Better integration with primary care can help address the ongoing mental health and addiction crisis, report finds

• Integrating primary care and behavioral healthcare can shore up the nation’s capacity to address the surging mental health crisis, according to a new report.
• Existing value-based payment structures can be deployed to promote the availability of high-quality behavioral healthcare.
• To incorporate behavioral healthcare services, smaller primary care practices need technical assistance and the option to use telehealth.

Enhanced network adequacy standards, value-based payment models and targeted investments in technology are vital to improving behavioral healthcare in a way that will meet escalating needs, according to a new report.

The issue has become more urgent during the COVID-19 pandemic, panelists said during a March 31 discussion hosted by the Bipartisan Policy Center (BPC), which released a comprehensive report on how to better integrate behavioral healthcare with primary care.

As rates of depression and anxiety have surged over the last year, manifesting in record-breaking levels of drug overdoses, there also has been “a growing treatment gap,” said Sheila Burke, RN, a BPC fellow and the chair of government relations and public policy at Baker Donelson Berman & Berkowitz. “We see the percent of adults with mental health conditions receiving treatment actually decreasing rather than increasing.”

To improve access and outcomes, an integrated approach is required. The net cost in public spending would be $2.2 billion, according to the report, based on projections of $6.9 billion in spending increases and $4.7 billion in savings.

“Behavioral comorbidities can lead to medical costs for physical conditions that are two to three times higher than those without behavioral health conditions, supporting the need for integrated care,” the report states.

Benefits of an integrated approach, as seen in a handful of states, include better access, reduced hospitalizations and improved management of diabetes and hypertension, according to the report.

Such benefits can be realized if primary care providers have the capacity to “deliver services of a behavioral health nature for patients who are experiencing mild and moderate sets of conditions,” Burke said. “We believe we can do that by providing them with additional support, with technical assistance, with compensation to encourage them to look at that opportunity in taking care of their patients.”

What’s certain is that to meet demand, the healthcare system cannot rely only on behavioral health specialists.

“We are never going to meet the needs of the nation’s mental health without active and deep participation by primary care providers,” said Richard Frank, PhD, professor of health economics at Harvard. “We will not ‘specialize’ our way out of this.”

Using VBP approaches to improve integration

Value-based payment (VBP) programs to bolster behavioral healthcare can build on existing structures in the form of Medicaid managed care organizations (MCOs), Medicare accountable care organizations and Medicare Advantage plans.

Those models “already have well-defined quality metrics, delivery standards and payment methodologies through which integration can be applied, enforced and incentivized,” the report states.

For practices outside those models, a capitated and risk-adjusted payment model should be implemented to give incentives to treat mild-to-moderate behavioral health cases. Capitated payments particularly can help smaller and more-remote practices muster the resources needed to incorporate behavioral health.

But VBP approaches can’t succeed unless network adequacy standards are updated across payers, the panelists said. In Medicaid MCOs, for example, time-and-distance standards should be reinstated and additional quantitative measures should be incorporated.

Such steps could add 800 to 900 behavioral healthcare providers across Medicaid managed care networks, improving access for 500,000 to 800,000 beneficiaries, according to the report.

Steps also should be taken to ensure the availability of providers who are “culturally competent,” said Patrick Kennedy, founder of The Kennedy Forum and a former U.S. congressman representing Rhode Island.

Offering help and support to practices

For practices to succeed in VBP models that focus on behavioral health, training and technical assistance are essential, said Regina Benjamin, MD, the founder and CEO of BayouClinic, Inc. and the 18^th surgeon general of the U.S.

“Transforming a practice into this type of [integrated] model really takes time, and it takes a lot of effort and up-front investment,” she said. “So, we can give that technical assistance and greatly improve the care and the workflow.”

One obstacle that may be overlooked is the discrepancy in electronic health record (EHR) systems for primary care compared with behavioral healthcare.

“They don’t talk to each other,” Benjamin said. “They’re just two different systems. We have to bring that together, and small practices can’t really afford that.”

Burke recalled that the HITECH Act of 2009 allocated $27 billion to increase utilization of EHRs but excluded behavioral healthcare providers from those incentives.

“Much more could be done to make sure that the EHR template is compatible and supportive of the behavioral health setting,” said John Sununu, a former U.S. senator from New Hampshire. “Even going so far as to make sure you have standard and common behavioral health terminology as part of that EHR.”

Barriers are more significant for smaller providers, with estimated costs ranging from $40,000 to $50,000 up front and then between $10,000 and $15,000 annually.

“One of our recommendations is to make sure we have a financing mechanism to help access that kind of technology for the small providers, and help [them] use that technology to deliver integrated behavioral healthcare,” Sununu said.

The task force that compiled the report specifically recommends a forgivable-loan program to assist smaller practices.

Viewing telehealth as a solution

Telehealth utilization for behavioral health was rising before the pandemic, and the past year has brought a surge in use across healthcare.

“It’s a format and technology that lends itself to the integration of behavioral healthcare and primary healthcare because you can have different providers in different locations,” Sununu said. “You can easily make referrals and save so much time on the part of the patient.”

Policymakers should strive to maintain the ongoing momentum around telehealth, he added. The emphasis should be on removing regulatory barriers to optimal use, not reimplementing them.

For example, the task force recommends eliminating the video-to-video requirement for coverage of telehealth services, thereby allowing Medicare beneficiaries to receive behavioral healthcare and other services via a landline or cellphone.

“If we make the mistake of reimposing these restrictions, I think we’ll really stifle the innovation and the acceptance of telehealth that we’ve seen over the past several months,” Sununu said.