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Behavioral health's future includes integration challenges

November 4, 2015
by Julie Miller, Editor in Chief
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Planning for the future is no small task. Behavioral health executives are chipping away at long-term visions, such as integration, operationalization and new technology application. Individual organizations are seeking to build out not just limited projects but foundational infrastructure across their enterprises in the next three to five years.



One of the larger infrastructure goals for behavioral health delivery is the advancement of integration. Many believe the best way to provide comprehensive care to consumers is to seamlessly mesh mental health and addiction medicine with medical specialties, particularly primary care. However, in real-world practice, implementation is wrought with logistical and philosophical barriers.

Even though most stakeholders know what the future should look like, the adoption of the integrated model is currently quite rare, according to C. Scott McMillin, consultant and principal with Recovery SI.

“It really is a vast challenge,” McMillin says. “We talk about integration, but it’s so far into the future, it’s almost an impossible dream. You find isolated examples of real integrated care, but you drive 50 miles in any one direction, and you see the complete absence of that.”

Too often, the best a primary care patient with behavioral needs can often hope for is a handout from a family doctor that lists phone numbers for local addiction and mental health providers. McMillin envisions a “no wrong door” approach in the future, in which those seeking health services can receive comprehensive care regardless of the access point.

For example, there is a growing number of federally qualified health centers (FQHCs) that have achieved degrees of integration, often in the form of two providers co-located or in close proximity that mutually can offer warm handoffs. In some cases, local providers count on grant money to drive integration, but efforts risk fading away when the funding dries up, McMillin says.

SAMHSA has allocated various grants for a variety of projects, including technology integration and co-location of service providers. For example, the administration offers grants to establish projects to coordinate services with primary and specialty care providers in community-based behavioral health settings.  The Primary and Behavioral Health Care Integration  grant program also offers tools for provider communities to help them figure out how to implement the integration vision on the ground.

Robert Wergin, a family physician in Milford, Neb., and board chair of the American Academy of Family Physicians (AAFP), says integration is indeed happening—right now. Primary care providers want to include the behavioral element of care because they’re driving toward the medical home model that offers them financial rewards for comprehensive care. Such care is incomplete without addressing behavioral health.

“Integrated behavioral health is the thing of the future, and as we move to value-based payment, I think it’s going to be accelerated,” Wergin says. “But it’s already happening now.”

For most treatment centers,  a co-location arrangement isn’t possible. In that case, the way to foster integration is to grow a patient-centered medical community, he says.

AAFP created its “Joint Principles” of behavioral health integration last year which include recommendations for co-location or patient-centered medical communities as an alternative. The principles also recognize that behavioral health providers should be paid as valuable members of the medical home and the comprehensive care team.

Likewise, the advent of accountable care organizations (ACOs) with their neighborhoods of cooperating, risk-sharing provider networks could signal an opportunity for behavioral health to integrate with comprehensive health systems. At the moment ACOs, whether driven by Medicare or commercial payers, are still getting their footing. Behavioral health components could be a later iteration for many communities.

“I have been in this field since 1970, and I see many efforts take hold and be abandoned,” McMillin says. “I’ll watch ACOs just like the rest of the country to see what kind of programs will be sustained—not just initiated or advanced, but sustained.”

He recommends that behavioral health providers start by breaking down the silos that separate them from other providers in their communities and begin a conversation—something they haven’t done often enough.



As private equity drives ready cash into the behavioral segment, more providers will have the opportunity to grow from single-site, mission-driven treatment centers to larger, structured enterprises with streamlined care delivery and centralized back-office operations. Frequently thought of as a cottage industry, behavioral health will see operationalization as well as consolidation in the next three to five years.

Kevin Ryan, member of the firm Epstein Becker Green, says more providers are operationalizing and seeking novel approaches that diverge from the older industry models as they position themselves for the future.

“There will be far more consolidation or affiliation between behavioral health providers,” Ryan says. “The single or two-person behavioral health practice will not disappear, but you’ll see some big changes and more affiliations. Whether it’s through management service organizations or independent practice associations, you’ll see more people practice as part of one program or a united program for contracting with third-party payers.”

The traditional grant-based models will endure, of course, as will the self-pay models.

“You’ll also see a lot of behavioral health providers take insurance that they previously had not participated in,” he says.