Barriers and Solutions to Sustaining Behavioral Health and Primary Care Integration

Achieving integrated care is complex because of different payment systems, staffing, and other challenges. Roger Kathol, M.D., a leading expert on primary care and behavioral health integration, provides his perspective on these problems as well as solutions in an interview with the Academy.

Behavioral health is the only health care discipline that has a completely different payment system for services. “The way payment is provided creates a challenge for primary care settings to bill for behavioral health services because they are billed to separate agencies, using separate coding and billing processes. This payment method needs to change so practices working on integration can become financially sustainable.”

Furthermore, “the majority of behavioral health payments come from public programs, which do not pay at a level that is commensurate with the type of cost and level of services that are delivered.” Dr. Kathol proposes consolidating the different payment systems for medical and mental health services into one integrated payment system.

Another challenge is staffing integrated clinics. “The number of behavioral health personnel that want to work or adapt their work process to (function) in a primary care setting and the number of behavioral health staff that are formally trained in primary care is limited.” A related issue is the limited number of primary care clinics with additional space to accommodate behavioral health providers seeing patients.

Other factors that influence whether integration is successful are quality control and accountability. To determine whether patients with comorbid mental and medical conditions are receiving effective integrated health care, Dr. Kathol recommends measuring improvements in these areas:

  • The degree to which the patient is stabilized,
  • Impairment due to management of the patient’s disease or disability,
  • Social functioning (e.g., volunteering, hobbies, or other activities),
  • Total health care costs, and
  • Quality of life and greater patient satisfaction with care.

Dr. Kathol sees effective integration of services as a system in which both disciplines have “joint accountability for medical and mental health outcomes and not just outcomes in their disciplines.” The goal is to have a “treatment team where practitioners have the capability to change outcomes – this means access to specialists in both medical and behavioral health disciplines with the kinds of qualifications that allow them to provide services that are evidence based.”

Health care systems often need transformation to accommodate integrated efforts, Dr. Kathol concludes. “Both behavioral health and primary care providers may need to redefine their clinical approaches and financial models for the U.S. health care system to move to a higher standard and integrated level of care.”

For more information:

Kathol RG, Butler M, McAlpine DD, et al. Barriers to physical and mental condition integrated service delivery. Psychosom Med 2010;72(6):511-8. Accessed June 2, 2017.

Mauch D, Kautz C, Smith S. Reimbursement of mental health services in primary care settings. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2008. HHS Pub. No. SMA-08-4324. (PDF - 1.67 MB). Accessed June 2, 2017.