Integrating Mental Health and Addiction Treatment Into General Medical Care: The Role of Policy

To date, integrated care policies have focused on overcoming payment barriers. Care processes central to integrated care—such as care management—have not historically been reimbursed by insurers, a major impediment to scale-up. To address this issue, in 2017 the Center for Medicare and Medicaid Services introduced behavioral health integration billing codes allowing general medical providers to bill Medicare; the codes have also been adopted by some state Medicaid and commercial plans for care planning and management services (17). However, uptake has been low: during 2017–2018, only 0.1% of Medicare beneficiaries with mental illness or substance use disorders received a service billed to one of the new integration codes (34). One likely driver of low uptake is that in order to bill, practices must have multiple integrated care process and structure elements already in place (35, 36). In addition, the entire reimbursement flows to the general medical provider that does the billing. In the absence of colocation, this one-sided payment structure places an administrative burden on practices to set up ledger transfers, contracts, or other arrangements to pay behavioral health partners (35). This issue is primarily relevant for single-specialty practices, although even multispecialty practices, including both general medical and behavioral health providers, have cited as an administrative hurdle the need to set up ledger transfer or other strategies to facilitate within-organization financial transfers (35).

Similar types of relatively modest payments—generally in the range of $20–$200 per-beneficiary per-month—to cover care management or other previously nonbillable integrated care activities have also failed to result in meaningful behavioral health integration in federal patient-centered medical home (PCMH) demonstration programs, including the Comprehensive Primary Care (CPC) and Multi-Payer Advanced Primary Care demonstrations (37, 38). PCMHs aim to implement the chronic care model to improve treatment of chronic conditions, including but not limited to mental illness and substance use disorders, and although they are not focused specifically on behavioral health, they include many of the core process and structure elements in Box 1 (39). The limited available evidence suggests that PCMHs have the potential to improve care for people with mental illness (40, 41). Like collaborative care, the PCMH model has struggled with scale-up. The National Commission for Quality Assurance (NCQA) created a PCMH recognition program in 2008 and currently recognizes about 13,000 U.S. primary care practices as PCMHs. The 2015 Medicare Access and CHIP Reauthorization Act created a financial incentive for obtaining this recognition: clinicians practicing in NCQA-recognized PCMHs are eligible for higher fee-for-service Medicare payments (42). In 2017, NCQA introduced a Distinction in Behavioral Health Integration Program as part of its PCMH recognition initiative, but the degree of adoption and effects on care and outcomes among people with mental illness or substance use disorders are unknown.

Like PCMHs, accountable care organizations (ACOs) are not specifically designed to integrate general medical and behavioral health services but have the potential to facilitate such integration, in this case through shared savings and (in two-sided risk arrangements) losses tied to achievement of targets involving quality of care and health care spending. However, the evidence suggests that ACOs have had limited to no impact on care for people with behavioral health conditions (43, 44). Frequently cited weaknesses in existing ACO models are limited inclusion of behavioral health specialty providers and lack of alignment between payments and behavioral health performance metrics (43).

Multiple existing policies operate as barriers to care integration. The federal 21st Century Cures Act of 2016 clarified that federal law does not prohibit organizations or individual clinicians from billing Medicaid for both a primary care service and a mental health service delivered to a single patient on the same day (45). Despite the federal clarification, same-day billing limits persist in many state laws. In the most recent review of state Medicaid laws available, which was conducted in 2015, a total of 24 state Medicaid programs prohibited some or all settings and provider types from same-day billing (46). Since the clarification to federal law in 2016, some states have introduced and passed legislation to do away with state prohibitions, but they persist in multiple states (47).

Insurance carve-out arrangements, in which behavioral health benefits are administered by an organization different from the one that administers general medical benefits, are commonly cited as a barrier to integrated care delivery. Importantly, “carve-in” arrangements, in which a single organization manages both general medical and behavioral health benefits but still uses internally segregated budgets and separate adjudication practices for general medical and behavioral health claims, have also been cited as impeding integration (48). Multiple state Medicaid plans are considering eliminating carve-outs, although evidence on the effects of doing so on care delivery and patient outcomes is limited. One study found that integrated management of behavioral health and general medical benefits in Illinois Medicaid decreased behavioral health costs without affecting service utilization (49). Other policy barriers exist for specific behavioral health conditions—for example, federal laws limiting primary care physicians’ ability to prescribe opioid agonist medications to treat opioid use disorder (50, 51). Although we recognize the significance of such policies, a comprehensive assessment of condition-specific policies is outside the scope of this article.

Payment policies have to date fallen short of incentivizing widespread adoption of integrated care. Evidence points to a need for multipayer financing arrangements that support not only process-of-care elements but also structural elements of integrated care, adequately incentivize participation of both general medical and specialty mental health providers, and hold multidisciplinary teams accountable for improved care and health outcomes among persons with mental illness or substance use disorders.

Reimbursement mechanisms that provide modest per-beneficiary per-month payments for integrated behavioral health activities appear to be inadequate to cover the costs associated with structural integrated care elements. Difficulty paying for behavioral health staff and lack of needed health information technology (IT) infrastructure are consistently identified as barriers (15, 37, 48). Health IT is critical, because clinical information systems underpin the process-of-care elements included in evidence-based integrated care models. The federal Comprehensive Primary Care Plus initiative, which includes health IT development for primary care practices implementing advanced PCMHs with integrated behavioral health care, may yield important insights into the types of IT systems best suited to supporting integrated care. Financing of structural elements of integrated care could also be achieved through bundled payments; the American College of Physicians has recommended separate prospective bundled payments for structural and process-of-care elements (52).

Neither general medical nor specialty mental health providers are currently held accountable for “whole person” health outcomes among persons with behavioral health conditions. Value-based financing arrangements structured so that both general medical and specialty mental health providers are subject to the same incentives could address these issues. One approach is to strengthen ACOs through increased inclusion of behavioral health specialists in ACO networks and by aligning payment with behavioral health performance measures. Hub-and-spoke models may also facilitate integrated care. Vermont’s hub-and-spoke Medicaid health home program, in which specialty addiction treatment programs serve as “hubs” that collaborate with primary care and other general medical “spokes”—with payment following directly from Medicaid to both hubs and spokes—has increased delivery of buprenorphine for treatment of opioid use disorder (53, 54).

Ideally, all these payment policy options need to be multipayer so that integrated care can be implemented practicewide versus only for a subset of insured patients. There are many common elements across effective integrated general medical–behavioral health models and other chronic care model–informed efforts, such as PCMHs. Lessons learned from the various alternative payment models being tested by public and private insurers to incentivize primary care redesign in alignment with the chronic care model could yield important insights for optimal payment policies to support integrated care (55). The Affordable Care Act Medicaid Health Home Waiver provides opportunity for integrated care payment innovation by giving states flexibility in designing payment methodology to support implementation of health home programs for subsets of high-cost, high-need Medicaid beneficiaries (56). As of November 2019, a total of 13 states had used this waiver to support integration of behavioral health services into general medical settings (56). Importantly, it is unclear whether any of these models will overcome what Pincus and colleagues (57) termed the “cost-effectiveness conundrum” of integrated care models, which require significant up-front investments and, by design, identify previously unmet patient needs, which require additional services; as noted above, this conundrum is particularly salient to small, single-specialty groups and low-resource settings.

Policies to fund integrated care are necessary but not sufficient to spread implementation of effective integrated care models. This point is illustrated by Minnesota’s DIAMOND initiative, which is often held up as a model for collaborative care scale-up. DIAMOND is a multipayer initiative that finances collaborative care through bundled payments designed to cover both structural and process-of-care elements, and the initiative also provides intensive training and an electronic registry to participating practices (58, 59). Although DIAMOND facilitated adoption of collaborative care, it had no effects on depression outcomes (59). This illustrates the challenges to replicating the beneficial effects of integrated care models shown to improve patient outcomes in clinical trials and the need to address remaining barriers. We posit two policy priorities: workforce and social determinants of health.

General medical practices attempting to integrate behavioral health care cite lack of available specialists as a barrier (60). Common policy tools, such as loan repayment programs, for addressing health care workforce gaps may help increase recruitment into the field, but significant expansion will likely require increasing insurance payment for behavioral health services to levels that allow organizations to offer compensation high enough to incentivize people to choose behavioral health careers (61). Siloed general medical and specialty mental health training impedes integration (62). Institutional or graduate medical education accreditation policies could require general medical clinicians to demonstrate key behavioral health competencies and vice versa. Such competencies are critical, given studies showing that general medical providers’ discomfort with and potential bias toward patients with behavioral health conditions can translate into suboptimal care (63–67). Policies could also require training in team-based and integrated care for both professions. Telehealth and mobile health (mHealth) applications may ease workforce shortages and facilitate integrated care by reducing the need for in-person services (68, 69). Although robust discussion of the many policy issues surrounding expansion of these strategies (70) is outside the scope of this piece, policies supporting scale-up—for example, insurance reimbursement policies for “telemental” health services and evidence-based behavioral health mHealth applications, such as the Food and Drug Administration–approved prescription digital therapeutic reSET (71)—could support integration.

Finally, it is critical to address social factors that underlie and exacerbate poor health outcomes among people with mental illness and substance use disorders. Integrated care models should go beyond the current focus on general medical–behavioral health integration and also consider integration of social services. ACOs and the more recent accountable health community model may serve as avenues for social service integration (72, 73). Societywide policies strengthening the social safety net are needed, as are policies targeting people with behavioral health conditions specifically, such as state laws allocating resources to evidence-based supportive housing and employment programs (74, 75) or insurance reimbursement mechanisms to pay for these services.