Report: To Boost Access to Mental and Behavioral Health, Integrate Primary Care

The U.S. healthcare system is poorly equipped to meet the needs of patients with mental health and substance use problems, but primary care integration can help, said public health specialists during a webinar on Wednesday.

Making temporary telehealth flexibilities triggered by the public health emergency permanent should also be a top priority, said panelists at the event, hosted by the Bipartisan Policy Center (BPC) and sponsored by the Well Being Trust and the Sunflower Foundation.

Less than half of adults with a mental health condition and almost 90% of adults with a substance use disorder did not receive treatment in 2019, said BPC Vice President G. William Hoagland. “To a large extent, this is because our behavioral healthcare system does not have the capacity to serve everyone who needs treatment.”

While primary care providers “pick up some of the slack,” they have neither the training nor the resources to provide integrated physical and behavioral healthcare services, he explained.

Anita Burgos, PhD, senior policy analyst for the BPC, shared the story of her mother, an immigrant from the Dominican Republic who has a serious mental illness.

Burgos’ mother was receiving her mental healthcare from her primary care provider because he spoke Spanish, despite the fact that his office did not have mental health expertise or provide coordinated care.

About a year and a half ago, though, “my mother fell through the cracks,” Burgos said.

She stopped seeing her primary care doctor, stopped taking her medications, and ended up hospitalized for 2 weeks.

But there was a silver lining: After she was discharged, Burgos’ mother was linked to a nurse practitioner, a licensed clinical social worker, a care coordinator, and a psychiatrist, all of whom speak Spanish, and all of whom can share information about her care through the same electronic health record.

Now her mother is more engaged in her care, and her providers are finally “on the same page,” Burgos said.

Her only regret, she added, is that her mother didn’t get this kind of care sooner.

Integrated care is not only more patient-centered, but it also increases access to care, is more cost-effective, and reduces health disparities, Hoagland noted.

To that end, the BPC created a task force that deliberated on these issues over the past year, and on Wednesday issued a report, “Tackling America’s Mental Health and Addiction Crisis Through Primary Care Integration”, which included the following regulatory and legislative recommendations:

• Establish core minimum quality and service standards for integrated care

• Ensure that health plans’ network performance standards include adequate behavioral health providers to offer services

• Develop a capitated and risk-adjusted model for primary care providers serving patients with mild to moderate behavioral health issues

• Allow Medicare to reimburse services for other behavioral health provider types to serve in integrated settings and expand scholarships to grow and diversify the workforce

• Increase funding for statewide psychiatric consultation services responsible for sharing behavioral health expertise to primary care providers treating patients with mild to moderate conditions

The report also strongly recommended establishing a nationwide technical assistance program for primary care providers, giving them the training they need to participate in integrated care delivery.

Primary care physicians sometimes struggle to care for patients with complex mental and behavioral health needs, said former U.S. Surgeon General Regina Benjamin, MD, founder and CEO of the nonprofit Bayou Clinic in Bayou La Batre, Alabama.

Benjamin, a family physician, said being able to consult with behavioral health providers on site or remotely can be very helpful for those working in primary care: “We need to feel like we’re comfortable being able to just reach out to them and fill in those gaps.”

Benjamin also supports the recommendation to help train primary care providers and offer technical assistance to them, which could improve care and work flows and “incentivize us to do more,” she said.

The report’s authors also advised using financial incentives to encourage payers to incorporate integrated care services into their existing payment models in Medicaid managed care organizations, Medicare accountable care organizations, and Medicare Advantage plans.

Often these programs offer insurers a lot of flexibility in the way they tailor and manage the care for individuals, said Richard Frank, PhD, co-chair of the BPC task force and a professor of health economics at Harvard University in Boston.

“With that flexibility, and with the incentives to do well on whole-person health, that encourages greater attention to integration of behavioral health into the general medical system,” Frank said.

Additionally the report emphasized the need to codify or make permanent Medicare’s coverage of telehealth services to allow for better care integration and eliminate disparities.

Former Sen. John Sununu (R-N.H.), another co-chair of the task force, noted that prior to the pandemic, certain restrictions on telehealth required that patients be in rural areas, or that the first visit to a provider be in person. There were also requirements mandating video-to-video communication.

It’s important to ensure that those barriers to telehealth are not re-enacted, Sununu said.

Burgos noted that before her mother’s care transitioned to virtual care, her mother took three buses to get to her appointments. But “since her care has gone virtual, she hasn’t missed a single appointment,” Burgos said.

If all the recommendations in the report are implemented, the authors estimate the changes would provide additional benefits to over one million Americans and cost the federal government about $2 billion over 10 years.