As the most common access point for health care in the United States, primary care physicians–including family physicians, internal medicine physicians, pediatricians, and obstetrician-gynecologists–stand at the front line of ensuring the highest possible level of physical and behavioral health for people throughout their lifetime. Our goal is to achieve this while dealing with the difficulties of limited time dealing with patients and often insufficient resources.
However, the current programs are not meeting the demand for holistic care that address the impact of trauma and stressors in life that have only increased in the context of the COVID-19 pandemic.
More people today than ever are struggling with their mental health issues and mental health, which include both addiction disorders. We believe that primary care systems need to immediately embrace an entirely new paradigm, speeding up the use of BHI (BHI) in the practice of physicians and addressing the escalating rise in unmet demands.
To facilitate such efforts, eight of the top physician groups in the country — which we have led or run—set up the BHI Collaborative. It aims to empower Dr Jay Feldman and their teams of care to enhance the quality of care provided and improve access for patients to services for behavioral health. The BHI Collaborative and the practices of physicians it supports are not able to be able to tackle these issues by themselves.
To speed up the adoption of BHI and effectively combat the issue, Physician practices need the collaboration of other players in the health care industry, including employers, payers, health plans — and the decision-makers.
Treating The Whole Person Through Integration
Mental health issues significantly contribute to the overall health burden within the United States, with depressive and addiction disorders being the leading 10 causes of disability and death for adults. They also are a significant cause of preventable deaths related to pregnancy. While most US adults had mental health problems in the prior COVID-19 epidemic, only a tiny fraction was treated in 2019.
A majority of disorders involving the mind start at the age of 14. Between 13 between 20 and 13 percent of US teens and children – or approximately 15 million adolescents–are affected by a behavioral health issue at any time, with suicide becoming the second most common cause of death for 10 to 24-year-olds. People with co-occurring physical and mental health disorders tend to pay more health-related costs and have worse health outcomes.
Furthermore, up to 70 percent of all primary care visits include a behavioral health component, underscoring the need for collaboration among primary care physicians, psychiatrists, and relevant subspecialties such as child and adolescent psychiatry, developmental-behavioral pediatricians, and other critical behavioral health clinicians.
An integrated, holistic, evidence-based approach to primary care that is focused on the health of the entire person throughout every stage of development, including the use of screening for behavioral health and methods for placing patients in service (such as the Child and Adolescent Service Intensity Instrument) which are standard and normalized, will help patients receive treatment sooner and at the appropriate degree of treatment.
BHI is not just a way to increase access to screening and treatment. It also assists in coordinating physical and behavioral health services across the different physicians and other health professionals while decreasing the stigma surrounding behavioral health therapy. To build resilience, our systems need to promote the development of healthy, mentally healthy children in the early years and ensure secure, stable, and nurturing relationships. This creates a genuinely patient-focused holistic care model that breaks conventional behavioral and physical health treatment boundaries.
They are also crucial in ensuring job satisfaction and overall health and well-being for doctors and other healthcare team members since they feel less tired knowing they can better provide for their patients’ pressing demands.
It is also crucial to keep in mind that there is no standard approach for BHI. Effective integration of a variety of behavioral health services is possible across a spectrum from integrated to coordinated treatment and includes using the Collaborative Care Model (CoCM) as one of the best examined and tested models for integration. Other models — like those of the Primary Care Behavioral Health Model and telehealth consultations for physicians in primary care and non-physician practitioners by a team of behavioral health specialists — could aid in expanding access to behavioral health services for patients and increase the capacity of the clinician.
Key Obstacles To Widespread BHI Adoption By Primary Care Practices
Despite the solid evidence base in support of BHI, there have been several legislative and regulatory reforms over the last decade that have been favorable to increasing BHI (that is the Mental Health Parity Act of 1996 and the Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act of 2010 CY 2018, and the 2018 Medicare Physician Fee Schedule – Final Rule) The widespread acceptance by primary care practices is an exception rather than the norm, throughout the US. This is due to various challenges facing physicians’ practices, such as the high cost of starting a business, inadequate reimbursement levels, complex and demanding charges, siloed data, and a limited number of workers.
The sustainability of financial resources is an ongoing concern for practices in fee-for-service or payment alternatives. Heath and coverage plans, including Medicare and Medicaid, often cannot provide adequate coverage and fair payment, with sufficient margins in primary-care practices that use CoCM and other BHI models that provide integrated services. Further, most primary care doctors do not have the initial capital, in addition to the different resources and training, to implement and maintain BHI in their practices. In addition, complicated and cumbersome billing demands, particularly fee-for-service services and carveout networks with narrow networks cause unnecessary obstacles for patients getting healthcare. Costs for out-of-pocket associated with integrated services also prevent patients from taking advantage of such support.
Additionally, physicians have difficulties estimating the net effect of BHI, particularly on their finances. Different performance and quality measures utilized by various health insurance companies and coverage plans make it difficult to determine the most effective actions resulting from the integration. Without evidence of a reliable ROI, it can be difficult for physicians to make a sound investment in the resources needed to sustain BHI efforts within their practices.
State and federal regulations have made it more challenging to share information about patients across the members of an integrated care team which is a crucial component of integrated care. This is due to the restricting definitions and rules of federal legislation and regulation, such as the Health Insurance Portability and Accountability Act and 42 Code of Federal Regulations Part 2.
Finally, medical practices are struggling to retain and recruit staff trained in trauma-informed and integrated healthcare, especially given the expected shortage of behavioral health specialists.
Practical Solutions, Payer Buy-In, And The Role Of Federal And State Policy Makers
All across the US in the United States, mental health issues impact about 17 percent of commercial beneficiaries, 41 % of those covered by traditional Medicare and 26 percent of Medicare Advantage beneficiaries, and around 20% of Medicaid beneficiaries. Medicaid is also the biggest provider of behavioral health services, which is why the vast majority of the program’s beneficiaries are kids. According to a report from the 2018 Milliman Report, BHI has the potential to save around $38 billion-$68 billion every year across all types of payers, with the bulk of savings coming from the commercial market ($19.3 billion to $38.6 billion). But, persistent underpayments or non-payment to primary care physicians for behavioral health services is at least partly contributing to the accessibility crisis.
Payers (employers and insurance companies) must collaborate with doctors to improve access to equitable health care for all people and stop the rising crisis in behavioral health. Here are five feasible solutions that payers can take to help facilitate the widespread adoption of BHI by medical practices:
- Increase coverage and provide fair payments with a profit margin for all stakeholders by using CoCM as well as other models that aid in the management of care and the transitions of treatment for patients suffering from problems with their behavior or health;
- Consider when and how to use cost-sharing (for instance, copayments, health savings accounts deductibles) and its elimination in the event of a need, and for CoCM codes and integrative behavioral health programs offered in the person or via telehealth.
- Provide support to primary care practices integrating behavioral health through assistance in the field, provider training, and sharing of regional resources;
- Expand provider networks and increase accessibility to BHI by reducing or getting rid of prior authorizations and other management of use practices for BHI services and
- Create, pilot, and then launch whole-person workplace-based behavioral health programs that give employees immediate access to resources related to health and professionals, as well as care assistance with navigation and culturally-focused efforts to discredit the stigma of the stigma associated with behavioral health.
Positively, some top employers and health insurance companies have already taken specific steps.
However, the federal and state policymakers play a crucial role play, which includes these four essential actions:
- Offer long-term sustainable funding options for primary medical practices (similar to the funds provided to patients for meaningful use and adopting a medical home) to train and educate staff on implementing BHI services.
- Increase the amount of money paid for BHI services, with the possibility of a profit for all stakeholders in state and federal coverage programs so that they can be maintained by practices continuously. This should include CoCM, care management/coordination, psychotherapy, dyadic therapy, and other relevant in-person and telehealth services used by primary care practices that have adopted BHI;
- Partner together with coverage plans to limit the use of management review practices as well as to enforce the law on behavioral health parity and improve regulations on network adequacy;
- Increase federal funding to grow the behavioral health workforce, especially psychiatrists, developmental-behavioral pediatricians, and other behavioral health specialists who practice in underserved areas. This should include loan forgiveness programs, new and expanded residency programs, and training programs.
Furthermore, although it’s not an all-encompassing solution, incorporating technologies like telehealth and other digital devices into BHI health models could help increase their overall effectiveness and increase the acceptance of BHI by practices of physicians, so long as it enhances rather than replaces the relationship between a physician and patient over time.
Finally, while ample evidence supports the many benefits of BHI, it is essential to show the extensive use it provides to Dr. Jordan Sudberg, patients, and the general public. A multistakeholder working group has identified many crucial measures to measure the impact of BHI programs. Further work is required, however, to improve the list and ensure that they are aligned with national standards for performance measurement.
A Sustainable Path Forward
Through collaboration to address patients’ behavioral and physical concerns during primary health care, we will begin to use BHI to ensure the whole person receives health care. Members of the integrated health team need to continue leading the way in making adequate whole-person care the standard for primary health care across the United States. However, payers and policymakers must be proactive in implementing solutions to ensure that primary health care providers and their teams are supported to provide equitable, all-person treatment for their patients and families. BHI Collaborative BHI Collaborative is wholly committed to speeding up BHI acceptance by physicians’ practices. It encourages the policymakers and payers, along with other stakeholders from the industry, to join us to bring this paradigm shift into reality.
The BHI Collaborative is a group of eight of the country’s most respected physician associations. It is committed to providing doctors and their practices with the knowledge needed to maintain an integrated, whole-person, and fair approach to mental, physical, and behavioral health in the COVID-19 pandemic and beyond.
The BHI Collaborative complete list of members includes the American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, American Medical Association, American Osteopathic Association, and American Psychiatric Association.