Combating A Crisis By Integrating Mental Health Services And Primary Care
As the most common access point for health care in the United States, primary care physicians—including family physicians, internal medicine physicians, pediatricians, and obstetrician gynecologists—stand at the front line of ensuring the highest possible level of physical and behavioral health for people throughout their lifetime. We aim to do this all while navigating the challenges of limited time with patients and often with inadequate resources.
Yet, existing systems are failing to meet the need for whole-person care, including addressing the impact of life stressors and trauma, which have only intensified during the COVID-19 pandemic.
More people than ever are struggling with their behavioral health, including both mental health and substance use disorders. We believe, therefore, that our primary care systems must urgently embrace a paradigm shift, accelerating the adoption of behavioral health integration (BHI) in physician practices and addressing this rampant increase in unmet needs.
To help enable such efforts, eight of the nation’s leading physician organizations—which we lead or have led—established the BHI Collaborative with the mission of empowering physicians and their care teams to improve the quality of care and expand patients’ access to behavioral health services. The BHI Collaborative, and the physician practices it supports, cannot and should not tackle these challenges alone.
To accelerate BHI adoption and sufficiently combat this crisis, physician practices require the partnership of other key stakeholders across the health care ecosystem, particularly payers—including employers and health plans—and policy makers.
Treating The Whole Person Through Integration
Behavioral health conditions are a leading contributor to disease burden in the United States with depressive and substance use disorders among the top 10 causes of death and disability for adults. They are also a leading cause of preventable pregnancy-related deaths. Although many US adults reported a behavioral health condition prior to the COVID-19 pandemic, less than half received treatment in 2019.
As many as 50 percent of behavioral health disorders begin by age 14. Between 13 percent and 20 percent of US children and adolescents—or approximately 15 million youth—experience a behavioral health disorder in any given year with suicide as the second leading cause of death among 10- to 24-year-olds. Individuals with co-occurring physical and behavioral health conditions also tend to incur higher health care costs and experience worse overall health outcomes.
Furthermore, up to 70 percent of all primary care visits include a behavioral health component, underscoring the need for collaboration among primary care physicians, psychiatrists, and relevant subspecialties such as child and adolescent psychiatry, developmental-behavioral pediatricians, and other key behavioral health clinicians.
A holistic, evidence-based integrated approach within primary care settings that focuses on the well-being of the whole person through all developmental stages, including the implementation of behavioral health screening and service intensity placement tools (such as the Child and Adolescent Service Intensity Instrument) that are standardized and normalized, can help individuals receive treatment earlier and at the right level of care.
BHI not only enhances access to behavioral health screening and treatment but also supports the coordination of both physical and behavioral health care services among the various physicians and other clinicians while reducing the stigma associated with behavioral health treatments. To proactively build resilience, our systems must promote early childhood healthy mental development and support safe, stable, nurturing relationships. This generates a true patient-centered, whole-person care approach that breaks down the traditional silos of physical and behavioral health care.
These efforts are also essential to advancing job satisfaction and overall improved quality of life for physicians and the broader care team as they report feeling less burned out knowing they can more fully care for their patients’ most pressing needs.
It is also important to note that there is no one-size-fits-all approach to BHI. Successful integration of behavioral health care can occur along a spectrum from coordinated to fully integrated care, with the Collaborative Care Model (CoCM) being one of the most studied and validated models of integration. Other models—such as the Primary Care Behavioral Health Model, or telehealth consultation to primary care physicians and non-physician clinicians by a behavioral health team—can help expand access to behavioral health services for patients and increase clinician capacity.
Key Obstacles To Widespread BHI Adoption By Primary Care Practices
Despite a strong evidence base alongside several statutory and regulatory changes over the past decades favorable to encouraging BHI (that is, the Mental Health Parity Act of 1996, the Mental Health Parity and Addiction Equity Act of 2008, the Affordable Care Act of 2010, CY 2018 Medicare Physician Fee Schedule—Final Rule), widespread adoption by primary care practices remains the exception, rather than the standard, across the US. This is due to several obstacles facing physician practices including high start-up costs combined with low reimbursement levels, complicated and burdensome billing requirements, siloed data, and limited workforce availability.
Financial sustainability continues to be a pervasive concern for practices—both in fee-for-service and alternative payment models. Heath plan products and coverage programs, such as Medicare and Medicaid, frequently lack sufficient coverage and fair payment with adequate margin for primary care practices using CoCM and other BHI models to provide integrated services. To make matters worse, many primary care physicians don’t have the necessary upfront capital, among other required training and resources, to adopt and sustain BHI within their practices. Furthermore, complex and burdensome billing requirements, particularly in fee-for-service products, and narrow/carveout networks create unnecessary impediments to patients’ accessing care. Out-of-pocket patient costs associated with integrated services also deter patients from using such support.
Additionally, physician practices have difficulty estimating the net effects of BHI particularly on their financing. Variations in quality and performance measures used by different health plans and coverage programs make it challenging to identify the most impactful actions from integration. Without a convincingly calculated return on investment, it is challenging for physicians to confidently invest in resources to sustain BHI efforts in their practices.
Federal and state regulations have also made it challenging to share patient information across integrated care team members, an essential component for integrated care. This includes overly restrictive interpretations of federal laws and regulations such as Health Insurance Portability and Accountability Act and 42 Code of Federal Regulations Part 2.
Lastly, physician practices struggle to find and retain requisite workforce trained in integrated and trauma-informed care particularly given the estimated shortage of behavioral health providers.
Practical Solutions, Payer Buy-In, And The Role Of Federal And State Policy Makers
Across the US, behavioral health conditions affect about 17 percent of commercial beneficiaries, 41 percent of traditional Medicare, 26 percent of Medicare Advantage beneficiaries, and about 20 percent of Medicaid beneficiaries. Medicaid is also the largest payer of behavioral health services with the majority of its beneficiaries being children. According to a 2018 Milliman Report, BHI has the potential to save about $38 billion to $68 billion annually across all payer types with the majority of savings to be gained in the commercial space ($19.3 billion to $38.6 billion). Yet, persistent underpayment or lack of payment to primary care clinicians for behavioral health services are at least in part fueling the access crisis.
Payers (that is, employers and health plans) must work with physicians to accelerate access to equitable, whole-person care and stem the growing behavioral health crisis. Here are five key practical solutions payers can pursue to support the widespread adoption of BHI by physician practices:
- Expand coverage and fair payment with a margin for all stakeholders using CoCM and other BHI models that facilitate care management and transitions of care for patients with behavioral health concerns or conditions;
- Evaluate how and when to apply cost sharing (for example, copayments, health savings account deductibles), including its elimination where appropriate, for CoCM codes, as well as integrated behavioral health services delivered in person or via telehealth;
- Assist primary care practices in integrating behavioral health by offering technical support, provider training, and regional sharing of resources;
- Expand provider networks and improve access to BHI by minimizing and/or eliminating prior authorization and other use management practices for BHI services; and
- Design, pilot, and launch whole-person, employer-based behavioral health programs that provide employees with immediate and direct access to behavioral health resources and providers, including care navigation support, with intentional culture-focused work to destigmatize behavioral health.
Encouragingly, some leading employers and health plans have already begun to take some of these steps.
At the same time, federal and state policy makers also have a key role to play including these four critical steps:
- Provide long-term sustainable funding opportunities for primary care practices (similar to funding provided for meaningful use and patient-centered medical home adoption) to support training and education on implementation of BHI services;
- Raise payment levels for BHI services with a margin for all stakeholders in federal and state coverage programs such that they can be sustained by practices on an ongoing basis. This should include CoCM, care management/coordination, psychotherapy, dyadic therapy, and other relevant in-person and telehealth services used by primary care practices that have adopted BHI;
- Work with health plans and coverage programs to limit use management review practices, enforce behavioral health parity laws, and strengthen network adequacy regulations; and
- Increase federal funding with the aim of growing the behavioral health workforce, especially psychiatrists, developmental-behavioral pediatricians, and other behavioral health specialists who practice in underserved areas. These should include loan forgiveness programs, new and expanded residency, and training programs.
Additionally, while not a panacea, incorporating technology such as telehealth and other digital tools into BHI care models can help enhance their overall effectiveness and accelerate the adoption of BHI by physician practices—so long as it augments, rather than replaces, the longitudinal physician-patient relationship.
Lastly, while there is ample evidence of the numerous benefits of BHI, it will be important to further demonstrate the comprehensive value it generates for physicians, patients, and society at large. One multistakeholder working group has already identified several high-priority measures to assess the value of BHI programs. More work is needed, however, to further refine this list and align them with national approaches to performance measurement.
A Sustainable Path Forward
By working collaboratively to address both physical and behavioral patient concerns in primary care, we can begin to properly use BHI to enable holistic health care for all. Members of the integrated care team must continue to lead the charge in making equitable, whole-person care the standard for primary care in the United States. But also: Payers and policy makers must act now to implement solutions and ensure primary care physicians and their care teams have the support to provide equitable, whole-person care for their patients and families. The BHI Collaborative is fully committed to accelerating BHI adoption by physician practices and calls on payers and policy makers, among other industry stakeholders, to join our effort to make this paradigm shift a reality.
Authors’ Note
The BHI Collaborative, a collection of eight of the nation’s leading physician organizations, is dedicated to equipping physicians and their practices with the necessary knowledge to sustain a whole-person, integrated, and equitable approach to physical, mental, and behavioral health care during the COVID-19 pandemic and beyond.
The BHI Collaborative full member list includes: American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Medical Association, American Osteopathic Association, and American Psychiatric Association.