Ms. Smith has generally been healthy. She lost a close member of her family a few weeks ago and since then, she has been feeling sad much of the time. On a few days she had trouble getting out of bed in the morning and was late for work as a result. She starts having stomach pains and a family member urges her to see her physician.
Under Current Payment Systems
Under Patient-Centered Payment
Ms. Smith calls and schedules an appointment to see her primary care physician. The physician is told that Ms. Smith is having stomach pains and so a short visit is scheduled to address that problem.
Ms. Smith is enrolled with her primary care practice for wellness care and so she calls the practice and describes her symptoms to the nurse she has talked to in the past. The nurse feels that she should be examined right away, since stomach pain could be a sign of either minor or major problems with her stomach, but the nurse recognizes the pain could also be a manifestation of depression, particularly when Ms. Smith mentions her sadness and difficulty getting up in the morning.
The nurse arranges for Ms. Smith to come to see her regular physician either the same day or the soonest that is convenient for Ms. Smith. She ensures that the practice’s behavioral health care manager is aware that Ms. Smith is coming so he is available to talk with Ms. Smith after the visit with the physician if appropriate.
The physician asks about the frequency and severity of the stomach pain and briefly examines Ms. Smith. The physician recommends that she modify her diet and take an antacid to see if that addresses the problem. The physician tells Ms. Smith to schedule another appointment if the antacid and changes in diet do not solve the problem. Ms. Smith does not mention her sadness or difficulties in working, and the physician doesn’t ask about anything other than the stomach pain because of the need to move on to the next patient on the schedule.
The physician conducts a physical examination of Ms. Smith and also screens her for depression. Based on his overall assessment, the physician believes that Ms. Smith is depressed and the stomach pain may be a symptom of the depression.
The physician prescribes an anti-depressant medication for Ms. Smith but also tells her that he’d like her to talk to one of the other staff in the practice who specializes in helping people who feel the way she does. He takes Ms. Smith to the behavioral health care manager’s office, introduces them, and then leaves them to talk with each other.
Ms. Smith takes the antacids but continues to experience stomach pain, so she schedules another appointment. The physician asks her more questions, discovers her mood and sleep problems, and learns about the death in the family.
The physician concludes that Ms. Smith probably has depression, so he prescribes an anti-depressant medication and also refers her to see a psychiatrist.
The behavioral health care manager talks with Ms. Smith in more depth about the death in her family and other factors that may be contributing to her depression. He explains the medication that the physician prescribed in more detail and the importance of taking it as prescribed, he determines whether Ms. Smith will face any financial or other barriers in taking the medication, and he discusses other strategies she can use to help address her depression. He develops a plan for talking with her regularly to monitor her progress and providing counseling to help her overcome her depression.
Ms. Smith contacts the psychiatrist’s office but the soonest appointment she can get is six months away. She gets the prescription for the anti-depressant medication filled, but she does not take the medication every day and soon stops taking it at all.
The behavioral health care manager talks with Ms. Smith regularly, either in person, by telehealth, or by phone depending on what is most convenient or comfortable for her, and provides counseling and support. The care manager has access to a consulting psychiatrist, and he can get advice from her about what changes to make if the medication and counseling do not seem to be working for Ms. Smith.
No one from the primary care practice is aware that Ms. Smith did not see the psychiatrist and is not taking the medication that was prescribed. Ms. Smith does not contact the primary care practice to make any follow-up appointments, so the primary care physician does not see her again.
If Ms. Smith does not improve after a few months, the behavioral health care manager will make an appointment for her to see a psychiatrist or other specialist, and will follow up with them to ensure that any therapy or treatments they provide are coordinated with the other health care services Ms. Smith is receiving from the primary care practice.
If Ms. Smith’s condition improves, the behavioral health care manager, the physician, and the other practice staff will continue to monitor Ms. Smith’s progress and ensure that all of her other services are coordinated and adjusted appropriately.
The primary care practice bills Ms. Smith’s health insurance plan for two office visits. Since Ms. Smith was screened for depression and prescribed medications to treat it, she is considered to have received high-quality care for the purposes of the depression care quality measure used by her health insurance plan, and the practice receives the standard payments for her visits.
The primary care practice bills Ms. Smith’s health insurance plan an Acute Care Visit Fee in addition to the monthly Wellness Care Payment and Integrated Behavioral Healthcare Payment they have been billing for her each month.
Because the primary care practice is receiving the Integrated Behavioral Healthcare Payments, it was already organized to provide integrated behavioral health care services to Ms. Smith when she needed them.
If Ms. Smith needs additional services, such as psychotherapy or counseling from a psychiatrist, psychologist, or other behavioral health specialist, those providers would bill Ms. Smith’s health insurance plan for their services.