A coalition of eight leading medical associations is calling for the integration of behavioral health into primary care practice, plus the expansion of mental health and substance abuse disorder services to fill the unmet needs for these kinds of treatments.
Behavioral health integration (BHI) could save as much as $68 billion per year in healthcare costs across all payers, the group wrote in Health Affairs. But underpayments for behavioral health treatment are contributing to the crisis in mental healthcare access, they wrote.
The BHI Collaborative — which includes the American Medical Association (AMA) and several primary care societies — is urging payers and policy makers to take several actions it said would enable primary care practices to assume this additional burden. In particular, the authors wrote, the practices need expanded coverage and fair payment for behavioral health integration (BHI). Another key requirement is training and technical support for the physicians who would be responsible for this transformation of primary care.
The paper also called on both government and private payers to improve patient access by evaluating how and when to apply cost-sharing to integrated services; to minimize and/or eliminate utilization management for behavioral healthcare; and to launch employer-based behavioral health programs that would both improve access and reduce the stigma attached to mental health treatment.
Federal and state policymakers can support widespread adoption of the BHI if they raise payment levels for behavioral healthcare in public programs and invest in training and education to implement BHI services, according to the coalition. In addition, the government should work with health plans and behavioral health coverage programs to limit utilization review, enforce behavioral health parity laws, and strengthen network adequacy regulations. And federal funding of behavioral healthcare should be increased to expand the size of the counseling workforce, especially in underserved areas.
The physician organizations that produced the paper are the 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.
Pandemic Driving New Interest in BHI
Members of the BHI Collaborative stressed that the COVID-19 pandemic has helped focus attention on this issue.
“Pediatricians have observed and raised alarm about the mental health crisis confronting children and adolescents well before the pandemic, and we are now facing a pivotal moment where urgent action is needed in and outside of pediatric offices to help confront it,” said Mark Del Monte , JD, CEO of the American Academy of Pediatrics, in an AMA news release on behalf of the collaborative.
Sterling N. Ransone Jr, MD, president of the American Academy of Family Physicians, said, “The COVID-19 pandemic has exacerbated an already-present mental health crisis in our country, and our patients deserve primary care that sees the whole person. Enhanced mental health screening and coordination of physical and behavioral healthcare services will serve our patients best.”
Ransone, who practices in rural Virginia, said 40% of the visits to his practice involve behavior health issues. Nationally, he added, up to 70% of primary care visits may entail behavioral health. Behavioral health integration “is something we’ve needed for quite some time, and the pandemic has only heightened the awareness of the need,” Ransone Medscape Medical News.
Why Colocation Makes Sense
When Ransone refers patients to a behavioral health provider today, he said, they often must wait 3 months to see a psychiatrist. The wait for a psychologist or social worker can be nearly that long. Ransone’s wife is a pediatrician, and her patients have waited as long as a year to get into a psychiatrist’s office, he added.
This situation wouldn’t exist, he argued, if behavioral health providers were colocated with primary care physicians. Patients who needed this kind of care could be referred within the practice and see a therapist fairly quickly. The “warm handoff” from the primary care doctor to the therapist would increase compliance by patients who otherwise might not see a behavioral health provider because of the perceived stigma.
Ransone stressed the interdependence of physical and mental health and the need to address both in treating patients. Recently, he said, the children of a woman with heart failure brought her in to see him because of the swelling in her legs.
“It turned out that she had stopped taking her diuretic pills. The medical condition was pretty easy to resolve: She had to start retaking the fluid pills,” Ransone said. “But when you asked her why she stopped taking them, she said, ‘I didn’t want to take anything.’ She was depressed because there had been a death in her family, and we had an extended visit because we were dealing with the behavioral component.”
Why Integration Remains Uncommon
According to the paper in Health AffairsBHI with primary care “remains the exception, rather than the standard, across the US.”
Among the factors that have deterred primary care physicians from trying this approach are high start-up costs, low reimbursement, complicated and burdensome billing requirements, siloed data, and limited availability of the workforce.
Private health plans, Medicare, and Medicaid often fail to provide sufficient coverage of behavioral health services and don’t pay enough to provide an adequate margin for primary care practices to try BHI, advocates said.
In addition, many primary care practices lack the capital to adopt and sustain this approach. Estimating the financial impact of BHI is challenging, and they’re unlikely to invest in the strategy without a guaranteed return on investment. A 2011 survey found that 78% of providers who had integrated behavioral health services with primary care had done so with the help of grants.
‘Great Opportunity for Integration’
Despite all of these challenges, “there’s a great opportunity for integration right now,” Reginald D. Williams II, vice president of the International Health Policy and Practice Innovations program at the Commonwealth Fund, told Medscape.
One reasons Williams sees for optimism is the wide gamut of potential approaches to integration. These range from primary care doctors coordinating more closely with behavioral health providers in separate offices to colocating the two types of providers in the same practice to “the fully articulated, team-based approaches that you see in integrated health systems,” he said.
Paying for BHI now is easier than in the past. Besides enhanced fee for service codes and the linkage of fee for service to quality bonuses for achieving certain goals, he said, alternative payment models such as accountable care organizations (ACOs) offer incentives for integration. Population-based payments to ACOs and other types of organizations can cover integrated services, as well.
Under Medicare’s new payment system for evaluation and management, Ransone said, he can bill for the extra time he spends with a patient to discuss behavioral health. But if he stays too long with any one patient, he doesn’t have enough time left to properly care for the rest. So he sees the need to get paid enough to hire more assistants, along with having behavioral health professionals in the practice to handle people who need to be seen for mental health conditions.
Another way to meet the demand for behavioral healthcare, Williams said, is to expand the range of providers who can bill for it.
“Medicare covers a set of traditional providers, including psychiatrists, psychologists, and some licensed clinical social workers,” Williams said. “But we know there are a variety of professionals that can provide good mental health services.”
These include marriage or family therapists, paraprofessionals like community health workers, or behavioral health managers. “There’s an opportunity to expand and diversify the workforce so there’s a wider range of providers available to triage people to,” he said.
This approach could also alleviate the current shortage of behavioral health professionals, Williams added, although increasing the supply of psychiatrists, psychologists, and clinical social workers is necessary, too: “We want the clinical professionals with the most training to work with the patients who have the greatest needs.”
The authors reported no relevant financial conflicts of interest.
Health Affairs. July 8, 2022. Full text.
Ken Terry is a journalist and author. His latest book is Physician-Led Healthcare Reform: A New Approach to Medicare for All.
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