Patient Protection and Affordable Care Act – Behavioral Health Integration

One year ago a poll was published in the LinkedIn group, Behavioral Health Integration:

What is the greatest challenge for integrating behavioral health and primary care services?

The poll generated a tremendous amount of interest, both in voting on the poll and in comments. Much has happened in the healthcare industry in the past twelve months, changes that have an impact on the way behavioral health and primary care will be delivered in the future.

The greatest impact has come from the Patient Protection and Affordable Care Act (ACA) that was upheld by the Supreme Court of the United States on June 28, 2012. Though passed in 2010, the flurry of activity toward implementing began after the Supreme Court ruling. As states prepare for the 2014 implementation of the new health laws, more and more are agreeing to participation in the Medicaid Health Home plan.

Poll Results

As we near the end of the first quarter 2013, time is running out quickly for implementation. With integrated care playing a crucial role in health reform, the challenges for integrating healthcare services are more and more apparent. Revisiting the below results of the poll conducted one year ago, one has to wonder whether the perceived challenges remain the same among healthcare providers.

Finance and Billing

Poll responses indicated that sustainability issues related to finance and billing were the greatest challenge for integration efforts. While many providers have successfully overcome this barrier, it is no easy feat to develop a financially sustainable integrated services delivery system. Fortunately, the ACA created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with chronic conditions who receive Medicaid benefits. While only a handful signed on initially, there are currently 24 states and the District of Columbia who have elected to participate in the Medicaid Expansion. Fourteen states have elected not to participate; and 12 states remain undecided. (Click here for more information on where each state stands on ACA’s Medicaid expansion.)

States that are moving forward with Medicaid Health Homes are in the process of making adjustments to policies, billing, and service delivery to enable service providers to integrate behavioral health and primary care services, a requirement of Health Homes:

“Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.” – Medicaid.gov

Partnership Issues

Regular visitors to this blog know that much has been published here about the partnership between behavioral health and primary care providers. This was ranked as second most challenging in the poll.

Why do so many people find partnership issues as challenging? It’s counterintuitive. Most providers approach the integration of behavioral health and primary care with a blind eye to the process of partnership development. It is assumed that the interpersonal aspects will fall into place. Unfortunately, it is far more likely that an integration effort will fail due to partnership issues than financial ones. They are not unlike other partnerships, requiring attention to building a strong foundation from the onset.

Here are additional resources:

Operations/Workflow Issues

All healthcare administrators acknowledge the importance of operations for successful service delivery. That’s why 15% of respondents to the poll indicated that this area is the greatest challenge. Once a smooth-running clinic takes on an entirely new service-line, a degree of disruption is inevitable. The workflow will likely be drastically different than the service providers and support staff have grown accustomed to. Of course, taking on a new service also means addressing the organization’s policies, regulatory requirements, physical space requirements, etc.

With a little careful planning and a LOT of patience, your new integrated clinic will be operating smoothly in no time. Click here for a useful integration planning checklist.

Workforce Issues

Seven percent of the respondents indicated that workforce is the greatest challenge. With the current shortage of primary care providers, nurses, and psychiatrists, it’s no wonder that this is of concern. Fortunately, programs for training about integrated care delivery are available, such as the University of Massachusetts Medical School’s Center for Integrated Primary Care, which offers three programs aimed at training healthcare providers for providing integrated services:

Certificate Program in Primary Care Behavioral Health
Certificate Program in Integrated Care Management
Certificate of Intensive Training in Motivational Interviewing

Health Information Technology Issues

Despite concerns over the dilemma of sharing health records for integrating behavioral health and primary care, health information technology garnered 5% of the responses. Fortunately vendors of electronic health records are working earnestly to develop products that allow for the seamless sharing of behavioral health and primary care records. (Click here for more information on the role of HIT in integrated healthcare.)

One Year Later

What are the greatest challenges to integrating behavioral health and primary care in 2013? What will be the challenges next year? Dare we suggest that in the near future there will no longer be challenges?

Additional Resources:

The Agency for Healthcare Research and Quality’s publication, Experts call for integrating mental health into primary care, provides additional useful information on addressing the barriers to integrated care.
Integration of Behavioral Health and Primary Care: Preparing for Service Delivery

In the midst of talk of healthcare reform, it is apparent that the face of healthcare is undergoing numerous changes from the traditional delivery system. Accountable Care Organizations and other collaborative efforts are proving to be viable solutions for addressing the gaps within healthcare, providing a glimpse of its future structure. Efforts are underway across the nation (and internationally) to integrate behavioral health and primary services within the ACOs as well as between community behavioral health and primary care providers.

The Patient Protection and Affordable Care Act has created a health home option in Medicaid for treatment of chronic conditions. Thus, the concept of the health home was created, with incentives in place for a more holistic approach to healthcare in an attempt to improve quality of care, contain or reduce costs, and improve outcomes. With behavioral health conditions meeting the established criteria for chronic conditions, behavioral health homes are the ideal solution for meeting the needs of people with serious behavioral health disorders who have not traditionally accessed healthcare on an ongoing basis. While the majority of information circulating regarding healthcare integration is related to integrating behavioral health into a primary care setting, it’s a mistake to assume that primary care will absorb all behavioral health services. Specialty behavioral healthcare plays a distinct and important role within healthcare. Individuals with serious mental illnesses historically receive the majority of their services in community behavioral health settings. Many prefer to receive their primary care services within this setting as well for a variety of reasons. Primary care, in its typical current structure, would require significant modifications to take on the added line of business. Many organizations have successfully managed this, with Cherokee Health Systems leading the way for decades. However, primary care clinics that are not prepared nor inclined to follow this model may defer to the Behavioral Health Home.

What is a Behavioral Health Home?

First, let’s talk about what it is not. It is not a group home or nursing home. It is not a physical structure meant to house those in need of behavioral health services. The behavioral health home is a behavioral health organization that serves as a health home for people with mental health and substance use disorders.

Behavioral Health Homes for People with Mental Health and Substance Use Conditions prepared by Dr. Benjamin Druss and Dr. Laurie Alexander for the SAMHSA-HRSA Center for Integrated Health Solutions provides a thorough overview and guidance for establishing the behavioral health home. This document provides practical information for providers in their efforts to provide a more comprehensive delivery system to address the triple aim of healthcare. Behavioral Health Homes for People with Mental Health and Substance Use Conditions is an excellent resource and a must-read for providers in their efforts toward transitioning their organizations into a behavioral health home.

Tag: Patient Protection and Affordable Care Act

Challenges to Integrating Behavioral Health and Primary Care Services Revisited