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Will 'integration' include CMHCs?

June 1, 2008
by Douglas J. Edwards, Editor-in-Chief
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Integrating behavioral healthcare with primary care sounds great. After all, mental health and substance use problems affect the entire body. Integrated care promotes a whole health approach and hopefully would reduce the stigma surrounding behavioral health disorders.

Yet there is another side to integration that some are very concerned about: what it could mean for behavioral healthcare provider organizations.

On the public side, community mental health centers (CMHCs) have several disadvantages if the push toward integrated care accelerates or intensifies, as the natural “medical home” would be community health centers. CHCs have simpler and more robust funding streams, and they are not associated with the stigma of behavioral health disorders (I suspect the “not in my backyard” mentality is not as great of a problem for them). I have heard that some states are considering dismantling their CMHC networks for some of these reasons.

States would be wise, though, to not assume that CHCs could absorb behavioral healthcare services easily. To start with, patients without behavioral healthcare diagnoses may not be comfortable sharing a waiting room with people who have severe psychiatric and substance use problems. That's the reality of stigma. In addition, CMHCs have long institutional histories of treating these populations that cannot be replaced by just shifting around where clinicians work. CMHCs also have developed nuanced networks of community supports (e.g., schools, homeless shelters, child welfare and family service providers, long-term care providers, and so on) that cannot be easily replaced or assumed.

I asked several members of Behavioral Healthcare's Editorial Board if an “integrated” future is bleak for CMHCs, and their opinions were mixed. Some said it's even worse than I had assumed, but others don't see it as so dire. One noted that if national healthcare reform gains traction, CMHCs should highlight their role as centers of excellence for mental health and substance use care. Another noted that the National Council for Community Behavioral Healthcare already has an initiative under way to incorporate primary care into specialty settings. One board member reminded me that there is no single model of integration and that we should advocate for a flexible system that doesn't reinvent the wheel, but rather builds upon existing infrastructure. He pointed out that perhaps we should let those who really matter—consumers—decide by giving them the purchasing power to spend their healthcare dollars where they want.

Everyone agrees that integrated care is best, and I know you are dedicated to ensuring that your organizations remain strong contributors to healthcare in your communities. CMHCs probably will not vanish, but they may need to reinvent themselves. One example is the merger of three community behavioral healthcare organizations to create the nation's largest such provider, detailed in this month's cover story. Centerstone, named after the merger's largest partner, sees its size as an advantage, and its executives are encouraging other provider organizations to pursue their own mergers. I suppose that if you don't want to be the underdog, you need to have a larger bark—and bite.

Let me know what you think the field needs to do to make sure CMHCs play a vital role in an integrated future. I will keep my eye on this issue, and let me know what's going on in your state.

Douglas J. Edwards, Editor-in-Chief