Providing Integrated Behavioral Health in Primary Care: A Financially Sustainable Approach

Thursday, April 19, 2018

Post submitted by Patrick Hemming, MD, Duke GIM Assistant Professor of Medicine. 

As part of a new series of Special Symposia at this year’s annual meeting of the Society of General Internal Medicine, I was fortunate to lead a presentation entitled “Behavioral Health Integration and Value-Based Care: Creating a Financially Sustainable Program.”  I co-taught the session with two leaders of behavioral health integration: Drs. Shahla Baharlou (Associate Professor of Geriatrics at Icahn Mount Sinai Medical Center) and Priya Radhakrishnan (Chief Academic Officer at Honor Health, Physician Advisor of the Practice Innovation Institute of Arizona).  Using our experiences at our institutions, we outlined new steps that practices and health systems can take to create better financial support for the integrated behavioral health patient care their primary care teams provide.

Why is whole patient care so rare?

During our presentation, we outlined several factors that are beginning to bridge some of the false divisions that have made integration of “physical” and “mental health” so rare.  Historically, federal and state policy has treated medical care and behavioral health care (often defined as mental health disorders and substance abuse disorders) as separate endeavors, with different regulations and payment structures.  This legacy has created barriers for patients and providers and made it difficult for practices to collect revenue to support integration of behavioral health services into primary care.  Three major developments are opening new doors to allow better whole patient care.                

First, effective models of integration have robust evidence of effectiveness.  New collaborative primary care models of integration boast a growing number of randomized controlled trials showing effectiveness in delivering evidence-based care with improved outcomes for primary care patients with common BH conditions. A particularly prominent model (IMPACT), uses collaborative care managers to follow-up with patients who have positive screenings for mental health and substance abuse disorders.  These care managers offer counseling and algorithm-based follow-up on medications.  Organizations such as the AIMS Center at the University of Washington offer free resources and training for physicians, administrators and care managers about implementation.

Second, insurers are beginning to reimburse for primary care collaborative care management services.  In 2018, Medicare officially adopted several new billing codes for the time spent by the BH care manager.  In a recently published micro-simulation study, Duke’s John Williams and collaborators found that in a variety of practice types the new codes could financially sustain the added services and actually increase net practice revenues.  As we presented during the special symposium, various states such as New York are adopting new Medicaid initiatives to allow payment for integrated services. For more about BH Integration and ACO's, read here.

The third major development is the move toward value-based care.  As Duke and many other health centers adopt accountable care organization (ACO) frameworks, practices such as the DOC can improve the financial health of the health system by providing services that decrease use of other more costly interventions (like Emergency Department and Hospital care).  Hospitals incur a large proportion of their costs in providing medical care for patients with incompletely treated behavioral health conditions.  Integration projects such the one at the Duke Outpatient Clinic offer relatively low-cost interventions that hold the potential to move high-cost care out of the hospital, using a team-based multidisciplinary approach.

Online resources to help

The case for behavioral health integration is becoming increasingly easier to implement and sustain.  Several sites offer a wealth of resources for practices in various stages of integration.  I have included links to these resources below:

The Agency for Healthcare Research and Quality (AHRQ) manages an Integration Academy, which provides a centralized source for behavioral health integration.  Their website links to many of the other federal and state organizations involved with integration.  They also have an excellent resource called The Playbook that has a step-wise approach to integration.  It can be found here.  Practices that are integrating must seriously assess the strengths and needs of their organization.  An alternative assessment tool is available here. The SAMHSA-HRSA Integration Center offers an array of other resources, including models, finances, operations. 

Practices wishing to obtain training for their team members can go to several excellent sites for training.  The AHRQ Integration Academy offers webinars.  An online certificate program in BH Integration (as well as shorter specific modules) is available from the University of Massachusetts’ Center for Integrated Primary Care.  A list of other training opportunities are available here.

Another excellent organization for integration resources is the Collaborative Family Healthcare Association.  The CFHA brings together a nationwide network of behavioral health clinicians (health psychologists, social workers, medical family therapists and substance abuse counselors and psychiatrists) and primary care physicians from an array of practice settings. CFHA offers a job center where primary care sites can post new available behavioral health conditions.

Finally, in the important work of financial sustainability, new resources are available at the Farley Policy Institute using the new Cost Assessment of Collaborative Healthcare.  By entering details regarding patient population, insurance mix, practice size, and scope of clinical services, practices can develop detailed business models to support behavioral health integration.

With careful attention to these opportunities, Duke can better lead the way in offering comprehensive whole-person care to our patients through integration of behavioral health and primary care.