By Katie Kerwin McCrimmon

Colorado health providers from small rural clinics to large urban health centers are trying to integrate physical and mental health care, but nearly all are struggling to pay for this proven innovation.

An inability to fund the care appears to be the biggest stumbling block to expanding integration efforts.

Preliminary results from a survey of 56 clinics around Colorado found that 70 percent of those surveyed had “no source of revenue” to cover costs of the services they were trying to provide. Clinics were writing off at least one-third of their expenses because they lacked revenues to support them. And billing systems are so complex that one respondent told of a single bill at large Denver hospital that 21 different people touched before it got paid.

Most of the providers were relying on grants to fund their integration efforts and few envisioned a sustainable way to pay for combined behavioral health and medical care.

The survey was conducted for a new project called Promoting Integrating Care Sustainability (PICS). The effort is being funded by the Colorado Health Foundation. The Collaborative Family Healthcare Association conducted the survey and interviews with providers to learn about obstacles to care. PICS leaders met this week to consider draft recommendations and are slated to release a full report in December. As part of the study, researchers also analyzed integrated care in California, Tennessee, Texas and Maine.

“I wish we could report that they have it figured out,” said Dr. Benjamin Miller, a clinical psychologist and assistant professor of family medicine at the University of Colorado School of Medicine, who is part of the team conducting the study and survey. “But this is something that everybody across the country is struggling with.”

Miller said study after study shows that integrated care works, especially for patients with depression, but also for patients with other conditions from obesity to diabetes.

“It works. Providers like it and patients like it. This is a good thing,” Miller said.

Colorado’s legislature this year passed HB 11-1242, which calls for state Medicaid managers to propose better ways to integrate physical and behavioral health.

Now the PICS group is poised to make recommendations for both short- and long-term solutions.

“This is a great first step at fighting fragmentation,” Miller said.

The needs are profound among patients who are coping with behavioral health woes that often lead to physical problems or the reverse: medical problems that spawn depression and other behavioral problems. Among adults:

  • More than 68 percent of adults with a behavioral health disorder have at least one physical health condition.
  • 29 percent of adults with a physical health condition also have a behavioral health disorder.
  • Roughly one in five people who have heart attacks become severely depressed.

The PICS survey found that children are in great need as well. The providers reported that nearly one-third of their patients were under 18 and nearly 65 percent of all patients were uninsured, had Medicaid or were covered through Colorado’s Indigent Care Program. About 40 percent of patients were male and 60 percent were female.

The providers ranged from very small clinics that served about 100 people a month to large urban systems that treated 31,000 patients per month. With respect to behavioral health visits, the clinics provided from 15 to 3,000 visits per month.  Primary care providers handle about 90 percent of visits while behavioral health experts handle 9 percent and a team with both a medical provider and a behavioral health expert saw 2 percent of the patients.

Among the short-term solutions the PICS group is proposing:

  • Clarifying billing regulations and training integrated care sites to optimize revenue sources.
  • Resolving confusion about  “same-day” billing for both physical and behavioral health services. Currently, providers struggle to bill for both services on the same day. The confusion results from separate funding streams and different paper work to bill for physical and behavioral health services.
  • Exploring the viability of using “Health and Behavior Assessment Codes.”  These codes allow providers to help patients with behavior change needed to successfully manage a physical health condition such as obesity or diabetes. Colorado Medicaid and private insurance companies currently do not reimburse for these codes. Other states use these codes and leaders see this as a transitional funding mechanism until they can find more permanent solutions.

Longer-term solutions include:

  • Testing “global funding” strategies. This type of model shifts away from paying providers per visit. Instead providers get paid a “global” fee to care for a patient over a designated period of time. Rather than paying for individual visits to a physical or a behavioral health provider, a care team provides whatever the individual needs to become stable and healthy. Over the long run, policy experts believe intensive care from a team of providers can help people stay healthier and thus save money.
  • Implementing a statewide data collection system so researchers and providers can measure the costs and quality of integrated care.

Dr. Kavita Patel, an internal medicine doctor and a national expert on integration at the Brookings Institution in Washington, D.C., attended the session this week and urged the group to be more ambitious.

“I don’t think that what you’ve recommended goes far enough,” said Patel, a former Obama Administration health expert, a former staffer for the late Sen. Edward Kennedy, and a former RAND Corp. researcher who also practiced medicine in both California and Oregon.

Patel predicted that the congressional “super-committee” in Washington will fail in its efforts to cut a deal on spending cuts by Thanksgiving.  But, she said that the need to make cuts in health care spending is not all bad. She said she’s hearing from congressional staffers who believe that integrated care and models like medical homes, which provide extensive high quality primary care, keep patients healthier and ultimately save money.

She said that the Affordable Care Act failed to address problems with delivery of health care.

“We didn’t fundamentally change delivery of care,” Patel said. “In Colorado, you can be one of the first to do this.”

Even so, she said practitioners need to be open to working directly with behavioral health experts and they need the data to prove that integrated care saves money.

She said Colorado is perceived as a national innovator on various health policy fronts and can produce grassroots change on integration as well.

“What you’ve done is reflective of why people who are inside the Beltway want to do anything we can to scale your ideas for the rest of the country.”

She said the attitude among health policy experts in Washington is: “Let’s all flood Colorado and try to copy it.”




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