Implementing an Evidence-Based Intervention to Improve Behavioral Health Outcomes
Special billing codes for Collaborative Care Model and Behavioral Health Integration with measurement-based care were first introduced into Medicare in 2017. This change in coding reflected that, despite voluminous evidence for the efficacy and cost-effectiveness of addressing behavioral health in primary care, payment policy did not facilitate these practices and few primary care providers delivered integrated behavioral health interventions. With the new billing codes, payment policy does enable evidence-based behavioral health interventions in primary care, but still uptake remains limited – practice transformation to fully implement effective models is time-consuming and challenging for many providers.
Notably, the 2018 National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Report found precipitous increases in the rates of screening for depression over the past several years (2018 National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Report. Centers for Medicare & Medicaid Services. Feb 28, 2018). However, among those Accountable Care Organizations in Medicare Shared Savings Program reporting in performance year 2016, after removing all ACOs who did not report the measure or reported a score of zero, the median rate of Depression Remission at Twelve Months reported was approximately nine percent (Shared Savings Program Accountable Care Organizations (ACO) PUF. Centers for Medicare and Medicaid Services. https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/SSPACO/). Providers are struggling to deliver integrated behavioral health care and collect related outcomes.
This submission seeks to build on CMS’s successes, while further supporting providers to meet CMS’s goals. By creating a Quality Improvement Activity devoted to implementing an evidence-based intervention to improve behavioral health outcomes, providers can have the additional financial incentive to defray the costs of practice transformation and have a clearer path to meaningfully addressing behavioral health in primary care. This submission also offers providers flexibility and avoids constraining innovation – as long as providers begin with evidence-based steps and perform measurement-based care to ensure that outcomes are achieved. For some practices, full fidelity to evidence-based integrated care models might not be feasible, but deploying an evidence-based digital health intervention with appropriate follow-up may be. In other cases, providers will leverage the flexibility to innovate and find models of practice that best meet their context, and even contribute to shared learning across the Quality Payment Program.
Below are selected systematic reviews and meta-analyses that provide evidence for models of primary care and behavioral health provider integration that eligible providers can implement when billing the Collaborative Care Model and Behavioral Health Integration codes. Also included are selected systematic reviews and meta-analyses that demonstrate the efficacy of certain digital health interventions that could be deployed in integrated primary care.
Integrated Behavioral Health Care for Depression:
Coventry PA, Hudson JL, Kontopantelis E, Archer J, Richards DA, Gilbody S, Lovell K, Dickens C, Gask L, Waheed W, Bower P. Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials. PloS one. 2014 Sep 29;9(9):e108114.
Thota AB, Sipe TA, Byard GJ, Zometa CS, Hahn RA, McKnight-Eily LR, Chapman DP, Abraido-Lanza AF, Pearson JL, Anderson CW, Gelenberg AJ. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. American journal of preventive medicine. 2012 May 1;42(5):525-38.
Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD006525.
Gillies D, Buykx P, Parker AG, Hetrick SE. Consultation liaison in primary care for people with mental disorders. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD007193. DOI: 10.1002/14651858.CD007193.pub2.
Purington K, Townley C. Physical and Behavioral Health Integration: State Policy Approaches to Support Key Infrastructure. National Academy for State Health Policy. May 2017.
Twomey C, O’Reilly G, Byrne M. Effectiveness of cognitive behavioural therapy for anxiety and depression in primary care: a meta-analysis. Family practice. 2014 Sep 22;32(1):3-15.
Conejo-Cerón S, Moreno-Peral P, Rodríguez-Morejón A, Motrico E, Navas-Campaña D, Rigabert A, Martín-Pérez C, Rodríguez-Bayón A, Ballesta-Rodríguez MI, de Dios Luna J, García-Campayo J. Effectiveness of psychological and educational interventions to prevent depression in primary care: a systematic review and meta-analysis. The Annals of Family Medicine. 2017 May 1;15(3):262-71.
Schleider JL, Weisz JR. Little treatments, promising effects? Meta-analysis of single-session interventions for youth psychiatric problems. Journal of the American Academy of Child & Adolescent Psychiatry. 2017 Feb 1;56(2):107-15.
Integrated Behavioral Health Care for Substance Use:
Chou R, Korthuis PT, Weimer M, et al. Medication-Assisted Treatment Models of Care for Opioid Use Disorder in Primary Care Settings [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Dec. (Technical Briefs, No. 28.)
Wray JM, Funderburk JS, Acker JD, Wray LO, Maisto SA. A meta-analysis of brief tobacco interventions for use in integrated primary care. Nicotine & Tobacco Research. 2017 Sep 16.
Bully P, Sánchez Á, Zabaleta-del-Olmo E, Pombo H, Grandes G. Evidence from interventions based on theoretical models for lifestyle modification (physical activity, diet, alcohol and tobacco use) in primary care settings: a systematic review. Preventive medicine. 2015 Jul 1;76:S76-93.
Digital Health Interventions for Depression:
Andrews G, Basu A, Cuijpers P, Craske MG, McEvoy P, English CL, Newby JM. Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. Journal of anxiety disorders. 2018 Feb 1.
Digital Health Interventions for Substance Use:
Álvarez-Bueno C, Rodríguez-Martín B, García-Ortiz L, Gómez-Marcos MÁ, Martínez-Vizcaíno V. Effectiveness of brief interventions in primary health care settings to decrease alcohol consumption by adult non-dependent drinkers: a systematic review of systematic reviews. Preventive medicine. 2015 Jul 1;76:S33-8.
K Nair N, C Newton N, Shakeshaft A, Wallace P, Teesson M. A systematic review of digital and computer-based alcohol intervention programs in primary care. Current drug abuse reviews. 2015 Aug 1;8(2):111-8.