California PCPs coordinate Medi-Cal behavioral health

December 1, 2010

Behavioral health issues are garnering attention in California, and the increasing overlap of primary care and mental health has prompted a new collaboration

SACRAMENTO-Behavioral health issues are garnering attention in California, and the increasing overlap of primary care and mental health has prompted a new collaboration.

The Primary Care Behavioral Health Project brings together EHS Medical Group, a large California-based Medicaid accountable care organization, and Anthem Blue Cross' state-sponsored business unit, which is a sizable provider of Medi-Cal benefits in California.

"Our initiative is a tiny step toward solving the problem," says Gilbert Simon, MD, creator of the Primary Care Behavioral Health Project, and Sacramento Family Medical Clinic physician. "The goal is to make PCPs better than they are in recognizing and treating moderate to mild mental health issues and to provide psychiatric services to a select number of patients. We want to improve chronic care and conditions that are being worsened by mental health complications."

BUSINESS MODEL

The state of California already is planning to move populations of seniors and people with disabilities into managed healthcare. These populations tend to be sicker than the average population and have higher-than-average behavior and mental healthcare needs.

"It's a crisis of unmet health needs," Dr. Simon says. "Until now, mental health needs of the Medicaid population had been met by the county, and the county had been funded by the state. But once the state stopped sending money due to lack of funds, the county was no longer able to provide the service. Now counties are receiving far less revenue at a time when costs are increasing."

California currently operates with a carveout, says Jeff Flick, regional vice president, State Sponsored Business, Anthem Blue Cross. There are two disparate systems of care-one to treat physical health needs and one for mental health needs.

"We want to train the PCP to recognize mental healthcare needs and treat or refer patients to a specialist," he says. "But then we would like the PCP to follow up with the patient and stay coordinated so that physical needs and behavioral and mental health needs are met."

According to research conducted by the National Association of Psychiatric Health Systems, although many behavioral health issues are first diagnosed by a primary care physician, just one-half of primary care patients with behavioral health issues receive a diagnosis.

"The expectation is that if we do a better job than what is happening today-physical health needs being covered in one system; mental and behavioral health in a different system-if we can combine systems, we'll have healthier members, not as much mortality and morbidity, and all at a better cost," Flick says.

In the Sacramento area, 110,000 seniors and those with disabilities will move into managed care. These patients currently receive care through fee-for-service Medicare.

LINKING BACK TO THE PCP

Through the initiative, patients will be able to seek treatment from PCPs with advanced understanding of mental health conditions. The end result, program officials suggest, will be improved management of chronic care and fewer emergency room visits for anxiety-related issues, for example.

Specifically, according to Dr. Simon, a half-time psychiatrist would be dedicated for every 20 providers.

"The goal is not to have a psychiatrist see every behaviorally ill patient," he says. "We want to improve the PCP's ability to select who needs treatment. We will be discussing criteria on how to select who needs a psychiatrist."

There is a two-page referral form with questions about the patient. The psychiatrist can complete an intake from that information. He or she may make a determination that a certain patient can go back to the PCP for follow-up care.

"Or that patient may need to be directed to a full-time, better staffed psychiatric facility, as the PCP is not equipped to deal with schizophrenic patients, for example," Dr. Simon says.

He says he wants the PCP to be comfortable enough to administer the basic psychiatric evaluation to determine where patients fall on the continuum. Once a patient is on treatment and stable, that patient is mainstreamed and goes back to the provider group. The provider group continues to monitor the patient.

Flick says Anthem Blue Cross will track readmission rate, admissions per 1,000, and use of the emergency department.

"Where quality improves, you get lower cost," Flick says. "As a result, you won't be admitted to the hospital as often."

Dr. Simon says because the program is Medicaid-based it has to be efficient and cost-effective. Because PCPs are paid by the number of patients seen, the additional cost of a psychiatrist is significant. To date, Anthem Blue Cross has agreed to fund the additional services for the Primary Care Behavioral Health Program.

Anthem expects a return on the investment in six to 12 months, according to Dr. Simon. And the patient will benefit by receiving behavioral healthcare more immediately and under the same roof as routine care.

EHS Medical operates with a physician-centric accountable care model to encourage sustainability for individual physicians by enabling access to various services and management tools.