Implementation And Sustainability of Behavioral Health Integration

Mental health is at the forefront of discussion in the nation for myriad reasons. Nearly 20 percent of the U.S. population suffers from a mental illness, with 11.2 million adults enduring severe mental illness. These disorders can have grave consequences if left untreated. Yet, behavioral health services are difficult to access. Recent data shows that most Americans who required treatment for behavioral health conditions did not receive necessary services, according to the inaugural State of the Nation's Mental Health report released last year by Anthem, the largest for-profit managed health care company in the Blue Cross Blue Shield Association.

Usually, the first contact for patients seeking mental health care is through a primary care provider. As a result, behavioral health integration (BHI) has emerged nationally as an opportunity to deliver essential behavioral health services. BHI refers to various primary and mental health care models that connect patients to care by bridging the gap between physical and mental health care. BHI is linked to improvements in depressive symptoms, quality of life, patient experience, physical health, and reduced costs, as well as reductions in racial and ethnic disparities.

Despite the potential of BHI to improve outcomes, its implementation has faced significant operational and financial impediments. Presently, Medicaid is the single largest payer for all behavioral health services. Integrative work has yet to be reimbursed across the board: non-clinical costs of integration can be numerous, consisting of documentation review, collaboration, and care coordination, but are often ignored. Additionally, reimbursement among public payers continues to be hindered based on limitations on billable providers. Furthermore, rarely do clinics receive funding for the integration work. Only direct patient contact is considered reimbursable, limiting BHI sustainability.

While access to mental health care continues to be burdensome, and there is a critical need for behavioral health providers explicitly trained in integrated care, significant obstacles still exist in the financial recognition of many providers. Unfortunately, there are discrepancies between state Medicaid and federal Medicare reimbursement of these providers, hindering access further by decreasing the quantity of those serving in BHI settings.

There are various financial policy options to address barriers and promote the sustainability of BHI. Primary care models that aim to integrate behavioral health should consider alternative payment structures. Presently, multiple states—including Colorado, Minnesota, and Rhode Island—use regional Medicaid accountable care organizations and provide capitated and population-based payments for behavioral health care. These efforts demonstrated the positive effects of payment reform on access to behavioral health care, as seen by an increase in appropriate behavioral health use. Medicaid reimbursement augmentation through non-traditional payment structures, such as modified fee-for-service, bundled, or global/capitation, could promote BHI sustainability.

Notably, H.R. 3032 and S. 1879, titled the Mental Health Access Improvement Act of 2017, were introduced to amend title XVIII of the Social Security Act. Medicare created these to cover marriage and family therapists and mental health counselors as behavioral health providers. However, they did not progress far. H.R. 432 and S. 828 were introduced within the past several months as the Mental Health Access Improvement Act of 2021. Advocating for such legislation could indirectly promote BHI and promote its implementation.

It is increasingly vital that in the face of a growing mental health care crisis, mental health care workers can provide necessary services with as few impediments as possible. To meet patient demands, mitigating barriers and streamlining services are critical. Regardless of the chosen policy options, BHI must be recognized as an essential service with a multidisciplinary focus.