Integrating Behavioral Health Into Primary Care
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Integrating Behavioral Health into Primary Care A Technology Assessment Final Report June 2, 2015 Completed by: Institute for Clinical and Economic Review ©Institute for Clinical and Economic Review, 2015 i AUTHORS: Jeffrey A. Tice, MD Associate Professor of Medicine, Division of General Internal Medicine, Department of Medicine, University of California San Francisco Daniel A. Ollendorf, PhD Chief Review Officer, Institute for Clinical and Economic Review Sarah Jane Reed, MSc Program Director, Institute for Clinical and Economic Review Karen K. Shore, PhD Program Director, Institute for Clinical and Economic Review Jed Weissberg, MD, FACP Senior Fellow, Institute for Clinical and Economic Review Steven D. Pearson, MD, MSc President, Institute for Clinical and Economic Review DATE OF PUBLICATION: June 2, 2015 We wish to thank all of the national and program experts for their time participating in key informant interviews for this report. We would also like to thank Erin Lawler, Anne Loos, Matt Seidner, and Patricia Synnott of ICER for their contributions to this report. ©Institute for Clinical and Economic Review, 2015 ii About ICER The Institute for Clinical and Economic Review (ICER) is an independent non-profit research organization that evaluates medical evidence and convenes public deliberative bodies to help stakeholders interpret and apply evidence to improve patient outcomes and control costs. ICER receives funding from government grants, non-profit foundations, health plans, provider groups, and health industry manufacturers. Through all its work, ICER seeks to help create a future in which collaborative efforts to move evidence into action provide the foundation for a more effective, efficient, and just health care system. More information about ICER is available at www.icer-review.org. About CTAF The California Technology Assessment Forum (CTAF) – a core program of ICER – reviews evidence reports and provides a public venue in which the evidence on the effectiveness and value of health care services can be discussed with the input of all stakeholders. CTAF seeks to help patients, clinicians, insurers, and policymakers interpret and use evidence to improve the quality and value of health care. CTAF is supported by grants from the Blue Shield of California Foundation and the California HealthCare Foundation. The CTAF Panel is an independent committee of medical evidence experts from across California, with a mix of practicing clinicians, methodologists, and leaders in patient engagement and advocacy, all of whom meet strict conflict of interest guidelines, who are convened to evaluate evidence and vote on the comparative clinical effectiveness and value of medical interventions. More information about CTAF is available at www.ctaf.org. About CEPAC The New England Comparative Effectiveness Public Advisory Council (CEPAC) is an independent, regional body of practicing physicians, methodological experts, and leaders in patient advocacy and engagement that provides objective, independent guidance on the application of medical evidence to clinical practice and payer policy decisions across New England. Council members are elected for three-year terms and represent a diversity of expertise and perspective; they are purposely not selected for expertise in the clinical topic under discussion in order to maintain the objectivity of the Council and to ground the conversation in the interpretation of the published evidence rather than anecdotal experience or expert opinion. Led by ICER, CEPAC is supported by a broad coalition of state Medicaid leaders, integrated provider groups, public and private payers, and patient representatives. For more information on CEPAC, please visit www.cepac.icer-review.org. ©Institute for Clinical and Economic Review, 2015 iii Table of Contents List of Abbreviations Used in this Report............................................................................................... v Executive Summary ............................................................................................................................ ES1 Introduction ........................................................................................................................................... 1 1. Background ........................................................................................................................................ 3 2. BHI in Context: Barriers, Opportunities, and other Considerations for Integrated Care .................. 9 3. Existing Approaches to Integrated Care Delivery ............................................................................ 23 4. Clinical Guidelines and Policy Statements ....................................................................................... 27 5. Coverage and Reimbursement Policies ........................................................................................... 29 6. Ongoing US Studies .......................................................................................................................... 35 7. Evidence Review (Methods & Results) ............................................................................................ 38 8. Comparative Value of BHI ................................................................................................................ 57 9. CEPAC and CTAF: Voting Process and Results ................................................................................. 78 10. Recommendations to Guide Practice and Policy ........................................................................... 85 References ........................................................................................................................................... 98 Appendix A: Prevalence of Mental Health Disorders ........................................................................ 118 Appendix B. Patient Confidentiality Legislation: New England and California .................................. 120 Appendix C. Summary of BHI in New England SIM Efforts ................................................................ 122 Appendix D. Key National Models for BHI ......................................................................................... 124 Appendix E. Sample Worksheets for Practice-Level Expenses Associated with BHI ......................... 127 Appendix F: CTAF and CEPAC Conflict of Interest Policy ................................................................... 134 Appendix G: Key Informant Interviews .............................................................................................. 135 Appendix H: CTAF and CEPAC Voting Results .................................................................................... 137 Appendix I. Billing and Reimbursement for BHI ................................................................................ 140 Appendix J: Policy Roundtable Panelists: CTAF and CEPAC ............................................................... 141 ©Institute for Clinical and Economic Review, 2015 iv List of Abbreviations Used in this Report AACP: American Association of Community Psychiatrists AAFP: American Academy of Family Practice ACA: Affordable Care Act ACO: Accountable care organization ACT: Advancing Care Together ADP: Department of Alcohol and Drug Programs AHRQ: Agency for Healthcare Research and Quality AIMS: Advancing Integrated Mental Health Solutions ANP: Advanced nurse practitioner BHC: Behavioral health consultant BHI: Behavioral health integration BCBSMA: Blue Cross Blue Shield of Massachusetts BMI: Body mass index BSCA: Blue Shield of California CALM: Coordinated Anxiety Learning and Management CBOC: Community-based outpatient clinic CBT: Cognitive behavioral therapy CCM: Collaborative Care Model CEPAC: Comparative Effectiveness Public Advisory Council CHEC: Consensus on Health Economic Criteria CHW: Community Health Worker CIHS: Center for Integrated Health Solutions CMS: Centers for Medicare & Medicaid Services CMMI: Center for Medicare & Medicaid Innovation CNS: Clinical Nurse Specialist COPD: Chronic obstructive pulmonary disease CPI: Consumer Price Index CPT: Current Procedural Terminology CT: Connecticut CTAF: California Technology Assessment Forum DHCS: Department of Health Care Services DMH: Department of Mental Health E&M: Evaluation and Management ED: Emergency department EHR: Electronic health record EPHC: Enhanced Personal Health Care FFS: Fee-for-service FQHC: Federally qualified health center ©Institute for Clinical and Economic Review, 2015 v FTE: Full-time equivalent HBAI: Health and behavior assessment and intervention HIPAA: Health Insurance Portability and Accountability Act HMO: Health maintenance organization HPHC: Harvard Pilgrim Health Care HRSA Health Resources and Services Administration IBHP: Integrated Behavioral Health Project ICSI: Institute for Clinical and Systems Improvement ICER: Institute for Clinical and Economic Review IMBH: Integrate Medical and Behavioral Health IMPACT: Improving Mood – Promoting Access to Collaborative Treatment IT: Information technology LCSW: Licensed clinical social worker LTSS: Long-term support and services MA: Massachusetts MBHO: Managed behavioral health organization MCP: Managed care plan ME: Maine MFT: Marriage and family therapist MHP: Mental health plan MHSA: Mental Health Services Act NCQA: National Committee for Quality Assurance NH: New Hampshire NP: Nurse practitioner PA: Physician assistant PBM: Pharmacy benefits manager PCP: Primary care physician PCMH: Patient-centered