Physicians continue to face major barriers integrating mental health services into medical care, including getting paid for services and health IT issues.
One in five adults in the U.S. has a clinically significant mental health or substance use disorder, yet many people do not receive treatment for their problems because of a shortage of mental health providers and lack of access to mental health services.
One potential solution to the low levels of mental health treatment is integrating behavioral health into medical care.
But few primary care providers are physically colocated with behavioral health clinicians, according to recent research, suggesting persistent barriers to behavioral health integration.
Findings from a study published in Annals of Internal Medicine shed light on what physicians say are the challenges to integrating behavioral health services into their practices.
Rand Corporation researchers interviewed 47 physician practice leaders and clinicians, 20 experts, and five vendors at 30 physician practices to examine the factors influencing physician practices' implementation of behavioral health integration. RAND conducted the study in collaboration with the American Medical Association.
Most approaches to behavioral health integration fall into two general archetypes: a colocated model where onsite behavioral health clinicians provide enhanced access within physician practices or an offsite model where behavioral health clinicians, usually psychiatrists, supervise onsite care managers who help nonbehavioral health clinicians meet their patients’ behavioral health needs.
“We found that behavioral health integration is possible in a wide variety of medical practices, not just in primary care,” said Dr. Peggy G. Chen, co-author of the study and a physician-researcher at RAND, in an AMA press release about the study.
“The key factor in the success of behavioral health integration was adaptation to each practice’s needs and resources," Chen said.
Physician practice leaders reported positive effects of behavioral health integration on their practices, such as creating an increased sense of providing high-quality patient care and meeting more of their patients’ needs, according to the study.
However, physician medical practices ran into cultural and financial barriers in these efforts.
Practice leaders reported that behavioral health clinicians, who may be accustomed to 50-minute patient visits and long-term patient relationships without substantial staff supervision responsibilities, could have challenges acculturating to medical clinics.
Physicians also reported incomplete information flow between behavioral and nonbehavioral health clinicians. Most participating practices reported that behavioral health records were shared infrequently with nonbehavioral health clinicians or were accessible only with special permission, for example through electronic health record systems "break the glass" alerts.
Practices also said that billing for behavioral health integration could be complex, burdensome and unfamiliar to behavioral health providers.
Even within the study’s sample of practices that had successfully adopted behavioral health integration, financial sustainability was a pervasive concern, regardless of the payment models used by the practices, the study found.
Medical practices in the new study reported difficulty in estimating the specific effects of behavioral health integration on total medical expenses. Few practices reported positive financial returns.
One practice leader reported that it would take years to determine the financial effect of behavioral health integration under alternative payment models: “Philosophically, this [behavioral health integration] model is not meant to succeed in fee-for-service," the physician said, according to the study.
There was no one-size-fits-all payment model that practices used to support behavioral health integration. Roughly one-third of practices reported losing money on their integrated behavioral health services, the study found.
Researchers determined that payment models that improve the business case for this approach are needed to enhance the long-term sustainability of behavioral health integration.
In an accompanying editorial, Sue Bornstein, M.D. of Texas Medical Home Initiative said fundamental changes must occur in payment and delivery systems in order for primary care to reach its full potential for achieving better health for persons and populations.
"The current pandemic has exposed the fragile state of primary care and underscores the need to strengthen the foundations of our system," she said.
Medical practices also need tailored, context-specific technical support to make this approach successful.
Efforts to improve interprofessional training and collaboration may help address cultural barriers and facilitate patient care that addresses both medical and behavioral health needs, researchers said.
Enhancements to EHRs and clarification of privacy regulations may also help to improve communication between behavioral and nonbehavioral health clinicians, according to the study authors.
The COVID-19 pandemic has exposed and magnified the flaws in the mental health system and the true burden of mental illness in our country, Patrice Harris, M.D., president of the American Medical Association, said in a statement.
“Behavioral health care integration can help save lives and is a proven model that has many advantages over a more divided one. The AMA is committed to establishing a viable pathway for combining physical and behavioral health care to make a real impact in our nation’s growing mental health crisis," Harris said.