These include cultural, informational, and financial challenges

While attempts to integrate behavioral healthcare into physician clinics have been encouraged through legislation and regulation, and while they appear to have positive impacts on physician practices, challenges to successful implementation still remain.

According to a study of practices with behavioral health implementation, physicians must hurdle a number of cultural, informational, and financial barriers if they are to successfully integrate behavioral health into their practices.

The study, by Angèle Malâtre-Lansac, Institut Montaigne, Paris, France, and colleagues, was published in the Annals of Internal Medicine.

Approximately 1 in 5 adults have significant mental health or substance use disorders. And, according to Malâtre-Lansac and colleagues, the stigma associated with those disorders, as well as shortages of staff equipped to treat those disorders, means that many of those patients fail to receive effective treatment.

One approach to dealing with this issue is a model in which behavioral health is integrated into physician practices. Significantly, policies conducive to behavioral health integration have been incorporated into a number of legislative and regulatory actions, including the Mental Health Parity Act of 1996, the Mental Health Parity and Addiction Equity Act of 2008, and the Patient Protection and Affordable Care Act of 2010.

Despite this, practices have been slow to implement behavioral health integration. For example, Malâtre-Lansac and colleagues pointed out that a study of U.S. primary care providers showed that only 44% were physically co-located with behavioral health clinicians (and only 12% of solo practice providers and 26% of rural practice providers), “suggesting persistent barriers to behavioral health integration.”

Therefore, in order to better understand the factors influencing behavioral health integration, the authors conducted a qualitative study of practices that have implemented it. This study included semi-structured interviews with 47 leaders and clinicians from physician practices, as well as 20 experts and five vendors in the field.

The authors found that four major themes arose that affected practices’ implementation of behavioral health integration:

  1. There were three primary motivations for practices to integrate behavioral health into their practices: expanded access to behavioral health services, improved behavioral health screening, and enhanced practice reputation.
  2. Rather than base behavioral health integration efforts on existing paradigms, integration efforts were tailored depending upon the availability of local resources, financial incentives, and patient populations. Practices tended to adopt a co-located model, in which onsite behavioral health clinicians provide enhanced access within physician practices.
  3. There were a number of barriers to behavioral health integration, including cultural differences between behavioral and nonbehavioral health clinicians. For example, a number of interviewees noted that behavioral health clinicians may have difficulty acculturating to medical clinics because of differences in workflow, while some nonbehavioral health clinicians do not always understand the purpose of behavioral health integration. The authors also found that there were impediments to information flows between behavioral and nonbehavioral health clinicians, and that billing for behavioral health integration “could be complex, burdensome, and unfamiliar to behavioral health providers.”
  4. Interviewees reported there were advantages and disadvantages to both fee-for-service and alternative payment models in supporting behavioral health integration. However, only a few reported positive financial returns from their efforts, with one-third of practices reporting that they lost money on their integrated behavioral health services. Others didn’t know, or hadn’t even tried to determine, the financial effects of behavioral health integration on their practices.

The study “demonstrates that implementing behavioral health integration is possible in a wide variety of practices, not just primary care,” concluded Malâtre-Lansac and colleagues. “Tailored, context-specific technical support to guide practices’ implementation and payment models that improve the business case for practices may enhance the dissemination and long-term sustainability of behavioral health integration.”

In an editorial accompanying the study, Sue Bornstein, MD Texas Medical Home Initiative; Dallas, Texas, noted that a practice leader quoted in the study had commented that behavioral health integration model “is not meant to succeed” in a fee-for-service payment model.

“For primary care to reach its potential for achieving better health for persons and populations, fundamental changes must occur in payment and delivery systems,” wrote Bornstein. “The current pandemic has exposed the fragile state of primary care and underscores the need to strengthen the foundations of our system. Malâtre-Lansac and colleagues have provided us with excellent insights to continue our sacred work to improve care of the whole person.”

  1. Physicians have been slow to implement behavioral health into their practices despite the promulgation of legislation and regulations designed to help with this integration.

  2. There are a number of barriers to behavioral health integration, including cultural, informational, and financial challenges.

Michael Bassett, Contributing Writer, BreakingMED™

Malâtre-Lansac reports grants from The Commonwealth Fund during the conduct of the study.

Cat ID: 925

Topic ID: 915,925,556,730,192,925