August 23, 2022
CMS prioritizes role of behavioral healthcare in overall cost control
Whole Person Care

CMS prioritizes role of behavioral healthcare in overall cost control

Social determinants impact patient outcomes, hospitalization risk     

Behavioral healthcare is taking the spotlight in Medicare’s bid to reduce overall healthcare spending, creating new opportunities for behavioral health providers to expand services, improve patient outcomes and reduce hospitalization.

Policymakers, payors and providers are recognizing the health impact of underlying factors such as housing and transportation needs, limited food budgets and addiction or other behavioral health issues.

“The new acronym being used to encompass all those underlying factors is SDoH, which stands for Social Determinants of Health,” said Eloy Paez, Executive Vice President Behavioral Health, INFINITY.

“We’re seeing a new understanding of the importance of these social determinants across the entire spectrum of healthcare. Medicare is focusing on creating a whole person care initiative that recognizes social determinants, including behavioral health, as key elements for controlling healthcare costs, achieving better outcomes and improving overall health,” he said.  

Social determinants and risk

The Centers for Disease Control (CDC) defines Social Determinants of Health as, “Factors that contribute to a person’s current state of health: biological, socioeconomic, psychosocial, behavioral, or social in nature.”

Behavioral issues such as alcoholism, mental health conditions and addiction are prime examples of social determinants with the potential for significant impact on a patient’s overall health and well-being, Paez said.

As an example, clinical depression might prevent a patient with a diagnosis of diabetes from practicing the self-care regimen required for controlling the disease, leading to a higher risk for rehospitalization.

Addiction often interferes with nutritious eating habits, which can increase health risks for disease and lower life expectancy.

“SDoH are considered the greatest risk factors contributing to rehospitalizations,” said Judy Connelly, a Senior Manager in Clinical Operations Consulting for SimiTree, INFINITY’s strategic partner.

Connelly, who is often asked to speak or write about SDoH as part of industry education efforts, said the COVID-19 pandemic brought into sharp focus the relationship between social determinants and hospitalization risk, including some behavioral health issues.

“As a result of COVID-19 isolation, social determinants became a key factor in mental health conditions leading to high emergency department utilization. Failure to identify and address determinants and disparities are core factors in fragmented healthcare and poor outcomes,” she said.

CMS and whole person care

The Centers for Medicare and Medicaid Services (CMS) has responded to issues highlighted by the COVID-19 pandemic with an accelerated emphasis on whole person care, a holistic approach that Deputy Administrator Meena Seshamani has described as “marrying efforts” in physical health, behavioral health and health-related social needs.

Some of the ways CMS is addressing behavioral health aspects of whole person care include:

  • A new emphasis on behavioral health. Earlier this year, CMS introduced a new Behavioral Health Strategy aimed at strengthening patient access to prevention and treatment services for substance use disorders, mental health services, crisis intervention, and pain care. Additional goals are to remove barriers to care and services, and to adopt a data-informed approach to evaluate our behavioral health programs and policies. Read more about the Behavioral Health Strategy.
  • Proposed regulations to expand access to behavioral health care. One of the most significant indications of the growing role of behavioral healthcare in overall CMS health care strategy came this summer in the proposed Physician Fee Schedule (PFS) for CY 2023. The rule proposes to increase access to behavioral healthcare services by loosening some requirements for direct physician supervision and allowing providers to practice to the full scope of their state licensure under the general supervision of a physician. It also proposes to reimburse clinical psychologists and clinical social workers for coordinating integration of behavioral healthcare services.

Learn more about proposed regulations changes in the CY 2023 Proposed Physician Fee Schedule.

CMS wants to reimburse clinical psychologists and clinical social workers for behavioral health integration services. 

Read more about Social Determinants of Health  


INFINITY can help

Behavioral healthcare providers have many new opportunities ahead for expanding services and playing a significant role in achieving better healthcare outcomes. But the springboard for growth is efficient reimbursement.

Getting fully reimbursed in a timely manner hinges on understanding many revenue cycle complexities. INFINITY offers the resources behavioral health providers need for compliance and profitability, from compliance assessments to efficient billing and claims management, including payor source management, benefits verification, utilization review, and other components of an effective revenue cycle.

Our knowledgeable team identifies and corrects problems that impact cash flow and profitability, reducing claim denials, accelerating cash flow and remedying obstacles to profitability.

Use the form below to reach out to us today to see how we can make your organization stronger and healthier overall.

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