Promising results from a federal demonstration has spurred a bipartisan group of senators to push for new pay models that support integrating primary care and behavioral health. It comes at a time when demand for mental health servcies have spiked due to the COVID-19 pandemic.
"Unfortunately, the COVID-19 pandemic has highlighted—and exacerbated—the mental and behavioral health challenges we continue to confront," Sen. Mike Crapo, R-Idaho said during a Senate Finance Committee hearing Tuesday. "Loss of loved ones, increased isolation and delayed treatment prompted a spike in anxiety, depression and other debilitating conditions. While many are returning to their pre-pandemic lives, we should not be content to allow our mental health care delivery system to revert to its pre-pandemic ways."
Over half the country has reported not receiving treatment for their mental illness in the last year, according to data from Mental Health America. Experts say current pay models reinforce a "siloed" healthcare delivery model that often minimizes mental health in comparison to physical health services. They advised lawmakers to alter existing payment plans from Medicare Advantage, Medicaid managed organizations and Medicare accountable organizations to integrate primary care and mental health coverage.
"We need to meet people where they are," said Benjamin Miller, chief strategy officer at Well Being Trust, a foundation investing in community and clinical solutions to mental health.
A 2020 survey by the Bipartisan Policy Center showed that during the pandemic nearly 40% of adults were more likely to get mental health and substance abuse treatment from their primary care provider than they were from a behavioral health specialist. Looking at it by market, 45% of people in rural areas, 38% in urban areas and 37% in suburban areas were more likely to get mental health services from a primary care doctor.
In Oregon it can take up to six months statewide to receive treatment for mental health or substance abuse. But, Wallowa Valley Center for Wellness Clinic, a rural Certified Community Behavioral Health Clinic, provides same-day treatment to residents through their primary and mental health integrated model. The clinic is one of 12 CCBHCs in the state, as part of a two-year federal demonstration program taking across eight states. It is funded by an enhanced Medicaid reimbursement rate based on expected costs of care, providing more consistent resources than previously used grant funding, which expires every two to three years. More funding and resources allowed Wallowa to hire highly skilled professionals able to provide specialized treatment like medication assisted services for opioid disorder. The Medicaid funding also enabled them to partner with a federally certified health center to integrate primary care into their clinic.
"There are people who want to access behavioral health services, specifically those with severe mental illnesss, from the behavioral side, and there's people who want to access behavioral health services from their primary care doctor," said Chantay Jett, executive director of Wallowa Valley Center for Wellness Clinic. She explained the model creates the integration necessary to expand mental health access to more populations. Since the demonstration began, emergency department admissions for mental health in the county is down and the amount of veterans, an underserved group comprising about 1,000 Wallowa County residents, accessing behavioral healthcare is up 300%.
But, the funding is not permanent.
Crapo expressed interest in using state waivers to fund primary and behavioral care integration, while Sen. Debbie Stabenow (D-Mich.) urged fellow lawmakers to consider making CCBHC enhanced Medicaid reimbursements permanent. She and Sen. Roy Blunt (R-Mo.) on Tuesday introduced a bill to fully fund more CCBHCs. Other lawmakers expressed interest in sponsoring similar legislation building on current community models presented at the hearing.
At Boston Medical Center, which serves predominantly low-income patients, primary and mental health services have been integrated across a variety of models. One called Team Up For Children, allows federally qualified hospitals to increase their capacity for pediatric patients. Over the last year suicide attempts rose by nearly 50% among teenage girls, according to Center for Disease Control and Prevention Data. In this model, behavioral health clinicians are able to work with community healthcare workers and primary providers to offer adolescents care that is well coordinated across the facility.
"I dont think we have a clue how much we're running up in bills. We could do a better job if we just had integration in case management for people," said Sen. Maria Cantwell (D-Wash), on the need for even more coordination efforts to help the most underserved populations.
Some impediments to scaling up these models were insufficient Medicaid reimbursements and a lack of behavioral health staff. Lawmakers promised to revisit talks of loan repayment programs and raising GME slots to encourage more physicians to enter the field. They also entertained talks of removing behavioral health clinicians' exclusion from the Electronic Health Record Incentive Program.
