Improving Payment for Collaborative Mental Health Care in Primary Care.

BACKGROUND: There is strong evidence supporting implementation of the Collaborative Care Model within primary care. Fee-for-service payment codes, published by Current Procedural Terminology in 2018, have made collaborative care separately reimbursable for the first time. These codes (ie, 99492-99494) reimburse for time spent per month by any member of the care team engaged in Collaborative Care, including behavioral care managers, primary care providers, and consulting psychiatrists. Time-based billing for these codes presents challenges for providers delivering Collaborative Care services. OBJECTIVES: Based on experience from multiple health care organizations, we reflect on these challenges and provide suggestions for implementation and future refinement of the codes. CONCLUSIONS: Further refinements to the codes are encouraged, including moving from a calendar month to a 30-day reimbursement cycle. In addition, we recommend payers adopt the new code proposed by the Centers for Medicare and Medicaid Services to account for smaller increments of time.

Medication access and continuity: the experiences of dual-eligible psychiatric patients during the first 4 months of the Medicare prescription drug benefit.

OBJECTIVE: This study attempted to systematically assess the experiences of Medicare and Medicaid "dual-eligible" psychiatric patients, including evaluating patients' access to medications and the administrative functioning of the program, during the first 4 months of the Medicare Part D prescription drug benefit. METHOD: Psychiatrists (N=5,833) were randomly selected from the American Medical Association's Physicians Masterfile. After exclusion of those not practicing and with undeliverable addresses, 64% responded; 35% met study eligibility criteria of treating at least one dual-eligible patient during their last typical workweek and reported clinically detailed information on one systematically selected patient. RESULTS: A total of 53.4% had at least one medication access problem to report between Jan. 1 and April 30, 2006. Although 9.7% experienced improved medication access, 22.3% discontinued or temporarily stopped taking medication because of prescription drug coverage or management issues, and 18.3% were previously stable but were required to switch medications. Among those with medication access problems, 27.3% experienced a significant adverse clinical event; 19.8% had an emergency room visit. Most drug plan features studied, including preferred drug/formulary lists, prior authorization, medication dosing/number limits, "fail-first" protocols, and requirements to switch to generics, were associated with significantly higher rates of medication access problems. CONCLUSIONS: The findings indicate consequential medication access problems for psychiatric patients during the implementation of Medicare Part D. Although Centers for Medicare and Medicaid Services policies were enacted to ensure access to protected classes of psychopharmacologic medications, the high rates of medication access problems observed indicate further refinement of these policies is needed.

Clinically unintended medication switches and inability to prescribe preferred medications under Medicare Part D.

Medicare Part D has expanded medication access; however, there is some evidence that dually eligible psychiatric patients have experienced medication access problems. The aim of this study was to characterize medication switches and access problems for dually eligible psychiatric patients and associations with adverse events, including emergency department visits, hospitalizations, homelessness, and incarceration. Reports on 986 systematically sampled, dually eligible patients were obtained from a random sample of practicing psychiatrists. A total of 27.6% of previously stable patients had to switch medications because clinically indicated and preferred refills were not covered or approved. An additional 14.0% were unable to have clinically indicated/preferred medications prescribed because of drug coverage/approval. Adjusting for case-mix, switched patients (p = 0.0009) and patients with problems obtaining clinically indicated medications (p = 0.0004) had significantly higher adverse event rates. Patients at greatest risk were prescribed a medication in a different class or could not be prescribed clinically-indicated atypical antipsychotics, other antidepressants, mood stabilizers, or stimulants. Patients with problems obtaining clinically preferred/indicated antipsychotics had a 17.6 times increased odds (p = 0.0039) of adverse events. These findings call for caution in medication switches for stable patients and support prescription drug policies promoting access to clinically indicated medications and continuity for clinically stable patients.

Meeting the mental health needs of low-income immigrants in primary care: a community adaptation of an evidence-based model.

Low-income, uninsured immigrants are burdened by poverty and a high prevalence of trauma exposure and thus are vulnerable to mental health problems. Disparities in access to mental health services highlight the importance of adapting evidence-based interventions in primary care settings that serve this population. In 2005, the Montgomery Cares Behavioral Health Program began adapting and implementing a collaborative care model for the treatment of depression and anxiety disorders in a network of primary care clinics that serve low-income, uninsured residents of Montgomery County, Maryland, the majority of whom are immigrants. In its 6th year now, the program has generated much needed knowledge about the adaptation of this evidence-based model. The current article describes the adaptations to the traditional collaborative care model that were necessitated by patient characteristics and the clinic environment.

First-year Medicare Part D prescription drug benefits: medication access and continuity among dual eligible psychiatric patients.

OBJECTIVE: This study provides national data on medication access and continuity problems experienced during the first year of the Medicare Part D prescription drug program, which was implemented on January 1, 2006, among a national sample of Medicare and Medicaid "dual eligible" psychiatric patients. METHOD: Practice-based research methods were used to collect clinician-reported data across the full range of public and private psychiatric treatment settings. A random sample of psychiatrists was selected from the American Medical Association Physician Masterfile. Among these physicians, 1,490 provided clinically detailed data on a systematically selected sample of 2,941 dual eligible psychiatric patients. RESULTS: Overall, 43.3% of patients were reported to be unable to obtain clinically indicated medication refills or new prescriptions in 2006 because they were not covered or approved; 28.9% discontinued or temporarily stopped their medication(s) as a result of prescription drug coverage or management issues; and 27.7% were reported to be previously stable on their medications but were required to switch medications. Adjusting for case mix to control for sociodemographic and clinical confounders, the predicted probability of an adverse event among patients with medication access problems was 0.64 compared to 0.36 for those without access problems (P < .0001). All prescription drug utilization management features studied were associated with increased medication access problems (P < .0001). Adjusting for patient case mix, patients with "step therapy" (P < .0001), limits on medication number/dosing (P < .0001), or prior authorization (P < .0001) had 2.4 to 3.4 times the increased likelihood of an adverse event. CONCLUSIONS: More effective Part D policies and management practices are needed to promote clinically safer and appropriate pharmacotherapy for psychiatric patients to enhance treatment outcomes.

Medicaid prescription drug policies and medication access and continuity: findings from ten states.

OBJECTIVES: The aims of this study were to compare medication access problems among psychiatric patients in ten state Medicaid programs, assess adverse events associated with medication access problems, and determine whether prescription drug utilization management is associated with access problems and adverse events. METHODS: Psychiatrists from the American Medical Association's Masterfile were randomly selected (N=4,866). Sixty-two percent responded; 32% treated Medicaid patients and were randomly assigned a start day and time to report on two Medicaid patients (N=1,625 patients). RESULTS: A medication access problem in the past year was reported for a mean+/-SE of 48.3%+/-2.0% of the patients, with a 37.6% absolute difference between states with the lowest and highest rates (p<.001). The most common access problems were not being able to access clinically indicated medication refills or new prescriptions because Medicaid would not cover or approve them (34.0%+/-1.9%), prescribing a medication not clinically preferred because clinically indicated or preferred medications were not covered or approved (29.4%+/-1.8%), and discontinuing medications as a result of prescription drug coverage or management issues (25.8%+/-1.6%). With patient case mix adjusted to control for sociodemographic and clinical confounders, patients with medication access problems had 3.6 times greater likelihood of adverse events (p<.001), including emergency visits, hospitalizations, homelessness, suicidal ideation or behavior, or incarceration. Also, all prescription drug management features were significantly associated with increased medication access problems and adverse events (p<.001). States with more access problems had significantly higher adverse event rates (p<.001). CONCLUSIONS: These associations indicate that more effective Medicaid prescription drug management and financing practices are needed to promote medication continuity and improve treatment outcomes.