The pandemic's negative impact on the mental health of millions of people has renewed discussions around why that nation's behavioral healthcare system has been inadequate to meet the level demand for care.
But the failure to meet patients' mental health needs predated the pandemic. Approximately 43% of the more than 51 million adults estimated to have had a mental health condition in 2019 received treatment, according to care access data compiled by Mental Health America.
The care gap has prompted calls for healthcare providers to move swiftly toward integrating behavioral healthcare services into primary care. Holistic approaches to physical and mental healthcare have been shown to help identify more patients experiencing a mental health issue and provide them with earlier interventions that can improve outcomes.
But that transition has hit financial, labor, regulatory and technological roadblocks.
"We have essentially set up two separate delivery systems," said Dr. Harold Pincus, professor and vice chair of the department of psychiatry and co-director of the Irving Institute for Clinical and Translational Research at Columbia University and the New York State Psychiatric Institute.
Much of the problem comes down to how behavioral healthcare providers get paid, Pincus said. Low reimbursement has disincentivized behavioral healthcare professionals from participating in insurance networks, which has made it difficult for primary care to refer patients or consult with them on care plans, according to a Bipartisan Policy Center-commissioned report released Wednesday.
Most providers still get reimbursed through a fee-for-service model that does not incentivize primary care practitioners to address behavioral health conditions, Pincus said. Also, the low rates of reimbursement for mental healthcare services has led to an increasing number of psychiatrists to not accept insurance. Only 55% of psychiatrists accepted commercial coverage compared to 88% among other medical specialties; 54% of psychiatrists accepted Medicare and 43% took Medicaid for payment.
The BPC report called for regulatory changes that provided financial incentives for integrated care delivery under Medicaid and Medicare managed care plans as well as the creation of new capitated models to pay primary care professionals who provide behavioral healthcare services to patients with mild and moderate mental health issues.
"It's a symptom of how broken the system has been and how difficult it is to coordinate that we're still trying to figure out these sort of baseline processes," said John Snook, director of government relations and strategic initiatives for the National Association for Behavioral Healthcare.
A lack of on-the-ground coordination between medical and behavioral healthcare providers continues to be a major barrier to integration, a problem that has been compounded by shortages in the number of professionals available to meet the demand for services, Snook said. Nationally, more than 50% of U.S. counties do not have a licensed behavioral health provider, according to the Health Resources and Services Administration.
The BPC task force recommended the federal government create a technical assistance program for primary care practices to receive the training on delivering integrated care. Other suggestions included expanding Medicare coverage to allow social workers to bill Medicare for chronic care management services.
The report called for permanently removing some of the restrictions that limited the use of telehealth services prior to the pandemic. Over the past year, mental health was the leading health condition where telehealth was used, accounting for 44% of all visits.
"Expanding telehealth access permanently would eliminate access disparities and address the digital divide," said former New Hampshire Gov. John Sununu, co-chair of the task force. "Telehealth will help treat far more people faster and in their own homes. Removing the telehealth video requirement would also enable those without broadband, video technology, or an understanding of how to use it, to access care from afar."
But technological barriers to integration go beyond expanding telehealth. For years there has been limited information sharing between behavioral health and medical providers, with the majority of mental healthcare setting still lacking electronic health record systems with the capabilities to effectively integrate with hospital EHR platforms.
BPC's report recommended Congress direct CMS to provide funding to help support the adoption of health information technology within behavioral healthcare settings.
Overall, Snook said he was hopeful the report's recommendations would provide policy makers with a path toward addressing some of the longstanding issues that have kept providers from more robustly integrating behavioral and physical health.
"That's the real opportunity that we have to seize," Snook said.
