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Integration of care is about money too: the health and behavior codes as an element of a new financial paradigm.

Article Excerpt
Collaboration between behavioral health and medicine and integration of behavioral health as part of non psychiatric medicine has been a difficult task. Part of the difficulty has been a lack of fit between the financial models for coding and reimbursement that behavioral health and medicine is governed by. Because of this lack of fit, the tensions between the clinical, administrative, and financial worlds (Patterson, Peek, Heinrich, Bischoff, & Scherger, 2002) have often been contentious and have limited the progress of collaboration and integration. Recently, a set of billing codes known as the health and behavior codes were proposed by the American Psychological Association and approved by the American Medical Association. Although reimbursement of these codes has been mixed, there have been slowly increasing indicators of acceptance of the codes. This article describes the evolution of the codes, their implications, and limitations and ends with discussion of a strategy to move acceptance forward as a method of assisting the evolution of integrated behavioral health and medical care.

Keywords: integration, collaborative care, healthcare finance, behavioral health in medicine, health and behavior codes

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Clinicians know that the world of health care is really three simultaneous worlds including the clinical, operational, and financial. Unless daily practice is designed to incorporate the views of all three worlds tension results (Patterson et al., 2002). Perhaps the most important thing about the integration of behavioral and biomedical care is that much of the behavioral care is done on behalf of medical patients with medical problems who are primarily seeing physicians for medical care. This is quite different than behavioral health services provided in specialty care settings. This difference means that when it comes to the financial aspects of integrated behavioral/medical care, there needs to be an alternative set of billing codes for behavioral health clinicians working as part of medical teams with medical patients who have medical diagnoses as the focus of behavioral care. The health and behavior codes are a viable way of accomplishing that.

The purpose of this article is to briefly review the history of the codes and to trace the uneven trajectory of understanding and acceptance of the codes across health care policy and reimbursement. The article further reviews the obstacles that must be overcome to generate the operational decision making to accomplish such acceptance. Operational decision making is affected by financial viability and stability. It is an area that leaves behavioral health clinicians working in medicine particularly vulnerable to reimbursement underpayments.

Part of the dilemma is that we can identify increased overhead, time, and frequent medical and cost benefits of integrated behavioral health and medical care. However, reimbursement for medical behavioral health services is usually at par with services provided in community settings. This certainly has both operational and financial consequences to those who make decisions about the operational and financial viability of integrating behavioral health and medical care, where the same square footage in a multispecialty medical clinic that a behavioral health clinician occupies could be occupied by another medical provider who can generate a much larger pool of income.

There is considerable evidence that patients receive behavioral health care primarily through primary care and that physicians prefer to have patients seen in collaborative models (Cummings, O'Donahue, Hayes, & Follette, 2001; Kessler, 2005). We can further state that there is evidence that the services and the model of delivery are clinically effective and in some cases cost-effective, both improving outcomes and reducing medical costs. In about a third of studies, there is a demonstrated cost offset (Blount et al., 2007; Chiles, Lambert, & Hatch, 1999). However, what is needed are administrative and financial methods geared directly to the to the difference between behavioral health care positioned as a mental health specialty in community based care, and behavioral care positioned as part of a medical team focused on medical problems. Without shifting the financial dimension along with the clinical dimension, collaborative medical behavioral health care becomes difficult to sustain. It remains very difficult to track the new services, their outcomes or their impact on utilization and costs of medical care. This is crucial if this effort is going to be taken seriously by policymakers and payers. Until then, behavioral health practitioners in medical settings remain a somewhat expendable add on.

Further compounding the issue is that what primary care behavioral health providers do in practice is often different. We provide psychological treatments to medical patients who often have no "diagnosable mental disorder." However, the mandated billing codes are for treatment provided for a diagnosable mental disorder. I have often felt uncomfortable about the ethical and professional implications of writing down a code and diagnosis that is accepted and mandated administrative practice but not an accurate reflection of the encounter. Also, much of what we provide is collaboration, feedback, and consultation--valuable but mostly not reimbursed.

Historically, before the innovation of the health and behavior codes, the field has not been very successful at creating alternatives. Medicare, which often but not always drives what gets reimbursed and what does not, has not allowed Medicare behavioral health providers to...

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