The Business Case for Integrated Behavioral Healthcare Delivery

Abstract

The need for integrated behavioral health leaders to develop competencies for financial management is growing as healthcare delivery transitions from traditional fee for service to value-based models of reimbursement. This chapter is focused on developing a business case for sustainable integrated behavioral health programs. Key competencies include determining program costs, projecting revenue, completing a pro forma, and calculating return on investment (ROI) for integrated behavioral healthcare delivery. Examples of measurement and evaluation of these competencies are included.

Appendices

Appendix A: Degree Program Discussion Board Rubric

Criteria	Unacceptable	Acceptable	Good	Excellent
Quality of initial post (2 points)	Post meets one or fewer of the four criteria or did not submit (0 points)	Post meets two of the four criteria (1 point)	Post meets three of the four criteria (1.5 points)	Initial post meets all of the following criteria Is well developed Fully addresses all aspects of the discussion board question Meets criteria for substantive (**salutations and references do not count toward minimum word requirements**) Post is factually correct (2 points)
References and support (.5 points)	Post incorporates zero course materials or did not submit (0 points)	Post incorporates one piece of information or meets one of the three required criteria (0.1 point)	Post incorporates two pieces of information or meets two of the three required criteria (0.3 point)	Post incorporates three pieces of information from course materials (e.g. assigned readings, lectures, etc.) and meets all of the following criteria: Includes in-text citations Includes reference list At least one reference is from an assigned reading (0.5 point)
Clarity and mechanics	Post meets two or fewer of the required criteria or did not submit (0 points)	Post meets three of the five required criteria (0.1 point)	Post meets four of the five required criteria (0.3 point)	Post meets all of the following criteria: Reference is in APA style (indentation not required due to formatting limitation of discussion board) In-text citation is in APA style Has no more than two errors in clarity/mechanics and/or grammatical/spelling errors Communicates in a friendly and courteous manner Post is well organized and easy to read (0.5 point)
Follow-up postings	Post meets two or fewer of the required criteria or post does not add to the discussion or did not submit (0 points)	Response post adds to the discussion and post meets three to four of the nine required criteria (0.5 point)	Response post adds to the discussion and post meets five to six of the nine required criteria (0.75 point)	Response post adds to the discussion through the provision of a new idea or concept based on course content and meets six of the nine following criteria: Is well developed Meets criteria for substantive (**salutations and references do not count toward minimum word requirements**) Post is factually correct Post does not merely restate the student’s initial post Includes in-text citations and/or a reference list Reference list and/or in-text citations are in APA style Post is free of grammatical/spelling errors Communicates in a friendly and courteous manner Post is well organized and easy to read (1 point)

Appendix B: Assignment Instructions and Grading Rubric for Written Assignment: Integrated Behavioral Health Intervention Utilization, Cost, Cost Savings, and Return on Investment Results and Analysis (25 points)

Assignment #1 Instructions

Complete a proposal for the design, implementation, and evaluation of an integrated behavioral health intervention designed to result in cost savings and a return on investment. The intervention must address at least two conditions: one must be medical (e.g., diabetes, hypertension) and one must be behavioral (e.g., depression, anxiety, substance use disorder). The intervention should be based on the population health management (PHM) model. Examples and instructions for the PHM model are included in the assigned readings. You will write the proposal as an integrated behavioral health provider. The intended audience for this report is the CEO for a Patient-Centered Medical Home and Accountable Care Organization primary care clinic network. The proposal must include each of the following sections:

Program/Intervention Costs

List staffing, administrative support, supplies, physician and nurse time, data entry and analysis, etc. You must use dollar estimates for each cost category and a grand total for program costs.

Pre-intervention (Baseline) Utilization and Cost

List each category of utilization and associated dollar cost (e.g., physician visits, emergency department visits, hospital admissions and days, pharmacy, specialist referral visits, labs, and imaging). Include aggregate mean utilization and cost for at least 2 years and ideally 3 years pre-intervention. For each unit of service, assign a specific dollar amount. Compute the total pre-intervention cost based on the mean (average) annual utilization multiplied by the unit cost for each category.

Post-Intervention Utilization and Cost

List each category of utilization and associated dollar cost (e.g., physician visits, emergency department visits, hospital admissions and days, pharmacy, specialist referral visits, labs, and imaging). Include aggregate mean utilization and cost for at least 1 year post-intervention. For each unit of service, assign a specific dollar amount. Compute the total post-intervention cost based on the mean (average) annual utilization multiplied by the unit cost for each category.

Return on Investment Calculation

Use the formula listed in the readings to calculate return on investment: total cost savings (pre-intervention costs minus post-intervention costs) divided by the total cost of the intervention.

ROI Analysis

Executive summary: brief summary of entire project, rationale for leadership investment in project, overall benefits, and long-term sustainability of program.

Assignment #1 Grading Rubric (Edited, Selected Sections Only for Illustrative Purposes)

Item	Excellent 2.0	Fair 1.0	Unacceptable 0
Problem statement	Clear statement of need based on evidence for high costs for the selected conditions and population	Vague or partial statement of need based on evidence for high costs for the selected conditions and population	No statement of need based on evidence for high costs for the selected conditions and population
Population	All key elements described: age, gender, ethnicity, setting	Partial description of key elements: age, gender, ethnicity, setting	No description of key elements: age, gender, ethnicity, setting
Patient identification	Clear description of how patients will be identified based on more than one criteria, such as patient self-report measures, claims data, lab, or diagnostic data in the electronic medical record, physician referral	Vague or partial description of how patients will be identified based on more than one criteria, such as patient self-report measures, claims data, lab, or diagnostic data in the electronic medical record, physician referral	No description of how patients will be identified based on more than one criteria, such as patient self-report measures, claims data, lab, or diagnostic data in the electronic medical record, physician referral
	Excellent 5.0	Fair 4.0	Poor 3.0
Program costs	Clear description of costs for program including staffing, administrative support, supplies, physician and nurse time, data entry and analysis, etc. Use dollar estimates for each cost category and a grand total for program costs	Vague or partial description of costs for program including staffing, administrative support, supplies, physician and nurse time, data entry and analysis, etc. Incomplete use of dollar estimates for each cost category and a grand total for program costs	Poor description of costs for program including staffing, administrative support, supplies, physician and nurse time, data entry and analysis, etc. No use of dollar estimates for each cost category and a grand total for program costs
Pre- and post-intervention utilization and cost intervention costs)	Clear, detailed description of each key type of utilization such as physician visits, emergency department visits, hospital admissions and days, pharmacy, specialist referral visits, labs, and imaging that you will report based on the mean number of visits per patient for at least 1 year prior to the intervention and 1 year post-intervention. For each unit of service, assign a specific dollar amount, and compute the total cost of pre- and post-intervention based on utilization. Includes a total dollar amount for pre-intervention utilization/costs and post-intervention utilization/costs	Vague or partial description of each key type of utilization such as physician visits, emergency department visits, hospital admissions and days, pharmacy, specialist referral visits, labs, and imaging that you will report based on the mean number of visits per patient for at least 1 year prior to the intervention and 1 year post-intervention. Unclear description of how each unit of service is assigned a specific dollar amount and unclear computation of the total cost of pre- and post-intervention based on utilization. Unclear plan to have a total dollar amount for pre-intervention utilization/costs and post-intervention utilization/costs	Poor description of each key type of utilization such as physician visits, emergency department visits, hospital admissions and days, pharmacy, specialist referral visits, labs, and imaging that you will report based on the mean number of visits per patient for at least 1 year prior to the intervention and 1 year post-intervention. Poor description of how each unit of service you will assign a specific dollar amount and compute the total cost of pre- and post-intervention based on utilization. Lacking plan to have a total dollar amount for pre-intervention utilization/costs and post-intervention utilization/costs
ROI calculation	Clear description of the ROI calculation based on the formula listed in the readings to calculate return on investment: total cost savings (pre-intervention costs minus post-intervention costs) divided by the total cost of the intervention	Vague or partial description of the ROI based on the formula listed in the readings to calculate return on investment: total cost savings (pre-intervention costs minus post-intervention costs) divided by the total cost of the intervention	No description of ROI based on the formula listed in the readings to calculate return on investment: total cost savings (pre-intervention costs minus post-intervention costs) divided by the total cost of the intervention

Appendix C: Sample Quiz Question

Multiple choice: PCMH and diabetes cost savings

Points:1

Question	In the article by Wang et. al., “Patient-centered medical home impact on health plan members with diabetes,” Table 3, which of the following outcome measures was not associated with a significant reduction in costs between baseline and at least one year 1, 2, or 3 in the study for the PCMH?
Answer	Total medical care PMPM Inpatient PMPM ED PMPM Pharmacy (Rx) PMPM

Appendix D: Group Activity: Billing and Reimbursement in Integrated Healthcare (Edited)

Overview

In this assignment, you will research billing codes and reimbursement for integrated healthcare services in a primary care clinic. This group activity is designed to help you prepare for written assignment #1.

Instructions

In this week Chap. 7 in Corso et al. (2016) “Integrating Behavioral Health into the Medical Home,” a strong emphasis is on analyzing reimbursement rates as a component of your business case or integrated behavioral health. In this group assignment, I would like each of you to research the billing codes specific to the institution, payer, and provider license for either (a) your current clinical practice (if you work in a clinical setting) or (b) a primary care Accountable Care Organization (ACO) clinic in your state (for students who do not work in a clinic). Approach this with the assumption that you are the clinic leader interested in developing/enhancing integrated behavioral health in your clinic. You plan to evaluate which reimbursement codes your clinic is eligible for and what types of clinicians are eligible for reimbursement for reimbursement codes that are available in your clinic.

Evaluate each of the specific codes listed below for your clinic scenario. Which codes are eligible for reimbursement? For those codes that your clinic is eligible for, answer these questions: What provider license types? What payers? What reimbursement rates (if available)?

• Health and Behavior Codes

• Psychotherapy Codes

• Screening, Brief Assessment, Referral and Treatment Codes

• Wellness Codes

• Screening and Prevention Codes

• Care Coordination/Chronic Care Management

The presentation should be brief, simple, and delivered as if you were in a team meeting in a clinic setting making your presentation to your integrated behavioral health “team.” You are making a presentation to your “team” based on your initial analysis and expect questions, discussion, and next steps.

Instructions for Discussion Board Post and Substantive Reply

After the meeting is completed, each student should write a summary post on the group discussion board that describes his/her experience in the group. Was the group meeting helpful? Were there challenges? Describe how the group discussion helped to refine your approach to this assignment. Finally, post a brief (one paragraph) summary of your research on reimbursement for services in support of integrated behavioral health in your scenario. What services in support of integrated care are reimbursable in your scenario? Which one’s are not?