However, Dorfman and Smith (2002) reviewed preventive mental health and substance abuse programs and concluded that six types of preventive interventions would be appropriate for a managed care organization to deliver from both a cost-effective and feasibility perspective. These interventions include four programs that would benefit children and adolescents: prenatal and infancy home visits, smoking cessation counseling for pregnant smokers, targeted short-term mental health therapy, and brief counseling to reduce alcohol use. A combination of screening, brief intervention, referral, and treatment is one Medicaid-eligible service that includes early intervention for those at risk for developing substance abuse disorders.

SAMHSA recently reported the results of a study on barriers to and recommendations for reimbursement of mental health services in primary care settings, focusing on services for those with public insurance (Kautz, Mauch, and Smith, 2008). The report highlights a number of barriers that apply to both preventive and treatment services, including limitations on same-day billing for physical and mental health services, limitations on reimbursement for mental health services provided by primary care practitioners rather than mental health specialists, lack of reimbursement for collaborative care and case management, lack of reimbursement for services provided by nonphysician practitioners, and inadequate reimbursement for services in rural and urban settings. The report also specifically identifies the lack of reimbursement incentives for screening and for providing preventive mental health services as a priority barrier (Kautz, Mauch, and Smith, 2008).

Reimbursement for services is sometimes limited by the choices of state Medicaid offices, by local carriers of intermediaries’ interpretations in processing claims, and by specific private insurance plans. Delivery of behavioral health services is frequently covered only if the services qualify as a “medical necessity,” which may vary in definition in managed care contracts and may vary for different services and by different state Medicaid programs and private insurance plans (Kautz, Mauch, and Smith, 2008; Nitzkin and Smith, 2004). For preventive services, the combination of limited available billing codes and the limitations on what is interpreted to qualify as a reimbursable billed service can lead in practice to very restricted reimbursement for preventive services. This contributes to inadequate provision of preventive services by primary care practitioners or promotion of these services by health care systems (Nitzkin and Smith, 2004). In Clinical Preventive Services in Substance Abuse and Mental Health Update: From Science to Services (Nitzkin and Smith, 2004), SAMHSA provides more detailed suggestions for primary care physician reimbursement for preventive services.

There is also only limited reimbursement for mental health services, including preventive services, in schools. Schools can be reimbursed by



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement