. “But I think we need to bite the bullet somewhere and people need to realize their treatment outcomes will be compromised if the person giving them treatment doesn’t have all of the information. If we want integrated treatment, we need to have an integrated medical record.”
Fowler says the integration of behavioral health in primary care settings – whether it’s through co-location or other models – will increase access to services. “We’re not invested in one particular clinical model, but just that in any primary care setting, there is consultation linkage; particularly in prenatal and pediatric settings,” Fowler says. “We can’t ignore the data that 50 percent of chronic mental health conditions present prior to age 14 and 70 percent before 24. It’s vital that we pay attention to that data and integrate mental health into that setting where we know kids are going to be seen – by their primary care.”
Care coordination is a key element necessary to achieve quality integration. “We can’t expect all of this to happen in the doctor’s office, nor should it,” Fowler says. For example, a person with diabetes may benefit from a peer support group and support from a nutritionist. “It’s really those lifestyle changes that will have positive outcome and that’s true on the mental health side, as well,” she says.