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Criteria and Funding Critical for Establishing New Level of Outpatient Care
Editor’s note: This is the second in a 3-part series on the concept of Primary Behavioral Care. | Part I
Health plans have vague criteria for outpatient behavioral care. While their medical necessity guidelines for higher levels of care are more detailed, the door is wide open for accessing outpatient care. Consider Cigna’s rationale for why care might be needed: 1) reduce symptoms; 2) improve functioning; 3) prevent deterioration that might lead to the need for a higher level of care.
Few people would not qualify in some way. Outpatient is the gateway to care, the lowest level in the care continuum. Requirements for payment are more exacting. The clinician (in-network possibly) must provide a diagnosis to bill for reimbursement dictated by the health benefit.
By contrast, billing for employee assistance (EAP) services sets a lower bar. While the clinician might need a network contract, the billing forms require no diagnosis for this problem-focused benefit. Services are intended for detection, prevention, and early intervention with mental health and substance use issues.
Some payers weigh limiting access to therapy through exclusions. For example, managed care in the 1990s initially tried paying only for brief therapies, while today, restricting payment to a select group of empirically validated treatments is under debate. This approach may be crass, but its motivation is not entirely irrational. Payers genuinely question whether everyone needs therapy.
The Making of a Level of Care
Payers once questioned the need for inpatient treatment. Partial hospitalization and intensive outpatient (IOP) grew because it seemed unlikely everyone needed inpatient care—the pioneers “shared a belief in the commonsense notion that individuals with acute mental illness had a better chance of recovery and health functioning if they could pursue their treatment in the same communities where they worked.”
Common sense may be needed again today. The simple logic that drove alternative levels of care could help restructure outpatient behavioral care. Why? It does not seem likely that everyone with symptoms needs traditional therapy. Restricting access to therapy or limiting it by clinical model is a step backward, but a better answer is available.
The primary care setting is ideal for an initial (or primary) level of outpatient behavioral care (Primary Behavioral Care). We already have many therapists in this setting who provide traditional therapy or consult with primary care physicians (PCPs). Many complain that the role is stressful today because very few therapists are hired to manage a heavy workload. Yet, we must ask: Who decides the staffing or the workload?
In a behavioral level of care, the staffing and workload are set by behavioral clinicians. This would undoubtedly involve PCP collaboration, but specialists establish a level of care. This setting needs a measurement-based care system (like any behavioral setting) and resources like digital therapeutics to supplement the brief interventions fitting this environment—all specialty decisions.
Staffing for Primary Behavioral Care is an open question. It might need to approximate PCP staffing levels (1 therapist for each PCP) because we know that nearly 75% of office visits involve some behavioral issue—many being disruptive but non-pathological. Primary care visits are routine, intermittent, and longitudinal. This fits well with an EAP mindset of using a few visits to plant seeds for change.
Finding the Funds
Might there be a connection between reforms at the highest and lowest levels of care? The linkage involves simple logic. Many people admitted to a hospital do not need such confinement—it exceeds what they need to stabilize clinically. This is true as well for people not needing traditional therapy. A less time-consuming, less intrusive intervention would suffice.
Another logic applies to both: Lower levels of care prevent deterioration and a need for higher levels. This is clear for partial day and intensive outpatient programs. As the earlier Cigna criteria suggest, they can avert deterioration that leads to inpatient admissions. We similarly need primary behavioral care (i.e., EAP-type services) to prevent deeper problems that might require psychotherapy.
EAP’s value may emerge here, but a fundamental problem also appears. Many employers have been astute in offering EAPs, but the place of service has been wrong. People often struggle to locate and access behavioral services connected with their EAP benefits. Consumers are surprised that the access door is separate from the entrance to other healthcare services. A solution waits.
The EAP benefit perfectly aligns with the rationale for having behavioral services based in primary care. We should consider reformulating EAP benefits to cover services there. This connects benefit and care delivery rationales. We need an early intervention benefit that covers brief interventions in a setting people know well. No diagnosis is necessary since none may exist, yet.
This logic can be extended. EAP is not the only opportunity for funding reallocation. Other health benefits are also better tied to this setting, with disease management and wellness services high on such a list. This would end a separation from primary care that was never optimal. We can reinvigorate this setting as a new level of behavioral care—better yet, funds outside of insurance may be available.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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