December 2017

2018 Outlook: What's in Store for Behavioral Health Incentives?
By Charlie Hutchinson
For The Record
Vol. 29 No. 12 P. 32

Established in 2009, the HITECH Act was designed to spur the adoption of EMR technology through financial incentives. Originally, physician and hospital communities were the only ones that stood to benefit from this act.

The behavioral health community, excluded from the act's financial benefits from the beginning, has been vocal regarding its inclusion in meaningful use incentives. It is assumed that the incentive money to modernize technologies and adopt EMRs would bring the behavioral health sector up to speed with the rest of the health care community and make whole patient health care a reality.

But despite the hype, this has not taken place; nothing has formally materialized in favor of the behavioral health community. However, small steps have been taken and progress has been made to give behavioral health practitioners hope for future inclusion.

Mental Health's Roller-Coaster Ride in Congress
The path to inclusion in meaningful use incentives for behavioral health is full of legislative starts and stops.

Most prominently, the Mental Health Reform Act of 2016 aimed to boost the status of the behavioral health community in the following ways:

• improve coordination between federal agencies and departments that provide individual mental health services;

• authorize grants for the SAMHSA-HRSA (Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration) Mental and Behavioral Health Training Program;

• increase access to care for individuals, including veterans, homeless individuals, women, and children; and

• promote better enforcement of existing mental health parity laws.

Initially, the bill was met with much criticism, notably from National Review and the Treatment Advocacy Center. Both organizations claimed that the proposed bill would do nothing to legitimately help individuals who suffered from severe mental health issues and that it plainly ignores other proposals with more support from the behavioral health community.

This was the case until Senator Sheldon Whitehouse (D-RI) proposed an amendment to the bill that would allow behavioral health professionals to receive incentives for adopting EMR technology. Unfortunately, the bill has been stuck in the committee phase and is presumed to have died.

In many ways, what this legislative activity has demonstrated to the behavioral health community is that there is a lot of talk about parity and whole person health care but no real action. It's hypocritical for legislators to push for behavioral and physical health integration while turning their backs on making true parity—and equality—a reality.

The Progress Thus Far
The news isn't all negative. Parity laws such as the Mental Health Parity and Addiction Equity Act are legislative strides to bring equality for patients' mental health by ensuring health insurance plans offer similar benefits, protocols, and practices for mental health and medical/surgical issues.

Additionally, mental health is taking on a more prominent position in chronic care management through Collaborative Care Model (CoCM) and Behavioral Health Integration (BHI) programs. These initiatives are aimed at positioning mental health practitioners as central players in a patient's collaborative care, which not only strengthens mental health's reputation in the industry but also greatly improves a patient's chances of receiving optimal whole patient care. Although reimbursements in these models favor primary care practices, they are yet another small but positive step on the journey toward tighter and more meaningful integration between the general medical and behavioral health communities.

Arguably the most progress made in the name of mental health came with the passing of the 21st Century Cures Act. Aside from major bipartisan support in Congress, the Cures Act is unique in that it has finally provided the mental health community with a leader in government through the creation of a new assistant secretary for mental health and substance abuse to head the Substance Abuse and Mental Health Services Administration, which will "lead public health efforts to advance the behavioral health of the nation."

While there was much hype about the behavioral health component of the Cures Act, the truth is that only a small portion of the law's funds was directed to mental health initiatives.

Overall, there has been mostly positive news for the mental health community in recent years, but there remains some mystery regarding when more significant steps—such as incentives from the Centers for Medicare & Medicaid Services (CMS)—will be taken to improve operating conditions for mental health practitioners and their patients.

Traditional Barriers Preventing a Complete Solution
While the concept of incentivizing behavioral health practitioners makes sense, there are barriers to overcome.

First, there is historically low participation in insurance by psychiatrists. According to a National Ambulatory Care survey, only 55.3% of office-based psychiatrists accepted health insurance compared with 88.7% of office-based physicians in other specialties. Also, insurance acceptance rates among psychiatrists are declining faster compared with other specialties.

EHR adoption rates among mental health practitioners are low. Not only are psychiatrists reporting a lukewarm 56% EHR adoption rate, but a Centers for Disease Control and Prevention survey also discovered psychiatrists and other mental health practitioners are the least likely to adopt EHR technology.

These low adoption rates are the predictable consequences of excluding mental health practitioners from HITECH's original meaningful use incentive plans. In short, without incentive payments, it is hard for psychiatrists and others to justify a steep investment in EHR technology.

Even within CoCM and BHI, there is still more progress to be made. Behavioral health practitioners can be included in collaborative care, but they cannot bill for services. That distinction lies only with primary care practices, meaning there are no guarantees that mental health professionals will be reimbursed. Additionally, commercial insurers continue to lag, having not yet copied the CMS programs for CoCM and BHI.

And with no incentives to adopt EHR technologies or achieve other quality measures, it will be an uphill battle to convince behavioral health practitioners that EHR technology is a worthwhile investment.

Potential Disastrous Effects
The effects of a lack of CMS incentives for behavioral health practitioners goes beyond mental health providers. Patients, too, are at risk of suffering the consequences.

There will be less behavioral health involvement in patient care, and with mental health issues affecting nearly 44 million Americans each year, whole patient health care will suffer as many miss out on the mental health treatments they desperately need.

No incentive payments for mental health professionals also means a sizable investment—likely coming from their own pockets— for EHR adoption, which can be as much as $15,000 to $70,000 per provider.

Unfortunately, while the meaningful use program succeeded in creating more widespread adoption of EHR technology on the physical health side, some of its other goals were not met. As a result, there is little legislative support now for expanding meaningful use into the behavioral health community, an effort that would cost an estimated $1 billion.

Ultimately, the lack of incentives helps no one in the behavioral health community. Until the situation changes, low EHR adoption and poor integration between mental health professionals, psychiatric hospitals, and nursing homes will persist.

An Improving Environment
Things are getting better, but real work remains.

The exclusion of the behavioral health community from CMS incentives has only damaged the state of mental health. If the landscape were to change and mental health providers were incentivized for EHR investments, the industry and the state of whole patient care would significantly improve. It would allow for mental health professionals to achieve a level playing field with their physician colleagues, empowering greater integration between the behavioral health and medical communities.

Through prior legislative achievements and attempts at more fully incorporating mental health within health care, tangible progress has been made. However, with much work left to be done before true equality is reached, greater advocacy, stronger legislation, financial stimulus, and more awareness of the disparities between the mental health and medical communities are needed to sufficiently remedy this ongoing issue.

Without action and genuine change, patients will continue to suffer.

— Charlie Hutchinson is CFO of InSync Healthcare, a provider of solutions for behavioral health and primary care practices that want to focus on patients, not technology.