How to Align Primary Care With Behavioral Health

There is an inextricable and well-documented connection between physical health and behavioral health. Behaviors such as smoking, alcohol and drug abuse, eating low-nutrition foods, lack of exercise, and insufficient sleep can greatly affect an individual’s physical health. 

Conversely, poor health can contribute to depression, substance abuse, and inactivity, perpetuating a vicious cycle that can ruin lives and contribute to healthcare costs. The impact of social determinants of health (SDoH), including lack of transportation or housing, unemployment,  and discrimination, can exacerbate both physical and mental health problems.

These issues are particularly prevalent among underserved populations, such as rural Americans, for whom behavioral health support and services either are inaccessible or not integrated with their primary care. As the National Institute for Health notes, though, “the prevalence of serious mental illness and most psychiatric disorders is similar between U.S. adults living in rural and urban areas; adults residing in rural geographic locations receive mental health treatment less frequently and often with providers with less specialized training, when compared to those residing in metropolitan locations.”

Toward tighter care alignment

While primary care providers long have been aware of these challenges and inequities, far too often they are unable to do anything about them due to a lack of resources. To encourage tighter integration of behavioral health into primary care for these populations, the Centers for Medicare and Medicaid Services (CMS) has created a primary care reimbursement model to enable a more equitable, innovative, and team-based approach. 

The voluntary ACO Primary Care (PC) Flex Model, set to debut on Jan. 1, 2025, aims to address health equity and drive better outcomes for underserved populations by increasing access to higher-quality primary care, including unique services such as behavioral health integration. The PC Flex model is intended to boost participation in ACOs and the Medicare Shared Savings Program.

PC Flex’s Prospective Primary Care Payment (PPCP) option should be attractive to low-revenue rural ACOs and providers that could benefit from a flexible but predictable revenue stream and that want a greater alignment between primary care providers and behavioral health services for their underserved patient populations. 

Under PPCP, reimbursement for primary care will shift away from the traditional fee-for-service, visit-based payment model. For example, rather than basing an ACO’s PPCP rate on the organization’s historical spending, the rate is based on the average primary care spending in the county where it’s located. 

Thus, the ACO is paid that same rate for a specific patient in a region, prior to considering social and clinical risk factors. This allows providers with patterns of inappropriately low spending for underserved areas and populations to be paid more. The PPCP also includes payment enhancements and adjustments to the county rate for providers offering care to underserved populations.

There are several other ways PC Flex should help reduce health inequities for rural Americans and other underserved populations. These include directing more healthcare dollars toward these cohorts and providing primary care practices with the flexible funding needed to improve care coordination and identify and address people’s unmet health-related social needs.

Overcoming alignment obstacles 

PC Flex and other value-based care (VBC) payment models offer a framework for collaborative, team-based care between primary care providers, clinical and behavioral health specialists, community-based organizations, and payers.

Humana reports that VBC practices “are hiring or partnering with behavioral health specialists and stationing them at primary care centers where physicians with patients in need can quickly and easily connect with qualified help.”

Meanwhile, Cigna’s Evernorth Health Services last fall launched a VBC management program for its behavioral health network that measures how well treatments produce positive outcomes. The program’s goals are to “create meaningful, standardized metrics for behavioral healthcare” and to align providers and payers on treatments that drive improvements in care, cost, and collaboration while removing administrative burdens.

For some healthcare organizations, particularly low-revenue providers in rural areas, integrating primary and behavioral care remains a formidable challenge. Among the most common obstacles are lack of funding or resources to fully integrate the two types of care and a shortage of qualified behavioral health professionals in the service area. 

Then there are technological hurdles. An outdated or insufficient digital infrastructure can make it difficult and even impossible for providers to align primary care with behavioral health services. To overcome this technology barrier, providers must implement a scalable, cloud-based digital infrastructure that creates a many-to-many network of participants. 

Such an integrated care network could include behavioral health providers and community-based organizations (CBOs), many of which have minimal digital capabilities. In addition, integrating a robust analytics platform on top of a scalable digital infrastructure can provide network participants with metrics that are essential to monitoring performance under VBC contracts.

Conclusion

Reimbursement models that align primary care with behavioral health offer low-income provider organizations serving rural Americans and other vulnerable populations an opportunity to enhance coordination and improve outcomes while generating sorely needed revenue. 

CMS’s PC Flex Model is designed to produce better health outcomes for underserved populations by improving their access to higher-quality primary care integrated with behavioral healthcare. However, to fully align primary care with behavioral health services, healthcare organizations need a scalable digital infrastructure that can handle the demands of a many-to-many collaborative care network.

Editor’s Note: The author has no financial relationship with any of the companies / products mentioned.

Photo: Benjavisa, Getty Images

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