NUTS

Financing is probably the most common perceived barrier in implementing integrated or collaborative mental health care. However, integrated health care is fundable in nearly every state right now! Even with the state by state difference in Medicaid programs, the complexity of Medicare billing, and uniqueness of healthcare coverage for those we serve, there are short term solutions that allow programming to proceed and services to be provided in integrated programs. In Medicaid fee-for-service and capitated states there are nearly a dozen ways to fund collaborative care and integrated mental health care initiatives.

The Community’s Money -

A consistent barrier in financing integrated healthcare services is that organizations think of the funding in a siloed way. It’s not uncommon to hear “this is my money” or “our money.” With this old approach to financing, the outcomes often need to benefit the organization and sometimes even the individuals within an organization. Success with financing integrated care requires a paradigm shift that involves putting the consumers’ and community’s best interest first. Agencies and organizations are stewards of the public money. It is a behavioral healthcare organization’s responsibility to make behavioral health resources available to the community as part of a package of services. This approach to financing integrated healthcare results in creative, effective service packages that meet everyone’s needs.

Generating the Will -

In these difficult financial times it seems natural to hunker down and wait for things to improve. Now, more than ever is the time to be creative and to stretch mental health resources to the maximum and assist consumers in their path to recovery. It may seem counter-intuitive but now may be when change is most possible and most effective. Now is the time to get the most creative financial minds together with the most conservative financial minds and hammer out exactly what is possible with the funding that is received. Partnering and collaboration are often keys to making money go further. This is particularly true in integrated healthcare where shared resources improve consumer outcomes while enhancing the bottom line of all the partners.

Advocating for State Level Medicaid Changes -

Medicaid regulations are made state by state in this country. This is both a blessing and a curse. A blessing in that there is often more ability to influence state policy rather than federal policy and a curse because the same work has to be done 50 times! A number of states already allow for billing two services on one day. It is possible to get a copy of that policy work in one state and work with another state to implement it.

Tips for Financing Mental Health Services Right Now -

Two series of codes are already approved for commercial, Medicare and Medicaid billing: SBIRT (Screening, Brief Intervention, Referral and Treatment) and the Health and Behavior Assessment/Intervention (96150-96155). The Health and Behavior Assessment/Intervention codes can be used to bill a behavioral health service ancillary to a primary care diagnosis. This would include providing services regarding chronic care management such as diabetes care, cardiac support, and consulting and assistance with COPD management. SBIRT can be billed in the primary care setting for screening for substance use/abuse.

In Wisconsin, case/care management services are billable for primary settings working with individuals with a serious mental illness. In Michigan the Primary Care Association has negotiated a memorandum of understanding that allows for FQHCs to bill two services in one day (www.mpca.net). In states where two services rendered on one day by one provider are not billable, programs have found innovative ways to collaborate that allow both partners to bill, using two provider numbers to provide the services. They key here is creative, collaborative thinking that maximizes the current financing options. Improving the health status of those we serve requires all of us to come to the table and work within existing financing structures to find solutions rather than use financing as way to delay discussions.

In states where capitation is used, it often provides the flexibility for local decision-making regarding services and funding. Don’t be afraid to expand thinking about creative ways to secure better outcomes by integrating staff into primary care setting to provide mental health services. Often, it requires no new approvals for mental health centers to provide community based services. In fee for service states, review the regulations and find any way you can to bill for services at a primary care site. You’ll generate better health outcomes and support your organization’s bottom line.

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Mental health disorders and mental illnesses affect a greater number of children and juveniles than many people are aware of. These emotional and behavioral disorders can have profound negative effects on the growth and development of children, especially when they go unnoticed and untreated. A greater proportion of children and youth in the child welfare and juvenile justice systems have mental health problems than children and youth in the general population.

-50% of children and youth in the child welfare system have mental health problems.
-67% to 70% of youth in the juvenile justice system have a diagnosable mental health disorder.

Prevalence Estimates of Mental, Emotional and Behavioral Disorders In Young People

DISORDER                                            PERCENTAGE OF YOUNG PEOPLE AFFECTED

Learning D/O:                                                                5%
Substance use / addiction disorder:                                  10.3%
CD:                                                                              3.5%
ODD:                                                                            2.8%
ADHD:                                                                           4.5%
Anxiety Disorders (various):                                             8%
Unipolar Disorder:                                                           5.2%
One or more disorders:                                                   17%

(D/O = Disorder; CD = Conduct Disorder; ODD = Oppositional Defiant Disorder; ADHD = Attention Deficit Hyperactivity Disorder Source: Preventing Mental, Emotional and Behavioral Disorders Among Young People, 2009. National Research Council and Institute of Medicine, of the National Academies.)

Early Detection and Intervention are Critical

The onset of major mental illness may occur as early as 7 to 11 years old.
-Research supported by the National Institute of Mental Health indicates that half of adults with MEB disorders were first diagnosed by age 14 and three fourths were diagnosed by age 24.  
-Factors that predict mental health problems can be identified in the early years, with children and youth from low-income  households at increased risk for mental health problems.  

Age at Onset of First Symptom of Full Psychiatric Disorder, by Age 21

DISORDER                        AVG. AGE OF FIRST SYMPTOM            AVG. AGE OF FIRST DIAGNOSIS

ADHD:                                            Age 5                                                 Age 5
ODD:                                              Age 5                                                 Age 10
CD:                                                Age 6                                                 Age 11
Anxiety Disorders (Various):              Age 7                                                 Age 8
Depression:                                     Age 12                                               Age 15
Substance Abuse:                             Age 14                                               Age 15
Substance Dependence:                    Age 16                                               Age 17
Any Psychiatric Diagnosis:                  Age 9                                                 Age 11

(Source: Preventing Mental, Emotional and Behavioral Disorders Among Young People, 2009. National Research Council and Institute of Medicine, of the National Academies)

Obstacles to Access and Quality in Mental Healthcare

Several federal commissions and workgroups federal task forces have documented the need for improved and expanded mental health services for children and youth.

-It is estimated that less than 1 in 5 of these children receive the appropriate needed treatment  
-Only 15% of youths who had difficulties had parents that actively talked to a health care provider or school staff about their child?s emotional or behavioral difficulties.  

There is not adequate financial support for quality services to prevent and treat mental health problems of children and youth. Many child mental health services are not covered by managed care payers. In 2007, 3.1 million youths, (12.5 percent of 12 to 17 year olds) received treatment or counseling for problems with behavior or emotional disturbances in specialty mental health settings (which include inpatient and outpatient care).

Effective Treatment and Prevention Exists

Clear windows of opportunity are available to prevent MEB disorders and related problems before they occur. An intervention before a disorder manifests itself is possible and offers the best opportunity to protect young people. Effective prevention includes strengthening families by targeting problems, strengthening individuals by building resilience and skills, preventing specific disorders by screening individuals at risk, promoting mental health in schools and promoting mental health through health care and community programs. The key to most approaches is to identify risks (biological, psychological and social factors) that may increase a child?s risk of MEB disorders.