The growing need for mental health and substance use services in the U.S. is shining a spotlight on an already alarming inability to get care. Before the pandemic, almost 1 in 5 Americans were experiencing mental illness, with over half of them not receiving treatment. As the Omicron variant creates a new wave of fatigue and feelings of hopelessness, mental illness rates continue to rise, emphasizing the need to strategically—and quickly—increase the availability of providers.
Yet, a surprisingly important question is which providers.
Psychiatrists, psychologists, clinical social workers, and other behavioral specialists may seem the obvious focus, and indeed they are an important source of help for people in need, especially those with severe mental illness. However, primary care providers also require attention. In fact, 39% of people who received behavioral health services from 2020 to 2021 did so through a primary care provider. That’s not far off from those who got treatment through a specialist (45%), according to a poll BPC conducted with Morning Consult in May 2021. Often it is less expensive to get care through a primary care provider; there is limited participation of behavioral health providers in insurance networks. People are also more likely to express mental health concerns with a provider that they trust and see regularly for their physical health concerns, which helps reduce stigma. Patients are more comfortable receiving care if the provider is also culturally competent and can meet their cultural and linguistic needs; communities of color and those with limited English proficiency tend to turn more to primary care providers to access health care services.
With these issues in mind, BPC’s Behavioral Health Integration Task Force recently released a report with federal policy recommendations that would create a clear pathway for primary care and behavioral health integration, with a strong focus on providing primary care providers with the supports they need to handle some of the mild to moderate behavioral health care needs of their patients.
Although 60-80% of all primary care visits include a behavioral health component, part of the unmet need for services is a lack of primary care providers willing to treat these conditions. While many providers screen, diagnose, and treat the mild to moderate conditions, they report often feeling overwhelmed and ill-equipped to meet their patients’ behavioral health needs. To incentivize and enable primary care clinicians to take on a greater role in providing behavioral health care to their patients, they will need training, technical assistance, and access to a larger pool of behavioral health providers for both consultations and referrals.
Many behavioral health and primary care providers operate in silos without sufficient incentive or financial flexibility to integrate services. Reforming payment structures and adopting alternative payment models could provide financial incentives for more providers to participate in integration models.
The task force recommended focusing first on risk-bearing payment models, which already have structural elements that make them an ideal home for integrated care. Medicaid managed care organizations, Medicare accountable care organizations (ACOs), and Medicare Advantage plans have existing payment structures with well-defined quality metrics, delivery standards, and payment methodologies through which integration can be applied, enforced, and incentivized.
As part of the Medicare Shared Savings Program (MSSP), for example, ACOs could take on financial risk and receive flexibilities to provide enhanced integration—as defined by the HHS secretary—such as a more robust panel of behavioral health services, improved clinical outcomes, and higher performance benchmarks. In exchange for exceeding the minimum MSSP quality performance standard, the ACO could receive incentives depending on the risk it is assuming. An ACO could receive a two-year extension of rewards if it is participating in a one-sided risk arrangement, meaning that the ACO shares in the savings but is not responsible for paying back any financial losses if they spend more than the agreed-upon rate. ACOs already participating in two-sided risk, meaning they receive higher shared savings but have to pay back excess spending, could receive a permanent 5% increase to their shared savings cap. This is estimated to incentivize MSSP enrollment and retention, saving the federal government $3.8 billion over 10 years.
The task force also recommended incentives for solo primary care providers or those in small groups to integrate care. The creation of a new payment model would allow primary care providers to deliver the full range of primary care services and a specific set of core behavioral health services, as defined by the HHS secretary. They would receive a per member per month, risk-adjusted payment that accounts for health and social risk factors, enhanced by 3% of the prior year average cost for Medicare enrollees. This model would benefit primary care providers by simplifying billing, increasing flexibility, providing compensation for upfront costs, and ensuring a steady stream of revenue. It would also align care delivery and payment transformation to allow practices to better integrate and meet the needs of their patients.
Importantly, the task force recommendations address one of primary care physicians’ top concerns about identifying behavioral health conditions: the lack of available behavioral health providers for consultation or referral. Ensuring primary care clinicians are actually available to consult with psychiatrists would help to fill knowledge gaps, allow for real-time training, and eliminate the need for an on-site psychiatric provider.
To address the lack of available behavioral health providers, the task force recommended updating network performance standards across payers to ensure adequate specialty care for referral and support for primary care providers. Health plan networks often include participating behavioral health providers who are not taking new patients or have long wait times for appointments. The HHS secretary should standardize HHS-regulated plans by developing core network performance metrics for application across all plans. CMS should develop requirements that include time and distance standards; consider telehealth as an option; report specifically on behavioral health provider availability; include a uniform set of quantitative performance measures; are transparent and publicly reported; and define adequate diversity and cultural competence.
The task force also recommended that Congress appropriate more funding to the Health Resources & Services Administration for statewide primary care-to-psychiatric consultation services. This would make the services more widely available in all primary care settings and would provide necessary assistance that primary care providers may need in managing their patients’ mild to moderate behavioral health conditions.
To ensure successful integration of primary care and behavioral health services, providers must receive adequate training that prepares them to work in integrated care teams, which in turn helps prevent burnout for both primary care and behavioral health providers. The task force recommended technical assistance for provider practices participating in integration to assist with organizational training, billing and financing, and implementation of electronic health records (EHR). These training programs also benefit the patient, as they assist providers in effectively communicating with patients, appropriately diagnosing conditions, and being more culturally responsive, thus addressing behavioral health equity issues and reducing disparities.
Continuing education is also important. Providers commonly enter the workforce with limited experience working on integrated care teams and limited knowledge responding to health disparities. The task force recommended that Congress provide funding to expand post-degree training opportunities to increase primary care providers’ knowledge of behavioral health and the unique needs of diverse populations. Many post-degree training programs can be completed online; Project ECHO, for example, is a medical education model that uses video-conferencing technology to train, advise, and support primary care providers on a variety of issues. Models like these benefit patients in underserved and rural areas, where there are fewer behavioral health providers.
Technology also plays a large role in successful integration. Recognizing the benefits that technology and telehealth services provide in enhancing behavioral health integration, the task force recommended optimizing health information technology for behavioral health and expanding telehealth access.
EHRs should support screening tools, provide recommendations for next steps based on patient responses, and track follow-up. To assist primary care providers with screening patients for behavioral health conditions, the task force recommended requiring Certified EHR Technology to include clinical decision support tools. These tools would help providers with decision-making and thorough collection of patient data, allowing them to make patient-specific treatment recommendations.
To ensure that more behavioral health providers are available for primary care providers to refer their patients to, the task force also recommended removing site of service, geographic, and established patient restrictions for telehealth services. Due to the pandemic, flexibilities are currently in place to expand coverage and remove these barriers. As Congress deliberates the future of telehealth services, it will be important to consider how expanding telehealth supports integrated care.
The U.S. is currently facing a growing workforce shortage and behavioral health integration provides an opportunity to improve access to care. In addition to benefiting patients and reducing health disparities, increasing capacity for primary care providers can create a more successful, equipped, and satisfied workforce.
Read the full BPC Behavioral Health Integration Report here.
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