Medicare Fee Schedule Reforms Payment for Behavioral Health, Chronic Disease

CMS on Wednesday finalized the 2017 Medicare Physicians’ Fee Schedule, which features a host of payment reforms to promote the transformation to value-based care.

Besides final eligibility rules for the diabetes prevention program, the new schedule comes with several new codes that recognize some complex cases—especially those involving patients with multiple chronic conditions—take more time to resolve and involve planning and consulting functions, not just writing a prescription.

The new codes will improve payment for clinicians “who are making investments of time and resources to provide coordinated and patient-centered care,” the CMS statement said. The entire schedule involves codes for billing visits, surgical procedures, diagnostic tests, therapy services, and preventive care.

“These policies will give significant support to the practice of primary care and boost the time a physician can spend with his or her patients listening, advising and coordinating their care,” said CMS Acting Administrator Slavitt. “By better valuing primary care, behavioral health, and prevention models like the Medicare Diabetes Prevention Program expanded model, we help beneficiaries access the services they need to stay well and live long, healthy lives.”

Three key changes that will be new under the 2017 schedule promote principles of coordinated care, and especially the collaborative care model, which seeks to put behavioral health and primary care under one roof. This care model offers more convenience and less stigma for patients while also ensuring that medical and mental health needs are aligned—and that providers are talking to one another. These changes are:

• Care Coordination. CMS has revised payment models for chronic care management with new codes to cover management of multiple chronic conditions as well as extra care for complex cases beyond the initial visit.
• Behavioral Health. New codes will reimburse behavioral health services furnished using the psychiatric collaborative care model, which has been shown to help patients treated with a team-based approach involving the primary care doctor, the psychiatric consultant, and a case manager. According to CMS, a new code will “broadly describe behavioral health integration services,” and help some practices that offering some behavioral health care but have not completely implemented the collaborative model.
• Cognitive Impairment. A new code will let physicians bill for performing assessments of patients with suspected cognitive decline, including possible Alzheimer’s. Doctors will be paid to work with patients and families on advanced care planning, an essential step as the number of adults over age 80 increases.

The new schedule comes after CMS has spent years gathering evidence that a small number of beneficiaries with multiple conditions—typically including a mental health problem—account for a disproportionate shares of healthcare spending.

The idea of collaborative care—to move behavioral health services into the primary care setting—was pioneered at the University of Washington Medical School as far back as 1995. Research showed this that patients with both diabetes and depression who were treated in these settings experienced decreased symptoms of depression and improved health outcomes.

The Affordable Care Act specifically called for making it easier for practices to organize and bill Medicare using this approach.