Skip to main content

Behavioral health integration: an essential element of population-based healthcare redesign

ABSTRACT

The fundamental aim of healthcare reform is twofold: to provide health insurance coverage for most of the citizens currently uninsured, thereby granting them access to healthcare; and to redesign the overall healthcare system to provide better care and achieve the triple aim (better health for the population, better healthcare for individuals, and at less cost). The foundation for this improved system will rest on a redesigned (i.e., sufficiently comprehensive and integrated) system of primary care, with which all other providers, services, and sites of care are associated. The Patient-Centered Medical Home (PCMH) and its congeners are the best current examples of the kind of primary care that can achieve the triple aim, if they can become sufficiently comprehensive and can adequately integrate services. This means fully integrating behavioral healthcare into the PCMH, a difficult task under the most favorable circumstances. Creating functioning accountable care organizations is an even more daunting task: this requires new principles of collaborating and financing and the current prototypes have generally failed to incorporate behavioral healthcare sufficient to meet even the basic needs of the target population. This paper will discuss (1) the case for and the difficulties associated with integrating behavioral healthcare into primary care at three levels: the practice, the state, and the nation; and (2) how this looks clinically, operationally, and financially.

This is a preview of subscription content, access via your institution.

References

  1. Marrs Maddocks & Associates. Patient Protection and Affordable Care Act (PPACA). 2010; http://ppaca.com/, 2012.

  2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press;2001.

  3. DeVoe JE, Dodoo MS, Phillips RL Jr, Green LA. Who will have health insurance in the year 2025? American Family Physician. 2005;72(10):1989.

    Google Scholar 

  4. Organisation for Economic Co-operation and Development. Health Care Spending in the United States and Selected OECD Countries. April 2011 2011.

  5. Nolte E, McKee, M. Measuring the health of nations: analysis of mortality amenable to health care. BMJ. 2003;327(7424).

  6. Thorpe K, Howard, DH, Galactionova, K. Differences in disease prevalence as a source of the U.S.–European health care spending gap. Health Affairs Web Exclusive October 2, 2007.

  7. deGruy F. Mental health care in the primary care setting. In: Donaldson MS, Yordy KD, Lohr KN, Vanselow NA (Eds.) Primary care: America's health in a new era. Washington, D.C.: Institute of Medicine; 1996.

  8. Butler M, Kane RL, McAlpin D, et al. Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared by the Minnesota Evidence-Based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 09-E003. Rockville, MD: Agency for Healthcare Research and Quality; October 2008 2008.

  9. Lurie IZ, Manheim LM, Dunlop DD. Differences in medical care expenditures for adults with depression compared to adults with major chronic conditions. The Journal of Mental Health Policy and Economics. 2009;12(2):87-95.

    PubMed  Google Scholar 

  10. Stoner SC, Marken PA, Sommi RW. Psychiatric comorbidity and mental illness. Medical Update for Psychiatrists. 1998;3(3):64-70.

    Article  Google Scholar 

  11. Collins C, Hewson DL, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care 2010.

  12. National Institute of Mental Health. The numbers count: mental disorders in America. 2008.

  13. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. American Journal of Medicine. 1989;86:262-266.

    PubMed  Article  CAS  Google Scholar 

  14. Flottemesch T SS, O’Connor PJ, Solberg L, Asche S, Pawlson LG. 2010. Under review. Are characteristics of the medical home associated with diabetes care costs?

  15. Robinson PJ, Reiter JT. Behavioral consultation and primary care: a guide to integrating services. New York: Springer; 2007.

    Google Scholar 

  16. Owens P, Mutter, R.L., & Stocks, C. Mental health and substance abuse-related emergency department visits among adults, 2007. 2010. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf]

  17. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry. 2005;62(6):593-602.

    PubMed  Article  Google Scholar 

  18. Trask PC, Schwartz SM, Deaner SL, et al. Behavioral medicine: the challenge of integrating psychological and behavioral approaches into primary care. Effective Clinical Practice. 2002;5:75-83.

    PubMed  Google Scholar 

  19. Evans DL, Charney DS, Lewis L, Golden RN, Gorman JM, Ranga Rama Krishnan K, Nemeroff CB, Bremner JD, Carney RM, Coyne JC, Delong MR, Frasure-Smith N, Glassman AH, Gold PW, Grant I, Gwyther L, Ironson G, Johnson RR, Kanner AM, Katon WJ, Kaufmann PG, Keefe FJ, Ketter T, Laughren TP, Leserman J, Lyketsos CG, McDonald WM, McEwen BS, Miller AH, Musselman D, O’Connor C, Petitto JM, Pollock BG, Robinson RG, Roose SP, Rowland J, Sheline Y, Sheps DS, Simon G, Spiegel D, Stunkard A, Sunderland T, Tibbits P, Valvo WJ. Mood disorders in the medically ill: scientific review and recommendations. Biological Psychiatry. 2005;58:175-189.

    PubMed  Article  Google Scholar 

  20. Daniel J, Honey, W., Landen, M., Marshall-Williams, S., Chapman, D., Lando, J. Mental health in the United States: health risk behaviors and conditions among persons with depression—New Mexico, 2003. Morbidity and Mortality Weekly Report. 2005;39:989-991.

  21. Allison TG, Williams DE, Miller TD. Medical and economic costs of psychological distress in patients with coronary artery disease. Mayo Clinic Proceedings. 1995;70:734-742.

    PubMed  Article  CAS  Google Scholar 

  22. Compas BE, Haaga DAF, Keefe FJ, Leitenberg H, Williams DA. Sampling of empirically supported psychological treatments for health psychology: smoking, chronic pain, cancer, and bulimia nervosa. Journal of Consulting and Clinical Psychology. 1998;66:89-112.

    PubMed  Article  CAS  Google Scholar 

  23. Spiegel D, Bloom JR, Yalom I. Group support for patients with metastatic cancer: a randomized prospective outcome study. Archives of General Psychiatry. 1981;38:527-533.

    PubMed  Article  CAS  Google Scholar 

  24. Spiegel D, Bloom JR, Kramer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet. 1989;2:888-890.

    PubMed  Article  CAS  Google Scholar 

  25. Fawzy FI, Fawzy NW, Hyun CS. Effects of an early structured psychiatric intervention, coping and affective state on recurrance and survival 6 years later. Archives of General Psychiatry. 1993;50:681-689.

    PubMed  Article  CAS  Google Scholar 

  26. Anderson BL. Psychological interventions for cancer patients to enhance quality of life. Journal of Consulting and Clinical Psychology. 1992;60:552-568.

    Article  Google Scholar 

  27. Spiegel D, Sephton SE, Stites DP. Effects of psychosocial treatment in prolonging cancer survival may be mediated by neuroimmune pathways. Annals of the New York Academy of Sciences. 1998;840:674-683.

    PubMed  Article  CAS  Google Scholar 

  28. Richardson JL, Shelton DR, Krailo M, Levine AM. The effects of compliance with treatment on survival among patients with hematologic malignancies. Journal of Clinical Oncology. 1990;8:356-364.

    PubMed  CAS  Google Scholar 

  29. Hermann C, Brand-Driehorst S, Kaminsky B. Diagnostic groups and depressed mood as predictors of 22-month mortality in medical inpatients. Psychosomatic Medicine. 1999;60:570-577.

    Google Scholar 

  30. Ries DK. ACO mission: behavioral healthcare under the Medicare Shared Savings Program. June 2011 ACO Special Edition 2011. Accessed October, 23, 2011.

  31. Fields D, Leshen E, Patel K. Driving quality gains and cost savings through adoption of medical homes. Health Affairs. 2010;29(5):819-826.

    PubMed  Article  Google Scholar 

  32. Reid RFP, Yu O, Ross T, Tufano JT. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. The American Journal of Managed Care. 2009;15(9):71-87.

    Google Scholar 

  33. Patient Centered Primary Care Collaborative. PCMH—Evidence of Quality. 2011; http://www.pcpcc.net/content/pcmh-outcome-evidence-quality. Accessed October, 24, 2011.

  34. Miller BF, Kessler R, Peek CJ, Kallenberg GA. A national research agenda for research in collaborative care: papers from the Collaborative Care Research Network Research Development Conference. AHRQ Publication No. 11-0067. 2011. http://www.ahrq.gov/research/collaborativecare/

  35. Miller BF, Mendenhall TJ, Malik AD. Integrated primary care: an inclusive three-world view through process metrics and empirical discrimination. Journal of Clinical Psychology in Medical Settings. 2009;16:21-30.

    PubMed  Article  Google Scholar 

  36. “Patient Protection and Affordable Care Act”, 111 H.R. 3590 [including the Medicare Shared Savings Program under Title III—named “Improving the Quality and Efficiency of Health Care”—under the subpart for “Encouraging Development of New Patient Care Models.”].

  37. BlueCross Blue Shield of Minnesota has launched a “shared incentive” payment model with four of Minnesota’s largest care systems—Allina Hospitals & Clinics, Essentia Health, Fairview Health Services, and HealthEast Care System. (See http://www.bcbs.com/news/plans/minnesota-largest-health-plan-signs-new-total-cost-of-care-contracts.html) In San Diego, Anthem Blue Cross is collaborating with Sharp Community Medical Group and Sharp Rees-Stealy Medical Centers on an ACO (see http://www.sharp.com/news/anthem-blue-cross-scmg-srs-collaborate.cfm).

  38. Takach M, Purington, K., Osius, E. A tale of two systems: a look at state efforts to integrate primary care and behavioral health in safety net settings. Portland: National Academy for State Health Policy; 2010.

  39. Bachman J, Pincus HA, Houtsinger JK, Unutzer J. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry. 2006;28(4):278-288.

    PubMed  Article  Google Scholar 

  40. National Association of Public Hospitals and Health Systems. What is a Safety Net Hospital? http://www.literacyworks.org/hls/hls_conf_materials/WhatIsASafetyNetHospital.pdf.

  41. Collaborative PCPC. Payment Reform Task Force Agenda 2011. http://www.pcpcc.net/content/payment-reform-task-force-agenda-1182011-4pm-et.

  42. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease. 2006;3(2):A42.

    PubMed  Google Scholar 

  43. 42 U.S.C. § 256a-1 [Under the PPACA section for “Establishing Community Health Teams to Support the Patient-Centered Medical Home” one requirement of health teams is that they “implement interdisciplinary, interprofessional care plans” § 256a-1(c)(4)] and 42 U.S.C. § 1396w-4 [Under PPACA’s “State Option to Provide Health Homes for Enrollees with Chronic Conditions”, the care team is comprised of “physicians and other professionals, such as a nurse care coordinator, nutritionist, social worker, behavioral health professional, or any professionals deemed appropriate by the State.” § 1396w-4(h)(6).]

  44. 42 U.S.C. § 1899(b)(1)(E).

  45. Proposed rule 42 C.F.R. § 425.4.

  46. Proposed rule 42 C.F.R. § 425.5(d)(15)(ii)(B)(4).

  47. Proposed rule 42 C.F.R. § 425.5(d)(15)(ii)(B)(3).

  48. 29 U.S.C. § 1185a; 29 C.F.R. § 2590.712.

  49. 42 U.S.C. § 13951(c).

  50. States with mental health parity statutes are: Alabama (§ 27-54-4(b)), Alaska (§ 21.54.151), Arizona (§ 20-2322), Arkansas (§§ 23-99-501 to 23-99-12), Connecticut (§ 38a-476a), Georgia (§ 33-29-24.1), Hawaii (§ 431 M-5), Idaho (for state employees at § 67-5761A), Illinois (215 § 5/370c), Indiana (§§ 27-13-7-14.8, 27-8-5-15.6), Kansas (§ 40-2,105a), Minnesota (62Q.47), Missouri (§ 376.811), Montana (§ 33-22-703 ), Nebraska (§ 44-793), New Hampshire (§ 415:18-a), New Mexico (§§ 59A-23E-18), New York (Ins. § 3221(1)(5)(A)), North Carolina (§ 58-3-220), North Dakota (§26.1-36-08), Ohio (§§ 3923:29, 3923:281, 3923:282), Oklahoma (§ 6060.11), Oregon (§ 743A.168), Rhode Island (Ch. 27–38.2), South Carolina (§ 38-71-290), South Dakota (§ 58-17-98), Tennessee (§ 56-7-2360 [mental health], § 56-7-2602 [substance abuse]), Texas (Ins. § 1355), Vermont (8 § 4089b), Virginia (38.2 § 3412.1:01 [mental health only]), and Wisconsin (§ 632.89).

  51. National Advisory Mental Health Council Parity in Financing Mental Health Services (National Institute of Mental Health Archive, 1998) at 54 (listing states that had enacted mental health parity laws by 1997 as: Arizona, Arkansas, Colorado, Connecticut, Indiana, Maine, Maryland, Minnesota, Missouri, New Hampshire, North Carolina, Rhode Island, South Carolina, Texas and Vermont).

  52. Insurance coverage for the treatment of mental illness is required by Alabama (27-54-4(a)), Arkansas (§ 23-86-113), California (Ins. § 10125), Connecticut (§ 38a-488a), Delaware (Ins. § 3578), Florida (§ 627.668), Georgia (§ 33-24-28.1), Hawaii (§ 431 M-4(c)), Illinois (215 § 5/370c), Iowa (§ 514 C.22), Kansas (§ 40-2,105), Louisiana (R.S. 22:1043), Maine (Title 24-A, §§2749, 2843, 4234-A), Massachusetts (Ch. 175, § 47B), Missouri (§§ 376.814, 376.1550), Montana (§ 33-22-703), Nevada (§§ 689A.0455, 689 C.169), New Hampshire (§ 417-E:1), New Jersey (§§ 17:48-6v, 17:48A-7u, 17:48E-35.20, 17B:26-2.1 s, 17B:27-46.1v), North Carolina (§ 58-3-220), Ohio (§ 3923:282), Oklahoma (§ 6060.11), Oregon (§ 743A.168), Rhode Island (Ch. 27-38.2), South Carolina (§ 38-71-290), South Dakota (§ 58-17-98), Tennessee (§ 56-7-2601), Texas (Ins. § 1355), Utah (§ 31A-22-625 [mandating offer of coverage]), Vermont (8 § 4089b), Virginia (38.2 § 3412.1), Washington (§ 48.21.241 [commercial insurance] and § 48.41.220 [coverage by state insurance pool]), West Virginia (§ 33-16-3a) Wisconsin (§ 632.89), and Wyoming (§§ 26-22-102, 26-22-106).

  53. Insurance coverage for the treatment of substance abuse is required by Arkansas (§ 23-79-139), Colorado (§ 10-16-104.7), Delaware (Ins. § 3343(b)), Florida (§ 627.669), Hawaii (§ 431 M-4(b)), Kansas (§ 40-2,105), Louisiana (R.S. 22:1025), Maine (24-A, §2842), Maryland (§ 15-802), Mississippi (§ 83-9-27), Missouri (§ 376.811), Montana (§ 33-22-703), Nevada (§§ 689A.046, 689 C.166), New Jersey (§§ 17:48-6a, 17:48A-7a, 17:48E-34, 17B:26-2.1), New Mexico (§§ 59A-23-6; 59A-47-35), North Dakota (§26.1-36-08), Ohio (§ 3923:29), Oregon (§ 743A.168), Tennessee (§ 56-7-2601), Texas (Ins. § 1368), Utah (§ 31A-22-625 [mandating offer of coverage]), Vermont (8 § 4089b), Virginia (38.2 § 3412.1), and Wisconsin (§ 632.89).

  54. Insurance coverage of autism spectrum disorders is required in California (Health & Safety Code § 1374.72), Connecticut (§ 38a-514b), Illinois (215 ILCS 5/3562.14), Indiana (§ 27-13-7-14.7), Louisiana (§ 22:1050), Nevada (§ 689A.0435), Pennsylvania (40 P.S. § 764 h), South Carolina (§ 38-71-280), Vermont (8 § 4088i), Virginia (38.2 § 3412.1:01), and Wisconsin (§ 632.895(12 m)).

  55. 42 U.S.C. § 18031(j).

  56. 42 U.S.C. § 18022(b)(1)(E).

  57. Affordable Care Act § 1311(j); see also PHS Act § 2726 E, Internal Revenue Code § 9812. See also interim final regulations at 75 FR 5410 (February 2, 2010) and guidance published on June 30, 2010 (http://www.dol.gov/ebsa/faqs/faq-mhpaea.html), December 22, 2010 (http://www.dol.gov/ebsa/faqs/faq-aca5.html), and November 17, 2011 (http://www.dol.gov/ebsa/faqs/faq-aca7.html).

  58. Department of Health and Human Services. Essential Health Benefits Bulletin. In: Oversight CfCIaI, ed2011:13.

  59. National Committee for Quality Assurance. Patient-Centered Medical Home. 2011; http://www.ncqa.org/tabid/631/default.aspx. Accessed April, 14, 2011.

  60. Blount A, Kathol R, Thomas M, et al. The economics of behavioral health services in medical settings: a summary of the evidence. Professional Psychology: Research and Practice. 2007;38:290-297.

    Article  Google Scholar 

  61. Kautz C, Mauch D, Smith SA. Reimbursement of mental health services in primary care settings. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration;2008. HHS Pub. No. SMA-08-4324.

  62. Kessler R, Stafford D, Messier R. The problem of integrating behavioral health in the medical home and the questions it leads to. Journal of Clinical Psychology in Medical Settings. 2009;16(1):4-12.

    PubMed  Article  Google Scholar 

  63. Peek CJ. Planning care in the clinical, operational, and financial worlds. In: Kessler R, Stafford D, eds. Collaborative Medicine Case Studies: evidence in Practice. New York: Springer; 2008.

    Google Scholar 

  64. Green L, Ottosen, JM. From efficacy to effectiveness to community and back: evidence based practice vs. practice based evidence. Paper presented at the From Clinical Trials to Community: The Science of Translating Diabetes and Obesity Research conference; Jan 12–13, 2004; Bethesda, MD.

  65. Pace WD, Staton EW. Electronic data collection options for practice-based research networks. Annals of Family Medicine. 2005;3(suppl1):s21-s29. doi:10.1370/afm.270.

  66. NCQA. Patient-Centered Medical Home (PCMH) 2011 Draft Standards Overview2010.

  67. Solberg SS LI, Scholle SH, Asche SE, Shih SC, Pawlson LG, Thoele MJ. Practice systems for chronic care: frequency and dependence on an electronic medical record. American Journal of Managed Care. 2005;11(12):789-796.

    Google Scholar 

  68. Solberg LA S, Pawlson LG, Scholle SH, Shih S. Practice systems are associated with high-quality care for diabetes. American Journal of Managed Care. 2008;14(2):85-92.

    Google Scholar 

  69. Smith ML, Glass GV. Meta-analysis of psychotherapy outcome studies. American Psychologist. 1977;32(9):752-760.

    PubMed  Article  CAS  Google Scholar 

  70. Kessler RC, Demler O, Frank RG, et al. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med. June 16, 2005 2005;352(24):2515-2523.

    Google Scholar 

  71. Pincus HA, Tanielian TL, Marcus SC, et al. Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialties. JAMA: The Journal of the American Medical Association. 1998;279(7):526-531.

    Article  CAS  Google Scholar 

  72. Singer S, Shortell SM. Implementing accountable care organizations: ten potential mistakes and how to learn from them. JAMA: The Journal of the American Medical Association. 2011;306(7):758.

    Article  CAS  Google Scholar 

  73. Fisher ES, Shortell SM. Accountable care organizations: accountable for what, to whom, and how. JAMA: The Journal of the American Medical Association. 2010;304(15):1715-1716.

    Article  CAS  Google Scholar 

  74. Cohen JT. A Guide to Accountable Care Organizations, and Their Role in the Senate’s Health Reform Bill. Health Reform Watch: A Web Log of Seton Hall Law School’s Center for Health & Pharmaceutical Law & Policy 2010. http://www.healthreformwatch.com/2010/03/11/a-guide-to-accountable-care-organizations-and-their-role-in-the-senates-health-reform-bill/.

  75. Hong BA, Robiner W. Accountable care organizations and psychology: getting on the invitation list to the party. Clinical Psychologist. 2011;64(3):4-7.

    Google Scholar 

  76. Kathol RG, Butler M, McAlpine DD, Kane RL. Barriers to physical and mental condition integrated service delivery. Psychosomatic Medicine. 2010;72(6):511-518.

    PubMed  Article  Google Scholar 

Download references

Acknowledgment

We would like to thank Larry Green, MD for his contribution and guidance in creating this paper.

Conflicts of interest

The authors have no conflict of interest.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Shandra M Brown Levey PhD.

Additional information

Implications

Policy: Without the inclusion of behavioral health in healthcare reform efforts, comprehensive, whole-person care will be unachievable and make it more difficult to achieve the triple aim.

Research: It is challenging to truly research primary care without also examining the impact of behavioral health conditions and in some cases behavioral health providers.

Practice: Better understanding of the relationship of behavioral health conditions on medical conditions can help achieve comprehensive, whole-person care.

About this article

Cite this article

Levey, S.M.B., Miller, B.F. & deGruy, F.V. Behavioral health integration: an essential element of population-based healthcare redesign. Behav. Med. Pract. Policy Res. 2, 364–371 (2012). https://doi.org/10.1007/s13142-012-0152-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13142-012-0152-5

KEYWORDS

  • Mental health
  • Behavioral health
  • Primary care
  • Integrated care
  • Collaborative care
  • Healthcare policy