Physicians See the Need, Not the Pay for Mental Healthcare

Marcia Frellick

October 12, 2018

NEW ORLEANS — It is vital and cost-effective to provide mental health services in primary care, but without reimbursement, the challenge becomes insurmountable, said delegates who testified here at the American Academy of Family Physicians (AAFP) 2018 Congress of Delegates.

Joe Miller, MD, an alternate delegate from Nebraska, speaking on his own behalf, said that up to one-third of the patients served by the accountable-care organization he is a member of, which has about 35 primary care physicians, have a mental health diagnosis.

"We need to support primary care mental health coverage or we're not going to be able to take care of these people," he said.

Miller was one of the delegates who supported a resolution proposing that the AAFP convene a meeting of groups — including the Relative Value Scale Update Committee, the Medicare Payment Advisory Commission, the Centers for Medicare and Medicaid Services (CMS), and national health plans — to mandate full reimbursement for mental healthcare services directed and supervised by primary care physicians. The resolution stipulated that the AAFP provide a report each year to the Congress of Delegates until such reimbursement is fully implemented.

Some supporters of the resolution were particularly frustrated with mental healthcare "carve outs" from some insurance plans.

"Medicare Advantage plans carve this out, Medicaid carves this out, as do many health plans," said Robert Jackson, MD, an alternate delegate from Michigan who helped author the resolution.

The literature is convincing that mental healthcare brings great benefit to practices, "but if we can't pay for it, we can't give that benefit," he pointed out.

Tim Alford, MD, a delegate from Mississippi, said that in the Mississippi Delta, "we have one of the highest — if not the highest — incidence of schizophrenia in the world. And a patient with hard-core schizophrenia carries the same cost burden to society as a quadriplegic."

There is little mental health infrastructure in the state, Alford said, and the care largely falls to the family doctor.

Payment reform needs to include mental health because it's eating us alive and it's eating this country alive.

"We have to stake our ground when it comes to payment to physicians," he said. "Payment reform needs to include mental health because it's eating us alive and it's eating this country alive."

The resolution was referred to the board of directors for study and a report to next year's Congress.

Michael Munger, MD, speaking on behalf of the AAFP board of directors, said that although the board is "100% behind" the intent of the resolution, it opposes the resolution as written because position papers and policy are already in place that ask for "full payment to family physicians who provide behavioral health services and who supervise behavioral health clinicians."

"We routinely advocate for this, not only with CMS, but also in our yearly meetings with the big five commercial payers. This is something we're actively engaged in," he added.

The AAFP does not have the authority to convene the groups the resolution asks for, Munger noted, and although the board sees the end goal as critically important, it sees the direction proposed to get there as flawed.

Miller, Jackson, Alford, and Munger have disclosed no relevant financial relationships.

American Academy of Family Physicians (AAFP) 2018 Congress of Delegates. Presented October 10, 2018.

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