The healthcare system is moving towards integration. However, the passageways for integrating behavioral health with primary care are not so simple or straightforward. Whether one pursues full integration, colocation, or a digitally advanced referral network, providers and health plans are seeking different pathways to accelerate change and transform to delivery and relationship models that better serve people living with severe mental illness, substance use disorders and chronic physical health conditions. The vision for integration is there, but the steps toward achieving it across the entire continuum of care with seamless care coordination activities that addresses social determinants of health (SDOH), has yet to be realized. Achieving integrated care that is also accessible, affordable and person-centered involves pushing through barriers and unraveling the conventional ways of thinking.
The case for integration has already been made. Historically, primary care issues are not sufficiently attended to in behavioral health settings and behavioral health conditions are often undiagnosed and untreated in primary care practices. The prevalence of mental illness and substance use disorders commonly exist among the costliest users of Medicaid and most frequently hospitalized patients. In addition, the lack of accessible, integrated care that addresses SDOH, such as affordable and safe housing, transportation, food insecurity, income inequality, education, employment, etc., drives up costs in the form of avoidable trips to emergency rooms, stays in homeless shelters and prison sentences. People living with mental illness continue to die prematurely—up to 25 years earlier than the general population—due to treatable chronic medical conditions like cardiovascular, pulmonary and infectious diseases, diabetes and hypertension.
There are several behavioral health reform pieces in play that are shaping the healthcare delivery system and how we operationalize integration. Eight states, including New York and New Jersey, were selected to participate in the Certified Community Behavioral Health Clinics (CCBHC) federal pilot program. In addition, the states are taking steps towards collaborative care models and integrated licensure, which is critical for unifying the care delivery system.
In New York, reforms are taking place through the rollouts of Medicaid managed care, health and recovery plans (HARPs), Home and Community Based Services (HCBS), Health Homes care coordination, the Delivery System Reform Incentive Payment (DSRIP) program, as well as the seeding of Value-Based Payment (VBP) networks through Behavioral Health Care Collaboratives (BHCCs). In addition, providers are forming Accountable Care Organizations (ACOs) and Independent Practice Associations (IPAs) to deliver quality care, produce and share cost savings, and leverage their joint market share with health plans.
In New Jersey, the state reshuffled oversight of its behavioral health programs and is working to fill in regulatory gaps to make it easier for behavioral and medical providers to operate at the same location and form unique partnerships to deliver integrated care. Efforts for integrated service delivery models in New Jersey include community and hospital integration under its DSRIP program, Children’s and Adult Behavioral Health Homes, Medicare and Medicaid ACOs, Office Based Addiction Treatment (OBAT), as well as individual agencies leveraging grants to deliver integrated care and train physicians, nurses and psychiatrists to function as an integrated team. New Jersey is also one of seven states recently selected to develop a value-based model for Medicaid.
Building a healthcare system based on value adds a critical dimension to the integration rubric. VBP includes another level for delegating risk, shifting payment structures, developing collaborative networks, managing care and quality, and measuring outcomes. It requires the ability and technological infrastructure to collect and analyze qualitative and quantitative data on critical factors impacting health and wellness across the entire care delivery system. While there are HEDIS and QARR measures that directly involve behavioral health, measuring outcomes in the behavioral health world is still evolving, not clearly defined, consistently agreed upon or developed as physical health indicators.
A Labyrinth of Integration
In an ideal world, consumers could walk into any provider and receive care through a multidisciplinary team that addresses their holistic needs. At CCBHCs, where access to integrated care has increased significantly, sophisticated providers horizontally integrated their delivery systems to provide whole care in-house or work effectively with partners to deliver all of the various services that consumers need. CCBHC status has also made it easier to synchronize data across different systems and build data hubs with greater outcome measurement validity (SAMHSA requires CCBHCs to collect data on 21 of 32 quality measures). CCBHCs also receive enhanced Medicaid reimbursement rates to accomplish their work, and while funding for the CCBHC program was recently extended, long-term, targeted advocacy is required to sustain and expand the program nationwide. The National Council for Behavioral Health has led this charge and advocates in New Jersey recently met with Governor McGreevey and former Governor Christie to push for the White House and Congress to act, which is no easy lift.
Outside of the CCBHC realm, several capacity and regulatory issues continue to thwart integration and require our attention. Facility and physical plant requirements, from the size of examination rooms down to the closets, make it expensive for community-based providers to upgrade and retrofit their clinics to be certified for integration. Billing and reimbursement barriers, such as insufficient guidance on contracting and credentialing, inability to be reimbursed for same day behavioral and physical health services and lack of coordination in the claims payment process, make it difficult to keep fiscally solvent. Inadequate workforce funding, staffing shortages, training and licensing/scope of practice issues, exacerbate problems with capacity and waiting lists. Oversight and record keeping requirements, from health information technology readiness, information sharing, interoperability and confidentiality concerns, make it hard to sufficiently track and communicate patient data across systems. Moreover, managing smooth care transitions across disconnected regulatory and reimbursement frameworks can get tricky, to say the least.
Providers are advancing ways to overcome roadblocks. Many are co-locating their practices, though it is quicker and less complicated to integrate behavioral health into primary care than vice-versa. Under colocation, a primary care, mental health or substance use clinic brings in another physical or behavioral health service provider into the same location, but they remain separate administrative entities. In one example where a provider in New Jersey embedded a licensed primary clinic into their mental health center, a team was setup to identify medical problems that people living with chronic mental illness may not be aware of, such as symptoms that were being caused by lyme disease and not mental illness. Another provider in New Jersey integrated behavioral health clinics into their primary care practices, where physicians or nurse practitioners screen for anxiety or depression, and patients are evaluated by a consulting psychiatrist. The close physical proximity of colocated providers allows for better communication and follow through with licensed specialists. It also enhances consumer experience through smoother care transitions, less stigmatization and not feeling so overwhelmed about attending to their medical needs at separate locations. Nonetheless, each practitioner must keep their own records, communicate across different organizational cultures, ensure accountability, stay patient informed and practice inside the scope of regulations and guidance.
New York is taking steps toward a more simple and flexible model for integrated licensure. Providers with existing Article 28, 31 and 32 licenses can apply to have their primary care, mental health and substance use disorder services overseen by one state agency instead of up to three. In New Jersey, stakeholder discussions are underway on integrated licensure. As progress is made towards single licensure, many providers are utilizing care coordination to enable “warmer handoffs” to other behavioral or physical health services and levels of care, along with peer navigators and community outreach workers to better engage and connect people to the care and services they need. Organizations also persist with continuously improving data and systems flow, engaging with consumers, increasing prevention services, participating in care networks, and using telehealth solutions to break down barriers to care.
Integrating a Future with Promise
It takes renewed commitment and investment to develop a system of care that consumers need and deserve. As healthcare networks evolve and grow, the entities that bind the network together, the conveners, are critically important for deliberating and bringing the right groups together to drive healthcare integration. Think through the urgent needs in your community, where you are best positioned to make a difference and who needs to get onboard. No one can achieve it on their own.
The same principles hold true for provider advocacy with public and private payers. In states with a unified association, where the advocacy voice is stronger and the work happens more efficiently, providers can push more effectively for regulatory flexibility and economic support. It is also easier to facilitate sector wide collaboratives to operationalize best practices, find synergy between service providers and structures, and further greater opportunities for collaborations and partnerships. Think of how much more power and resources could be leveraged toward achieving full integration at the service delivery level if advocacy more harmoniously. Legacy associations were successful at breaking down the institutional barriers of the past, but today’s challenges require full cooperation amongst all entities. It is only logical that we speak with one voice, particularly in this age of vertical integration and provider consolidation. In several ways, the future for integration is as limited as our current way of thinking.
You may contact Jason Lippman at jason.lippman@gmail.com.
