Editor’s Note: The American Medical Association (AMA) and Manatt Health gathered a diverse working group of stakeholders representing physician practices and health systems, large employers, health plans, and patient advocates to meet twice during the fall of 2021 and inform the development of a new report on advancing the adoption of behavioral health integration (BHI) through digitally enabled care. Jointly developed by the AMA and Manatt Health, the report, summarized below, shares the working group’s proceedings. It builds on the AMA’s ongoing efforts to advance effective and sustainable BHI, including the BHI Collaborative and the AMA Return on Health framework for measuring the comprehensive value of virtual care. Click here to download a free copy of the full report.

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The United States is in the midst of a decades-long behavioral health crisis that has been exacerbated by the COVID-19 pandemic. The number of American adults reporting symptoms of anxiety and/or depressive disorder grew from 1 in 10 in 2019 to 4 in 10 by early 2021.^{1, 2} In 2018, deaths due to drug overdose were four times higher than in 1999.³ The prevalence and severity of mental health conditions among children and teens have also increased sharply during this time, with suicide now the second-leading cause of death among individuals between the ages of 10 and 24.⁴ Stakeholders across the health care system have committed to addressing this crisis; however, the long-standing shortage of behavioral health providers has limited timely access to treatment.

Behavioral health integration (BHI), or the integrated delivery of both behavioral and physical health care, is essential to reaching more individuals who need behavioral health treatment and solving the nation’s growing behavioral health crisis. Experts agree that behavioral health is a core component of primary care; however, BHI adoption among primary care practices remains low due to persistent workforce, financial, information and cultural barriers.⁵

The current shift within the U.S. health care system toward digitally enabled care models presents a unique opportunity to enhance the overall effectiveness of BHI. Appropriately applied, the incorporation of technology—including digital tools for screening and intake, clinical decision support, and telehealth care delivery—can support current BHI models by helping engage more people in behavioral health treatment and possibly encouraging broader adoption by providers. It is important to note, however, that the adoption of technology-based solutions can augment but cannot replace interactions between providers and their patients. In addition, persistence of disparities in access to technology, such as broadband internet or smartphone-enabled devices, may impede equitable adoption of digitally enabled BHI.

Stakeholders across the health care ecosystem have a role to play in advancing the adoption and sustainability of digitally enabled BHI. The AMA’s and Manatt Health’s joint report proposes a set of practical solutions that stakeholders—physician practices and health systems, health plans and coverage programs, federal and state policymakers, employers, and venture-backed behavioral health companies—can pursue in order to accelerate the widespread adoption of sustainable BHI.

Summary of Practical Solutions to Advance Digitally Enabled BHI

Stakeholders	Practical Solutions to Advance Digitally Enabled BHI
Physician Practices and Health Systems	Increase behavioral health diagnosis and treatment rates by incorporating evidence-based digital health solutions and enabling technology in standard workflows. Address the siloed delivery of care by primary care specialists and behavioral health providers by implementing technologies that facilitate care coordination and enable highly collaborative care. Raise provision of evidence-based treatment to best practice standards by adopting standard measurement tools and integrating them into provider and patient-facing technologies and by promoting data-driven continuous quality improvement. Increase BHI training for primary care specialists and behavioral health providers by incorporating digitally enabled BHI into standard curricula.
Health Plans and Coverage Programs	Increase BHI adoption by expanding coverage and fair payment with a margin for all stakeholders utilizing the Collaborative Care Model (CoCM) and other BHI models that facilitate care management and transitions of care for patients with behavioral health conditions. Encourage the incorporation of telehealth into BHI by implementing payment parity for behavioral health services delivered via video or audio-only telehealth modalities. Make integrated behavioral health care more affordable for people by evaluating opportunities to individualize the application of cost-sharing (e.g., copays, health savings account deductibles) for CoCM codes, as well as integrated behavioral health services delivered in person or via telehealth. Assist primary care practices in integrating behavioral health by offering technical support, provider training and regional sharing of resources. Expand provider networks and improve access to BHI by minimizing and/or eliminating prior authorization and other utilization management practices for BHI services.
Federal and State Policymakers	[Federal and States] Help primary care specialists overcome financial barriers to adopting BHI by providing long-term sustainable funding opportunities and fair payment rates with a margin for providers delivering BHI services in federal and state coverage programs. [Federal and States] Provide funding to achieve universal and affordable access to broadband internet. [Federal] Pass legislation to remove originating site and geographic restrictions for all telehealth services in Medicare that limit access to care. [Federal] Grow the behavioral health workforce by increasing federal funding for efforts such as loan forgiveness and new residency and training programs. [Federal] Advance the BHI evidence base by funding health services research related to digitally enabled BHI, including a focus on health equity. [States] Increase adoption of telehealth within BHI by requiring private payers and Medicaid programs to cover behavioral health care delivered via video or audio-only visits at parity with in-person care. [States] Expand access to BHI and reduce coverage-related barriers by prioritizing the adoption of BHI within primary care initiatives, working with health plans and coverage programs to strengthen networks, and enhancing consumer awareness.
Employers	Enhance coordination among employers, employees, primary care specialists and behavioral health providers by: Increasing the number of employees with regular sources of primary care Adopting technologies that enable coordination among providers Launching whole-person, employer-based behavioral health programs with care navigation support, with intentional culture-focused work to destigmatize behavioral health Contracting with primary care specialists that offer BHI and with venture-backed behavioral health companies that enable primary care specialists to adopt BHI, to drive delivery of coordinated high-quality behavioral health services through the primary care system Reduce out-of-pocket costs for employees seeking care by evaluating opportunities to individualize the application of cost-sharing (e.g., copays, health savings account deductibles) for integrated behavioral health services conducted in person or via telehealth.
Venture-Backed Behavioral Health Companies	Evolve current and develop new businesses to support BHI, address patient and physician needs, complement in-person care, support comprehensive care delivery, and enable asynchronous communication among patients and providers. Generate robust clinical and economic evidence for digitally enabled BHI by working with BHI stakeholders to develop national standards for BHI technologies and by partnering with practices to test new solutions and develop clinical and economic evidence.

 

Conclusion

There is ample evidence that BHI, specifically the Collaborative Care Model, produces superior patient outcomes, improves patient experience and access to care, and can generate cost savings.^{6, 7, 8, 9} The evolution toward digitally enabled BHI models that incorporate the use of technology has the potential to accelerate BHI adoption and impact; however, technology is only one part of the solution needed to meaningfully drive adoption of sustainable BHI.

All stakeholders have a critical role to play in making accessible and equitable treatment that addresses people’s behavioral and physical health needs a more standard practice within primary care. It is essential that all stakeholders act now to ensure that primary care specialists receive dedicated support to operationalize digitally enabled BHI and that BHI is paid for with a margin in both fee-for-service and value-based payment models in order to achieve widespread adoption.

_{¹ Panchal N, et al. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation, February 2021. Available here.}

_{² Kaiser Family Foundation. Adults reporting symptoms of anxiety or depressive disorder during COVID-19 pandemic. Available here.}

_{³ Panchal N, et al. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation, February 2021. Available here.}

_{⁴ Centers for Disease Control and Prevention. WISQARS data visualization. 2020. Retrieved from https://wisqars.cdc.gov/data/lcd/home.}

_{⁵ Malâtre-Lansac A, Engel CC, Xenakis L, Carlasare L, Blake K, Vargo C, Botts C, Chen PG, Friedberg MW. Factors influencing physician practices’ adoption of behavioral health integration in the United States: A qualitative study. Ann Intern Med. Jul 21, 2020;173(2):92–99. doi: 10.7326/M20-0132. Epub Jun 2, 2020. PMID: 32479169.}

_{⁶ American Hospital Association. The value initiative—Issue brief: Integrated behavioral health is high-value care. December 2019. Available here.}

_{⁷ Balasubramanian BA, Cohen DJ, Jetelina KK, Dickinson LM, Davis M, Gunn R, Gowen K, DeGruy III FV, Miller BF, Green LA. Outcomes of integrated behavioral health with primary care. J Am Board Fam Med. March–April 2017;30(2):130–139. doi: 10.3122/jabfm.2017.02.160234. PMID: 28379819.}

_{⁸ Unutzer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14(2):95–100.}

_{⁹ Barton T, et al. Tackling America’s mental health and addiction crisis through primary care integration. Bipartisan Policy Center. March 2021. Available here.}