Transcript Slides B3 - Collaborative Family Healthcare Association

Session # B3
Making a Behavioral Health Program
Financially Sustainable: A Look at Costs
and Revenue Generation at a Fully
Integrated Federally Qualified Health
Center
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Alysia Hoover-Thompson, PsyD, Staff Psychologist
James L. Werth, Jr., PhD, ABPP, Behavioral Health and Wellness Services Director
Emily C. Stacy, PMHNP
Malcolm Perdue, Chief Executive Officer
Stone Mountain Health Services
CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Faculty Disclosure
The presenters of this session have NOT had any relevant financial relationships
during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Identify strategies for overcoming financial barriers to
implementing integrated primary care.
• Discuss ways that an organization can maintain a financially
sustainable model of integrated care.
• Define the “hybrid” model of integrated primary care.
Bibliography / Reference
1.
Burke, B. T., Miller, B. F., Proser, M., Petterson, S. M., Bazemore, A. W., Goplerud, E., & Phillips, R. L.
(2013). A needs-based method for estimating the behavioral health staff needs of community health centers.
BMC Health Services Research, 13, 245-256. doi: 1472-6963/13/245
2.
Davis, M. M., Balasubramanian, B. A., Cifuentes, M., Hall, J., Gunn, R., Fernald, D., Gilchrist, E., Miller, B.
F., DeGruy, F., & Cohen, D. J. (2015). Clinician staffing, scheduling, and engagement strategies among
primary care practices delivering integrated care. The Journal of the American Board of Family Medicine, 28,
S32-S40. doi: 10.3122/jabfm.2015.S1.150087
3.
Hall, J., Cohen, D. J., Davis, M., Gunn, R., Blount, A., Pollack, D. A., Miller, W. L., Smith, C., Valentine, N., &
Miller, B. J. (2015). Preparing the workforce for behavioral health and primary care integration. The Journal of
the American Board of Family Medicine, 28, S41-S51. doi: 10.3122/jabfm.2015.S1.150054
4.
Hudgins, C., Rose, S., Fifield, P. Y., & Arnault, S. (2013). Navigating the legal and ethical foundations of
informed consent and confidentiality in integrated primary care. Families, Systems, & Health, 31(1), 9-19. doi:
10.1037/a0031974
5.
Miller, B., F. Brown Levey, S. M., Payne-Murphy, J. C., & Kwan, B. M. (2014). Outlining the scope of
behavioral health practice in integrated care: Dispelling the myth of the one-trick mental health pony.
Families, Systems, & Health, 32(3), 338-343. doi: 10.1037/fsh0000070
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of
this presentation.
Behavioral Health Integration:
Support from the CEO’s Office
MALCOLM PERDUE
CEO
STONE MOUNTAIN HEALTH SERVICES
JONESVILLE, VA
Organizational Background
Stone Mountain Health Services is a Federally Qualified Health Center (FQHC) with 11
primary care clinics and 3 respiratory care sites across seven of the Westernmost
counties in Virginia
◦ 25 medical providers across the sites
Catchment area includes three of the poorest and least healthy counties in the state
◦ All counties have HPSA scores of 16, 17, or 18
Primary medical care (all clinics), dental care (1 clinic), and behavioral health care (10
clinics)
Payment mix: : 20% Self-pay, 20% Medicaid, 40% Medicare, and 20% Insurance
History of Behavioral Health Program
Behavioral health (BH) program started in 2001 with 3 social workers and 1 professional
counselor
◦ Salaries were grant funded from a project with Working Partners for Success and a
grant from the Bureau of Primary Health Care
◦ Four positions were filled but only two LCSWs stayed for long-term positions
Rural Workforce Development Grant (2010-2013)
◦ Written in collaboration with East Tennessee State University and Radford University
to establish Social Work and Psychology internships
◦ 2 Social Work and 2 Psychology interns began in August 2011
◦ New staff hired beginning August 2012
◦ Funding extended to the end of August 2014
Some reasons why the BH Program struggled before the recent expansion in 2011/2012:
◦ Difficulty developing of billing sources and billable services within the medical umbrella (e.g.,
problems with reimbursement for same day billing)
◦ General lack of training / understanding / shift of BH role in medical clinic setting
◦ Medical providers, administrators, and the BH providers had difficulty determining what to do
and how to do it in light of traditional mental health models
◦ Lack of qualified practitioners to do BH work
◦ Lack of resources in the general region for patient services and professional training
Why CEOs Should be
Proponents of BH Integration
Helps patients
Helps medical providers
Can help communities
Can help, or at least not hurt, organizational bottom line
Brings additional skill sets to organization
The right thing to do
Building a Sustainable BH Program in
an FQHC
JAMES L. WERTH, JR., PHD, ABPP
BEHAVIORAL HEALTH AND WELLNESS SERVICES DIRECTOR
STONE MOUNTAIN HEALTH SERVICES
[email protected]
Current Status of the BH Program
Strong support of CEO and other Management Team members
Strong support by overall Board of Directors and local clinic Boards
Strong support by most site managers and primary care providers
Strong support by most nurses
Mixed support by front end staff
Behavioral Health and Wellness Services Director
◦ Executive Management level position
◦ Currently filled by a Licensed Clinical Psychologist
◦ Part-time administrative (3 days) / part-time clinical work (2)
Psychiatric Mental Health Nurse Practitioners
◦ 2 currently on staff
◦ Each has a nurse assigned to her
Social Workers
◦ 2 LCSWs
◦ 1 post-MSW working toward licensure
◦ Bills what she can under her LCSW supervisor
◦ 1 pre-MSW intern (most years)
◦ Does not bill for individual service provision
Psychologists
◦ 5 additional LCPs (beyond BH&WS Director) for the fiscal year in question
◦ 1 of whom is focused solely on psychological assessment
◦ 1 of whom is focused on children and adolescents
◦ 1 who had an emphasis on substance abuse and on pain management [may try to hire a
replacement for this slot]
◦ 2 of the psychologists were hired from internship so they were not licensed/credentialed for some
of the year in question
◦ 2 doctoral interns
◦ Part of internship consortium with another intern placed at Radford University Student
Counseling Services
◦ Recently became APA-accredited for 7 years
◦ Do not bill for individual service provision
Case/Care Manager/Coordinator
◦ Moving toward hiring a SW to help with substance use patients and provide other support for BH
providers
Stone Mountain’s BH Model
“Hybrid” model
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Integrated care – “warm hand-offs” / BH sessions can be interrupted
Typically, 15-30 min sessions, 1-3 times spread over several weeks
Traditional outpatient counseling (e.g., weekly, 45-60 min long)
Goal of 5 encounters per day [need to schedule 8] in addition to time for informal warm handoffs and “curbside consultations”
Introduction to every new patient (if possible)
◦ These do not count as encounters
Screening forms given to patients in waiting room / triage – a work in process (waiting for technology
option)
Assessment position
Supervisors observe trainees (do not bill)
No show / cancellation policies (vary by provider)
Moving toward adding technology-based services – a work in process
An Overview of the Financial
Numbers
◦ For FY 2015-2016, the 10 full-time BH providers and their interns had almost 9700
encounters, which placed productivity at 97%
◦ Subtracting about 1050 unbillable intern encounters leaves approximately 8650
encounters for professional BH staff
◦ We do not bill for warm hand-offs unless the patient consents
◦
We had around 650 encounters billed as WH (590 were 90832WH) – no charge
◦ For approximately 8000 billed encounters
◦ Major CPT Codes (rounded numbers):
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90791 (Diagnostic Evaluation): 720
90832 (16-37 min): 2575
90834 (38-52 min): 1160
90837 (53+): 500
- 99213 (OV Est Level 3): 225
- 99214 (OV Est Level 4): 990
- 99215 (OV Est Level 5): 1160
- 96101 (Testing by Psych): 550
- 96102 (Testing by Intern): 75
◦ The charges for these encounters totaled almost $1.4M
◦ The payments from co-pays and insurance totaled almost $480,000
◦ This means that our payments were only 34% of charges
◦ Medical is 50%
◦ Because Stone Mountain is an FQHC, services are offered on a sliding
scale to patients who qualify
◦ Approximately $390,000 was collected through the federal grant that covers the
cost of care for people receiving services on the sliding scale
◦ Note: 28% of BH patients are on sliding scale, higher than medical
◦ Non-FQHCs would not receive this reimbursement, but they also may not see as
many people without insurance or who cannot pay out-of-pocket
◦ Adding these numbers together, the total payments were approximately
$870,000
For our purposes, the “cost” of the 10 full-time professional BHPs is their salary + benefits
The cost of the staff was approximately $860,000
Thus, these BHPs generated around $10,000 in revenue
In addition, Stone Mountain received 2 grants to expand services that covered some of the
salary and benefits for 3 BHPs (2 psychologists and 1 PMHNP)
◦ The BH portion added $250,000 to the organization’s base FQHC grant
Bottom Line
The BH Team broke-even / generated money
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Without relying on non-sustainable grant funding
Even with “expensive” providers
Even with 3 new providers not licensed for some or all of the fiscal year
Even with the new providers not reaching 100% productivity
Even with some of the licensed providers spending time supervising interns/non-licensed professionals
Hard to measure impact on PCPs’ productivity but they report an improvement in the quality of their
professional worklife
The “hybrid” model of integrated care can be sustainable
Behavioral Health Integration:
Costs and Revenue Generated by
One Behavioral Health Provider
ALYSIA HOOVER-THOMPSON, PSYD, LCP
STAFF PSYCHOLOGIST
STONE MOUNTAIN HEALTH SERVICES
HAYSI & ST. PAUL, VA
Weekly Schedule
Clinic 4 days/week (32 hours)
◦ Provide services at 2 different clinics
◦ Fridays = offsite with our doctoral level interns for training
Supervise 1 doctoral level intern (2 hours scheduled + as needed)
Total clinical hours = 30
Cost to Stone Mountain Health Services (salary + benefits) = $90,000
Scheduled Appointments vs. Patients
Seen
Pre-Scheduled
Appointments
Haysi +
St. Paul
1421
No Shows/ Same
Day Reschedule
or Cancellation
570
◦ ~60% show rate based on pre-scheduled appointments
Warm
Handoff
41
Total
Seen
892
Billing Codes Used
Revenue Generated: Payees
Revenue Generated
Total Charges = $155,863.50
Total Payments = $98,797.79
Payments ($98,797.79) – Cost to SMHS ($90,000) = $8,797.79 in revenue
On average, we collect ~ $110/encounter
If I saw patients 5 days/week (instead of 4)
◦ 5 patients/day x 45 weeks = 225 encounters @ $110/encounter = $24,750 in revenue
Actual Revenue ($8,797.79) + Potential Revenue ($24,750) = $33,547.79
Psychiatric Mental Health Nurse
Practitioners
EXPANDING ROLES AND INTEGRATING CARE IN A RURAL FQHC
EMILY STACY, PMHNP
STONE MOUNTAIN HEALTH SERVICES
DAMASCUS, HAYSI, & ST. PAUL, VA
The Role of Nurse Practitioners
“THE TIME IS ALWAYS RIGHT TO DO THE RIGHT THING” MARTIN LURTHER KING, JR.
* Profession born of necessity in 1955 (National Institutes of Mental Health)
* By 1965 more than 30 programs nationwide
* Historically served economically / socially disadvantaged populations
* Master prepared or higher, Nationally Certified, and State Licensed
Statistics
* Virginia Healthcare Workforce Data (02/2016) on Licensed Nurse Practitioners
◦ Total Licensees: 7724
◦ Virginia Workforce: 6505
◦ 18% of all NPs in Virginia work in non-Metro (which includes rural) areas
◦ Median Salary: $90K-100K
◦ Median Educational Debt Burden: $50K-60K
◦ Job Satisfaction: 66%
◦ Adult Psychiatric Mental Health Nurse Practitioners (PMHNPs): 84
◦ Family PMHNPs: 73
◦ Approximately 2.5% of NP Workforce
◦ If the same % holds for PMHNPs as NPs overall (i.e., 18%), there are 4 PMHNPs working in
non-Metro areas in Virginia
Stone Mountain’s PMHNPs
* Stone Mountain Health Services
◦ 2 PMHNPs
◦ First hired in 2013: Case Management/Behavioral Health and Critical Care experience
◦ Works in 2 clinics
◦ Second hired in 2015: Oncology/Palliative Care and Critical Care experience
◦ Works in 3 clinics
◦ 40 hours weekly
◦ Both are available using technology for other clinics
◦ NHSC loan reimbursement
Care Integration: Finding a Path
“I HAVE LEARNED OVER THE YEARS WHEN ONE’S MIND IS MADE UP, THIS DIMINISHES FEAR; KNOWING WHAT MUST BE DONE DOES AWAY WITH FEAR”
ROSA PARKS
BENEFITS
CHALLENGES
Increased Communication
We Speak Different Languages
Coordinated Care
Provider Split Between Distant Sites, No Shows
Disease Self Management
“You want me to do want??”
Medications
Abuse, Polypharmacy
Wellness Goals
$ = Better Health
Positive Effect on Cost and Quality
Cost and Quality Expected to Exceed Private Sector
Fostering Community Partnerships
Telehealth
Developing Referral Sources
Electronic Medical Records!!!!!
Billing vs. Revenue
“EDUCATION IS THE MOST POWERFUL WEAPON WHICH YOU CAN USE TO CHANGE THE WORLD” NELSON MANDELA
* Number of Encounters: 1226
* Charges Billed: Approximately $250,000
* Adjustments off Charges: Approximately $160,000
* Payments (co-payments + insurance): Approximately $80,000
◦ Adjusted Charges: Around 37% of billed
◦ Remaining $10,000 in Accounts receivable
* Income: Approximately $190,000.00
◦ This includes grant-related sliding scale payments in addition to the above
E/M Guidelines
“JUST BECAUSE YOU ARE A CHARACTER DOESN’T MEAN YOU HAVE CHARACTER.” WINSTON WOLF (HARVEY KEITEL) IN PULP FICTION
• Developed by the AMA & CMS
• First set released in 1995, Second set released in 1997
• Key Components: History, Physical Exam, and Medical Decision-Making
• Most Commonly billed codes 99213, 99214, 99215
• 99213 - $101.00
• 99214 - $165.00
• 99215 - $237.00
• Keys are to Maximize Revenue and Streamline Documentation
Example
99214 - $165 E/M CODE
97 WORDS - $1.70 PER
WORD
90833 - $58
16 MIN. THERAPY
TOTAL - $223
35%
CC: Depression, PTSD, ADHD
Interval History: The pt presents for follow up. She feels sadder than
usual.
◦ Neat, clean, alert, good eye contact
◦ Speech is hypophonic and lacks spontaneity
◦ Thoughts organized
◦ Association are intact
◦ No hallucinations or SI
◦ Judgment and insight are intact
◦ A&Ox3
◦ Attention span and concentration are impaired
◦ Mood is anxious and depressed. Affect is congruent
IMPRESSION:
◦ Recurrent MDD
◦ Worsening, Stable PTSD
◦ Stable ADHD
PLAN: Increase Celexa to 40mg PO QD, Continue Lamictal for PTSD,
Continue Adderal for ADHD, PTSD continues to respond to intermittent
exposure therapy and stress management.
16 Minutes spent on psychotherapy today above and beyond time spent
on the E/M service.
Rational Coding…
(Documentation to Pass Audit & Provide Platform for Care)
“Start where you are. Use what you have. Do what you can.” Arthur Ashe
• Let Medical Necessity Drive Documentation
• Determine Highest Ethical Level of Care
• Save Time - Don’t Over Document
• Will Increase Revenue and Prevent Undercoding
• Eliminates E/M Code Anxiety
• Focuses on Patient Care
(E/M UNIVERSITY http://www.emuniversity.com Dr. Ken Jennings)
Session Evaluation
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this session.
Thank you!