Funding Integrated Primary Care

Because the US healthcare system is essentially 50 state health systems plus Medicare, it is very hard to make statements about how to adequately fund Integrated Primary Care that are true in all locations, much less in other countries.  This page is a gradually growing collection of facts and ideas about how to use existing payment mechanisms to fund IPC.  We will try to be clear about where each applies, but this will not always be possible.  As a general rule, there is a combination of diligence in understanding and using current regulations and advocacy for small changes in accounting and payment practices required to make it work financially.  Everyone at this stage is still creating their own arrangement.  Turn key approaches are still a thing of the future.  The information on the Cost Effectiveness page can be brought into play in the advocacy for changes in accounting and payment practices.  Showing that the presence of a behavioral health practitioner in the flow of primary care increases the number of patients the physician can see and bill for, or allows for increased coding for the services provided, or reduces the utilization of the emergency department by certain patients, can be as important to building a foundation for funding as increased behavioral health billing.  These, in turn, require sophisticated administrative systems to provide the necessary documentation to demonstrate a program's viability.  The "did you bill what you cost" approach to administrative accounting only works in a system where separate service lines are designed to stay separate.  Integration of programs takes integration of administrative and fiscal practices.

The Politics of Health and Behavior Codes:  The "health and behavior codes" (96150-96155) are billing codes that pay for behavioral health services for patients without a psychiatric diagnosis.  They can be used for services to support medical compliance, health behavior change, relaxation response therapies for many chronic illnesses, other behavioral health components of medical treatment for chronic illness such as group visits for diabetes.  Check the Indications for Coverage from the CMMS Website. In several states, the implementation of these codes have made integrated care financially viable in Federally Qualified Health Centers. Because they are medical and not mental health codes, they are treated as medical services and paid from the medical benefit.  Usually there is no need for pre-authorization or onerous multi-disciplinary sign-off.  Medicaid in each state is mandated to fund them in FQHCs by HRSA Program Information Notice.  Presently compliance is uneven.  Only in a few states (eg, Arizona) have health providers actively advocated for the state to comply with the PIN and therefore achieved a difference in reimbursement possibilities. Requirements for documentation. The same advice from Medicare. Advice on solving some billing problems with H-B codes. Wisconsin Medicaid has an Update about Health and Behavior Codes.  They are paying them.

SAMHSA put out guidance for reimbursement for mental health services in primary care.

The National Association of State Medicaid Directors has also put out a study on mental health services for Medicaid participants in primary care.

HRSA's web seminar on billing for behavioral health in primary care for HRSA-funded

Grantmakers in Health: Integrating Mental Health Services and Primary Care, Findings from the Grantmakers in Health Resource Center.

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