Integrating primary care with behavioral health services, improving provider training on mental health, and policy changes were all noted as strategies to combat the rising mental health and substance abuse epidemic during a keynote session at AHIP 2022.
In combating the mental health and substance abuse epidemic, evidence has shown that the integration of behavioral health care into primary care has led to significant improvement of clinical outcomes and cost. However, panelists of a keynote session at AHIP 2022 note that several barriers remain in integrating behavioral health care, which has historically been siloed from physical health.
Shantanu Agrawal, MD, MPhil, chief health officer, Anthem, opened the discussion by acknowleding the impact of COVID-19 on mental health, which he described as a “burgeoning crisis” characterized by substantial demand and uneven access to care services. Even prior to the pandemic, disparities between physical and behavioral health care were shown to be worsening for American families seeking affordable and available mental health care and addiction treatment.
“What I find is many primary care providers [PCPs] do not really feel comfortable with addressing behavioral health issues, they don’t feel comfortable without knowing exactly what to do, and so often they end up referring for those services, which I think is increasingly more challenging,” said Agrawal.
“We need to better support our PCPs, physicians, nurse practioners, all of the above, with better training around different types of topics. And give them consultative services—support them in their ability to retain behavioral health issues within their practices and get them addressed.”
Along with PCPs, Agrawal said that the diversification of the behavioral health workforce, including health coaches and peer support counselors, is warranted to meet the high demand of mental health services.
“We need to do more to bring in different kinds of care—access however possible and that includes digital care, virtual care, both asynchronous and synchronous, and doing everything we need to do from a policy and payment standpoint to really make that possible,” he added.
“And then finally, there are models that we and I know many other companies are working on that really integrate behavioral and physical health care—anytime you really bring these needs together and combine them with social needs care delivery at the same time, that has a tremendous impact on outcomes.”
Touching further upon the utility of collaborative care models, Miriam Delphin-Rittmon, PhD, assistant secretary for Mental Health and Substance Use, HHS, and administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), said that integrated care has become a priority at HHS as data have shown substantial improvement of health outcomes when primary care is paired with mental health and substance abuse services.
“It creates additional entryways into services and supports individuals who are struggling with mental health or substance use services,” explained Delphin-Rittmon.
She noted that one of the programs HHS has helped to support and fund is the Screening, Brief Intervention and Referral to Treatment (SBIRT) model within the primary care setting, which helps to identify individuals who are struggling with mental health or substance use challenges and connects them with services and supports.
As individuals within behavioral health settings often are not connected to PCPs, Delphin-Rittmon added that screening of primary care conditions in behavioral health settings can also help with overall health and wellness.
“So, really, what this means, from a training and education perspective, we have to think about training a bit differently, and that it’s important to expose both physicians and behavioral health providers to screening within each of the other arenas, so that people can connect to vital services.”
In her work as CEO and cofounder of Psych Hub, which provides multimedia education to people dealing with mental health challenges, Marjorie Morrison said that one strategy her organization employs to improve quality is to train providers and certify them into behavioral care specialties.
“Once they’re acting more as specialists, everybody wins. The consumer gets better care, better production in fewer sessions, the provider has a lot less burnout, and there’s total cost of care savings,” said Morrison.
“At a high level, mental health can be so confusing. You have types of providers, psychiatrists, psychologists, social workers, coaches, peers, then you have different types of interventions like digital CBTs [cognitive behavioral therapies], [as well as] symptoms and diagnoses…when you think about how confusing it is for the average consumer, they have to be informed.”
From a policy and reimbursement perspective, Morrison emphasized the disparity in incentives for PCPs who can be reimbursed for educating on diabetes, weight loss, or smoking cessation, but not for mental health.
In adopting a holistic approach, she noted that the move to telehealth can also assist in providing consultation for patients with lower acuity to lower levels of care providers such as peers and coaches. But to do that, integrated models that can reimburse these providers is warranted.
“We need to be able to save our psychiatrists and our psychologists for those that need that help. We also got to start pushing on measurement-based care, feedback-informed care, and reimbursement for quality. Being able to start taking risks and doing value-based contracts—we have to get more innovative in our reimbursement.”
“There are policy constraints on the different kinds of providers that can be reimbursed with these services. Part of the issue is just implementing what we know works and that doesn’t necessarily require a lot of policy changes, it requires making a variety of changes in health systems and organizations like mine,” concluded Agrawal.
“I think the pandemic really put this on display—required us all to make shifts that, frankly, we could have made prior…This is about implementing stuff that you know works. and encouraging ecosystem changes when necessary.”