Strengthening the Integrated Care Workforce

Executive Summary

A significant treatment gap exists for individuals living with mental health and substance use conditions. As of 2023, 55% of adults who experienced some form of mental illness receive no treatment and 60% of youth with major depression go without help.^[i],[ii] Currently, and for the foreseeable future, the United States is experiencing a shortage of behavioral health providers to deliver needed services.^[iii] One of the most effective ways to close the prevention and treatment gap in the mental health and substance use fields is through behavioral health integration (BHI). For the purposes of this report, the term BHI refers to the integration of mental health and substance use services into primary care settings in a manner that is agnostic to model and service design.

High quality, integrated primary care services provide continuous, person-centered behavioral health care that considers the needs and preferences of individuals. Vital to increasing the reach of integrated care models is a health care workforce that is adequately trained and supported in BHI delivery. Several evidence-based models—including the Collaborative Care Model (CoCM) and the Primary Care Behavioral Health Model—integrate behavioral health into primary care and are reimbursed by Medicare, some state Medicaid plans, and commercial payers.

Over the past year, the Bipartisan Policy Center undertook an extensive effort to develop evidence-based, federal policy recommendations to support and grow the workforce responsible for delivering integrated behavioral health and primary care services. BPC conducted a series of interviews and hosted two private roundtables with health care policy and workforce experts, providers, payers, and patient advocates to gain insight into the opportunities and barriers related to the integrated care workforce.

BPC’s March 2021 Behavioral Health Integration Task Force report looked broadly at ways to achieve the integration of behavioral health and primary care.^[iv] This report builds on those recommendations by focusing on ways to train, recruit, pay for, and flex the BHI workforce. Although our recommendations focus on Medicare and Medicaid beneficiaries, the workforce investments outlined here have broad implications for the entire health care delivery system.

Policy Recommendations:

A. Training and Recruitment

• The Health Resources & Services Administration (HRSA) should include language in notices of funding opportunity for programs that give preference to applicants or entities that demonstrate they have relevant BHI programs in place, as well as those that intend to use funding to support BHI activities. These should include the Title VII Sections 747 and 748 primary care training programs, Title VIII programs, and the Teaching Health Center program.
• To expand the available behavioral health workforce, Congress should direct HRSA to use existing sources of funding—such as the Substance Use Disorder Treatment and Recovery Loan Repayment Program and the Community Health Worker Training Program—to create a pipeline program that enables interested behavioral health support specialists to become licensed behavioral health professionals.

B. Payment and Administrative Strategies

• Congress should increase reimbursement for behavioral health integration codes, including for the Collaborative Care Model, for up to three years. Congress should evaluate doing the same for provider-to-provider interprofessional consultations with behavioral health specialists. For both, Congress and the Centers for Medicare & Medicaid Services (CMS) should evaluate the impact of and determine best practices that result from additional funding on the volume of integrated care services delivered, as well as the quality of care and patient outcomes.
• Congress should fund long-term, sustainable investments in state, regional, and tribal mental health e-consultation services—especially Pediatric Mental Health Care Access programs—that provide primary care providers with behavioral health expertise for treating mild to moderate conditions and symptoms.
• The Center for Medicaid and Children’s Health Insurance Program (CHIP) Services should issue a State Medicaid Director or State Health Official letter on how states can implement best-practice BHI models leveraging permissible Medicaid authorities.
• The CMS Innovation Center should require applicants and participants in primary care or total cost of care-oriented models to articulate BHI plans, the degree of integration achieved, and report on associated outcomes.

C. Network Requirements and Flexibility

• Congress and the U.S. Department of Health and Human Services (HHS) should require BHI in behavioral health plan network adequacy standards.
• Congress should direct CMS to audit Medicare Advantage plans to ensure that they are providing accurate information on the availability of their in-network providers. Congress should also require that private health plans use independent auditors to assess the accuracies of their provider directories.
• Congress should direct the secretary of HHS to develop a set of limited circumstances under which health care providers can deliver telehealth services to patients located out of state. Congress could then allow licensure flexibility for the specific set of circumstances deemed appropriate by the secretary.

[i] Mental Health America, “Adult Ranking 2023,” 2023. Available at: https://www.mhanational.org/issues/2023/mental-health-america-adult-data.

[ii] Mental Health America, “Youth Ranking 2023,” 2023. Available at: https://www.mhanational.org/issues/2023/mental-health-america-youth-data.

[iii] Health Resources & Services Administration, “Health Workforce Shortage Areas,” 2023. Available at: https://data.hrsa.gov/topics/health-workforce/shortage-areas.

[iv] Bipartisan Policy Center, Tackling America’s Mental Health and Addiction Crisis Through Primary Care Integration, March 2021. Available at: https://bipartisanpolicy.org/report/behavioral-health-2021/.