It's been more than 20 years since a landmark Institute of Medicine study reported siloing behavioral and primary health leads to inferior care, yet walls between the two still remain.
A Milliman research report earlier this year found that delayed and avoided behavioral care led to $406 billion in added healthcare costs in 2017.
Patients who see a doctor for a chronic physical condition often have comorbid mental health issues that go unnoticed and untreated, but models for integrating behavioral health into primary care settings have shown improved health outcomes and cost savings.
The Milliman report suggested practices start integrated care models whereby normally isolated healthcare professionals collaborate in a merged practice and identify patients needing behavioral services, jointly co-manage them and participate in shared decision-making.
A small but growing number of providers are trying this approach and finding success.
Roger Kathol, president of Cartesian Solutions in Burnsville, Minnesota, told Healthcare Dive that integrating behavioral healthcare transforms care from retrospective to proactive. For instance, in an inpatient setting, a proactive model could include a behavioral health professional as part of the admitting team rather than being considered at the end of a hospital stay.
Kathol, who consults with practices, payers and employers about behavioral health integration, said the proactive model decreases length of stay by at least a day and saves money. The savings come in part through reduced acute care stays and emergency department visits.
For an integrated model to take flight, a payer needs to partner with both medical and behavioral providers. However, getting buy-in from all three isn't easy.
There also has to be a reimbursement system that pays behavioral health providers properly. One way payers are doing that is creating a system that rewards improved health outcomes and lower costs.
“It requires patience, the right partners, especially payer partners and community backing,” Ben Miller, chief strategy officer at Well Being Trust, told Healthcare Dive. “Practices thinking they can just integrate may be in for a challenging lesson as many levers need to be pulled at once.”
Integrating behavioral health isn't about adding to primary care’s already demanding workload. Instead, it’s working together to bridge a care and mental health parity gap and using a behavioral health professional’s expertise.
Kathol said there are too many patients with behavioral health needs for those experts to handle the workload. Instead, an integrated care model can train primary care providers to feel more comfortable handling less severe mental health cases. Behavioral health specialists on staff can back them and more severe cases can be referred to an in-house behavioral health expert.
“You always need specialists for certain types of issues, but PCPs, in our experience, can handle a lot provided they get the right training,” Sarah Bliss Matousek, senior consultant at Day Health Strategies, told Healthcare Dive.
Improved outcomes, reduced costs
There is evidence showing integration improves outcomes and the bottom line.
A recent report in Translational Behavioral Medicine found a Colorado program called Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) saved about $1.08 million in net cost for Medicare, Medicaid and dual-eligible patients. The savings came via fewer hospitalizations and other downstream utilization. Practices receiving payments showed higher rates of screening and diagnosing of depression and anxiety-related disorders.
The project involved six practices in the Denver area and payer Rocky Mountain Health Plans. The program used risk-adjusted global payments.
Study co-author Kaile Ross, faculty fellow at the University of Colorado-Denver, told Healthcare Dive that the program achieved an estimated cost savings of between 3% and 5% of total healthcare costs during the 18-month implementation period.
A crucial part was finding a payer willing to invest in the project.
“What the SHAPE project demonstrated was that payers may also stand to gain from supporting delivery of integrated behavioral health services in primary care through non-fee-for-service or alternative payments. It can be a win-win of improving the comprehensiveness of care for patients, while reducing healthcare costs,” Ross said.
Another critical piece was allowing each practice to use the payments in whatever way made sense for them.
“In terms of generating cost savings at the practice-level, I believe that allowing the primary care practices autonomy in how they delivered integrated behavioral health services as well as how they utilized the SHAPE payment was important,” Ross said.
Collaborative care model
The collaborative care model is one of the better-known ways health systems are integrating behavioral health into primary care. Developed by the University of Washington, CCM is a primary care-based care manager program that includes a consulting psychiatrist and internist to review care of patients with depression.
Anne Shields, associate director of the University of Washington Advancing Integrated Mental Health Solutions (AIMS) Center, said CCM is a cost-effective use of limited behavioral health time. It holds the psychology consultant accountable for an entire caseload of patients.
The behavioral health professional may oversee 50 to 100 patients, conduct a case review process and use a registry to track those in treatment. Shields said this allows the team to work more efficiently and drive critical cases to quicker treatment.
Kathol said the CCM breaks even in about a year. The program costs more to launch in the first six months, makes back those costs in the next six months and then saves over the next three years, he said.
The AIMS Center said more than 80 randomized controlled trials tested CMM and found it consistently improves care, leads to better patient outcomes, better patient and provider satisfaction, improves functioning and cuts healthcare costs.
A 2016 study tested the Mayo Clinic’s Care of Mental, Physical and Substance-Use Syndromes (COMPASS) model, which incorporates aspects of CCM and found improved health and cost savings. The study of 7,340 patients with depression at four outpatient primary care clinics from March 2008 to June 2013 discovered that patients enrolled in CCM have a faster rate of remission and a shorter duration of persistent depressive symptoms than patients who received usual care.
Barriers to behavioral health integration
Studies of integrated programs show success, but they’re still a rarity for multiple reasons.
One factor is the siloed nature of healthcare. Another is that behavioral health and primary care are entirely different care models.
“Behavioral health services often require multiple sessions and extensive follow-up, which differs markedly from the way physical health needs are handled. None of this means that they can’t come together, but these make it more difficult,” Matousek said.
Separate funding is another barrier.
“Fragmentation in how we pay for mental health remains one of the most egregious barriers for supporting mental health integration in primary care. Period. Separate payment mechanisms make clinical integration very challenging for practices, if not impossible,” Miller said.
There has also been opposition within behavioral health. Kathol said behavioral health providers and payers often present obstacles to more integrated care.
“They’ve been paid so long in separate systems that they’re used to it,” Kathol said. “Medical providers and less so medical payers would love to have behavioral health services access in a medical setting. They just can’t get it.”
Creating a successful integrated program
Plenty of obstacles remain, but they’re not insurmountable. A good start is an alternative payment structure, such as an accountable care organization (ACO), that incentivizes practices and shares savings and a payer willing to champion a different model.
After that comes the need for buy-in from primary care and behavioral health and creating a system that respects the differences between the two types of care. Once that’s in place, there must be a system created to coordinate care and share data and provide behavioral health training to primary care staff.
What practices shouldn't do is merely bring on a behavioral health specialist and think the job’s done. Instead, Ross said a complete practice transformation is needed to create a successful program.
Another key is persistence coupled with a shared vision, leadership, knowledge, training, courage, meaningful data and thoughtful evaluation capacity.
“You have to have the right type of clinicians working together, operationalized in alignment with the integration vision and financially supported by a payment mechanism that allows a team to thrive under a new culture of care,” Miller said.
He acknowledged that moving to integrated care is a culture change. It’s about redefining the construct of health to be more inclusive and include mental, physical, spiritual and social elements.
“There is much goodness that can happen when we try and change the payment to ultimately change the care,” Miller said.