Many people in the United States live with a mental illness, and far too many suffer needlessly despite proven treatments to ease such suffering. Children are no exception. A report of the Surgeon General in 1999 estimated that 1 in 5 children have a diagnosable mental disorder but that only 20% to 25% receive treatment.1,2
Current estimates are similar, with about 1 in 5 adolescents aged 13 to 18 years expected to experience a severe mental disorder at some point in their life. In addition, most chronic mental illness begins by age 24 years with half of all cases beginning by age 14 years. Treatment for many of these children is delayed for years.3
One reason given for this dismal response is the challenge to children and their families in gaining access to services as well as continual follow-up once on treatment. What the 1999 report recommended as a solution to this access and continuity of care problem is the solution that stands today: making mental health a part of the medical home.
Despite this need, recognized over 16 years ago, the quality of care provided for mental health disorders in the primary care setting remains inadequate.4
A call for change
The need to change is highlighted by the long recognition that treatment of mental illness is highly successful and, for children in particular, imperative to catch early to halt the cascade of emotional and behavioral difficulties that often get worse over time if left unaddressed.
The burden on patients, families, and society is great, and in cost terms alone, unsustainable. Mental disorders are among the top chronic medical diseases driving healthcare costs, with a 2009 report by the Agency for Healthcare Research and Quality (AHRQ) listing mental health disorders in children aged younger than 18 years as incurring the highest expense for children. In 2006, cost to treating children with mental disorders totaled $8.9 billion.5
The incentives to make mental health services more accessible and better used are there, but pediatricians, like many physicians on the front lines of care, grapple with how to do this.
One approach singled out in the above mentioned 1999 report is to integrate mental health services into the primary care setting. Jay Rabinowitz, MD, FAAP, a clinical professor in the Department of Pediatrics at the University of Colorado in Denver, recently spoke to pediatricians at the 2016 American Academy of Pediatrics (AAP) annual conference on the need for better access and use of mental health services for pediatric patients as well as ways to address this need by integrating these services in the primary care setting.
In his talk “Integrating mental health services in the primary care office,” Rabinowitz, who practices at Parker Pediatrics and Adolescents, a comprehensive pediatric practice in Parker, Colorado, highlighted things he and his colleagues have learned over the 8 years in which they have succeeded in integrating mental health services in their clinic.
Why integrate services?
The reasons to integrate mental health services into the primary care setting are many, affecting both patients and providers. Along with the statistics cited above on the prevalence of mental disorders, Rabinowitz emphasizes that pediatricians are seeing more and more mental health issues in their patients and in most cases don’t have the easy means to manage them. “Mental health has always been carved out of the insurance contract,” he says. “We can see a child for pretty much anything medically, but if they have a mental health issue they need to go to a mental health organization.”
Unlike referral for other medical conditions, say to an otolaryngologist for an ear problem, in which pediatricians are kept in the loop and can track the follow-up care of these children, when children are referred out for mental health services, no such follow-up is done. This lack of continuity of care disempowers pediatricians from providing the best care to their patients, making it difficult to know which patients actually see an outside mental health specialist and receive and adhere to treatment.
Integrating mental health services within the primary care setting would help to provide this continuity of care and benefit a myriad of issues faced by children with mental illness and the pediatricians who care for them (Table 1).
Set up an integrated practice
Although Rabinowitz thinks that many pediatricians recognize the need for and want to integrate mental health services into their practices, he emphasizes that the question that everyone is asking is, “How do you do it?”
In his presentation at the AAP conference, he described several steps that practices can take to set up a successful integrated practice. First and foremost, he says, is a commitment by the practice to integrating mental health services. Such a commitment will include assigning responsibilities to select people to set up the integration and a time line to do so.
Once this commitment is in place, the next steps basically fall into 2 categories: procedural (how to set up the mental health services within the primary care practice) and reimbursement (how to charge for these services).
Fundamentally, the goal of setting up an integrated practice is to provide easy access to and continuity of care. As such, the procedural issues that pediatricians and practices need to think about to achieve these goals include the type of arrangements they want to create, the type of providers to carry out the mental health services, the types of mental health issues addressed (or referred out), and specific protocols to use to carry out these functions (Table 2).
For example, a practice may choose to hire a mental health provider as an employee to work in the practice, or it may choose to partner with a mental health provider who is in the same building, or it may work with a mental health consultant.
Whatever arrangement is made, the practice physicians will need to determine the type of provider they want to work with (eg, psychologist, social worker), the type of mental health issues they will address or refer out, and how to incorporate the provider into their practice (protocols).
Rabinowitz emphasizes the importance of narrowing down the types of mental health issues that a practice is willing to treat. At his clinic, for example, physicians address issues such as attention-deficit/hyperactivity disorder, depression, anxiety, and divorce- and behavior-related problems but refer patients out with more severe illnesses such as bipolar disease.
Taking the preceding steps to set up an integrated practice will help practices put in place the means to provide mental health services, but the biggest challenge remains: how to charge for those services.
“The biggest challenge to integrating mental health services is reimbursement,” says Rabinowitz, who describes a number of barriers that practices can face in gaining adequate compensation for mental health services (Table 3).
A main barrier, he says, is the lower reimbursement rate for submitting mental health claims using mental health codes. “Medical codes get reimbursed better than psych codes,” he says, “so if you bill medically and use medical codes you get better reimbursement.”
Rabinowitz says that his clinic initially used psych codes for reimbursement but found the reimbursement rates insufficient for covering the cost of running a medical office. His clinic switched to using standard evaluation and management (E/M) codes that, he says, work well.
In order to use E/M codes, however, he emphasizes the need to work with insurance companies and Medicaid to ensure these codes can be used to reimburse mental health services rendered. Saying that most insurance companies contract with behavior health organizations and therefore are limited in negotiating written agreements to honor E/M codes for reimbursement for mental health services, he nonetheless says that his clinic has been able to negotiate agreements by select insurance companies to use E/M codes for this reimbursement.
For Medicaid, he stresses the importance of getting written permission to use E/M codes for mental health services reimbursement.
Calling this arrangement a “financial integration” reimbursement model, Rabinowitz stresses that using this type of reimbursement option requires research to come up with a reimbursement structure that works within regional/state laws (Table 4). “Each state has its own rules as to what is allowed,” he notes.
For example, Rabinowitz and his colleagues researched and discovered a law in Colorado that allowed registered nurses working under a licensed dermatologist or plastic surgeon to be reimbursed for providing skin cosmetic services (ie, Botox). He says that his clinic physicians have applied this rule in their practice to successfully get reimbursement for mental health services provided by their in-house mental health provider.
Along with working with state laws to find ways to get reimbursed by private insurers, Rabinowitz emphasizes the importance of negotiating with a state Medicaid representative to get reimbursement of coverage for children covered by Medicaid.
As the number of children with mental health issues increases, so does the need to find better ways to get these children the help they need. One way is to provide easier access and continuity of care by integrating mental health services into the primary care setting.
To do this, pediatric practices need to think about the type of arrangement that works best for their particular practice, the type of provider to use, and protocols that will help the integration run smoothly and well.
Critical and most challenging is the need to find a reimbursement option that permits sufficient reimbursement for mental health services to make integration a viable option. Practices will need to research and work with state laws and private insurance plans to develop a reimbursement plan that works best for them.
1. US Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. https://profiles.nlm.nih.gov/ps/access/NNBBHS.pdf. Accessed February 24, 2017.
2. American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics Task Force on Mental Health. Improving mental health services in primary care: reducing administrative and financial barriers to access and collaboration. Pediatrics. 2009;123(4):1248-1251. Erratum in: Pediatrics. 2009;123(6):1611.
3. National Alliance on Mental Illness. Mental health by the numbers. Available at: http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers. Accessed February 24, 2017.
4. O’Connor BC, Lewandowski RE, Rodriguez S, et al. Usual care for adolescent depression from symptom identification through treatment initiation. JAMA Pediatr. 2016;170(4):373-380.
5. Soni A. The five most costly children's conditions, 2006: estimates for the US civilian noninstitutionalized children, ages 0-17. Statistical brief #242. Rockville, MD: Agency for Healthcare Research and Quality; 2009. Available at: https://meps.ahrq.gov/data_files/publications/st242/stat242.pdf. Accessed February 24, 2017.