Integrating behavioral health and primary care: a qualitative analysis of financial barriers and solutions

Abstract

The objective of this study was to characterize financial barriers and solutions for the integration of behavioral health in primary care at the practice and system levels. Semi-structured interviews were conducted March–August of 2015 with 77 key informants. Initially a broad thematic coding approach was used, and data coded as “financing” was further analyzed in ATLAS.ti using an inductive thematic approach by three coders. Themes identified included the following: fragmentation of payment and inadequate investment limit movement toward integration; the evidence base for integration is not well known and requires appropriately structured further study; fee-for-service limits the movement to integration—an alternative payment system is needed; there are financial considerations beyond specific models of payment, including incentivizing innovation, prevention, and practice transformation support; stakeholders need to be engaged and aligned to support this process. There was consensus that the current fragmented, fee-for-service system with inadequate baseline reimbursement significantly hinders progression toward integrated behavioral health and primary care. Funding is needed both to support integrated care and to facilitate the transition to a new model. Multiple suggestions were offered regarding interim solutions to move toward an integrated model and ultimately global payment. Payment, in terms of both adequate amount and model, is a significant obstacle to integrating behavioral health and primary care. Future policy efforts must focus on ensuring stakeholder collaboration, multi-payer alignment, increasing investment in behavioral health and primary care, and moving away from fee-for-service toward a global and value-based payment model.

Use of behavioral health care in Medicaid managed care carve‐out versus carve‐in arrangements

“…Advocates also voiced concerns that a blending of funds might favor physical health services at the expense of needed mental health services. Despite these rationales, legacy carve-out arrangements are now perceived as a critical barrier to better outcomes for Medicaid enrollees, [2][3][4][5][6][7] particularly given evidence supporting the integration of primary care and behavioral health care in clinical settings. [8][9][10][11][12][13][14][15][16] The goals of integrated care may be incompatible with separate financing of medical and physical health services.…”

“…Despite these rationales, legacy carve‐out arrangements are now perceived as a critical barrier to better outcomes for Medicaid enrollees, 2‐7 particularly given evidence supporting the integration of primary care and behavioral health care in clinical settings 8‐16 . The goals of integrated care may be incompatible with separate financing of medical and physical health services.…”

Clinical Psychologists as T-Shaped Professionals

“…Whether the psychologist is in a private practice, primary care clinic, or large health care organization, delivering clinical services is likely to require financial management. A long-standing and primary method for psychologists to receive reimbursement is through billing patients' insurance (Shmerling et al, 2020). However, receiving funds from insurance is often not straightforward, with many different payment models, reimbursement rates, and barriers for billing clinical services (Garfield, 2011).…”

Something Republicans and Democrats can agree on: Support for integrated behavioral health.

“…With integrated behavioral health providers, patients can receive evidence-based therapy and brief interventions in the same place they are treated for the bulk of their health issues, and with consultative relationships with psychiatry, patients can receive more complex medication management for severe behavioral health conditions from their primary care provider. However, the health care system has generally disincentivized this (Crowley & Kirschner, 2015; Shmerling et al, 2020), along with other aspects of comprehensive primary care.The collaborative care model is one way—but not the only way—to provide integrated behavioral health. There is evidence of improved patient outcomes (Asarnow et al, 2015; Balasubramanian et al, 2017) and reduced costs (Beil et al, 2019; Lanoye et al, 2017; Ross et al, 2018, 2019) with integrated behavioral health inclusive of a variety of approaches.…”

“…With integrated behavioral health providers, patients can receive evidence-based therapy and brief interventions in the same place they are treated for the bulk of their health issues, and with consultative relationships with psychiatry, patients can receive more complex medication management for severe behavioral health conditions from their primary care provider. However, the health care system has generally disincentivized this (Crowley & Kirschner, 2015; Shmerling et al, 2020), along with other aspects of comprehensive primary care.…”