More than 40% of people who seek help for mental health problems initially do so by visiting a primary care provider. The primary care setting was first labeled "the de facto mental health care delivery system" three decades ago. Integration of primary care and mental health services has long been recognized as a critical goal—in the 1999 Surgeon General's report on mental health, in the 2001 Institute of Medicine's Crossing the Quality Chasm report, and in the 2003 report of the President's New Freedom Commission.

Yet specific Medicaid policies and procedures for reimbursement of primary care providers actively discourage them from screening, diagnosing, and treating their patients who have symptoms of mental illness, according to a new report. The report was jointly funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA), with technical expertise provided by the Centers for Medicare and Medicaid Services (CMS).

Seven specific reimbursement barriers were identified by an expert panel of 24 mental health care consumers, providers, researchers, and government officials:

• State Medicaid limitations on payments for same-day billing for a physical health and a mental health service or visit

• Lack of reimbursement for collaborative care and case management related to mental health services

• Absence of reimbursement for services provided by nonphysicians, alternative practitioners, and contract practitioners and providers

• Medicaid disallowance of reimbursement when primary care practitioners submit bills listing only a mental health diagnosis and corresponding treatment

• Low reimbursement rates in rural and urban settings

• Difficulties in getting reimbursement for mental health services in school-based health center settings, and

• Lack of reimbursement incentives for screening and providing preventive mental health services in primary care settings.

Chapter 4 of the report describes these and related reimbursement barriers in detail. For example, although federal Medicaid rules do not restrict two practitioners or provider organizations from billing on the same day, some state Medicaid rules prohibit billing by two practitioners on the same day, such as for a primary care visit and a mental health visit. This policy "undermines one of the key strengths of the collaborative care model—the 'warm handoff,' in which the primary care practitioner brings the behavioral health practitioner into the exam room," the report notes. In addition, Medicaid does not allow for reimbursement of practitioner-to-practitioner communication, which does not meet the strict criterion for direct patient care. Such communication is a critical element of collaborative care models and team approaches in the provision of mental health services in primary care.

The expert panel suggested "practical and achievable" steps for addressing these specific reimbursement barriers and others. The steps, which are summarized in Chapter 6, fall into four categories: clarification; collaboration; education and technical assistance; and approval, authorization, and support of additional services. The panel's most commonly expressed recommendation was to clarify policies, definitions, and allowable services and broadly disseminate these clarifications to payers and providers. The panel also called for targeted collaboration of federal and state agencies and national organizations, not only to clarify current policies but also to change them. For example, the panel proposed a work project to encourage primary care settings to institute collaborative care models by establishing core competencies, service definitions, and reimbursement codes; the project would be jointly staffed by SAMHSA, HRSA, CMS, and the Agency for Healthcare Research and Quality.

The panel's education and technical assistance recommendations cross various types of settings, payers, and providers to ensure that consistent and correct information is shared among states, the federal government, national nongovernmental organizations, provider associations, payers, and others. Finally, the panel's recommendations for approving, authorizing, and supporting additional services apply primarily to state Medicaid agencies and private insurers, which have the flexibility to implement the recommendations. In particular, the panel calls for instituting simplified reimbursement procedures that would promote use of telemedicine and similar technologies in rural areas.

The report is the culmination of a three-year process to identify barriers created by reimbursement policies and practical steps to change them. The process began with a review of more than 400 published articles, reports, and memoranda, followed by interviews with 20 key informants working in organizations designated as safety-net providers. The interviews revealed several key challenges in operating under the rules for coverage and reimbursement in the Medicaid and Medicare programs, as well as promising practices in securing reimbursement. The findings were summarized in a white paper, which formed the basis of the expert panel's discussions.

The 48-page report, Reimbursement of Mental Health Services in Primary Care Settings, is available on the SAMHSA Web site at www.sam hsa.gov.