For far too long, mental healthcare and treatment for substance abuse weren’t viewed as essential health benefits.
Regarding coverage of behavioral health as optional contributed to misconceptions about disorders and further fueled stigmas about mental health, preventing patients from seeking help for both financial and social reasons.
Recent mandates for coverage of behavioral health, and the manner in which these services are reimbursed, are starting to change that, albeit slowly—leading the way to the integration of behavioral health into primary care.
A NEW PATH
The Mental Health Parity and Addiction Equity Act of 2008 required group health plans and insurers that offered mental-health and substance-abuse benefits to provide coverage comparable to that of general medical and surgical care.
By 2013, almost all large group plans included coverage for some mental-health and substance-abuse services, and the U.S. Department of Health and Human Services estimated that about 95 percent of those with small group market coverage had substance-abuse and mental-health benefits, but the federal parity law did not apply to small group plans. In many states, state parity laws offered those covered in this market some parity protection, but usually less than the federal parity requirement.
About one-third of those covered in the individual market had no coverage for substance-abuse services, and nearly 20 percent had no coverage for mental-health services. Even when individual market plans provided these benefits, the federal parity law did not apply to these plans.
In addition, at that time, 47.5 million Americans lacked health-insurance coverage altogether, and up to 25 percent of uninsured adults were estimated to have a mental-health condition or substance-use disorder, or both.
Enter the Affordable Care Act of 2014, one of the largest expansions of mental-health and substance-abuse coverage in a generation. Beginning in 2014, under the law, all new small group and individual market plans were required to cover 10 “Essential Health Benefit” categories, including mental-health and substance-abuse services, and were required to cover them at parity with medical and surgical benefits.
PAVING THE WAY
In 2017, the Centers for Medicare and Medicaid Services adopted a new coverage policy that is now catalyzing the integration of behavioral health into primary care. It began paying primary-care providers for what it’s calling “Collaborative Care” services that they provide to patients who are being treated for behavioral-health conditions. “Collaborative Care” includes medication as needed, the service of a behavioral healthcare manager, and consultations with mental-health specialists.
This new payment policy for behavioral-health integration immediately impacted primary-care providers who were already offering behavioral healthcare to their patients—and it’s having the tremendous effect of increasing the number of primary-care providers who decide to do so, thereby improving access to care for patients across the country.
It will also likely have the effect of encouraging private insurance companies to offer similar payment options for integrating behavioral healthcare with primary care, since those care models are beginning to become more pervasive and are proving to deliver more effective healthcare.
A STATE DIRECTION
A new law in Washington State, signed by the governor in March 2018, is a major step in transforming behavioral healthcare in that state. It could also serve as a model for others, as it greatly improves access to behavioral health programs by integrating them into other healthcare services by 2020.
Before care was integrated in Washington, Medicaid patients with physical, mental, and substance-use disorders had to navigate multiple systems in order to access the physical and behavioral healthcare they needed. These delivery systems often didn’t communicate or coordinate with one another, which led to lower health outcomes for the state’s Medicaid population.
But Washington is now changing how it pays for the delivery of physical- and mental-health services and substance-use-disorder services in the Medicaid program. According to the Washington State Health Care Authority: “Through this whole-person approach to care, physical and behavioral health needs will be addressed in one system through an integrated network of providers, offering better coordinated care for patients and more seamless access to the services they need.” This will bring together the payment and delivery of physical- and behavioral-health services for people enrolled in Medicaid, through managed care.
Laura Van Tosh is a leader and activist in mental-health peer (or consumer-run) services in Washington. Van Tosh has worked in advocacy and policy development, and has helped develop mental-health peer services in the past. She founded Peer Legislative Advocates of Washington State to engage the patient population in public policy in Washington and locally was the consumer-affairs director for Western State Hospital in Washington, as well as the adult-services coordinator for the Oregon Health Authority Addictions and Mental Health Division of the Department of Health Services for the state of Oregon. She also provided consultation services on many state and national healthcare policy committees, boards, and task forces. She sees integration as a positive development in many ways, but has reservations about the reimbursement model.
“We have to ask why this is ultimately being done,” she says. “Part of the reason is to save money. That’s the bottom line in Washington and nationally.” She has concerns that if the goal becomes more about efficiencies and saving money, patients may not reap the intended benefits. She cautions organizations to keep the goal of patient care at the forefront, and to avoid getting caught up in the expected savings from this model of care. “People who need behavioral healthcare are worth the money being spent,” she says.
Some mental healthcare policy experts agree with Van Tosh’s concern that we could end up spending less on behavioral health than we do now. These experts are concerned that once behavioral-health funding is combined with physical-health funding for an overall capitation rate throughout Washington, it will be much harder, or potentially impossible, to determine what the total Medicaid spend is for behavioral-health services. Nonetheless, some are hopeful that the requirement for a report from the Washington State Health Care Authority to the legislature on how the behavioral-health Medicaid enhancements will be distributed by the managed-care organizations will be a first step toward future oversight by the state on how behavioral-health funding fits into the overall payment received by the managed-care organizations to cover each Medicaid client.
Van Tosh anticipates other challenges to integration. “There needs to be provider education and training, or patients will fall through the cracks and crises will occur,” she says. Primary-care providers are already time-strapped, even without being tasked with identifying behavioral-health issues; Van Tosh believes primary-care providers could benefit from guidance and best practices on working closely with mental-health patients. (See the related article, “Critical Coursework.”)
Additionally, there may be cultural differences to address between behavioral-health and primary-care professionals. “There’s been a comfort level in keeping these silos separate in the past,” Van Tosh says, emphasizing that there may be a learning curve as these two disciplines begin to work together.
Reimbursement is at the heart of what kept behavioral health and primary care separate to begin with. The health system has traditionally reimbursed behavioral-health services separately and at a lower rate, which perpetuated the notion that mind and body should be treated separately in a medical sense, too.
“The whole mind-body understanding is the source of the disconnect,” Van Tosh says. “For some reason, people think they’re two separate things. Maybe it’s because you can’t see psychosis, like you can a broken arm, and treatment for behavioral healthcare affects everyone differently, unlike a simple cast for a broken arm.”
Aside from growing scientific evidence that physical and mental health are interrelated and should be treated in conjunction with one another, integration has also been shown to help patients seek comprehensive care in a practical sense.
One reason integration is so successful is that primary-care offices are a great place to address behavioral health, since patients are comfortable receiving those services there. This may involve receiving care on-site, in real time; or, for more complex cases, making referrals to providers who are known partners within the extended team. This practice is in contrast to the usual reliance on referrals to unaffiliated behavioral-health providers, which can lead to poor follow-up and communication and coordination breakdowns; it can also be disruptive and difficult for patients to get to a secondary appointment and location.
Then there’s the stigma associated with seeing a behavioral-health specialist at a separate location that specializes in that treatment—a factor that’s eliminated when it’s integrated into the primary-care clinic. The familiarity of the context normalizes these services by offering them alongside other primary-care services that carry no stigma. In smaller rural areas, where communities are tight-knit, this can be a game-changer, as patients receiving treatment in an integrated-care setting may not have to worry as much about privacy.
Even with all the progress toward integration, only about one in eight Americans who need substance-use treatment gets it, and less than half of Americans who need mental-health treatment get it, according to the Substance Abuse and Mental Health Services Administration. Clearly, much more action is needed. Still, these developments have pushed coverage for behavioral health in from the periphery—making the integration of behavioral health with primary care possible, and thereby starting to eliminate obstacles to efficient treatment, coordination of care, and management of resources.