Integration of Behavioral and Physical Health Care as an Essential Solution to our Growing Mental Health Crisis

On April 27, 2023, US Senators Catherine Cortez Mastro (D-NV) and John Cornyn (R-TX) introduced the Connecting Our Medical Providers with Links to Expand Tailored and Effective (COMPLETE) Care Act (S.1378), supported by over 50 organizations representing payors, providers, and patients1. The organizations in favor of the legislation include the American Psychiatric Association, Meadows Mental Health Policy Institute, and the National Alliance on Mental Illness. In September, a companion bill in the House of Representatives, H.R. 5819 COMPLETE Care Act of 2023, was introduced by a bipartisan group of US Representatives led by Dan Kildee (D-MI) and Michelle Steel (R-CA)2. This legislation would promote behavioral health integration in primary care by increasing the reimbursement rate on collaborative care codes for a period of three years, establishing quality measurement reporting requirements for participating primary care groups, and providing technical implementation assistance. Increased reimbursement on collaborative care codes was also included in Section 104 of the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act unanimously passed by the Senate Finance Committee this month. We are excited by the progress being made towards truly unifying physical and mental healthcare and encouraged by the broad support that this legislation has received to date.

To understand why the integration of behavioral and physical healthcare is necessary, it’s essential to understand the landscape of mental illness in the United States today. 1 in 5 U.S. adults will experience a mental illness each year, representing over 50 million Americans, while 1 in 6 U.S. youth aged 6-17 experience a mental health disorder each year with 16% suffering from at least one major depressive episode3. And it’s only becoming more prevalent – according to the World Health Organization, mental health conditions continue to increase worldwide to the tune of a 13% rise in mental health conditions and substance use disorders during the ten-year period ending in 20174. As the situation has continued to deteriorate, our healthcare system has not been able to keep pace. Although improved, access to care is still severely limited; 54.7% of adults with a mental illness do not receive any care while 59.8% of youth with major depression do not receive any mental health treatment5. The average delay between the onset of mental illness symptoms and treatment is 11 years3. The aggregate effect of the rapidly growing rate of mental illness and a slow-to-adapt healthcare system is a country in crisis and significant downstream costs associated with more advanced symptoms.

Until recently, the perception within the healthcare industry was that physical and behavioral health were separate and distinct. If your PCP did feel comfortable treating behavioral health conditions, they would prescribe medication and schedule a follow-up appointment months later. This is inefficient for the PCPs and results in a less supportive experience for patients. However, if your PCP did not feel comfortable prescribing a medication themselves, they would likely refer you out to an independent behavioral health provider group in the area. Most of these groups would have long waitlists and accept few or no insurance plans. If you did successfully access care, from this point forward, your physical health would be managed by your PCP while your behavioral health would be managed by your therapist or psychiatrist, with little to no communication between the two. This fragmented approach to care results in three main things – restricted access, increased cost of care to both the patient and the healthcare system, and worsened patient health outcomes. This connection is illustrated by studies showing people with depression have a 40% higher risk of developing cardiovascular and metabolic diseases (including stroke, diabetes, and obesity) than the general population, and 33.5% of US adults with mental illness also experienced a substance use disorder in 20213. Costs have also surged because of the low treatment rate; among US youth under the age of 18, depressive disorders are the most common cause of hospitalization.6

By virtue of their central role in a patient’s interaction with the healthcare system, primary care is an effective point of intervention for the identification and treatment of mild to moderate mental illness. This is evidenced by data showing that up to 80% of people with a behavioral health disorder will visit their PCP at least once a year, and up to 50% of patients referred to an outpatient behavioral health clinic will not attend a single appointment7. To really address the gap between the number of patients that need care and those that receive it, we must integrate behavioral health with physical health in the primary care setting.

The Collaborative Care Model (CoCM) is the most robust, evidence-based model for behavioral health integration, with documented benefits including better affordability, higher system capacity, and higher rates of patient engagement. Most importantly, CoCM has been shown to significantly improve patient outcomes over alternative treatment modalities. In one study of CoCM implementation in primary care, CoCM was found to have doubled the effectiveness of depression treatment when compared to usual care8. Primary care groups can bill for these services using CPT codes for psychiatric collaborative care management services (99492, 99493, 99494, G2214). The Centers for Medicare & Medicaid Services (CMS) began reimbursing for these codes in 2018, which has since led to wider adoption among commercial payors and close to half of state Medicaid agencies. While coverage has improved, there are still significant gaps, and some payors are reimbursing these services at a significantly lower rate than other primary care services. This has led many PCPs to balk at the upfront costs associated with implementing CoCM. By supporting and passing the COMPLETE Care Act, we will be closer to equitable reimbursement for behavioral health treatment alongside physical healthcare and many PCPs that have thus far refused to adopt CoCM will move to implement this needed service.

CoCM is a short-term intervention for patients that are experiencing mild-to-moderate symptoms of mental illness with an end goal of discharging the patient or transitioning them into a longer-term treatment plan, as clinically appropriate. Treatment is a collaborative effort between the PCP, the behavioral health manager, and a consulting psychiatrist. From the patient perspective, the end-to-end experience is provided in the primary care setting, allowing them to receive care in a familiar location.

There are certain key components that are essential in driving patient engagement and improving the treatment rate of mental illness9. First, universal screening, if not already part of the patient visit, will be implemented as part of CoCM. CoCM is a population-based treatment approach and the identification of patients in need of care is a core component of the model. The second key component is the warm handoff from the primary care physician to the behavioral health manager. If a patient is identified as having a mental health need, the behavioral health manager will be introduced to the patient during their PCP visit. This helps to build a relationship between the patient and the behavioral health manager and drives increased patient activation. Once a patient is in care, they are tracked via a registry to ensure the patient is actively supported and isn’t allowed to fall out of treatment due to delays or ineffective communication. The behavioral health manager reviews their caseload on a weekly basis with a consulting psychiatrist who actively provides diagnostic clarity and treatment recommendations to the PCP. The consulting relationship is an efficient way for a primary care provider to efficiently access psychiatric expertise and guidance while continuing to provide high quality care to the patient. The model is built on a measurement-based treatment to target approach, with patient progress regularly measured by evidence-based tools such as the PHQ-9 or the GAD-7. These widely used tools provide an objective way to assess and monitor symptom severity for common disorders such as depression and anxiety.

At LifeStance Health, we’re also able to join our collaborative care model with unparalleled scale in traditional outpatient therapy and medical management, creating more access for patients across a broader part of the acuity spectrum. Our primary care partners have the added benefit of rapid access to specialty care through our 6,400 clinicians across 33 states, virtually eliminating the hassle of the traditional waitlist experience for outpatient referrals. For patients with symptoms that are considered more severe, we can utilize collaborative care as a bridge into long-term treatment and continue to expand the mental and behavioral health treatment rate. These components differentiate the collaborative care experience for the patient from the traditional hands off, often ineffective, traditional referral process, where the patient is provided with a list of behavioral health resources and is responsible for coordinating their own care among the various healthcare groups involved. This experience is not only better for the patient but also for the physician, who now has the support of behavioral health experts in treating their patients.

While numerous studies overwhelmingly support the use of collaborative care in primary care, the model faces several implementation challenges, many of which would be alleviated by the COMPLETE Care Act. These challenges have limited the uptake of CoCM and restricted patients’ ability to access what is a highly effective care model. First, only about half of all states’ Medicaid programs include CoCM as a covered service, and some states have imposed additional administrative requirements beyond those of Medicare. These barriers restrict access to care, exacerbate the lack of parity between mental and physical health and prevent broad adaptation of the model. Second, as with any new program, there are start-up costs associated with integrating behavioral health. Increased reimbursement will reduce the risk that primary care groups face when investing in the integration of behavioral health services and will ensure that no group needs to choose between financial sustainability and better patient care.

Lastly, implementation of the program requires changes to the clinical workflows and billing practices of the primary care group. These challenges can be mitigated by partnering with an integrated mental health care specialist group, such as LifeStance, but the technical assistance included in the COMPLETE Care Act will provide important resources for primary care groups looking to adopt behavioral health integration. This act was designed to make it as seamless as possible for primary care groups while providing sufficient financial benefit to incentivize investment in the upfront work required to promote more effective, whole-person care.

As of the writing of this article, the COMPLETE Care Act is still under review by the Senate Committee on Finance, House Committee on Energy and Commerce and the House Committee on Ways and Means. We are committed to continuing our advocacy for increased access to appropriate behavioral health services on behalf of our patients and clinicians across the United States. This bill is a game changer for integrated care, and we encourage you to reach out to your representatives in support of this legislation. Together, we can change the way behavioral healthcare is delivered in this country and positively impact the outlook for millions of Americans that are dealing with untreated mental illness.

At LifeStance, we are passionate about improving the state of mental and behavioral healthcare across the entire nation. We’re excited to partner with primary care groups to make behavioral health integration the norm, rather than the exception. We believe that partnering with LifeStance will make the transition to collaborative care as seamless as possible, while providing patients with a best-in-class treatment experience. If you’re interested in discussing how we can partner in improving patient outcomes, please complete the form here and we will be in touch with you shortly.

References

https://www.cortezmasto.senate.gov/news/press-releases/cortez-masto-cornyn-introduce-bipartisan-legislation-to-improve-access-to-mental-health-care-for-hardworking-families/

https://www.congress.gov/bill/118th-congress/senate-bill/1378/text?s=1&r=24

https://www.nami.org/mhstats

https://steel.house.gov/media/press-releases/steel-introduces-bipartisan-bill-increase-access-mental-health-care-services

https://www.votervoice.net/AmericanPsych/Campaigns/95632/Respond

https://dankildee.house.gov/media/press-releases/kildee-introduces-bipartisan-bill-increase-access-mental-health-care

https://www.nimh.nih.gov/health/statistics/mental-illness

https://mhanational.org/issues/state-mental-health-america

https://www.cdc.gov/nchs/products/databriefs/db444.htm#:~:text=In%202021%2C%20nearly%201%20in,across%20metropolitan%20and%20nonmetropolitan%20areas

https://www.apaservices.org/advocacy/news/coalition-efforts-integrated-care-legislation

https://www.aafp.org/pubs/fpm/issues/2021/0500/oa1.html#:~:text=Up%20to%2080%25%20of%20people,at%20least%20once%20a%20year.&text=Moreover%2C%20some%20patients%20would%20rather,a%20specialty%20mental%20health%20provider.

https://aims.uw.edu/collaborative-care/principles-collaborative-care

https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/get-paid#:~:text=Reimbursement%20for%20the%20Collaborative%20Care,99493%2C%2099494%20and%20G2214).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegrationPrint-Friendly.pdf

https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2019.6b7

Citations

  1. “Cortez Masto, Cornyn Introduce Bipartisan Legislation to Improve Access to Mental Health Care for Hardworking Families.” Senator Catherine Cortez Masto, https://www.cortezmasto.senate.gov/news/press-releases/cortez-masto-cornyn-introduce-bipartisan-legislation-to-improve-access-to-mental-health-care-for-hardworking-families/.

  2. “Steel Introduces Bipartisan Bill to Increase Access to Mental Health Care Services.” Congresswoman Michelle Steel, https://steel.house.gov/media/press-releases/steel-introduces-bipartisan-bill-increase-access-mental-health-care-services

  3. “Mental Health By the Numbers.” National Alliance on Mental Illness, https://www.nami.org/mhstats

  4. “Mental Health.” World Health Organization, https://www.who.int/health-topics/mental-health#tab=tab_2

  5. “The State of Mental Health in America.” Mental Health America, https://mhanational.org/issues/state-mental-health-america

  6. Excluding hospitalization related to pregnancy and birth.

  7. “Now More Than Ever, Mental Health Care Needs Family Medicine.” Alexander Kieu, MD. https://www.aafp.org/pubs/fpm/issues/2021/0500/oa1.html#fpm20210500p11a-b5

  8. Richardson LP, Ludman E, McCauley E, et al. Collaborative care for adolescents with depression in primary care: a randomized clinical trial. JAMA. 2014;312:809-816.

  9. AIMS Center, University of Washington

Authored By 

Jared M. Regan, CPA
Jared M. Regan, CPA

Jared joined LifeStance Health in 2022 and focuses on growth initiatives for the company, which include helping to lead our Integrated Behavioral Health (IBH) and Ancillary Service Line strategy and supporting the acquisition and integration of new behavioral health practices. Outside of LifeStance, he currently serves on the Board of Directors of the Boys and Girls Clubs of Stoneham and Wakefield, a Greater Boston affiliate of Boys and Girls Clubs of America.


Reviewed By

Dr Rachel J Dalthorp, MD
Dr Rachel J Dalthorp, MD

Dr. Dalthorp is board certified by the American Board of Psychiatry and Neurology and a Fellow of the American Psychiatric Association. She is a former member of the board of directors for the American Association of Ketamine Physicians and founding board member of the nonprofit International Society of Reproductive Psychiatry. She currently serves as Secretary and member of the Executive Council, CME, and DEI committees of the Oklahoma Psychiatric Physicians Association.