Policy & Financing

Policy & Financing
Sustaining integrated behavioral health care is complicated by policies that often separate the payment of services.

For the field of behavioral health and primary care integration, there are often several health care policy issues that must be addressed to allow for more comprehensive integration across this country. As the field continues to demonstrate the impact of integration through research and demonstration projects, there is growing recognition that policy must change to accommodate a new model of care withstands.

For example, financial policy is often the first item mentioned as needing to be addressed to help sustain integration. Sustaining integrated behavioral health care is complicated by policies that often separate the payment of services into two categories: physical and mental. Having two pots of money to pay for an integrated model poses a challenge for sustaining that model. The separate payment structure often forces clinicians to operate within their professional silos to receive payment1. However, many opportunities and projects2 are occurring right now that could assist in better financing and sustaining integrated behavioral health and primary care.

For example, many health care organizations are discussing how they can better bundle3” payments around specific illnesses and/or episodes of care. Further, others are moving towards more global” payment models for primary care2 that could include behavioral health. Data shows how behavioral health interventions in an integrated model can reduce costs4and readmissions; savings from these reductions could be accrued and reapplied5 to behavioral health to support providers’ services. 

There are many examples of using research to help inform policy, such as with the Miller et al. (2011) paper on the importance of time in treating mental health in primary care6. This study found that patients who present to primary care with a comorbid mental or behavioral health condition spend about 4 minutes longer per visit with their primary care provider. While this may seem insignificant at first, time is a precious commodity in primary care7, and with the prevalence of behavioral health issues presenting to primary care8, these 4 minutes start to add up.

To use another example, consider the role of screening for depression in primary care. The United States Preventive Services Task Force9 (USPSTF) has recommended that primary care practices not screen for depression unless they have the adequate staff-assisted supports in place10 to take care of the positive screens. One study found11 that very few primary care practices (both family medicine and internal medicine) routinely screen for depression despite still reporting the presence of depression in their patients. With integrated practices, the staff-assisted supports are naturally in place due to the presence of an onsite behavioral health provider.

From a health care policy perspective, integration can make a stronger case for itself by showing the value it adds to primary care. Using the two examples above, integration can help save primary care providers time (therefore leading to savings over time) and by assisting primary care in better treating depression subsequent to identification.

Check out the literature repository for more information on integration and healthcare policy.


[1] Kathol RG, Butler M, McAlpine DD, et al. Barriers to physical and mental condition integrated service delivery. Psychosom Med 2010;72(6):511-518.

[2] Colorado Beacon Consortium. Available at: Author. Tear down this wall: Rocky Mountain Health Plans embarks on a mission to bring together behavioral health and primary care.

[3] Closing the Quality Gap Series: The Effects of Bundled Payment Strategies on Health Care Spending and Quality of Care.  Rockville, MD: Agency for Healthcare Research and Quality; June 2011.

[4] M, Palmer S, Hewitt C, et al. Screening for postnatal depression in primary care: Cost effectiveness analysis. BMJ 2009;339:b5203.

[5] Von Korff M, Katon W, Bush T, et al. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosom Med 1998;60(2):143-149.

[6] Miller BF, Teevan B, Phillips RL, et al. The importance of time in treating mental health in primary care. Fam Syst Health 2011;29(2):144-145.

[7] Agency for Healthcare Research and Quality. The Number of Practicing Primary Care Physicians in the United States: Primary Care Workforce Facts and Stats No. 1.

[8] Roca M, Gili M, Garcia-Garcia M, et al. Prevalence and comorbidity of common mental disorders in primary care. J Affect Disord 2009;119(1-3):52-58.

[9] Agency for Healthcare Research and Quality. U.S. Preventive Services Task Force (USPSTF): An Introduction.

[10] U.S. Preventive Services Task Force. Screening for Depression in Adults, Topic Page.

[11] Phillips RL,Jr, Miller BF, Petterson SM, et al. Better integration of mental health care improves depression screening and treatment in primary care. Am Fam Physician 2011;84(9):980.



Latest News

NAMI 2015 Report on State Mental Health Legislation

The National Alliance on Mental Illness (NAMI) has released State Mental Health Legislation 2015: Trends, Themes and Effective Practices,   its third annual report on state legislation enacted during 2015.

Integrated Behavioral Care Developments in Four States

The Collaborative Family Healthcare Association (CFHA) posted a series of four stories on their blog that highlight developments in the field of behavioral health and primary care integration. The series covers a wide range of topics, including health care policy, delivery, and financing. Multiple members of the National Integration Academy Council (NIAC) and AHRQ Academy Team are featured in the series.

Behavioral Health Integration and the Affordable Care Act after 5 Years

The Affordable Care Act (ACA) was signed into law 5 years ago. In the time since its passage, the ACA has increased the number of Americans with health insurance, increased access to affordable health care, and may be contributing to slowing the rate of increase in health care spending.1 In addition, the ACA has transformed the delivery of health care,1 including changes that advance primary care and behavioral health integration.

SUD Treatment in Primary Care: Sustainability and Policy Issues

There has been little research in the literature in the last few years on treating substance use disorders (SUD) in an integrated behavioral health and primary care setting. A good deal more research is available on treating mental health disorders in the integrated care setting. Most of the more current publications have been summarized on the Academy Portal, and may be found by using the general search function.

With regard to policy and financing related literature, we would refer you to the following  publications:

Rutgers Study Concludes Improved Integration Can Lower Hospital Utilization and Cost

A new Rutgers study, Role of Behavioral Health Conditions in Avoidable Hospital Use and Cost, focuses on the role of behavioral health (BH) conditions in potentially avoidable hospital use and cost.  The study builds on a series of publications, funded by The Nicholson Foundation, which examined opportunities provided by the Medicaid ACO Demonstration Program to improve health and lower costs in low-income New Jersey communities. Study authors found 

Aligning Payers and Practices to Transform Primary Care: A Report from the Multi-State Collaborative

The Milbank Memorial Fund has recently released a new report, Aligning Payers and Practices to Transform Primary Care: A Report from the Multi-State Collaborative. This report describes the efforts of several states that have developed and implemented initiatives to transform their primary care delivery systems in order to improve the health of their populations and reduce costs.

Medicaid Payment Reform Initiatives to Support Integration

Several payment reform initiatives are shaping the world of behavioral health and primary care integration.

“Perfect Storm” Encourages Integration of Behavioral Health and Primary Care

The Commonwealth Fund recently reported on new payment models as an impetus for integrating behavioral health and primary care.

The Paradox of Parity

With implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act (ACA) underway, the nation is “now in one of the most dynamic periods of mental health care change since the advent of the community mental health movement of the 1960’s” says Tom Insel, M.D., director of the National Institute of Mental Health (NIMH). MHPAEA, signed into law in 2008, calls for treatment of mental illness and substance abuse equal to that of other medical disorders.

Final Parity Ruling Issued on Mental Health and Substance Use Disorders

On November 8, 2013, the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury passed a final ruling increasing parity of benefits for the treatment of mental health and substance use disorder services. HHS Secretary, Kathleen Sebelius, said,

Behavioral Health and Primary Care Integration—The New York State Perspective

As New York State sees it, integration “opens the door to collaboration, timely care, improved quality, and parity for general medical and behavioral illnesses—and closes the door on disconnected treatment that is divisive, ineffective, and inaccessible.” In order to move toward integrated health care and to achieve triple aim outcomes, New York has implemented several statewide policy and program initiatives.

Same Day Billing Clarification Provided by CMS – Welcome Resource for Behavioral Health Integration

Integrated Behavioral Health and Primary Care providers have encountered a barrier due to regulations and systems that have prevented certain services from being billed together on the same day.  The Center for Medicare and Medicaid Services (CMS) has recently issued welcomed clarification on this matter about Medicare payment.

Integration in CMS Innovation: Johns Hopkins Community Health Partnership

The Centers for Medicare and Medicaid Innovation Center was created by Congress [section 1115A of the Social Security Act as a result of section 3021 of the Affordable Care Act] to test on a nationwide basis “innovative payment and service delivery models to reduce program expenditures …while preserving or enhancing the quality of care for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program  benefits.” Top priorities of the Center for Medicare & Medicaid Innovation (CMMI) are to “[evalua

Integrating Behavioral Health in Primary Care Reduces Costs and Improves Care

Treating mental health conditions in primary care settings can drastically improve patient health, reduce the rate of physician burnout, and ultimately reduce costs of care. A 2-year grant will fund a new program to integrate behavioral health services into six primary care medical practices at the Academic Innovations Collaborative under the Harvard Medical School Center for Primary Care.

Behavioral Health Providers and the Future of Health Care Teams

Although the Affordable Care Act (ACA) offers new opportunities that are well-suited to the skills of mental health professionals, it also requires that they develop more capabilities and business literacy.

Behavioral Health Integration Advisory Committee

The Behavioral Health Integration Advisory Committee, created by the Senate Bill 58 of the 83rd Texas Legislature (regular session), will be responsible for addressing planning and development needs for integrating Medicaid behavioral health services, including case management and mental health rehabilitative services, and physical health services by September 1, 2014.

Psychiatrists’ Role in a Post-ACA World

 Sosunmolu Shoyinka, M.D., assistant professor of psychiatry at the University of Missouri and director of psychiatric outreach services discusses how the role of psychiatrists will change with the implementation of the Patient Protection and Affordable Care Act (ACA). As Dr. Shoyinka explains, the ACA emphasizes value-based care, prevention and health promotion, and specifically focuses on improving mental health and substance abuse treatment in medical care.

Benefits and Impact of Integration in the PCMH

The Patient-Centered Primary Care Collaborative (PCPCC) recently released the “Overview of Benefits of Integrating Behavioral Health In PCMH” (Patient-Centered Medical Home). This document provides lists of the general and financial benefits of behavioral health integration. It also notes the benefits and impact of integration within the PCMH.  

Among the benefits listed are:

Two-thirds of primary care physicians report not being able to access outpatient behavioral health for their patients. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by primary care providers as critical barriers to mental healthcare access1.

Annual medical expenses ‒ chronic medical & behavioral health conditions combined ‒ cost 46% more than those with only a chronic medical condition2.                                                          

View the original article here: http://www.pcpcc.org/content/benefits-integration-behavioral-health

Reimbursement: A Barrier for Integrated Mental Health and Primary Care

Models for integrating mental health care into primary care such as the Chronic Care Model (CCM) have been shown to improve both medical and mental health outcomes for patients, but they have not yet been widely put into practice due to barriers created by the current health care reimbursement system. The CCM specifically includes activities that are core components of the model such as care management and provider decision support that are especially difficult to get reimbursed for.

Faster Government Health Care Payment Reform Sought by Providers

National and private sector global payment systems are needed to improve our inefficient and costly U.S. health care system, according to industry health care officials. Under the current model, fee-for-service payment includes charges specific to every medical visit, procedure, and test a patient receives.

Mental Health in ACOs: Missed Opportunities and Low-Hanging Fruit

The authors of a recent article in The American Journal of Managed Care discuss the benefits and importance of integrating mental health care into Accountable Care Organizations (ACOs). ACOs are patient-centered coordinated systems of care created through the Patient Protection and Affordable Care Act (PPACA) (also referred to as "Affordable Care Act" or ACA).

Michael Hogan Discusses Integration with Senate Committee on Health, Education, Labor and Pensions

On January 24, 2013, NIAC member Michael Hogan, PhD testified before the Senate Committee on Health, Education, Labor and Pensions, which convened to assess the state of America’s mental health system. In his testimony, Dr. Hogan reminded the Committee that previous evidence supports the inclusion of mental health care in health care.

Mental Health in the State of the Union

In her blog post from just before this year’s State of the Union, NIAC member Kavita Patel, MD, MSHS talks about the importance of addressing mental health in the national discussion.

Disparities in Unmet Need for Mental Health Services

A National Center for Health Statistics (NCHS) study indicates that population access to mental health services has declined in the past decade, partly due to limited health insurance coverage and the rising number of uninsured Americans. Study results show that the unmet need for health services increased from 4.3 million in 1997 to 7.2 million in 2011, the bulk of which is concentrated in the working age population (18-64). Rates of unmet need for mental health services were almost five times higher for the uninsured than for the privately insured.

Expert Insight

An Integrated Care Model

In their article titled “Fostering Sustainable, Integrated Medical and Behavioral Health Services in Medical Settings,” NIAC member, Roger Kathol, MD, CPE and Ron Manderscheid, PhD, propose an alternative approach to integrating behavioral health and primary care services.

Mon, 02/17/2014

The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes

In his May 2013 policy brief on the Collaborative Care Model, NIAC member Jürgen Unützer and colleagues reveal that rates of depression are 20% in the Medicaid population and 23% in the Medicaid-Medicare dually eligible population. In addition, Medicaid patients with major depression and a chronic condition (e.g., diabetes) have more than twice the overall health care costs than those without depression.