Care Integration in the Patient Protection and Affordable Care Act: Implications for Behavioral Health

  • Bevin CroftEmail author
  • Susan L. Parish
Original Report


Individuals with co-occurring serious mental illness and substance use disorders experience a highly fragmented system of care, contributing to poor health outcomes and elevated levels of unmet treatment needs. Several elements in the health care reform law may address these issues by enhancing the integration of physical and behavioral health care systems. The purpose of this paper is to analyze these elements, which fall into three domains: increasing access, restructuring financing and reimbursement mechanisms, and enhancing infrastructure. We conclude with a consideration of the implementation challenges that lie ahead.


Integration Co-occurring disorders Behavioral health services 



Partial support for the preparation of this manuscript was provided by an NIAAA doctoral training fellowship to the first author, grant number 5T32AA007567-17.


  1. Alexopoulos, G. S., Reynolds, C. F, I. I. I., Bruce, M. L., Katz, I. R., Raue, P. J., Mulsant, B. H., et al. (2009). Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the prospect study. American Journal of Psychiatry, 166(8), 882–890.PubMedCrossRefGoogle Scholar
  2. Blank, M., Mandell, D., Aiken, L., & Hadley, T. (2002). Co-occurrence of HIV and serious mental illness among Medicaid recipients. Psychiatric Services, 53(7), 868–873.PubMedCrossRefGoogle Scholar
  3. Buck, J. A. (2011). The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Affairs, 30(8), 1402–1410.PubMedCrossRefGoogle Scholar
  4. Cook, J. A., Razzano, L. A., Burke-Miller, J. K., Blyler, C. R., Leff, H. S., Mueser, K. T., et al. (2007). Effects of co-occurring disorders on employment outcomes in a multisite randomized study of supported employment for people with severe mental illness. Journal of Rehabilitation Research and Development, 44(6), 837–850.PubMedCrossRefGoogle Scholar
  5. Dausey, D., & Desai, R. (2003). Psychiatric comorbidity and the prevalence of HIV infection in a sample of patients in treatment for substance abuse. The Journal of Nervous and Mental Disease, 191(1), 10–17.PubMedCrossRefGoogle Scholar
  6. DeJong, G., Palsbo, S. E., & Beatty, P. W. (2002). The organization and financing of health services for persons with disabilities. Milbank Quarterly, 80(2), 261–301.PubMedCrossRefGoogle Scholar
  7. Dickey, B., Normand, S.-L., Weiss, R., Drake, R., & Azeni, H. (2002). Medical morbidity, mental illness, and substance use disorders. Psychiatric Services, 53(7), 861–867.PubMedCrossRefGoogle Scholar
  8. Donohue, J. M., Huskamp, H. A., & Zuvekas, S. H. (2009). Dual eligibles with mental disorders and Medicare part D: how are they faring? Health Affairs, 28(3), 746–759.PubMedCrossRefGoogle Scholar
  9. Druss, B. G., & Mauer, B. J. (2010). Health care reform and care at the behavioral health-primary care interface. Psychiatric Services, 61(11), 1087–1092.PubMedCrossRefGoogle Scholar
  10. Druss, B. G., Rohrbaugh, R. M., Levinson, C. M., & Rosenheck, R. A. (2001). Integrated medical care for patients with serious psychiatric illness: a randomized trial. Archives of General Psychiatry, 58(9), 861–868.PubMedCrossRefGoogle Scholar
  11. Druss, B. G., von Esenwein, S. A., Compton, M. T., Rask, K. J., Zhao, L., & Parker, R. M. (2010). A randomized trial of medical care management for community mental health settings: the primary care access, referral, and evaluation (PCARE) study. American Journal of Psychiatry, 167(2), 151–159.PubMedCrossRefGoogle Scholar
  12. Epstein, R. M., Fiscella, K., Lesser, C. S., et al. (2010). Why the nation needs a policy push on patient-centered health care. Health Affairs, 29(8), 1489–1495.PubMedCrossRefGoogle Scholar
  13. Federal Coordinated Health Care Office (2010) 75 Federal Register 82405.Google Scholar
  14. Fields, D., Leshen, E., & Patel, K. (2010). Analysis and commentary: driving quality gains and cost savings through adoption of medical homes. Health Affairs, 29(5), 819–826.PubMedCrossRefGoogle Scholar
  15. Garfield, R. L., Lave, J. R., & Donohue, J. M. (2010). Health reform and the scope of benefits for mental health and substance use disorder services. Psychiatric Services, 61(11), 1081–1086.PubMedCrossRefGoogle Scholar
  16. Harris, K. M., & Edlund, M. J. (2005). Use of mental health care and substance abuse treatment among adults with co-occurring disorders. Psychiatric Services, 56(8), 954–959.PubMedCrossRefGoogle Scholar
  17. Horvitz-Lennon, M., Kilbourne, A. M., & Pincus, H. A. (2006). From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Affairs, 25(3), 659–669.PubMedCrossRefGoogle Scholar
  18. Institute of Medicine. (1993). Access to health care in america. Washington, DC: National Academies Press.Google Scholar
  19. Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use conditions. Washington, DC: National Academies Press.Google Scholar
  20. Kaiser Family Foundation. (2010). Summary of new health reform law. Menlo Park: Henry J. Kaiser Family Foundation.Google Scholar
  21. Kessler, R., Stafford, D., & Messier, R. (2009). The problem of integrating behavioral health in the medical home and the questions it leads to. Journal of Clinical Psychology in Medical Settings, 16(1), 4–12.PubMedCrossRefGoogle Scholar
  22. Lord, O., Malone, D., & Mitchell, A. J. (2010). Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis. General Hospital Psychiatry, 32(5), 519–543.PubMedCrossRefGoogle Scholar
  23. Manderscheid, R. (2010). Assuring the social safety net for the newly insured under national health reform. Washington, DC: National Association of County Behavioral Health and Developmental Disability Directors.Google Scholar
  24. New Freedom Commission on Mental Health. (2003). Achieving the promise: transforming mental health care in America. Final report. DHHS Pub. No. SMA-03-3832. Rockville, MD: U.S. Department of Health and Human Services.Google Scholar
  25. Nutting, P., Miller, W., Crabtree, B., Jaen, C., Stewart, E., & Stange, K. (2009). Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Annals of Family Medicine, 7(3), 254–260.PubMedCrossRefGoogle Scholar
  26. O’Toole, T., Pollini, R., Gray, P., Jones, T., Bigelow, G., & Ford, D. (2007). Factors identifying high-frequency and low-frequency health service utilization among substance-using adults. Journal of Substance Abuse Treatment, 33(1), 51–59.PubMedCrossRefGoogle Scholar
  27. Peek, C. (2009). Integrating care for persons, not only diseases. Journal of Clinical Psychology in Medical Settings, 16(1), 13–20.PubMedCrossRefGoogle Scholar
  28. Pincus, H. A., Page, A. E., Druss, B., Appelbaum, P. S., Gottlieb, G., & England, M. J. (2007). Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions. American Journal of Psychiatry, 164(5), 712–719.PubMedCrossRefGoogle Scholar
  29. Shortell, S., Casalino, L., & Fisher, E. (2010). How the centers for medicare and medicaid innovation should test accountable care organizations. Health Affairs, 29(7), 1293–1298.PubMedCrossRefGoogle Scholar
  30. Substance Abuse and Mental Health Services Administration. (2008). Compendium of primary care and mental health integration activities across various participating federal agencies. Rockville, MD.Google Scholar
  31. Swarbrick, M., Murphy, A., Zechner, M., et al. (2011). Wellness coaching: A new role for peers. Psychiatric Rehabilitation Journal, 34(4), 328–331.PubMedCrossRefGoogle Scholar
  32. Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W, Jr, Hunkeler, E., Harpole, L., et al. (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA: the journal of the American Medical Association, 288(22), 2836–2845.CrossRefGoogle Scholar
  33. U.S. Department of Health and Human Services. (1999). Mental health: a report of the surgeon general. Rockville: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Institute for Behavioral Health, Heller School for Social Policy and ManagementBrandeis UniversityWalthamUSA
  2. 2.Lurie Institute for Disability Policy, Heller School for Social Policy and ManagementBrandeis UniversityWalthamUSA

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