Physical Health / Behavioral Health

Primary care doctors draw the connection, but can they address it in their practices?

Mind or body. Traditionally, if primary care physicians had to focus on one or the other when diagnosing and

treating a patient, they’d go for “body.” But that may be changing.

In 2020, the American Medical Association and seven other physician organizations, including the American Academy of Pediatrics, American College of Obstetrics and Gynecology, and the American Academy of Family Physicians – joined forces to form the Behavioral Health Integration (BHI) Collaborative. Its mission is to enable physicians to sustain a “holistic and equitable approach to physical and behavioral healthcare in their practices.”

The need to gather and act on “biopsychosocial” data has been recognized in the medical community for years. In 1996, for example, an Institute of Medicine report on primary care cautioned that mental health and primary care are inseparable, and that avoiding one or the other usually leads to inferior care. And in 2011, the Robert Wood Johnson Foundation noted that “having a mental disorder is a risk factor for developing a chronic condition, and having a chronic condition is a risk factor for developing a mental disorder. When mental and medical conditions co-occur, the combination is associated with elevated symptom burden, functional impairment, decreased length and quality of life, and increased healthcare costs.” As many as 40% of all patients seen in primary care settings have a mental illness, and given that mental and physical health problems are often interwoven, as many as 70% of primary care visits stem from psychosocial issues, concludes the National Center of Excellence for Integrated Health Solutions. While patients may initially present with a physical health complaint, data suggests that underlying behavioral health issues often trigger these visits. And in a study in the June 2020 issue of the Annals of Internal Medicine, researchers said that 68% of persons with a mental health problem also have medical conditions, and persons with chronic illness are twice as likely to have mental illness.

Despite all these statistics, integrating behavioral and physical health is still uncommon among U.S. physician practices, the researchers said. And the reasons are no surprise. “Philosophically, behavioral health integration is not meant to succeed in fee-for-service,” noted one primary care practice leader cited in the study. “The traditional [financial accounting] measures don’t apply.”

For four years, the Centers for Medicare & Medicaid Services has made separate payments to physicians and non-physician practitioners for BHI services. As of

January 1, 2018, these services were to be reported using new CPT codes. Although the agency has not taken any significant additional steps to explicitly incentivize behavioral health integration (BHI), many of its population-health or value-based care efforts indirectly work to incorporate and encourage such efforts, says Patrice A. Harris, M.D., AMA immediate past president and an Atlanta-based psychiatrist. That said, “utilization of the medical reporting codes for BHI is significantly less than the unmet need for behavioral healthcare services,” she adds.

What it looks like

Most approaches to behavioral health integration fall on a continuum between two “archetypes,” according to the Annals researchers. On one end is a “co-located model,” in which behavioral health clinicians are onsite with primary care physicians. On the other is a “collaborative care model,” in which offsite behavioral health clinicians (usually psychiatrists) supervise onsite care managers who help primary care providers meet patients’ behavioral health needs.

“An integrated approach to delivering behavioral health care is not a one-size-fits-all solution,” says Harris. “A consistent feature of practices that have adopted BHI is that medical and behavioral health clinicians work together as a team to identify and address the individual patient’s behavioral and medical health concerns. By comparison, practices without BHI may be unable to offer as many options or respond as quickly when new behavioral health needs are identified, and access to treatment may be limited due to significant wait times. Once an integrated approach is in place, it can be activated when and for people who need it, and it does not have to be established anew for each and every patient.

“With BHI, primary care practices frequently maintain contact with the patient and provide brief interventions – if deemed appropriate – while facilitating a handoff to a behavioral health clinician when warranted,” she says. Additionally, integration makes diagnosis and medication management much easier, since the primary care physician can consult with a behavioral health specialist about complex patients, such as someone who is not responding to therapy.

Behavioral care manager

In an integrated model, a “behavioral healthcare manager” coordinates the care of the patient and ensures effective communication among team members, says Harris. The manager – who frequently has a master’s level education or specialized training in nursing, psychology or counseling – ensures implementation of treatment plans, provides brief psychotherapy consistent with their training and licensure, supports medication management, alerts the primary care physician when a patient is not responding to treatment, and communicates with the psychiatric consultant regarding treatment changes.

In many instances, the salary of the behavioral health care manager is paid by the practice or health system if they are a full or nearly-full-time member of the staff,” she says. In some practices, and depending on an individual’s qualifications and licensure, a behavioral health manager may bill independently for their services. Some practices or health systems have received grants that cover or partially cover the salary of the care manager; however, this financial support may be limited to the term of the grant. “Ultimately, who pays for their salary depends on how the integration model is structured.

“As for the consulting psychiatrist, their salary is typically paid for by the practice or health system, since they are providing ad hoc consultation to the practice or health system and do not see the patients or prescribe medications, except in rare circumstances.”

‘Any steps taken toward integration – no matter how small – can have a significant impact on patients.’

Financial sustainability

A 2020 AMA-RAND study noted that financial sustainability is a pervasive and continuing concern for practices that have implemented BHI, says Harris. “Some practices are confident that they can achieve financial sustainability via fee-for-service payments negotiated with commercial payers and using the Medicare billing codes. Many other practices, however, continue to struggle when estimating the specific impact of BHI on revenue and expenses. More assistance is needed to help practices analyze the full cost of integration activities and assessing their financial viability.

“Adoption of alternative payment models may increase long-term sustainability of integrated behavioral healthcare through return of shared savings and improved care quality,” she says. “There may not be a direct benefit seen in the office expenses, and realizing real financial returns may take several years, so it is important to take a comprehensive view of whole patient care.” Calculations of the return on investment should account for improvements in patient satisfaction, chronic disease outcomes, medication adherence, and the frequency of emergency room visits and hospitalizations.

There is no one way to accomplish behavioral health integration, says Harris. “Primary care physicians can customize their approach to fit the circumstances of their practice, including how it is structured, resources available locally, specific patient population needs, etc. The better the fit to the practice culture and available resources, the better the outcome.

“At the same time, primary care physicians should not let the number of available choices discourage them from acting. Any steps taken toward integration – no matter how small – can have a significant impact on their patients.”

A new take on the H&P

When asked to predict the future of behavioral health integration, Patrice A. Harris, M.D., American Medical Association immediate past president and an Atlanta-based psychiatrist, says, “Ideally, in 10 years we won’t even be talking about ‘integration’ per se. We’ll be talking about total patient care, because all care – physical, mental and behavioral – is seamlessly integrated into physician practice.” Some medical schools are already steering their students in that direction.

A pilot project funded by a grant from the AMA Accelerating Change in Medical Education initiative is training students at four U.S. medical schools to incorporate a new history and physical (H&P) model – the H&P 360 – to collect biopsychosocial data, better manage chronic disease and address social determinants of health. The four schools are the University of Michigan, Eastern Virginia Medical School, Florida International University and the University of Chicago.

“Medical practice is necessarily undergoing a paradigm shift, and the new paradigm has to do with accounting for social determinants and behavioral health,” says Brent Williams, MD, MPH, director of the Global Health and Disparities Path of Excellence at University of Michigan Medical School. Early pilot results show that students trained in H&P 360 are more likely to recognize patient needs and to suggest appropriate resources.

The idea behind the H&P 360 is that by including in the routine history at least a few questions in each of the following six domains, physicians’ care of patients will improve: 1. Patients’ perceptions of health, goals and values. 2. Mental health conditions, including mood, thought patterns, pertinent social issues. 3. Behavioral health, e.g., health behaviors, medication

management/adherence, nutritional behaviors, physical activity, personality disorders, substance abuse. 4. Social support, including primary relationships, social support, caregiver availability, abuse/violence, community relationships. 5. Environmental or physical resources, such as food security, housing stability, financial resources, access to transportation. 6. Functional status, including affect, social and occupational functioning, satisfaction with life, activities of daily living.

Clinicians are not expected to collect the entire range of biopsychosocial data from their patients in a single encounter. Rather, specific information can be elicited over time as appropriate to individual patients, rather than an exhaustive generic checklist.

Editor’s note: The sample questions that the AMA suggests for each of the six domains makes for interesting reading. Go to https://cdn-links.lww.com/permalink/acadmed/a/acadmed_2020_07_24_kirley_acadmed-d-20-02813_sdc1.pdf

Editor’s note: For your physician customers who want to learn more about behavioral health integration, steer them to the online Behavioral Health Integration Compendium, © 2020 American Medical Association. In 30 pages, the guide covers the basics and background of behavioral health integration, with guidance on how to get started and implement BHI.