NAACOS: The Case for Behavioral Health Integration

A primary care physician’s biggest fear is a patient who comes in with a behavioral health issue, because they don’t feel equipped to handle it, Janet Niles, MS, RN, CCM, of Niles Associates, Inc, said to open a session on behavioral integration into accountable care organizations (ACOs) at the National Association of ACOs fall meeting in Washington, DC.

Connie M. Horgan, ScD, of Brandeis University, categorized behavioral integration as being in the dating stage still: a number of different models are being tried to find the right fit. With 25% of the adult population having a mental health condition or substance abuse disorder and 58% having a chronic condition, integration of behavioral health services is important, and the space where those 2 groups overlap is where ACOs can help, she said.

“Something that I think that gets lost in thinking about integrated care is the role of managed care at the population level,” Horgan said. Managed care can help with prevention, detection, and early intervention.

Patients with behavioral health issues are costly, but not because their anxiety or depression is expensive to treat, she added. The majority (80%) of their costs are for physical medical issues, not their behavioral health. So one of the goals of integration is to improve healthcare for individuals who have comorbid physical and behavioral health conditions.

“Clinical integration has been found to improve outcomes in depression, anxiety, alcohol abuse,” she said. “The data are there. Patients are generally happier, more pleased with their experiences.”

Unfortunately, there is currently a tremendous unmet need for people in the medical system who need behavioral health care. According to Horgan, 60% of adults and 70% of children with a mental health disorder do not receive services.

However, once patients are screened, primary care physicians wonder what to do next, explained Daniel F. McCarter, MD, of Well Virginia ACO.

His ACO has experimented with a few options to get a behavioral health specialist available to provide care for patients. In one practice, there was a co-located psychologist who would counsel patients when they came for their physical care. The problem was that the wait was 3 months, and someone who is distressed cannot wait that long.

Another practice had a behavioral health team that would make visits when needed, but even still they were only available half the time.

The newest strategy uses the IMPACT model so that a licensed behavioral health provider is co-located and primary care physicians can hand off patients to the behavioral health provider. Plus, the care manager is available for teleconsults. The practice still had a no-show rate of 28%, which highlighted how difficult it can be to get patients with behavioral health issues to show up for appointments.

“We’re not billing for the service right now,” McCarter said. “To have a 28% no-show rate on a free service just shows we have a hill to climb. It’s not just a matter of making this available.”

The other issue was that the ACO has only found the 1 behavioral health care manager. The workforce just isn’t there, he said.

In the entire country, there are roughly half as many psychiatrists as are needed, explained Joshua Israel, MD, of Aledade, a company that helps physician groups start and run ACOs. More than half of the counties in the United States have no mental health provider, and 77% of counties are considered severe shortage areas.

Just increasing access to psychiatric care brings down rates of conditions, but not costs. Siloed care does not work, it has to be integrated, Israel said.

He outlined some of the successes that have come out of integrating behavioral health care, such as standardized depression treatment protocols to put providers who don’t know how to treat these patients at ease; advanced planning discussions, which many providers aren’t comfortable with, so mental health providers can help; and even disaster relief guidance.

Israel provided the example of recent flooding in Louisiana and West Virginia and how providers operating out of trailers were able to connect patients who needed counseling with the right provider.