Physician organizations push for behavioral health integration in primary care

A group of national physician organizations has issued a call to action to integrate behavioral health services into primary care settings.

“More people than ever are struggling with their behavioral health, including both mental health and substance use disorders,” Gerald E. Harmon, MD, immediate past president of the AMA, and colleagues wrote in Health Affairs. “We believe, therefore, that our primary care systems must urgently embrace a paradigm shift, accelerating the adoption of behavioral health integration (BHI) in physician practices and addressing this rampant increase in unmet needs.”

While highlighting the importance of BHI, Harmon and colleagues also acknowledged that primary care physicians are struggling to navigate the challenges of limited time and inadequate resources.

“Existing systems are failing to meet the need for whole-person care, including addressing the impact of life stressors and trauma, which have only intensified during the COVID-19 pandemic,” they wrote.

To help facilitate BHI, the AMA and seven other physician organizations — the ACP, American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Osteopathic Association, American Psychiatric Association and American Academy of Child and Adolescent Psychiatry — previously established the BHI Collaborative to empower physicians and their care teams to improve care and expand access to behavioral health services. However, Harmon and colleagues said the group “cannot and should not tackle these challenges alone.”

Mental health crisis in US

Behavioral health conditions are a pervasive issue and a “leading contributor to disease burden in the United States,” the authors wrote.

According to Harmon and colleagues, suicide is the second leading cause of death for people aged 10 to 24 years. Depressive and substance use disorders are in the top 10 causes of death and disability for adults. Up to 50% of behavioral health disorders begin by age 14 years, the authors wrote. In any given year, approximately 15 million children and adolescents — between 13% and 20% of youth — experience a behavioral health disorder.

To “sufficiently combat” the mental health crisis, PCPs must have the support and partnership of “other key stakeholders across the health care ecosystem,” like policymakers and payers, Harmon and colleagues wrote. A key component of this, they added, is the implementation of a “holistic, evidence-based integrated approach” that is centered around the whole person’s well-being and includes resources like standardized and normalized service intensity placement tools and behavioral health screening.

“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 key behavioral health clinicians,” they wrote.

A way forward

Implementing behavioral health care successfully “can occur along a spectrum from coordinated to fully integrated care, with the Collaborative Care Model being one of the most studied and validated models of integration,” Harmon and colleagues wrote. There is “no one-size-fits-all approach to BHI,” but any implementation can help reduce the stigma surrounding behavioral health treatments, they wrote.

Regardless of what model one uses, Harmon and colleagues noted that primary care systems “must promote early childhood healthy mental development and support safe, stable, nurturing relationships” to “proactively build resilience.”

“This generates a true patient-centered, whole-person care approach that breaks down the traditional silos of physical and behavioral health care,” they wrote.

This paradigm shift would also help providers, who report feeling less burned out if they know they can “care for their patients’ most pressing needs,” Harmon and colleagues wrote. Therefore, implementation of these programs “are also essential to advancing job satisfaction and overall improved quality of life for physicians and the broader care team,” they wrote.

There is a sustainable path forward, according to the authors. They noted that policymakers can:

• offer funding opportunities for PCPs to support training and education on BHI;

• increase payment for BHI services “with a margin for all stakeholders in federal and state coverage programs such that they can be sustained by practices on an ongoing basis”;

• work alongside coverage programs and health plans to enforce behavioral health parity laws, strengthen regulations for network adequacy and limit the use of management review practices; and

• increase federal funding to grow the behavioral health workforce.

Harmon and colleagues also outlined five steps for payers, which, “encouragingly, some leading employers and health plans have already begun to take”:

• increase coverage and fair payment with a margin for those who use BHI models that facilitate care management and transitions of care;

• assess when and how it is appropriate to apply cost sharing, “including its elimination where appropriate,” for integrated behavioral health services delivered in person or via telehealth;

• help PCPs integrate behavioral health with a regional sharing of resources and by offering technical support and provider training;

• increase provider networks and expand access to BHI “by minimizing or eliminating prior authorization and other use management practices for BHI services”; and

• pilot, design and launch “whole-person, employer-based behavioral health programs that provide employees with immediate and direct access to behavioral health resources and providers, including care navigation support, with intentional culture-focused work to destigmatize behavioral health.”

“By working collaboratively to address both physical and behavioral patient concerns in primary care, we can begin to properly use BHI to enable holistic health care for all. Members of the integrated care team must continue to lead the charge in making equitable, whole-person care the standard for primary care in the United States,” Harmon and colleagues concluded. “But also: Payers and policy makers must act now to implement solutions and ensure primary care physicians and their care teams have the support to provide equitable, whole-person care for their patients and families.”