New Medicare Payment Option for Behavioral Health Integration

Medicare rang in the new year with four new codes to reimburse primary care teams for behavioral health services. According to an article that appeared in the New England Journal of Medicine on February 2, 2017, three of the codes support services using the Collaborative Care Model (CoCM) and the fourth allows for services provided under other behavioral health care models. The codes are meant to facilitate access and integration of behavioral health services such as care management and psychiatric consultation for the primary care team. They focus on improving quality of care and patient satisfaction and could play a pivotal role in supporting interdisciplinary collaboration in primary health care.

The most immediate impact of the codes may be felt by physicians already providing these services for common mental health conditions such as depression and anxiety; however, these codes could potentially be applied to care coordination services for other behavioral health conditions such as those supporting integration of substance use disorder treatment and primary care. Yuhua Bao, PhD, Associate Professor of Healthcare Policy & Research at Weill Cornell Medicine and former CHERISH pilot award recipient, is an expert in payment policy for behavioral health conditions. She comments that “these new reimbursement codes recognize that primary care practices need additional resources to coordinate behavioral health care services in an evidence-based way, and that the initial month requires more intensive services.”

The new codes include reimbursement for time delivering CoCM services, approximately $140 for 70 minutes per beneficiary for the first month; approximately $125 for 60 minutes per beneficiary for subsequent months; and for all months, approximately $65 for each additional 30 minutes per beneficiary. For time delivering other behavioral health integrations services, the new codes reimburse approximately $48 for at least 20 minutes of services per beneficiary per month.

Medicaid’s Most Costly Outpatient Drugs include Opioids, Opioid Agonists, and HCV and HIV Treatments

The Kaiser Commission on Medicaid and the Uninsured recently released an issue brief detailing the most costly outpatient drugs to Medicaid in 2014 and the first half of 2015. Using data from the Center for Medicare and Medicaid Services (CMS), the authors analyzed outpatient drug costs based on Medicaid spending (before rebates) to determine which drugs account for the greatest costs to Medicaid. In doing so, they found that the top 50 most costly outpatient drugs fall into one of three categories: a) frequently prescribed medications that are relatively inexpensive per prescription b) frequently prescribed medications that are also relatively expensive per prescription;  and c) medications that are prescribed less frequently but are relatively expensive.


The report shows that hydrocodone-acetaminophen, a low cost generic opioid pain reliever, is the most commonly prescribed drug from 2014-2015. Suboxone (buprenorphine/naloxone), an opioid agonist used to treat opioid use disorder, is also not among the most expensive drugs and is frequently prescribed to Medicaid patients despite prescribing limits that restrict who can prescribe this medication and how many patients can receive a prescription per prescriber. In the period covered by this study, buprenorphine/naloxone was limited to a maximum of 100 patients per authorized prescriber. A recent change by the Department of Health and Human Services has increased this limit to 275 patients.

Two HIV medications, Truvada (emtricitabine/tenofovir) and Atripla (efavirenz/emtricitabine/tenofovir), are in the second category, being both expensive and frequently prescribed. In contrast, two HCV medications are in the third category because they are expensive but not so frequently prescribed to Medicaid patients. These medications, Sovaldi (sofobuvir) and Harvoni (sofosbuvir/ledipasvir), are two of the top five most costly outpatient drugs per prescription for Medicaid. The lack of frequent prescriptions is not surprising because state Medicaid program limitations on HCV medication access due to budget constraints have been widely reported. The future may bring changes in access and cost, however. Some state Medicaid programs are eliminating HCV medication limitations as a result of legal challenges, and additional highly effective HCV medications have recently come to market, such as Zepatier (elbasvir/grazoprevir) and Epclusa (sofosbuvir/velpatasvir) at lower published prices. Thus Medicaid’s spending per prescription and the number of prescriptions for HCV medications may change in subsequent years.

Quality of Life of Opioid Users and their Spouses

There are more deaths in the US from opioids than from any other unintentional injury–one person died every 30 minutes from an opioid analgesic overdose in the US in 2014. The experience of living with opioid use is harmful both for the opioid user and for his or her spouse.

A recent study published in the journal Addiction quantified exactly how much opioid use and treatment affects quality of life for opioid users and their spouses. Led by Dr. Eve Wittenberg at the Harvard T.H. Chan School of Public Health, the study was a collaboration with two members of the CHERISH leadership, Dr. Brandon Aden and Dr. Bruce Schackman from Weill Cornell Medicine. The investigators surveyed over 2,000 individuals across the U.S. using a standard technique to assess quality of life for comparisons across different health conditions. Results showed that quality of life is poor for active opioid users and also for those in early treatment. Even during long-term treatment quality of life is still below that of a healthy person who has never misused opioids. Injection opioid users’ quality of life is worse than that of prescription opioid misusers’, and patients in methadone maintenance treatment have worse quality of life than patients treated with buprenorphine in doctors’ offices. The study is one of the first to also measure quality of life for spouses or partners of opioid users. Spouses’ quality of life was considered better than that of opioid users, but they still experience diminished quality of life when their partners were actively using opioids or were in the early stages of treatment.

These results are important because they allow comparisons of effects across health conditions. They provide a numerical value of quality of life that allows us to say which conditions have more or less effect on individuals’ quality of life, and therefore, which conditions have more “room” to improve health through effective treatment. These types of measures are often used in economic evaluations to explain the value derived from different treatments across different conditions.

As prescription opioid misuse and heroin use claims more lives, additional resources are being devoted to opioid use disorder treatment. In order to ensure these resources provide the greatest value, health economics research is needed to study the cost-effectiveness of treatment programs and of linking opioid dependent individuals to other healthcare and social services. The findings from this study will play an integral role informing future economic research related to opioid use disorder treatment and care linkage programs.