As many nephrologists and dialysis providers are aware, the ability to secure access to behavioral health services for their patients with chronic kidney disease and end-stage renal disease is often difficult.

Behavioral health providers in the community often have long waiting lists, and patients living with kidney disease do not want to go to yet another specialist. As a result, nephrologists and dialysis providers have become the providers of care for those who have mild to moderate depression, anxiety, and/or substance use. Many of these patients often present with multiple comorbid chronic physical and mental health diagnoses and can be challenging for nephrologists and dialysis providers to address systematically. Additionally, these patients are often the ones who are not successful managing chronic medical conditions or participating in recommended preventive care, impacting a provider’s ability to successfully care for the patient and to excel in alternative payment models, quality scores and measures.

In recognition of the need to provide better access to mental health services, Medicare has recently created a series of new reimbursement codes that will, for the first time, pay physician practices to implement evidence-based behavioral health care management for their patients. These are the new Collaborative Care codes. Given that 80% of dialysis patients are covered under Medicare and the prevalence of clinical depression is more than 40%, these collaborative care codes present an opportunity to provide needed mental health services across the spectrum of chronic kidney disease chronic kidney disease (CKD).

This article will provide a background to Collaborative Care, describe Medicare’s new reimbursement guidelines, and provide information for nephrology practices interested in adopting and utilizing these codes.

Nephrology needs a new approach to depression

The most common psychiatric illness in patients with CKD is depression. Prevalence of depression is as high as 23% among patients with CKD and 39.3% for patients on dialysis as evidenced by self- or clinician-administered rating scales. Depression is also a significant predictor of mortality in the CKD population. Many of these patients think depression is normally a part of CKD. Even some providers often think there can be good reasons for depression in these patients. As a result, they don’t offer much in the way of treatment or just give up too easily.

Figure 1. The collaborative care model deploys a therapist, care manager and psychiatric consultant into the primary care team. Source: Adapted from University of Washington AIMs Center

Chronic kidney disease is a difficult, chronic illness for patients and requires a lot of life changes, but clinical depression is not normal and can be treated. Screening of patients to know who is experiencing depression can be accomplished easily by routinely using the patient health questionare-9 (PHQ9), a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression.

Collaborative Care

There are a variety of ways to provide treatment for these patients. Collaborative Care is a systemic approach for the identification and treatment of depression and anxiety inside a patient’s “medical home.” This program has been shown to be effective in more than 80 randomized controlled trials and is now recognized by Medicare and multiple state Medicaid programs for reimbursement.

Collaborative Care (sometimes called IMPACT Care) was pioneered by a group of clinicians at the University of Washington who were focused on building a stronger behavioral foundation for the medical home. The model (see Figure 1 on page 17) deploys a therapist, care manager and psychiatric consultant into the primary care team. While this example is most common in primary care, it is easily transferable to a team lead by nephrologists.

There are four critical components for Collaborative Care.

Universal screening: Every year, patients should be screened with the PHQ9 (depression), the generalized anxiety disorder test (anxiety) and alcohol use disorders identification test (alcohol). Those who screen positive should be enrolled in Collaborative Care.

Warm connections: Instead of referring patients to outside specialists, the nephrologist employs a care manager as part of the practice. This person is introduced immediately (either down the hallway or a phone call in the next 24 hours) to the patient. Care managers usually have a social work or nursing background.

Regular behavioral health care management: The care manager regularly reaches out to the patient, multiple times a month, to re-assess symptom severity (using the same screening scale or scales) and conducting evidenced-based talk-therapy interventions, such as problem-solving therapy, behavioral activation or motivational interviewing.

Registry review and curbside consults: The final part of the model is to have the behavioral care manager spend an hour a week reviewing the panel with a psychiatric consultant (psychiatrist or psychiatric nurse practitioner). The registry acts as an efficient way to review each patient, their symptom severity over time, goals of therapy and current medications. Together, the team can set goals for care, and the psychiatric consultant can make medication recommendations directly into the patient’s chart for the provider to make the final decision and order medications if they agree. In addition to the registry time, the psychiatric consultant is available to the primary care office for curbside consults to review the recommendations or help provide guidance around care for the patient.

More than 80 randomized controlled clinical studies show collaborative care improves behavioral health symptoms when compared to usual care. While most of this research base has looked at depression or anxiety, increasingly studies are examining additional diagnoses, such as opioid and alcohol abuse.

Reimbursement for Collaborative Care

In 2017, Medicare created three new billing codes to support physician practices who are interested in this care model. Dubbed Collaborative Care Management (CoCM), Medicare’s new program will reimburse practices on a per enrolled patient per month basis, assuming certain criteria as outlined in Figure 2 are met. CMS also offers a FAQ document at…/Behavioral-Health-Integration-FAQs.pdf

Figure 2. Medicare will reimburse practices on a per enrolled patient per month basis assuming certain criteria are met.

The research is clear. Practices that effectively deploy behavioral health do a better job supporting their patients and see better outcomes. Innovative nephrology practices that embrace this model early have an opportunity to help patients and differentiate their practice. It’s clear that health care is tipping toward value-based care, whether your practice has opted into an end-stage renal disease seamless care organization, accountable care organization, or chronic condition special needs plans or is just starting to get a clear understanding of the new physician payment system.
Practices are often put in a double-bind: They know where they need to go, but without new revenue streams to support the infrastructure to get there. Medicare has not only created a path for behavioral health with codes that support implementation in today’s fee-for-service environment but also allows you to build the systems necessary to succeed in new value-based models.

For more information: Rita Haverkamp, MSN, PMHCNS-BC, CNS, is a consultant and a senior trainer with the AIMS Center at the University of Washington. Spencer Hutchins is co-founder of Concert Health, a San Diego-based firm that helps physicians incorporate screening therapy and psychiatric evaluations into their practice, including Collaborative Care. Gary L. Cellini, PharmD, MBA is a health care management consultant. He previously served as president of Satellite Health Plan, an end-stage renal disease Medicare advantage special needs plan, and as vice president of strategic initiatives for Satellite HealthCare. Disclosures: The authors have no relevant financial disclosures.