Offering more behavioral health services in primary care practices would help address lack of access to care.
Eight of the country's leading physician organizations recently issued a call-to-action urging support for primary care practices to integrate behavioral health services into their operations.
The country is arguably experiencing a behavioral health crisis. There is a nationwide shortage of psychiatrists. In 2019, about 50 million Americans experienced a mental illness, but more than half of U.S. adults with mental illness do not receive treatment, according to Mental Health America (MHA). The coronavirus pandemic has exacerbated behavioral health problems, according to data from the MHA Online Screening Program. From January to September 2020, there was a 62% increase in people who took a depression screen compared to 2019 depression screening.
The eight physician organizations that made the behavioral health integration call-to-action are members of the Behavioral Health Integration Collaborative: the American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Medical Association, American Osteopathic Association, and American Psychiatric Association.
HealthLeaders recently talked with a co-author of the call-to-action, Gerald Harmon, MD, immediate past president of the American Medical Association and a practicing family medicine physician based in South Carolina. Harmon was asked to comment on the call-to-action's five solutions to accelerate widespread adoption of behavioral health integration by primary care practices. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: How can payers expand coverage and fair payment for all stakeholders utilizing behavioral health integration models?
Gerald Harmon: The reason we do not have established resources for behavioral health integration is we have not had coverage or compensation to invest in the resources. Primary care practices want to be able to invest in technology and employ nonphysician providers, consultants, social workers, and case managers to help take care of the behavioral health needs of our patients.
It is critical for payers to expand coverage and give us fair payment, so we can invest in behavioral health. I need the resources and cash flow, so I can spend the time addressing behavioral health issues and keep my doors open.
We have a law—the Mental Health Parity and Addiction Equity Act of 2008—but many payers do not appear to be complying with this parity law. They need to cover mental health and substance use disorders like they cover physical and surgical benefits. This is medical care—it may not be for physical services such as endoscopy but addressing behavioral health conditions saves money in the long run and gives help to patients who need it.
HL: What are the primary considerations for evaluating how and when to apply cost-sharing for integrated services?
Harmon: I understand that cost-sharing and patient responsibility for certain services may be beneficial to the system. Otherwise, folks might just say it is convenient for them to go to the emergency department and consume the highest-cost resource because that is where they could find it available. Cost-sharing such as deductibles can be efficient governors on unnecessary medical expenses; but if you have deterrents such as high deductibles or co-pays for behavioral health services, you can create disparities. If you have high rates of cost-sharing, economically disadvantaged patients can be deterred from having timely access to services. The more people with behavioral health issues put off access to treatment, diagnosis, and care, the worse their morbidity and overall physical health will be, which can cost the system and the patients more.
We need to make behavioral health services as accessible as possible. Often, people seeking mental health care need it urgently. We need to catch these conditions early before they become a more complicated and expensive process for the patient and the system.
HL: What kinds of provider training and technical support can support primary care practices seeking to adopt behavioral health integration?
Harmon: The reason I have had a lot of on-the-job learning about behavioral health in four decades of family medicine practice is I did not have a lot of formal training. I was family medicine certified, which means I understood the wellness concerns about anxiety disorder, depression, and other behavioral health issues—but I was not a psychiatrist or a behavioral health specialist. If I am going to integrate behavioral health into my practice, I am going to need some support. I need to be trained on best practices.
I need to know the best approaches and staffing models. I need to maintain relationships with other community partners such as the Mental Health Commission and clinics in my area where we have intermittently staffed psychiatrists. We need training beyond on-the-job training to effectively integrate behavioral health into our practices at the best cost and with the best fiscal model.
We also need to fix Medicare reimbursement for physicians to support technological investments. If I am going to use telehealth to gain access to a psychiatrist to help me make a diagnosis and manage medications because I don't have a psychiatrist in the local community, then I am going to have to invest in technology, and that is not cheap. To have adequate technician support, I need to know that my Medicare physician payment is adequate to be able to make an investment in my physician practice.
HL: Why is it important to minimize or eliminate utilization management for behavioral health integration services?
Harmon: An example is prior authorization, which is a barrier to patient care and an impediment to physician satisfaction. We have prior authorization for medications and all manner of referrals including behavioral health specialists.
Narrow networks are also a concern. For many patients, there may not be a behavioral health specialist in network for more than an hour drive.
It is important to eliminate utilization management barriers such as prior authorization for behavioral health for the same reason as not having access to behavioral health specialists. If you put in a barrier for me to gain access to the limited number of specialists I have in a narrow network, that is a recipe for disaster and an impediment to patient safety.
All of us as a society are going to pay a price when we don't address behavioral health issues. We are in the midst of a crisis with substance use disorder and opioid deaths. We need to minimize or eliminate any barriers to this kind of care.
HL: Why is it important to launch whole-person, employer-based behavioral health programs that destigmatize behavioral health?
Harmon: If we can get some employer-based treatment and employer-based diagnosis such as a social worker or especially trained nonphysician provider, we can get people care before they are unable to work or are taken out of the workplace for an extended period. We need to get people support as soon as they notice degradation in their behavior or their performance. If an employee is over-stressed and worried about their family or all manner of things, they need to be able to seek help without stigma.
There can be stigma with substance use disorder, depression, anxiety, or feelings of self-worth. We should not label patients and have them be unable to work because of stigma. We need to avoid patients getting a permanent bias against them.
We need to make whole-person diagnoses. A holistic-medicine approach does not mean just taking vitamins, eating well, and meditating. We need to recognize that your behavioral health state does have an impact on your physiological response. If you get a burst of adrenaline, you can get a burst of catecholamines and burst of chemicals from your midbrain, which can depress you, agitate you, increase your heart rate, raise your blood pressure, affect your cognitive ability—all of these things become a physical reality.
You would not be embarrassed to seek help if you had blood pressure trouble, or you were having chronic headaches. So, if you have concerns about your emotional health, you should not be deterred from seeking that care, and we as healthcare providers should not label patients with mental health issues with any kind of disparaging comments.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
The Behavioral Health Integration Collaborative, which consists of eight physician groups, has proposed a set of five solutions to boost behavioral health integration.
One solution is for payers to expand coverage and fair payment for integrated behavioral health services offered in primary care practices.
Another solution is limiting patient cost-sharing for behavioral health services.