Many of us are aware that patients with both medical and behavioral health issues experience poorer outcomes and higher health care costs than those with a chronic medical condition alone. Patients with both a chronic medical condition and a behavioral health condition such as major depression have poorer outcomes and increased functional disability, health care utilization, and work absence, when compared with patients with a chronic illness without an accompanying behavioral health diagnosis. This is in large part due to fragmented care provided by different providers who do not communicate, share information, or collaborate to create a shared treatment plan.
Integrating behavioral health and primary care can combat fragmentation and address these burdensome and costly comorbidities. The idea of integration is really that of good health care, which leads to the Triple Aim through:
Better care with a team-based, collaborative approach;
Better health by improving the treatment and management of both chronic medical and behavioral health conditions; and
Lower per capita costs through decreasing unnecessary service utilization of high-cost specialty care and emergency department services.
While the benefits of integration are well known, this model of care has not taken root as much as we would expect. This is due to a number of challenges — clinical (e.g., restructuring care delivery), operational (e.g., issues around sharing protected health information), and financial (e.g., lack of reimbursement for integrated services in a fee-for-service environment) — as well as a lack of incentives to change the status quo. While changes in the US health care system are quickly creating a more favorable environment for systems and providers to integrate primary care and behavioral health there is still much work to do.
Valerie Lewis and colleagues highlighted this in an October 2014 Health Affairs article that examined the implementation of behavioral health integration by accountable care organizations (ACOs). Surprisingly, even though many ACOs are financially responsible for patients’ often costly behavioral health comorbidities, the authors found that only 14 percent of ACOs surveyed have fully integrated their primary care and behavioral health services. The other 86 percent need to get on board or their cost, patient experience, and medical and behavioral health outcomes metrics will suffer the consequences.
There is no better time to get started on integrating behavioral health: as health systems acquire primary care practices and hospitals, take capitated funds, and look at building a practice environment that is desirable to consumers, integrated medical and behavioral health care will become increasingly appealing. Payment reform will reward coordination of care and penalize poor outcomes, and Medicaid expansion means an influx of millions of newly insured patients with a disproportionate burden of comorbid physical and behavioral health conditions. Continuing to manage primary care and behavioral health separately, especially with limited primary care and behavioral health providers, is simply not a viable long-term strategy.
While many organizations are considering moving toward integrated behavioral health care, we still have a long way to go before integration is the standard of care in the US. Though integrating behavioral health and primary care is a significant challenge, it is a challenge that yields great rewards for patients, providers, and organizations.
In a new Collaborative, Optimize Primary Care Teams to Meet Patients' Medical AND Behavioral Needs, IHI is convening some of the leading thinkers and innovators in primary care transformation and behavioral health integration to help organizations more fully address the medical and behavioral needs of their population in primary care. We see this as a key area for improvement, as systems transform in pursuit of population health and the Triple Aim. Will you join us?
Mara Laderman, MSPH, IHI Senior Research Associate, leads IHI’s work in behavioral health.
See our Behavioral Health topic page on IHI.org for additional resources.