INTRODUCTION

Reimbursement models have not historically supported the integration of mental health services into primary care.1 In January 2017, the Centers for Medicare & Medicaid Services introduced fee-for-service (FFS) Medicare Part B billing codes for Psychiatric Collaborative Care Management (CoCM) and General Behavioral Health Integration (BHI).2 CoCM enhances primary care through the addition of behavioral health care managers and psychiatric consultation whereas BHI supports various integration models and staffing configurations. Qualitative research has identified barriers to using the CoCM codes and a recent study based on a random sample of Medicare beneficiaries found that 0.1% of those with behavioral health conditions received services through either type of code in 2017 and 2018.3 We expanded on that study to examine the uptake of these codes among a different group of beneficiaries—those with behavioral health conditions attributed to primary care practices, as those with primary care providers are most likely to benefit from these codes. We also examined whether the types of diagnoses and providers differed between CoCM and BHI claims, and if claims were concentrated within practices and states.

METHODS

We conducted these analyses using data from the Comprehensive Primary Care Plus (CPC+) evaluation, which requires practices to integrate behavioral health care and allows them to use these billing codes among others. We analyzed calendar year 2017–2018 Medicare FFS data that included 7.2 million beneficiaries located in 38 states and DC who were attributed to either the 2888 primary care practices that began CPC+ in 2017 or the 6921 comparison primary care practices. (Peikes et al. (2019) describe patient attribution methods, which used a 2-year lookback period).4 Among these beneficiaries, 2.1 million (22% of CPC+ beneficiaries and 22% of comparison beneficiaries) had a behavioral health condition (mental health or substance use) defined as any claim with a primary behavioral health diagnosis or 1 inpatient or 2 outpatient/ambulatory claims with any behavioral health diagnosis during each analytic year. We conducted descriptive analyses of CoCM and BHI claims among beneficiaries with behavioral health conditions.

RESULTS

Uptake

From 2017 to 2018, the number of CoCM and BHI claims and the proportion of beneficiaries represented by those claims increased but were less than 0.1% in both years (Table 1). Given the small number of claims using these codes and because CPC+ practices had not yet fully implemented integration during our analytic period, we did not compare CPC+ and comparison practices.

Table 1 Behavioral Health Integration Claims, Beneficiaries, and Providers
Full size table

Conditions

Almost all CoCM claims had a primary mental health diagnosis; major depressive disorder and anxiety disorder were most common. In contrast, 31% of BHI claims had a non-behavioral health primary diagnosis and the primary behavioral health diagnoses were more diverse. Hypertension, diabetes/metabolic disorders, and heart/vascular disease were common conditions among beneficiaries with CoCM or BHI claims.

Providers

Internal medicine physicians most commonly submitted CoCM claims whereas family physicians most commonly submitted BHI claims. Specialists, including psychiatrists, submitted few claims. The number of providers with claims increased from 2017 to 2018 but claims were concentrated in a small group of practices and states in both years. For example, in 2018, 384 providers submitted CoCM claims; 40% of these providers were affiliated with 25 practices, which together accounted for 70% of CoCM claims. Likewise, in 2018, 325 providers submitted BHI claims; 21% were affiliated with 20 practices that together accounted for 78% of BHI claims.

DISCUSSION

Consistent with another recent study, we found infrequent use of these codes even among beneficiaries with a primary care provider.5 Adoption of the codes increased over time but has been somewhat lower than other care management codes introduced by CMS.6 While our findings are not generalizable to all primary care practices nationally, the claims using these codes were concentrated in a small group of practices and states, some of which have integration initiatives. However, we cannot link our findings to specific initiatives. BHI claims were more common than CoCM claims and were submitted for a wider range of conditions, likely reflecting the greater flexibility of this code. As CMS plans to refine the future use of these codes, research could identify the features of integration models reimbursed through the BHI code and investigate if payment rates cover the costs of care management services to inform potential changes.2