Medicare-Proposed Standards for CMHCs Spotlight Psychiatrists’ Role on Treatment Team

The proposed Conditions of Participation (CoPs) from Medicare for community mental health centers (CMHCs) could expand the role and responsibilities of psychiatrists both in and beyond Medicare facilities. The CoPs, when final, will only apply directly to facilities offering Medicare partial hospitalization services-about 224 facilities.

Curley Bonds, MD, is the Medical Director at Didi Hirsch Mental Health Services in southern California and has clinical appointments at Charles Drew University, Los Angeles, and UCLA. The Hirsch CMHC serves 70,000 patients annually at 11 locations throughout southern California. It has no Medicare partial hospitalization program, so Hirsch will not be affected directly by the CoPs. But Bonds said the CoPs could have significant indirect effects on mental health centers that currently are not serving Medicare patients.

He thinks some CMHCs without Medicare partial hospitalization programs may be encouraged to start them once the CoPs are final. The CoPs will give that benefit a legitimacy it has lacked and give providers clear federal standards for the first time. “If you have standards published and they are widely understood, you wouldn’t face the risk of an audit where things are determined more arbitrarily,” Bonds suggested.

One of the most important aspects of the proposed CoPs is that they state that a CMHC must designate a “a physician-led interdisciplinary treatment” team responsible for coming up with an active treatment plan for each patient. Those plans would have to include the following:

• Patient diagnoses

• Treatment goals and the patient’s recovery goals

• Interventions

• A detailed statement of the type, duration, and frequency of services

• Drugs, treatments, and individual and/or group therapies

• Family psychotherapy, with the primary focus on the treatment of the patient’s conditions

The requirement for a “physician-led” treatment team trumps the Joint Commission’s requirement. Peggy Lavin, Senior Associate Director of the Joint Commission’s Behavioral Health Care accreditation program, said the Joint Commission’s Behavioral Health Care accreditation manual-used for the certification of CMHCs-calls for treatment teams to be led by a “qualified practitioner.” She explained that a qualified clinical psychologist, for example, would be qualified to lead an interdisciplinary treatment team.

Bonds argued that the treatment team should really be led by a psychiatrist “because of our ability to do comprehensive risk assessment, which is definitely part of our training.” Frequently, psychiatrists at CMHCs, whether funded partly through Medicare or not, are busy doing “back-to-back medication management.” He added, “Sometimes, physicians are marginalized because they are consulted too late by other members of the treatment team.” If a psychiatrist or other physician is working on a contract basis (often true at small centers and rural centers), he or she may not even be on premise when the treatment team meets.

Nicholas Meyers, Director of Government Relations, American Psychiatric Association (APA), said it was likely that the APA, whose comments were not filed as this report was being written, would ask Medicare to change the language on leadership of a treatment team to say it should be led by “a physician, preferably a psychiatrist.” Psychiatrists, according to the proposed CoPs, would have to be certified by the American Board of Psychiatry and Neurology or have a documented equivalent education, training, or experience (“equivalent” is not defined) and be fully licensed in the state in which he practices.

There is a lot in the CoPs that at least indirectly could strengthen CMHC reliance on psychiatrists. For example, the requirement for an “initial evaluation” means immediate care and support assessment related to a patient’s psychiatric illness. However, Medicare stated that the initial evaluation must be completed by a “CMHC psychiatric registered nurse or clinical psychologist.”

A comprehensive assessment, however, would be completed by “the CMHC physician-led interdisciplinary treatment team” no later than 3 days after admission. It would have to include a psychiatric evaluation, completed by a psychiatrist or psychologist with physician countersignature, and a history, with information on severity of symptoms.

Once the assessment was completed, services provided could include individual and group psychotherapy with a psychiatrist, psychologist, or other licensed mental health counselor, to the extent authorized under state law.

Henry White, MD, Clinical Director of the Brookline Community Mental Health Center, Brookline, Mass, and a psychiatrist, emphasized as Bonds did that the CoPs, when final, would resonate beyond the CMHCs that offer Medicare partial hospitalization services. “I expect that these regulations will be used as a template for Federally Qualified Behavioral Health Centers, that we hope Congress will approve.”

But White called the CoPs a mixed bag. One concern is the Center for Medicare & Medicaid Services’ (CMS) estimate of the cost of compliance. The agency says a CMHC offering Medicare partial hospitalization would have to spend $18,000 initially to comply with the CoPs and $11,000 a year thereafter. “Many CMHCs are struggling to break even every day,” White said.

Lastly, White argued that the CMS missed an opportunity to press CHMCs to move in the direction of integrated care-the treatment “ethic” endorsed by the Affordable Care Act, which established accountable care organizations and medical homes. The regulations should require CMHCs to coordinate and integrate care with patients’ primary care physicians. Adults with serious mental illness die on average 25 years earlier than other adults. CMHCs have a unique opportunity and responsibility to reduce this mortality gap, White stated. The Brookline Community Mental Health Center has started an innovative program, Healthy Lives, that provides intensive care coordination, disease management, and wellness and prevention services for their most at-risk population-adults with both serious mental illness and 2 or more serious chronic medical problems. “We are already seeing improvement in quality of care,” he explained. “We hope that all CMHCs will soon have similar programs in place.”