Integrating Behavioral Health Services into Medical Practices Faces Culture and Financial Barriers

For Release

June 2, 2020

Integrating behavioral health services into physician medical practices raises cultural and financial barriers, but providing technical support and improved payment models may enhance the long-term sustainability of the approach, according to a new RAND Corporation study conducted in collaboration with the American Medical Association.

Examining a diverse group of 30 physician practices that have pursued behavioral health integration, researchers found that there were many reasons that practices incorporated mental health services, including wanting to improve quality by expanding access to behavioral health services.

But even within the study's sample of practices that had successfully adopted behavioral health integration, financial sustainability was a pervasive concern, regardless of the payment models used by the practices. The findings are published online by the Annals of Internal Medicine.

“We found that behavioral health integration is possible in a wide variety of medical practices, not just in primary care,” said Dr. Peggy G. Chen, coauthor of the study and a physician researcher at RAND, a nonprofit research organization. “The key factor in the success of behavioral health integration was adaptation to each practice's needs and resources.”

“The COVID-19 pandemic has exposed and magnified the flaws in our mental health system and the true burden of mental illness in our country,” said Dr. Patrice A. Harris, president of the American Medical Association. “Behavioral health care integration can help save lives and is a proven model that has many advantages over a more divided one. The AMA is committed to establishing a viable pathway for combining physical and behavioral health care to make a real impact in our nation's growing mental health crisis.”

One in 5 adults in the U.S. has a clinically significant mental health or substance use disorder, yet many people do not receive treatment for their problems because of a shortage of mental health providers and lack of access to mental health services. One potential solution to the low levels of mental health treatment is integrating behavioral health into medical care.

Most approaches to behavioral health integration fall into two general archetypes: a co-located model where onsite behavioral health clinicians provide enhanced access within physician practices or an offsite model where behavioral health clinicians (usually psychiatrists) supervise onsite care managers who help nonbehavioral health clinicians meet their patients' behavioral health needs.

To explore the experiences of successful behavioral health integration, researchers interviewed leaders and clinicians from 30 physician practices in different parts of the country and from different medical specialties that have implemented behavioral health integration.

They also consulted with experts in clinical care, research and health policy related to behavioral health integration and vendors that provide behavioral telehealth services or technical integration assistance to physician practices.

Physician practice leaders reported positive effects of behavioral health integration on their practices, such as creating an increased sense of providing high-quality patient care and meeting more of their patients' needs.

Barriers to behavioral health integration, they said, included cultural differences with mental health providers and impediments to the flow of information between medical and behavioral health providers.

Researchers say that efforts to improve interprofessional training and collaboration may help address cultural barriers and facilitate patient care that addresses both medical and behavioral health needs. In addition, enhancements to electronic health records and clarification of privacy regulations may improve communication between behavioral and nonbehavioral health clinicians.

Although prior research has demonstrated a favorable return on investment for behavioral health integration, medical practices in the new study reported difficulty in estimating the specific effects of behavioral health integration on total medical expenses.

“Despite research evidence demonstrating the effectiveness of behavioral health integration, cultural, informational, and financial challenges remain,” Chen said. “Tailored, context-specific technical support to guide practices' efforts and payment models that improve the business case for those efforts may enhance the long-term sustainability of behavioral health integration.”

Support for the study was provided by the American Medical Association and The Commonwealth Fund.

Other authors of the study are Angèle Malâtre-Lansac, Dr. Charles Engel and Lea Xenakis, all of RAND, Lindsey Carlasare, Dr. Kathleen Blake, Carol Vargo and Christopher Botts, all of the American Medical Association, and Dr. Mark W. Friedberg of the Harvard Medical School.

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