A strong correlation exists between physical and behavioral health issues. In fact, as many as 70 percent of primary care visits stem from psychosocial issues. Yet, most primary care physicians lack the expertise or time to address behavioral health issues. Co-locating behavioral health and primary care staff members is a promising solution to this problem, and essential hospitals are implementing strategies to do just that.
In a recent article, “How to Integrate Behavioral Health with Primary Care,” we highlighted the work of essential hospitals Contra Costa Health Services, Eskenazi Health, Hennepin County Medical Center (HCMC), and New York City Health and Hospitals Corporation (HHC). In particular, we focused on the strategies they’re using to overcome some of the issues that arise with integration. This article builds on that discussion, focusing on a new set of issues related to the cost of care, information sharing, and culture change.
The Cost of Care
Providing mental health and substance abuse services can be very costly, especially when reimbursement is lacking. In many states, Medicaid regulatory provisions do not authorize reimbursement for behavioral health and substance abuse services when provided in the primary care setting.
For example, HCMC cannot bill for psychologists working in primary care, but the system can bill for psychologists working in specialty clinics. Similarly, HHC reports that same-day billing for behavioral and primary care services has been prohibited by New York’s Medicaid Program. These complex public insurance programs make integration of medical and behavioral services difficult to achieve. However, essential hospitals can look to federal agencies for help. The Substance Abuse and Mental Health Services Administration, for example, offers grants to implement SBIRT (Screening, Brief Intervention, and Referral to Treatment) programs, which helps to fill the funding gap for these programs.
Electronic health records (EHRs) can be a useful tool for sharing patient information between behavioral and primary health care providers. Such technology can help optimize integration by supporting providers in managing their target populations, sharing client-level information that is relevant across providers and delivery settings, and identifying gaps in care and evidence-based best practice guidelines. However, some federal and state laws, such as the Health Insurance Portability and Accountability Act (HIPAA), may limit sharing substance abuse treatment information between different provider types.
Essential hospitals Eskenazi Health and HCMC have found ways to overcome the restrictions imposed by these laws. At Eskenazi, medicine and psychiatry clinics have a shared EHR, shared appointment system, and shared patient registration – all of which have been developed as HIPAA compliant. Likewise, HCMC adapts the level of detail entered on the EHR, so different types of providers can view it without violating HIPPA.
Culture of Collaboration, Communication
Integration requires an organizational culture that supports partnerships, collaboration, and shared goals between physical and behavioral health. Developing a strong relationship between providers often requires cultural changes and mutual appreciation of the contributions of each field. Both Eskenazi and Contra Costa Health Services identified culture clash as one of their biggest challenges to address. Leadership in both hospitals have found that communication is the most important element to overcoming this divergence and achieving a middle ground that will make both behavioral and primary health care specialists comfortable, especially within a system that is not integrated.