Insurance Committee

 
If you have a question or issue in regards to a health care insurer, please first seek to resolve this directly by contacting the insurer or posting your concerns to other members on the MPA list serv. The Insurance Committee focuses on macro issues affecting Michigan psychologists and is unable to function as a "help desk" of sorts. If you are unable to resolve the issue directly, please contact the Insurance Committee Chair to see whether this is an issue which the committee can address. Thank you all for your understanding.

Article: The Future of Psychological Practice in the Era of Integrated Care
By Dr. Joy Wolfe Ensor

Article: Psychologists and BCBSM’s Physician Group Incentive Program
By Dr. Louis Post


 The Future of Psychological Practice in the Era of Integrated Care
 
On November 7, 2014, nearly 100 people filled the auditorium at MSU’s Henry Center to attend MPA’s conference on “The Future of Psychological Practice in the Era of Integrated Care.”  The conference brought together policy leaders at both the national and state level to address the opportunities and challenges that we psychologists face as the Affordable Care Act and other reforms move the health care delivery system from a fee-for-service to an integrated fee-for-quality model.
 
Katherine Nordal, Ph.D., the American Psychological Association Practice Organization’s Executive Director for Professional Practice, opened the conference with an overview of “Health Care Reform 2014: Implications for Professional Practice.”  Dr. Nordal summarized the economic context of health care reform and trends in mental health spending, including sobering statistics on the low percentage of psychologists in the behavioral health provider pool.  At the same time, she cited research demonstrating the positive impact on health care outcomes and costs when behavioral health issues are addressed.  Psychologists, said Dr. Nordal, have a unique contribution to make in integrated care not only by providing direct services (conducting thorough psychological assessments; promoting patient responsibility and resilience; treating more complex, complicated patients; attending to interpersonal barriers to behavior change; applying behavioral principles to modify health-risk factors; and understanding environmental determinants of behavior, including the impact of families and systems), but also by providing supervision, programmatic and organizational development, and quality outcome studies.
 
Heads in the audience bobbed in agreement as Dr. Nordal described how, in the evolving health care environment, increased business overhead combined with lower reimbursements, competition from other behavioral health providers, and growing demands to demonstrate treatment effectiveness make it increasingly difficult for private practice psychologists to earn a living if we rely on insurance reimbursements. The future of our profession, she said, will involve new care delivery systems (Patient Centered Medical Homes, Accountable Care Organizations), new skills and training models for integrated, inter-professional team-based care, technological advances (e.g., electronic health records), increasing demands for evidence-based treatments and quality measures, and payment reforms. 
 
While this trend will not seriously affect those of us who are within five or six years of retirement, it promises to have a critical impact on earlier-career psychologists, for whom, Dr. Nordal cautioned,  “Acting as an ‘N of 1’ has no future.”  Psychologists who wish to continue in solo private practice will need to develop practices that are free from third party payment.  Those of us who continue to treat patients who rely on insurance reimbursements, she said, are well advised to ally with each other in group practices in order to aggregate data to demonstrate our effectiveness to payers; to become employed by a large practice or hospital; or to join or form Independent Practice Associations (IPAs) in order to negotiate reimbursement rates with payers without risking anti-trust issues. 
 
“We need to organize,” Dr. Nordal said, “otherwise what is heard will be noise.  We need to create a culture of shared benefit.”  This involves using our psychological skills in the service of team building, understanding the value-added role of behavioral health services in improving population health, and training ourselves in evidenced-based brief interventions.
 
Dr. Nordal was sensitively attuned to our concerns about losing our hard-won professional autonomy in medical settings.  She noted that the rising generation of medical school graduates, compared to their predecessors, is more collegial and more respectful of psychologists as they develop their own integrated care practices.  “Go out and meet the primary care physicians in your area,” Dr. Nordal advised.  “It builds relationships; it lets them know what you’re good for.  Independent practice,” she emphasized, “means independence from physician supervision, not independence from the health care system.”
 
Benjamin Miller, Psy.D., Director of the Eugene S. Farley, Jr. Health Policy Center and Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine, complemented Dr. Nordal’s remarks with a presentation entitled “Change the Payment, Change the Care: The Role of Payment Reform and Comprehensive Primary Care.”  He noted that our current payment system reinforces the fragmentation of care and discourages inter-professional communication and integration.  In this fragmented system, only about 41% of people with identified mental health conditions receive care, and of those, only 44% (or about 17% of the total) receive care from a mental health professional.  Meanwhile, depression and anxiety comprise two of the top five conditions that affect overall health costs.  When treated in harmony with mental health, chronic physical health conditions improve significantly, along with patient satisfaction.  Thus, integration of care fulfills the “triple aim” of improving the health of the population, improving the experience of the individual, and improving affordability.
 
Dr. Miller defined integrated care as “a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.  This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.  Integration,” he concluded, “is good health policy and good for health.”
 
Dr. Miller clarified the range of existing payment models (fee for service, bundled payments, partial and full capitation) through which health care organizations manage care, assume risk, and promote or discourage efficiency and coordination.  He described a partnership between the Collaborative Family Healthcare Association, Rocky Mountain Health Plans, Colorado Health Foundation, and University of Colorado School of Medicine Department of Family Medicine to test an alternative payment model to sustain behavioral health in primary care.  The success of this new approach, as evidenced by extensive data, provides a roadmap for other states to follow in pursuing payment reform.  To achieve this, Dr. Miller said, we must understand our baseline costs and the cost savings we can provide, and engage with payers to discuss options beyond fee for service.    
 
Linda Zeller, M.P.A., Deputy Director in the Behavioral Health and Developmental Disabilities Administration at the Michigan Department of Community Health (MDCH), spoke on the “Delivery of Mental Health and Substance Abuse Services in Michigan.”  Her remarks were especially pertinent in light of the fact that over 60% of mental health spending comes from public dollars.  Ms. Zeller’s portfolio includes the state psychiatric hospitals, the Center for Forensic Psychiatry, and the Community Mental Health system that provides care to persons with severe mental illnesses and substance use disorders. 
 
Ms. Zeller reviewed MDCH’s Strategic Plan, which includes not only improving health outcomes but also transforming the health care system by strengthening mental health/substance abuse/physical health integration.  She echoed Dr. Nordal and Dr. Miller’s comments in encouraging us to “seek impact beyond your authority,” and to tout our value added by bringing our behavioral health expertise into physical health care settings. 
 
Ms. Zeller acknowledged the barriers that we psychologists face in providing services in the public health care system, including restrictions in accessing Health and Behavior (H&B) CPT codes and in participating with Medicaid.  She offered to facilitate further discussions with the State’s Medicaid director, Mr. Steve Fitton, around this issue.  Ms. Zeller acknowledged as well that there are persistent barriers to patients’ accessing behavioral health care, most notably in situations where patients in Medicaid health plans are referred to Community Mental Health for a higher level of care, and the CMH deems them ineligible for those services.  She invited audience members to provide her with both anecdotal and aggregate data about these barriers, in order to inform MDCH’s ongoing efforts to improve access to care.
 
Thomas Simmer, M.D., Senior Vice President for Health Care Value and Provider Affiliation, and Chief Medical Officer for Blue Cross and Blue Shield of Michigan (BCBSM) – who, importantly, had paid close attention to Dr. Miller’s presentation on payment reform – spoke on “The Changing Dynamics of Healthcare: Expanding Coverage and Managing Population Health.”  He provided a concise overview of how collaborative quality initiatives, especially Accountable Care Organizations and Patient Centered Medical Homes, yield demonstrable improvements in health care outcomes and costs.  These initiatives depend heavily on sharing information across levels of care, and Dr. Simmer described the “clear chain of trust” in the transmission of healthcare data. 
 
The Physician Group Incentive Program (PGIP) and tiered fee payment model is the mechanism that BCBSM has developed to reward practitioners for supporting practice transformation and for improving population-level performance.  Specialty practices (such as psychologists’) function as PCMH “neighbors,” maintaining effective communication, coordination and integration with PCMHs, ensuring appropriate and timely consultations and referrals, and participating efficiently in information sharing.
 
The PGIP operates in the context of Michigan’s Physician Organizations (POs), and Dr. Simmer spearheaded BCBSM’s efforts, beginning in 2013, to open the POs to psychologists.  He noted, however, that despite BCBSM’s offer of “bounties” (a $500 premium to POs for each psychologist recruited), the response of the POs has been disappointing.  Dr. Simmer noted further that, even when we are part of POs, we face additional challenges in reaping the benefits of the PGIP.  Mental health benefits for BCBSM subscribers are often “carved out” to non-BCBSM products, preventing an integrated care model; we are subject to a stricter standard for information sharing of sensitive mental health data; and, because of the nature of our practices, the size of our patient loads is typically very small compared to those of other health care providers, reducing their population-level impact.  During the panel discussion, Dr. Nordal challenged Dr. Simmer on BCBSM’s practice of applying a portion of our reimbursements to an incentive program from which so many of us cannot benefit, and Dr. Simmer did not dispute her critique.  He encouraged us to overcome these barriers by engaging with primary care physicians to build relationships and highlight our value.  He subsequently requested additional meetings with the MPA Insurance Committee (especially those committee members who also participate in BCBSM’s Subject Matter Experts committee) to address strategies for improving the role of psychology in the PCMH and policy system.
 
Conference attendees comprised a diverse group of psychologists as well as representatives from medical groups.  The audience was attentive and engaged, and in their evaluations, rated the conference highly.  The Insurance Committee will be continuing its dialogue with BCBSM and MDCH, and will also explore new connections with primary care physician organizations, including the Michigan Primary Care Association and the Michigan chapter of Family Practice Physicians.  We welcome input from the MPA membership to inform these ongoing discussions.
 
Joy Wolfe Ensor, Ph.D.
MPA Insurance Committee
 

Psychologists and BCBSM’s Physician Group Incentive Program

Introduction:  Over the last few months, MPA members have expressed strong concerns about BCBSM's Physicians Group Incentive Program (PGIP).  These concerns have centered on a variety of issues, including the rationale of the program; the relationship between psychologists in independent practice and Physician Organizations (POs); and above all, the reimbursement withholds as they relate to Blue Cross's allowed/published fees.

In response to our members' concerns, the MPA Insurance Committee has had five meetings so far with BCBSM pertaining to the Physicians Group Incentive Program.  We have sought to broaden and deepen our understanding of the PGIP, so as to be able to give MPA members the information you need to make a decision for yourself as to how you might wish to relate to this program.  This blast summarizes what we have learned to date from our meetings with BSBSM.  It has been our observation, however, that the process of the PGIP is one of evolution. Consequently, please assume that some of what we describe below will change in the future. Here are the broad points as we understand the PGIP.

Background:  BCBS launched the PGIP program five years ago and is aggressively expanding it, as they see it as a signature effort in health care delivery, consistent with initiatives nationwide to de-fragment health care delivery across specialties.  Until 2011, the PGIP was only open to participation by primary care physicians.  Starting in 2011, it became open to a limited number of sub specialties. BCBSM is seeking to involve psychologists in the PGIP, starting in July of 2012.

Incentive withholds and reimbursement rates:  From attending meetings at which physicians were present, and from our conversations with BCBSM, it is clear that the incentive withholds have been applied to all BCBS participating providers' fees, whether or not they are currently eligible to benefit from it.  The Insurance Committee has had numerous conversations with BCBSM regarding the withholds and their very negative impact on psychologists' relationship to BCBSM. We started off from the position that the published rates are the rates psychologists should receive and that the withhold is taking money out of psychologists' pockets. BCBSM is adamant that our understanding is not correct. The company does acknowledge that many health care professionals, including psychologists, have been subjected to the withholds without the ability to participate in the PGIP. You can find the most recent explanation of the withhold process in the April, 2012 issue of the Record http://www.bcbsm.com/newsletter/therecord/record_0412/Record_0412b.shtml.  According to BCBS the incentive withholds will increase on July 1, 2012, from 4.2% to 4.7%.

In our conversations with BCBSM we have communicated the deleterious impact of the successive rates cuts since 2008, on the delivery of mental health services in Michigan. We have communicated that while we understand that the application of the withholds is not specific to psychologists, that in our opinion the cuts in rates have taken place disproportionately in the area of mental health services,  as compared to overall medical spending. We have argued that the application of the withholds has further aggravated this serious discrepancy.

In response to the Insurance Committee's seeking an increase in reimbursement for mental health services, BCBSM has implemented, "as good faith gesture", starting on July 1, 2012, increases for the CPT codes most frequently billed by psychologists. The increases are for Traditional BCBS, Blue Preferred (Trust),   Community Blue PPO, and Blue Preferred Plus.

Traditional BCBS, Blue Preferred (Trust), Community Blue PPO, 2012, fees compared to 2011, fees

90801  +6.00%
90804   +4.3%
90805   +6.69%
90806   +2.92%
90847   + 3.73%

The increases, while modest, do reverse the four year trend of across the board fee decreases for all mental health services. Less commonly used CPT codes are seeing further decreases in rates of reimbursement.  The issue of rate cuts for mental health services continues to be an extremely high priority issue for the Insurance Committee. We intend to continue to press our arguments with BCBSM regarding the levels of reimbursement for these services.


PGIP and Physician Organizations:  BCBSM plans for future rate increases to occur predominantly within the framework of the PGIP. The PGIP is being implemented through forty one Physician Organizations (POs) around the state. These organizations were established long prior to the initiation of the PGIP. Each PO has a different structure, bylaws, and dues for new members.  The initial focus within the PGIP is integration/coordination of care via increasing communication between the various treating providers.  In order to participate in the PGIP providers must join a PO.  For purposes of the PGIP all providers, other than pcps, are classified as specialists. Consequently, within the PGIP psychologists have a specialist designation.

BCBS has not yet determined how the financial incentives for behavioral health care providers will work. In one model, that is currently being used, the PGIP does not evaluate the performance of individual health care providers. Rather, BCBS sets out the population based metrics which POs have to meet to qualify for incentive uplifts. It is up to each PO to determine for itself how it seeks to achieve the PGIP metrics. A PO qualifies for upgrades based on aggregate, not individual, measures for the patient population treated. Success depends on the aggregate measures based on population based performance.  Individual providers' performance is not evaluated or compared to other providers' performance. In another model  BCBS's  aim is to "incent for practices that deliver high value, well-coordinated, relationship-based, cognitive services". Clearly these are very different models, with different risks and benefits for psychologists. We will pursue  further with BCBS the practice implications of these two models. The emphasis on "cognitive services" will also require attention from MPA, as it implies the exclusion of other equally effective treatment approaches and implies that BCBS can prescribe the kind of treatment delivered by behavioral health care providers.

Uplifts are based on retrospective measures and are prospective for one year. If a PO achieves the PGIP metrics, all the providers within the PO are eligible for a 10% fee uplift,  for their entire BCBS fee schedule, for the subsequent twelve months. Patients are viewed as being within the PO to which their pcp belongs.

It is not clear yet whether the 10% uplift would apply to all BCBS covered patients treated by a specialist or only to those patients whose pcps are members of the PO to which the specialist belongs. One option,we are told, is being considered is that if a specialist's BCBS patients are treated by pcps who are in a number of POs than the specialist's uplift might be an average of the POs to which his/hers patients belong. This is not yet clear. It appears that there is a number of other formulas being discussed within BCBS to address this issue.

To participate in the PGIP a specialist has to be a member of only one PO. Specialists, however, can choose to be members of more than one PO. The total number of BCBS patients treated by a provider during a year, does not impact the degree of uplift the provider qualifies for.

BCBS considers specialists to be neighbors of the Patient Centered Medical Home (PCMH).  In order to qualify for an uplift specialists have to be nominated by the PO for the uplift. There are presently no formal criteria for whether or not to nominate a specialist for an uplift. Presently POs have nominated specialists for attending PO meetings, though specialists have been nominated who have attended no meetings. A specialist might have patients who belong to more than on PO. One of those POs may qualify for an uplift while the other(s) do not. If the specialist is not a member of the PO which qualifies for the uplift, in order to qualify for the uplift, the specialist needs to be nominated by the qualifying PO.

We have raised the issue that because of the relatively small number of patients psychologists treat at any one time, they will not be known by many pcps, as would other specialists such as oncologists and cardiologists, which may make it much easier  for POs to ignore the psychologists in nominating them. We believe that this an issue which will require considerable attention as we proceed.

In order to qualify for uplifts specialists within the PGIP need to bill using Evaluation and Management (E&M) CPT codes. At this time psychologists are unable to bill under E&M codes. We have been told by BCBS that they will address this issue. To our knowledge this has not, so far, been  resolved.

We have been very direct with BCBS about the need to address with POs language which classifies psychologists in any terms other than as full PO members. We have been told that the objective of the PGIP is to be inclusive of all professionals and that BCBS will work with POs to address this problem, if it arises.

A major issue, which BCBS has made us aware of, is that it is not clear how many POs are keen to include psychologists (and psychiatrists) in their membership and how many see the integration of mental health services as being important to achieving the objective of developing an organized processes of care co-designed by PCPs, specialists, and hospitals to de-fragment the American health care system. As such there is the major issue that we are not clear at this point how  open respective POs will be to psychologists seeking to join. BCBS is now engaged in devising an initiative aiming to address this problem. While this clearly could become a major issue we do not have sufficient information to determine its scope. If it is prevalent that it will have to be up to BCBS to solve it.

Blue Cross seeks input from content experts regarding metrics for integrating behavioral health into the PGIP.  Of the forty-one POs around the state, only two or three currently include psychologists, which complicates this effort moving forward.

What does this mean for psychologists and for MPA?:  Participating in the PGIP is entirely optional.  One can continue to practice entirely outside the PGIP without any changes. However, if  BCBS is successful in what it is seeking to do it will be difficult for a provider to qualify for substantive fee increases outside the PGIP.  Some psychologists will see the PGIP as a way to reinvigorate their clinical practice and as a means of increasing their income.  Others will perceive the PGIP as being alien to how they practice and will want no involvement with it.

MPA cannot take the position either with BCBSM that it should exclude psychologists from participation in the PGIP, nor with MPA members that psychologists should not participate.  Either position would constitute a restraint of trade, and could potentially put MPA in legal jeopardy.

MPA could have taken the position that it will refuse to engage with BCBS regarding the PGIP. It appeared to us, however, that a decision by MPA to not engage BCBS in discussions about the PGIP would on balance be more damaging to psychologists, than engaging with BCBS regarding psychologists' participation.  In the service of those psychologists who may have an interest in participating in the PGIP, the Insurance Committee has focused in its meetings with BCBSM on removing the structural and procedural impediments to successful participation by psychologists.

We have come to see possibilities in the PGIP for making some significant changes in the relationship psychology has with the medical establishment. Specifically, in the possibility of opening the door to a greater integration of psychological services in the delivery of health care overall, and of establishing psychologists on a par with medical professionals in the delivery of care.  It is a needle to thread, but BCBS is not going to abandon what they are viewing as a signature effort in health care delivery, so our effort is to shape BCBS'd effort to the benefit of psychologists generally .

Psychologists are currently, for the most part, far removed from the medical system.  The PGIP aims to change that for those psychologists who have an interest in doing so.  Because of the significant differences in  how psychologists' practices  differ from those of physicians', we expect that problems will need to be overcome to enable those psychologists who wish to do join a PO, to succeed within the PGIP.  We are committed to assisting those psychologists who have an interest in joining a PO, in being successful in this endeavor.

Thanks again to you all,

Dr. Louis Post