Researchers identify several barriers to integration of behavioral health in primary care
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Physicians face cultural, informational and financial barriers to integrating behavioral health services into their primary care practices in the United States, according to a qualitative analysis published in Annals of Internal Medicine.
“There is high-quality evidence to suggest that behavioral health integration improves patient outcomes, and there have been important national health policy changes over the past decade to increase behavioral health integration,” Peggy Chen, MD, MSc, MPH, physician policy researcher at the RAND Corporation and a board-certified pediatrician, told Healio Primary Care. “We wanted to understand why, given these factors, most physician medical practices have yet to successfully adopt behavioral health integration.”
Researchers conducted semi-structured telephone interviews with 72 participants — including 47 leaders and clinicians from medical practices that implemented behavioral health integration; 20 experts in clinical care, research or health policy related to behavioral health integration; and 5 vendors that provide behavioral telehealth services or technical integration assistance to medical practices.
Chen and colleagues said the physician practices were their primary focus in the analysis, and they questioned leaders and clinicians about their approach to integrating behavioral health, its cost and barriers to its implementation. The experts and vendors provided additional nuance and context for the study.
Four themes materialized from these discussions, according to the researchers:
- Reasons for integrating behavioral health included boosting access to behavioral health services, improving other clinicians' abilities to react to patients' behavioral health needs and enhancing practice reputation.
- Practices tailored their implementation of behavioral health integration to local resources, financial incentives and patient populations.
- Barriers to behavioral health integration included cultural differences and incomplete information flow between behavioral and nonbehavioral health clinicians on patients’ electronic health records as well asbilling difficulties.
- Practices described the advantages and disadvantages of fee-for-service and alternative payment models, and few reported positive financial returns.
Chen said that to overcome cultural differences between behavioral and nonbehavioral clinicians, practices should offer interprofessional training with both behavioral and nonbehavioral clinicians. training.
In addition, “EHR limitations can be addressed by ensuring that regulatory requirements are appropriately interpreted to allow for efficient information flow between behavioral and nonbehavioral health clinicians,” she continued. “Also, larger practices were sometimes able to dedicate financial and human resources to ensuring that the EHR system was well suited capturing care provided using a behavioral health integration approach. This was also beneficial to information sharing.”
Clinicians who participate in fee-for-service models should ensure that the logistics and workflow of the practice can handle additional steps that would allow effective use of behavioral health integration codes, according to Chen. Clinicians who use alternative payment models should make sure that staff and resources are available for any reporting requirements that might be needed, she said.
Chen added that clinicians should “consider the context of their practice and the resources available to them to ensure they identify the model of behavioral health integration that is optimal for their practice.”
The findings provide compelling evidence to enhance the well-being of patients, according to Sue Bornstein, MD, executive director of the Texas Medical Home Initiative in Dallas. She wrote in related editorial that Chen and colleagues’ paper “provides excellent insights to continue our sacred work to improve care of the whole person.”
References:
- Bornstein S. Ann Intern Med. 2020;doi:10.7326/M20-2887.
- Malâtre-Lansac A, et al. Ann Intern Med. 2020;doi:https://doi.org/10.7326/M20-0132.
Perspective
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Stephanie Gold, MD
Malâtre-Lansac and colleagues’ paper describes factors influencing the implementation of behavioral health integration based on semi-structured phone interviews with leaders and clinicians in practice; experts in clinical care, research, and health policy; and vendors that provide telehealth or technical assistance.
Their findings include important barriers related to payment, information sharing, and cultural differences that are reflective of prior literature. They mention workforce shortages are an issue, though this did not specifically come up in their findings. Workforce shortages are also a common barrier faced when integrating care, particularly in rural areas.
The authors describe useful practice-level solutions their informants found to address some of these barriers. The barriers they report also highlight the need for policy-level solutions, particularly with regard to financing integrated care.
The paper describes the complexities of billing for behavioral health integration in a fee-for-service model, limited billing capability for telehealth, and the difficulty in demonstrating return on investment. The authors also allude to instances where behavioral health services are funded separately from physical health services, called behavioral health carveouts, which cause financial barriers to integrated care.
Some additional barriers to financing integrated care bear mentioning. Both primary care and behavioral health have been chronically underfunded. This sometimes leads practices to be over-reliant on time-limited grant funding, which causes issues with sustainability of integrated care programs and practices. Financial support for integrated care can differ significantly across payers. Such differences increase the administrative burden on practices. With only a portion of a practice’s patient population covered under one payer’s support, the amount of funds for integration may not be sufficient.
The practice-level solution of billing for integrated fee-for-service codes noted in the paper supports behavioral health integration but should be considered an interim step to primary care payment reform. Prospective payments, rather than retroactive fee-for-service billing tied to specific services, better enable practices to flexibly design care to meet their patients’ needs. There has been a lot of national attention toward moving away from fee-for-service and an increasing number of alternative payment model demonstration projects from CMS and commercial payers, but primary care remains in a largely fee-for-service environment.
Despite the evidence supporting behavioral health integration, practices continue to encounter barriers when implementing integrated care. While there are workarounds at the practice level to address barriers, policy change is needed to get to their root causes.
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Bornstein S. Ann Intern Med. 2020;doi:10.7326/M20-2887.
Malâtre-Lansac A, et al. Ann Intern Med. 2020;doi:https://doi.org/10.7326/M20-0132.
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