Achieving Behavioral Health Care Integration in Rural America

Integrating primary care services and treatment for mental health and substance use conditions not only enhances patients’ access to needed care but also improves health outcomes in a cost-effective way. Yet the barriers to integrated care are substantial, and it is even more difficult to achieve in rural and frontier communities, which are home to 1 in 7 Americans.

This report builds on the Bipartisan Policy Center’s March 2021 Behavioral Health Integration Task Force report, which looked broadly at ways to achieve behavioral health and primary care integration across the United States. Primary care providers already handle some of the behavioral health care needs of their patients, but they describe feeling overwhelmed, ill-equipped to handle these tasks, and underpaid. To incentivize and enable primary care providers to take on a greater role in delivering mental health and substance use treatment services, they will need training, technical assistance, adequate reimbursement, and access to a larger pool of behavioral health providers for both consultations and referrals.

Our current work focuses on breaking down the barriers to integration in rural America, where the health care infrastructure and provider composition vary in distinct ways from urban and suburban areas.

Americans in rural areas face significant shortages of psychiatrists, psychologists, clinical social workers, and other behavioral health specialists. More than 60% of nonmetropolitan counties lack a psychiatrist, and almost half of nonmetropolitan counties do not have a psychologist, compared with 27% and 19% of urban counties, respectively. These gaps in specialty care force rural residents to rely heavily on primary providers for much of their care.

Over the past year, BPC conducted a series of interviews with rural health policy experts, national organizations, federal and state leaders, providers, payers, consumers, and academics to gain insight into the opportunities and challenges related to delivering integrated care in rural areas.

BPC’s recommendations provide a clear pathway to expand integrated primary care and behavioral health services in rural America, partially by leveraging the Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) that dominate health care delivery—particularly primary care—in these communities. The centers are key to integration in rural areas, as primary care providers often serve as a gateway into behavioral health care.

FQHCs experienced an 83% increase in patient visits for mental health and substance use disorder services between 2010 and 2016, outpacing the growth of medical visits and total visits. As such, RHCs and FQHCs are critical to providing not only primary care but also behavioral health care to the populations they serve.

BPC also takes a closer look at the needs of several populations that rely heavily on alternate delivery systems for much of their care in rural areas: veterans; American Indians and Alaska Natives (AI/AN); and individuals with high behavioral health needs, including those with serious mental illness and substance use disorders. The recommendations in this report would improve the ability of rural communities to better coordinate and integrate primary care and behavioral health services for these three high-risk groups.

The policy recommendations, if implemented, would also expand the ability of primary care providers to handle the lower-acuity behavioral health needs of their patients by providing enhanced payments, training, and improved access to behavioral health providers for consultation and referral. BPC’s recommendations call for the expanded use of telehealth, which took off during the COVID-19 pandemic, and new investments to ensure the delivery of integrated care in rural America.

A. Foundational to Integration

• The Department of Health and Human Services (HHS) should identify a set of standardized quality and performance metrics for delivering integrated care.
• HHS should prioritize a set of core service elements for behavioral health integration within primary care.
• The Centers for Medicare and Medicaid Services (CMS) should ensure network adequacy for Medicaid, the Children’s Health Insurance Program (CHIP), and Medicare Advantage; it should also ensure there is capacity for behavioral health specialty referrals and interprofessional consultation support for primary care providers.

B. Building and Supporting the Rural Integrated Care Workforce

• Congress should incentivize behavioral health providers to practice in rural areas by allowing additional behavioral health provider types to receive bonuses through Medicare’s Health Professional Shortage Area (HPSA) physician bonus program.
• To improve workforce retention, Congress should establish a federal tax credit for providers practicing in rural areas.
• To promote the training of residents in rural areas, Congress should permanently reauthorize the Teaching Health Center Graduate Medical Education (THCGME) Program and increase funding for the Health Resources Services Administration’s (HRSA) Rural Residency Planning and Development Program, which supports traditional graduate medical education rotations in rural communities.
• The Substance Abuse and Mental Health Services Administration (SAMHSA), HRSA, and the Department of Veteran Affairs (VA) should incentivize medical schools to offer—and issue guidance for practicing primary care providers to receive—training for prescribing buprenorphine to patients with opioid use disorder (OUD).
• The Center for Medicaid and CHIP Services (CMCS) should provide technical assistance to state agencies regarding integration strategies, such as leveraging the use of interprofessional consultations in Medicaid and CHIP as well as weighing the expansion of Medicaid coverage of licensed professional counselor services, as Congress recently approved for Medicare.

C. Payment and Delivery System Reform

• Congress should remove the cap on RHCs that requires them to provide no more than half of their total services for behavioral health.
• CMS should clarify Medicare’s same-day billing exceptions for FQHCs and RHCs to include substance use treatment in addition to mental health visits.
• To increase uptake of the Collaborative Care Model (CoCM), CMS should consider increasing reimbursement rates, rethinking beneficiary co-pays, and providing additional technical assistance or guidance to states on patient consent.
• Congress and CMS should ensure the continuation of most pandemic- era flexibilities for telehealth services delivered in rural areas, including audio-only telehealth, within the context of established patient-provider relationships.

D. Supporting Veterans, Tribal Communities, and Individuals with High Behavioral Health Needs

• VA should expand the scope of the VA Solid Start Program to provide additional support services to military members with behavioral health conditions who are transitioning from active service to veteran life, and educate veterans who might be eligible to upgrade their discharge status.
• The HHS secretary should direct departmental agencies to leverage existing grants to alleviate provider shortages among tribal communities.
• SAMHSA and CMS should increase integration within behavioral health specialty clinics by allocating grants to Community Mental Health Centers (CMHCs) and Certified Community Behavioral Health Clinics (CCBHCs); CMS should also clarify that opioid treatment programs (OTPs) can bill Medicare for primary care services.