The economic, political, and social contexts within which an organization resides (e.g., constrained funding, billing rules, and the influence of policies related to treatment and targeted populations).
The outer setting describes the environment within which health centers function. Key outer factors include patient needs and resources, cosmopolitanism (i.e., the availability and involvement of health centers with other health care and specialty substance use treatment providers), peer pressure from other health centers and competitors in the market, external policies, and incentives.
Patient Needs and Resources
Patient need for SBI is indisputable. People who drink alcohol in excess, use illicit drugs, or misuse psychoactive medications have elevated risks for a host of health problems, including violence-related trauma and injury, heart disease, breast and other cancers, sexually transmitted diseases, liver and pancreatic diseases, and fetal alcohol spectrum diseases.39 Alcohol use causes about 88,000 deaths in the United States each year.182
Patient desire for services is less clear. On one hand, patients are willing to have PCPs ask about their drinking or drug use if substance use is related to their presenting concern or their risk of health problems.117 PCPs and patients agree that certain office visits are more appropriate for SBI, especially those for physicals or wellness check-ups that also cover smoking, weight, blood pressure, exercise, etc.117 Patients report that they respond more positively in these circumstances because these are contexts in which they expect to be asked about health behaviors.117 Many PCPs believe that unless patients are able to directly link their substance use to their health or other problems, they will not respond to SBI.18, 183 Emerging in several recent articles is the increased willingness of PCPs to screen patients for non-medical use of prescription opioids, recognizing a shared responsibility for contributing to patients' misuse of psychoactive prescription medications.130, 184
The web of relationships between primary care practices and external organizations affects the ability and willingness of PCPs to implement innovations86 and the likelihood that innovations will be sustained.77
The external environment touches primary care in complex ways that impact adopting SBI. Government regulations and managed care contracting practices, accrediting and licensing requirements, and payment and funding streams powerfully affect the viability of integration options.91, 116 Instability among funders, regulators, and external SBIRT program managers can also adversely affect programs.101, 130, 131 Tumult in political leadership and changes in state managed care contracts can severely disrupt referral pathways between health centers and community behavioral health care providers.130
Across the sites and key informant interviews, the issue of funding was a common theme. Funding and grants were seen as integral to sites' ability to provide SBIRT services, although the extent, sources, and uses of funding varied. One site had minimal start-up funds to initiate and pilot test services and then expanded its SBIRT program using no external funding. Other sites developed SBIRT programs with larger grants that supported all or most components of the program. Some interviewees indicated, however, that federal grant expectations and requirements are often resource-intensive and unsustainable in primary care setting. Overall, sites and interviewees supported "continued, expanded, and diversified funding." Diversification through state and federal grants, foundations, partnerships, and taxpayer organizations were suggested as ways to provide more stability and allow organizations to submit proposals for a range of services with SBIRT built in. In some cases, funding was seen as necessary to pay for salaries (e.g., a health educator or LCSW) and provide resources to hire during periods of staff turnover, purchase computer tablets, pay for training, modify EHRs, and evaluate service delivery and patient outcomes (among other things). Sites and interviewees indicated that funding that supports sustainability is key. Without sustainability, a short-term grant mentality can develop among workers whose roles are short-term and who are paid solely by grants. A short-term grant mentality can also lead to hiring an applicant to perform a more narrow set of tasks that fulfills the specific requirements of a grant as opposed to hiring someone with a broader skill set, the "right" person who can fill a range of roles and responsibilities within the health center over the long term. Hiring for short-term purposes may create more of a disruption than build a sustainable, cohesive team for delivering services for the foreseeable future.
The scarcity of SUD treatment referral resources is repeatedly cited by PCPs as a reason for not screening for substance use.116, 130, 135, 160, 172, 181, 185, 186, 187, 188 PCPs describe local substance use treatment as physically inaccessible,116, 160 inconvenient, unaffordable, and of questionable quality.135, 160, 186 PCPs report long wait times for their addicted patients to get seen, and the very limited intensive treatment discourages attention to substance use in primary care.160 In some places, primary care practices and local specialty substance use treatment providers have forged close relationships, with positive results both clinically and financially.91, 103
Interviews with key informants and health center staff indicated that the scarcity of, unfamiliarity with, and lack of coordination with referral resources are major barriers. Moreover, follow-up and patient record sharing with partners and community providers through an EHR or otherwise can be difficult to implement; health centers need to improve the follow-up protocols for high-risk patients and build relationships with specialty care providers that enable sharing patient information.
Sites in rural or less populated areas reported significant challenges with access to substance use services. Moreover, even when relationships with SUD treatment and specialty care providers did exist, other challenges were commonplace, including lack of transportation for patients and provider availability (long wait times). Conducting a proper warm hand-off, providing transportation, and conducting check-in appointments and calls between the initial visit and the appointment with the referral source were seen as important in overcoming barriers to connecting patients to the appropriate levels of care.
Discussions with health center staff and informants also brought to light several key needs including the need to identify strategies to increase care coordination and partnerships as well as to build treatment capacity internally. Care coordinators can act as care managers and liaisons to high-intensity care providers for patients who want or need specialty services. More partnerships are needed with specialty care organizations to help heath centers divide up services and handle high-risk and complex cases. Building internal capacity by integrating more robust behavioral health services (including telepsychiatry) and co-location of more intensive treatment options (including MAT) were seen as potential strategies for overcoming barriers to providing care. Moreover, an internal warm hand-off enables more timely access to care and same-day referrals; providers can walk the patient over to the behavioral health consultant, psychiatrist, or treatment provider on the spot.
Competitive pressure among peer organizations can motivate organizations and providers to implement and sustain an innovation.84 For example, peer pressure and financial incentives among VA health care settings resulted in rapid and sustained increases in alcohol screening. Monitoring systems that used external medical record reviews and patient satisfaction surveys provided monthly, quarterly, and annual performance dashboards, and dashboard results were reported publicly so that each practice manager could see his/her performance relative to all of the other networks. Not surprisingly, routine screening for risky alcohol use rapidly increased in frequency and has been sustained at high levels.91, 97, 99, 162, 189, 190
Governments, health insurers, and accrediting bodies can propel or inhibit the adoption of innovation.191 For example, government funders often have separate policies for behavioral health and medical funding streams, with different provider and program licensure requirements, different service documentation and accountability requirements, different facility requirements, and separate clinical records.71, 191, 192, 193 Demonstration grant programs designed to launch SBI, such as the SAMHSA SBIRT program, require extensive accountability and performance reporting, which disrupts patient flow, frustrates clinicians, and forces a separate SBI specialist function that is often not financially and clinically sustainable after the end of grant funding.157 Standard practices of insurers often require separate behavioral health coding and billing procedures from medical service billing and/or prohibit behavioral health personnel from billing for services in the medical setting without complicated prior approval procedures; pay behavioral health at levels below cost; or simply exclude payment for behavioral condition services due to pre-set, location-specific utilization management procedures. The HHS Agency for Healthcare Research and Quality study of 11 successful PCBHI programs found that policies that were external to the clinical settings severely undermined or completely derailed all but one setting: that exception was the VA, which operates as an integrated health system.77
Among the external factors discussed by health center staff and key informants, billing and reimbursement were cited as particularly significant challenges. Billing is difficult for health centers to understand and to navigate, and the structure needs to be reorganized and clarified. Health centers would benefit from more education on reimbursement, being provided a matrix of the reimbursement process, and the standardization of reimbursement documentation across insurers.
Federal substance use privacy regulations impede care coordination between primary care and substance use services.194, 195 The federal rule known as 42 CFR Part 2 prevents the sharing of any information outside of a specialty substance use treatment program without the explicit permission of the patient except under very specific situations. The rule is widely perceived to hinder the coordination of care between PCPs and substance abuse specialists181, 191, 196, 197 and to prevent sharing clinical data, which is important for safe prescribing of potentially addictive medications.198, 199
At least 30 of the studies included in this review identified lack of reimbursement or inadequate reimbursement as a barrier.17, 71, 77, 100, 116, 119, 125, 131, 135, 136, 160, 168, 181, 183, 184, 185, 186, 192, 196, 198, 200, 201, 202, 203, 204, 205, 206, 207 Payers often do not reimburse PCPs or their staff for delivering behavioral health services, do not reimburse for same-day medical and behavioral health services, do not reimburse when behavioral health staff deliver services in medical settings, reimburse at levels below cost, or do not reimburse at all for SBI or similar services for other behavioral risks.77 Lack of adequate reimbursement is the predominant reason given by PCPs and program managers for the failure of SBI to take hold.17, 71, 100, 119, 135, 136, 160, 168, 181, 183, 184, 196, 202, 207 Reimbursement rates are inadequate to support the costs for treating patients with addictions in primary care,77, 185, 198, 201, 204 for providing continuing care and case management,71, 77, 116, 125, 196 and for specialty substance use treatment referral resources.125, 130, 135, 160, 172, 181, 185, 186, 187, 188
Interviews with key informants and FQHC staff strongly support findings from the literature--challenges with billing and reimbursement for SBIRT services are pervasive. Sites and key informants suggested that billing mentoring between FQHCs, redefining codes for FQHCs, and increasing and improving reimbursement rates for SBIRT services and care coordination are much needed. Furthermore, some indicated that value-based funding, cost-based reimbursement, and capitated and bundled payments that take the overall health of the population into consideration had shown better results. State service collaboration reimbursement that coordinates across populations rather than payers was also noted as having shown benefit for streamlining reimbursement structures. A number of interviewees indicated a need to shift away from fee-for-service billing models; at some sites, composite billing and the use of SBIRT billing codes for services and health educators showed positive benefits for billing processes. Additionally, patients and clinics were said to benefit from being able to bill for same-day services when clients received multiple services. Patient co-pays were also identified as a barrier. In some areas, if a BHP conducts SBIRT services, the patient must pay a co-pay but is not required to do so if the medical provider conducts the services. Additionally, there is a need to develop procedures for assisting non-Medicaid clients who decline services because they are unable to pay the co-pays.
Kautz, Mauch and Smith193 identified seven barriers that consistently inhibit integrating of behavioral health into primary care and that are consistent with the information gathered from site visits and key informant interviews:
Medicaid and other insurers' limitations on payments for same-day billing for both a physical health and a behavioral health service visit.
Lack of reimbursement for collaborative care and case management related to behavioral health services.
Absence of reimbursement for services provided by non-physicians, alternative practitioners, and contract practitioners and providers.
Medicaid and other insurers' disallowance of reimbursement when primary care practitioners submit bills that list only a behavioral health diagnosis and corresponding treatment.
Inadequate reimbursement rates in both rural and urban settings.
Difficulties in getting reimbursement for behavioral health services in school-based health center settings.
Lack of reimbursement incentives for screening and providing preventive behavioral health services in primary care.
Government and health insurer coverage policies can powerfully shape providers' behaviors. The HHS Centers for Medicare and Medicaid Services (CMS) approved SBI as a reimbursable primary care procedure for Medicare beneficiaries in 2008 and included SBI as a 100 percent Medicare-reimbursable preventive service in 2012.208 State Medicaid programs decide whether to cover SBI as a billable service and the types of providers that can bill those codes. About half of the state Medicaid programs have opted to reimburse for SBI,136, 209 but only 19 states have set up mechanisms to reimburse on the SBI codes.209 As of 2010, 30 state Medicaid programs allow same-day billing for medical and behavioral health services.71, 196, 204, 205 How all of these issues come together can be seen in Padwa's196 study of California county SUD administrators. The most commonly reported barrier to integrated substance use screening and treatment in primary care is inadequate or inflexible funding. More than nine in ten county administrators report that finding ways to adequately and sustainably finance integrated care is their major concern. California's Medicaid program does not reimburse for substance use SBI services, nor does it allow FQHCs to bill for both physical health and behavioral health visits provided to an individual patient on the same day.
Mike Brooks, policy director for the Center for Clinical Social Work, has a simple solution for the low levels of PCP adoption of SBIRT: "Pay them."210 Several comprehensive analyses of reimbursement strategies to promote integrated behavioral health care have been published recently.77, 193, 211 Powell's,211 Kautz's193 and Kathol's77 extensive structured literature reviews of strategies for implementing and sustaining integrated health/behavioral health innovations converge on several key issues, but they all come down to variations on Brooks' simple solution of paying providers.
Facilitators: Recommendations from Key Informants and FQHCs
Interviews with key informants and FQHC staff during site visits yielded a number of recommendations that are relevant to the outside setting for facilitating the implementation and sustainability of SBIRT in health centers. Below is a summary of those recommendations:
Share information and improve communication between PCPs and specialty BHPs. Simplify the specialty care referral process, scheduling appointments, and follow-up once a referral is provided. Providing access to a shared EHR is helpful.
Continue, expand, and diversify substance use screening and treatment funding. Most FQHCs used grants to start substance use services to pay salaries, bridge staff turnover, and fund EHR adaptation, but diversification of funding is essential for sustainability.
Reorganize and clarify the reimbursement structure. A variety of funding mechanisms show better results for supporting prevention and behavioral health risk management: value-based funding, cost-based reimbursement, and capitated or bundled payments.
Reimbursement documentation should be standardized across insurers, Medicaid, and Medicare; clarify what SBIRT services can be reimbursed; cover whole-person behavioral risk assessment and intervention (including substance use); and cover the extra care coordination and interviews that result from these screens.
Facilitate billing mentoring between community health centers.