Dale Jarvis on Changes to Healthcare Services: Organization, Funding & Delivery

by Dale Jarvis on October 3, 2010

Healthcare Reform Experts
The National Council welcomes guest blogger Dale Jarvis. Dale will be taking questions this week, beginning on Monday October 4.

The Patient Protection and Affordable Care Act is creating major changes.

Behavioral health providers, as members of the healthcare community, will likely be found in two parts of the diagram – embedded in healthcare homes supporting the delivery of primary care; and as specialty providers providing high quality behavioral health services to persons enrolled in their Accountable Care Organization.

Accountable Care Organization Diagram

This comprehensive approach has the potential to be a new and significant stabilizing force for the safety net population .

Click on “Comments” below to ask Dale a question!

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{ 35 comments… read them below or add one }

Patsy October 4, 2010 at 8:24 am

Will the private practice counseling/therapy realm be in part of this safety net?

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Dale Jarvis October 4, 2010 at 11:51 am

This is a wonderfully thought provoking question. I’m expecting that when medical homes ramp up and take more responsibility for ensuring that their patients health problems are properly addressed, the medical home staff will have more influence over the specialists patients see. In other words, a primary care physician won’t want a patient going to a surgeon that has a higher error rate than other surgeons in the community.
I expect this will carry over to behavioral health referrals. I think medical homes will create referral relationships with community behavioral healthcare organizations and private practice counselors and psychiatrists and help direct their patients to those they think will be of most help.
One colleague has suggested that clinicians in private practice should start marketing their services to their local physician practices immediately. This holds true for community behavioral healthcare organizations too.
As Accountable Care Organizations begin operations, community behavioral healthcare organizations and private practice clinicians will want to do the same with these groups.

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Amy H. October 4, 2010 at 8:33 am

I’ve been thinking about the new emphasis on integration of Behavioral Health and Primary Care and it sounds really good. I wonder if there has been any consideration given to training physicians to do Primary Care with an added year of training to incorporate Behavioral Health into their practices. How wonderful it would be for the bulk of mental health consumers to be able to go to ONE doctor and have several needs met. While it may not always work, there are enough “typical” Behavioral Health scenarios that a Primary Care doc could provide a lot of the care. I would also love to see more emphasis on training nurse practitioners and physicians’ assistants to provide maintenance-type care for BH patients. Would love to hear your thoughts.

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Dale Jarvis October 4, 2010 at 12:51 pm

You are talking about a world where the head has become reconnected to the body. This reconnection is occurring around the country at the local level much faster than it’s finding it’s way into the medical school curriculum. I was just in Colorado and they have almost one hundred pilots underway to integrate medical and behavioral healthcare; it’s quite exciting.
I have heard of efforts occurring at the medical school level, but can’t remember where this is occurring. Maybe other viewers of this blog can help.

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Patrick Gauthier October 5, 2010 at 7:01 pm

There are a number of schools around the country piloting “Behavioral Medicine” courses of study. I think it will catch on in consideration of conditions like obesity, diabetes and heart disease given that we (and the medical field) now know with much more certainty the dynamics at work between the mind and the body. We can no longer ignore the behavioral health aspects of these medical conditions

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Jalane Christian-Stoker October 4, 2010 at 8:41 am

Who is most likely driving the establishment of an Accountable Care Organization in any particular community?

Is there legislation mandating the formation of these ACO’s ?

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Dale Jarvis October 4, 2010 at 12:47 pm

The Affordable Care Act directs CMS (the Centers for Medicare and Medicaid Services) to create a national voluntary program for Accountable Care Organizations by January 2012. States are already designing ACO regulations and ACO pilots (Maine, Minnesota, Vermont, Massachusetts, Washington, etc.) Thus we are seeing states and the federal government leading this charge.
Locally, many physician practices and hospitals around the country are jumping on this idea and holding meetings to develop local ACOs so they can be prepared for the financial incentives embedded in these reform efforts.
I’ve been telling folks in the behavioral health community that they need to talk to the medical leaders in the community and find out where and when these meetings are occurring and get themselves invited. They can then pitch the case for how important quality behavioral healthcare services are to improving quality and bending the cost curve and how they can help the medical folks succeed in this brave new world.

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Alesha October 4, 2010 at 8:54 am

Hi Dale:

I work for a behavioral health provider in Ohio. We are one of 13 organizations funded by SAMHSA to offer intergrated care in a behavioral health setting for the severally mentally ill population.

Is it possible for behavioral health providers to bill private insurance for services ? Do you forsee this being an area where providers will need to become educated to access clients and new payment sources?

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Dale Jarvis October 4, 2010 at 2:25 pm

Congratulations on receiving one of the 13 first round SAMHSA integration grant. This was harder to win than getting into medical school (but not as hard as winning the lottery).
Now that the federal parity law is kicking in, more and more people, including those with a serious mental health or substance use disorder, will be able to use their insurance.
As the new Health Insurance Exchanges come online in 2014 with accompanying subsidies, many uninsured people with income levels between 133% and 400% of poverty will obtain insurance that includes behavioral health benefits. This will include many currently uninsured consumers of community behavioral healthcare organizations.
If you want to thrive in the new healthcare world, you need to be capable of getting on health plan provider panels, obtaining necessary authorizations, using credentialed providers, and billing and collecting for services. This is a BIG DEAL!

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Kristina October 5, 2010 at 5:39 pm

I work at a CMHC and have been working on integrating primary and behavioral healthcare for 3 years. One of the most significant issues for BH provider reimbursement w/ private insurance (and publicly funded programs) is access to the Health and Behavior Assessment codes which are allowed under Medicare. This service has proven to be extraordinaly valuable to our area and we can only provide it as we have a grant from the state to cover our costs as these codes are not available in MO.

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Dale Jarvis October 8, 2010 at 10:31 am

Thank you Kristina for this comment. We are encouraging states to add the Health and Behavior Assessment CPT Codes to their Medicaid State Plans. These include 96150-96155 (codes where mental health services are secondary to a primary care diagnosis); and codes in the following ranges: 90804-29, 90853-57, 90646-69es, and 99140-5 (codes where mental health services are primary). This may seem like just a bunch of numbers, but we are going to find that these codes are critical to improving quality and bending the cost curve for persons with mental health and substance use disorders. We will discover, sooner or later, that not including them in the state plan is another case of being penny wise and pound foolish.

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Pat Lynett October 4, 2010 at 10:04 am

I have placed phone calls to the Presidents’ office of 4 hospital systems in an effort to identify the system’s lead person related to the implementation of the Affordable Care Act. I understood, from previous Council information, that my agency(adult BH services) should seek opportunities to align with hospitals/large physician practices in order to be able to offer integrated medical and behavioral health care. The persons I have spoken with don’t seem to be working on this. Am I misunderstanding or miscommunicating the opportuntieis??

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Dale Jarvis October 4, 2010 at 2:33 pm

It’s great that you’re taking this assertive action. You are finding that hospitals don’t have a job title of “Affordable Care Act Implementer”.
Many hospitals are beginning to work on Accountable Care Organizations; see my comment to Jalane above. I think you want to inquire about their ACO efforts and begin a discussion of the importance of behavioral health services to the success of the ACO and how you can help.
The contact people vary from organization to organization. It might be the CEO, Medical Director, Director of Strategic Planning, or someone else. Good luck.

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Jerrold Melville October 4, 2010 at 10:13 am

In the process of integrating behavioral health and primary care, what protections will be in place to prevent the medicalization of psychiatric rehabilitation programs in the community ?

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Dale Jarvis October 8, 2010 at 9:38 am

The jury is still out. Each state is going to reorganize its healthcare system, taking advantage of the 100+ funding opportunities in the Affordable Care Act (or not) to improve quality and better manage costs. If State X “blows up” their psychiatric rehabilitation programs and replaces them with only a medical model they will almost certainly move backwards in helping citizens with mental health and substance use disorders better manage their total health expenditures. Meanwhile, State Y, which has used the ACA to implement robust, recovery oriented healthcare homes with a wider array of supports for persons with MH/SU disorders, will be improving the lives of their citizens and bending the cost curve. For me this is a timing question. How long it take for State X to “get it”?

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Jonathan Miller October 4, 2010 at 2:39 pm

A July 22nd New England Journal of Medicine article by John Iglehart (p. 304) discussed the dampening effect ACA anti-fraud provisions may have on medical homes and other forms of integrated practice. Quoting Lewis Morris, Chief OIG Counsel, the article noted that the ACA extends current anti-fraud policies that “limit economic ties between parties that are in a position to generate business for each other that would be paid for by a federal health care program.” While there has been some legislative interest in creating “safe harbors” for integrated practices, nothing specific has emerged. While evidence-based practice clearly supports an integrated model, current payment systems may make this criminal! What is NCCBH doing around this difficult issue, and how can providers advocate a unified position that will allow integrated practices to operate within the requirements of ACA and similar legislation?

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Dale Jarvis October 8, 2010 at 9:39 am

This is a very important issue for the National Council and the Obama Administration. In March 2010, two attorneys, Taylor Burke and Sara Rosenbaum, wrote another important article on the topic, “Accountable Care Organizations: Implications for Antitrust Policy”, that describes how medical groups can avoid antitrust problems under existing law and regulation. In the article they describe a case where the Federal Trade Commission “bought off” on a physician-hospital organization that includes a hospital and 212 physicians, both primary care and specialists, because their organization was designed to coordinate care and improve the health of their patients. You can find the article on the web. The Obama Administration is actively working on this issue through a multi-department task force in order to remove unnecessary barriers to integration and draw a clear line. This coming week the Federal Trade Commission, the Centers for Medicare and Medicaid Services and the Office of the Inspector General of the Health and Human Services Department are sponsoring a public meeting in Baltimore to address these issues. Stay tuned.

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Anita Everett October 5, 2010 at 4:59 pm

I am responding to an earlier question regarding medical education. There is a growth nationally of training programs that provide dual residency training in primary care and psychiatry. After medical school, instead of a typical 4 year residency training program in psychiatry or a typical three year training in pediatrics, family medicine or internal medicine, these Med-psych programs are five year combined programs that lead to joint board eligibility….they are usually called med psych or med peds programs. It is often hard to find a job that combines these practices…so comunity settings that easily support dual practices would be very desirable for these graduates. just a quick count on the ACGME (american council on graduate medical education) website revealed 16 training programs in internal medicine and payshicaty and 8 in family medicine and psychiatry. At least this is a start! Many community psychiatrists that I talk with do very basic medical treatments (diabetes, start hypertension treatment, etc). A big issue all around is funding these activities…which is why it is so great to have people with backgrounds like Dale’s interested in this area!

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Dale Jarvis October 8, 2010 at 9:41 am

Anita, thank you for adding your knowledge to the conversation. There are many timing questions and I believe this is one. We know that many wheels are turning (including several payment reforms) to make primary care a desirable occupation for medical school students and existing providers because the field is critical to changing our healthcare system from a “sick care” system to a true “health care” system. I’ve had the hypothesis that psychiatry is also going to become extremely important to improving quality and bending the cost curve and similar wheels will start turning.
In the field, the evidence is pointing to providing team supports to primary care providers, including a behavioral health clinician and a consulting psychiatrist, to get mental health and substance use services to people being served in primary care settings. The bi-directional evidence is still unfolding, but to appears to make most sense to put primary care providers into behavioral health centers rather than trying to retrain all psychiatrists as primary care providers. There is much to learn as we move forward with our integration efforts.

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Anita Everett October 5, 2010 at 5:08 pm

Reply to Pat Lynett…I am wondering if contacting your state affiliate of NCCBH or your state hospital association would help you find an answer regarding which hospitals are actively engaged in planning for accountable care organizations and other features of the federal healthcare reform, Acountable Care Act (ACA). The institution that I work for is huge and has all sorts of federal activity. Smaller local community hospitals probably gain much of their information through their state hospital association and their national affiliate American Hospital Association (AHA) and may be at very early stages of shock regarding figuring out the impact of ACA. You migth be able to help them solve a problem they are just figuring out they need to solve.

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Dale Jarvis October 8, 2010 at 9:43 am

Great suggestion. Your comment reminds me of a conversation I had last year with Brenda, Reiss-Brennan, a nurse practitioner who has been championing primary care-behavioral health integration at Intermountain Healthcare in Utah since 1985. Intermountain is considered by many to be the best healthcare system in the world! Brenda’s mantra to her primary care colleagues has been, “We (the behavioral health folks) can help you succeed in meeting the needs of your patients – and make your life easier.” What a concept!

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Trish October 7, 2010 at 11:49 am

There has been some discussion in our area of looking at person- centered health care homes bi-directionally. Private/non-profit SA providers are looking at what options there may be for becoming a health care home. Are you aware of existing assessments or preparation guides appropriate for determining direction/next steps?

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Dale Jarvis October 8, 2010 at 10:00 am

I have four suggestions. Interestingly enough, all roads lead back to the National Council.
First, Google the term, “substance use disorders and the person centered healthcare home”. Your first hit should be a rich and well researched paper written by my business partner, Barbara Mauer, for the National Council. This is my favorite starting point.
The Council also has a Resource Center for for Primary Care and Behavioral Health Collaboration containing other useful information. Again, you can Google this term.
Third, Google “assessment tool – Behavioral Health/Primary Care Integration” to find a tool that was developed in 2004 by the National Council. I don’t know of anything more current.
Finally, I would contact Kathy Reynolds, who is the Council’s primary care/behavioral health integration guru.
You will find from Barbara’s paper that Primary Care/Substance Abuse Integration is relatively new territory. Good luck!

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Steve October 7, 2010 at 4:24 pm

Hopefully healthcare reform will make it possible for patients to see a behavioral health clinician specificially trained to provide services at the primary care office. The clinician being one of the staff. This is true integration. Not everyone needs a therapist. Nor does everyone need to spend an hour a week with a therapist. Nor does every therapist even know how to treat co-morbid conditions be they physical, emotional or both. Patients deserve more than picking a name from a list.
New evidence-based practices make it possible to treat patients throughout their life span, perhaps bits at a time. Sometimes, they need meds. Most of the time they don’t. Psychiatrists are trained to dispense medication. Guess what treatment patients receive from psychiatrists? I’m not knocking it, I’m just stating a fact.

With integration, the “mental” stigma is substantially reduced, money is saved and everyone is happy. Everyone that is except the old school mental health providers who will fight amongst themselves as they always do as to who is deserving of being a BHC.

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Dale Jarvis October 8, 2010 at 10:13 am

Wow! What a rich comment. I met my wife 25 years ago when I was hired as the financial manager for a Community Health Center in Seattle. Diana, a Licensed Marriage and Family Therapist, had been hired to start mental health services in the five medical clinics in Seattle’s public housing projects. Much of what you say now was also true then.
What’s different is that we’re developing new, research-based, clinical models to treat mental health and substance use disorders in primary care and there are hundreds, if not thousands of pilot projects already underway.
I was just in Colorado and the existing network of community behavioral health providers has been working for over two years with the medical community on the ideas you discuss above. If you Google “cbhc integrated care mapping project” your first hit should be a link to this work. You will find a Google Map with nearly 100 color-coded projects. Click an icon on the map and you will drill down into greater detail that includes collaboration with Federally Qualified Health Centers, School Based Health Centers, Private Practices, Local Health Department or Social Services, Hospital/Medical Centers, and Community Non-profit Organizations. It’s very exciting to see this type of innovation occurring in an “industry” that’s been around for nearly 60 years.

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Steve Goldstein October 8, 2010 at 11:49 am

Dale-
It’s refreshing to hear that. I will definitely check out that site.

After 30 years in the business (state government analyst, local, private non-profit Director, CMHCs, etc.) I shut my private practice. I’ve returned to school and will be receiving my doctorate in behavioral health in a few months.

Over the past 10 months, I’ve been working in a independent family practice for my practicum and it’s been great for both myself and the practice. I’ve worked in many settings, but I could not receive this type of experience any place else. I work at no cost to the clinic, although they do bill for some of my services. Unfortunately, after practicum, I don’t believe even one day a week can be sustained financially (if you have any ideas, I’m open!).

As you are well aware, reimbursement is a huge problem. In fact, part of my final research project is finding the proper codes in order to bill for a BHC in today’s primary care practice (e.g.: E/M). I’m in CA and I know every state reimburses differently. Carve-outs have taken away many CPT codes. Patients can’t be seen for two things in one day. It seems like a fragmented tangled web of coding and rules. Some codes work in some places (e.g.: H&B) while not in others. Some insurance pays for such and such and other don’t. There do not seem to be any clear rules.

I will have a doctorate and an MFT license (MFT by default because it was the only license I qualified for in 1980). This is restrictive in today’s behavioral healthcare environment. As you know, MFTs and LPCs were taken out of health care reform at the last minute. Now there will be reimbursement and turf issues all over again. What a shame for consumers.

I hope any new directions my career may take, that I can help advocate in some manner for a saner system of providing behavioral health services to ordinary people.

Steve

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Dale Jarvis October 11, 2010 at 8:31 am

Who can provide care, what codes are available, and how much reimbursement is attached to those codes are all critical issues that we have to address at the state and federal level in order to ensure that the person with depression and diabetes is able to get care for their depression, which I consider a prerequisite to being able to manage their diabetes. Pick any other combination of behavioral health and physical health conditions and you have a different version of the same challenge.
Your comments relate to the “technical fixes” for healthcare reform. This is a ten-year work in process that will require many layers of legislation, pilot projects, advocacy, creativity, and hard work.
Best of luck to you and everyone else committed to supporting and promoting the ideas that behavioral health is part of health, prevention works, treatment is effective, and people recover. (taken from a speech given earlier this year by Pam Hyde, SAMHSA Administrator)

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Anne October 8, 2010 at 2:42 pm

With healthcare reform underway, I have seen a lot of focus on treating substance use disorders and mental health; where does prevention fit into the mix? How do we ensure prevention is a priority and support all providers in implementing evidence based approaches ?

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Dale Jarvis October 11, 2010 at 8:44 am

It’s quite simple. We can’t change the U.S. healthcare system from a “sick care” system to a true “health care” system without moving further upstream to help Americans move toward health and prevent health conditions from becoming chronic health conditions.
It’s interesting to note that 5 or 10 years ago insurance companies were saying that it didn’t pay to spend money on prevention because these services didn’t save them money. They claimed that because people switched coverage so frequently, longer term savings from prevention helped other insurance companies.
This attitude is changing and insurance companies are now reporting that spending on the “right” prevention services saves them money in the year those expenditures are made. The Accountable Care Act has codified this new approach and requires health plans to provide preventive services rated A or B (those proven to work) by the U.S. Preventive Services Task Force and waive the copay and deductible.
These are all very positive signs that we are moving in the right direction.

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Harriet October 8, 2010 at 4:42 pm

Thanks, Dale, for all the nice things you are saying about Colorado. But we still have so much futher to go in really making care integrated…. it is just a start – a really good start if I do say so but just a start – with many many challenges still to overcome.

Thanks also for doing this blog. Next time I’ll try to say something meaty and “rich”, but hey, it’s Friday afternoon late!

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Dale Jarvis October 11, 2010 at 9:04 am

When I was in Colorado recently, more than one person pulled me aside and said, “You’re telling me that Colorado is ahead of the pack in terms of primary care/behavioral health integration is a bit scary because we have so much more to do.”
But you are doing important and meaningful work; so are centers all over the country. Last night I finally watched the movie, The Soloist, and the final monologue of the Steve Lopez character provided a wonderful description of the grace involved in the work you do.
“I can tell you that by witnessing Mr. Ayers’s courage, his humility, his faith in the power of his art, I’ve learned the dignity of being loyal to something you believe in. Of holding onto it, above all else. Of believing, without question, that it will carry you home.”

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Michele October 14, 2010 at 1:14 pm

Will the new medical homes apply to healthcare settings outside of FQHC’s? I currently provide behavioral health services in an FQHC, and I would like to develop a private practice working with private healthcare practitioners. I am just curious if the mandates apply to ALL primary care settings, or just FQHC’s. Or, I should say that I’m wondering if I am marketable to private healthcare providers, or just those in FQHC’s.

Thank you!

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Diane Cross October 25, 2010 at 1:33 pm

We are a large non-profit that provides mental health, medical rehabilitation services , wrap around services ,and housing to children and adults with autism. We do not provide primary care or nursing.
We are currently reimbursed by MA and most insurance plans.
I am struggling to understnad how we will be affected? My concern lies in the “gatekeeper” notion that in order to save money we may no longer see referrals even though our outcomes are stellar.
Also, when do you think behavioral health programs like ourswill be impacted—2014? Thank you for providing this priceless information.

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Robert Irvin January 3, 2011 at 3:58 pm

Seeking information direction re: health care coverage, relative to California. Where might I find a discussion about;
how many sessions per year for mental health, medical, and substance use appointmentss. What types of services such as screening, assessment, routine check up and physicals are covered? For types of needs such as severe mentally ill, moderate problems, and mild problems are there any behavioral health services taking shape? Thank you.

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Amy A. January 4, 2011 at 8:51 pm

Greetings, I am so excited about this option. I sit as Vice Chair for the Multnomah County Health department who has for the past few years been developing the HEALTH HOME model. I am so much healthier since they began using the “TEAM” approach to healthcare, I am now wondering how PEER Support Specialists can be added to this requirement of the HOME model. I am working on developing a cirriculum that will have state support in billable service deliverys for Peers of the Mental health community. I do not see anywhere where PEER support services become a part of the process. Most of the agencies I work with desire to have a program led, ran and developed by PEERS to better support individuals with Chronic Health Conditions. How can we establish a section to add this style of Prevenative health care service delivery?

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