Behavioral Health integration can be challenging in the current health care ecosystem.
Health care organizations must continue to drive awareness of integrated care models, or referrals to behavioral health services will drop even in settings where behavioral health services are a part of primary care, Andrew Bertagnolli, national director of virtual behavioral health services at One Medical, told Behavioral Health Business during a panel talk at INVEST 2023.
San Francisco-based One Medical, a large primary care practice, has long integrated virtual behavioral health services into its primary care model. In 2023, it was acquired by retail giant Amazon for $3.9 billion. The reason behavioral health referrals may trail off is simple.
“In an entirely virtual or add-on solution, you run the risk of referrals trailing off because it’s not top of mind,” Bertagnolli said. “You have to look at how you’re going to keep promoting that in a primary care practice, or you’re going to get down to pretty low referral rates.”
One Medical trains new primary care providers early in their tenure about common behavioral health conditions and how the company addresses them. Its home-grown electronic health record dedicates space to behavioral health issues.
Primary care providers at One Medical also interface with master’s-level mental health clinicians or psychiatrists who do virtual rounds on patients. Additionally, a psychology team and artificial intelligence both analyze patient assessments before returning them to providers. Providers can also designate visits with patients to focus specifically on behavioral health concerns.
One Medical tried in-person services early on and later opted for virtual behavioral health services. Virtual options provided better flexibility for One Medical and its patients but presented additional challenges that the organization had to address.
In contrast, in-person models of behavioral health integration can help win over patients, providers, and potential business partners, Sentari Minor, vice president of strategy and chief of staff of Scottsdale, Arizona-based evolvedMD, said.
EvolvedMD conducts about 70% of its work in-person, co-located in its partners’ primary care practices.
“We believe that collaborative care should be truly collaborative with people on-site,” Minor said, adding that outcomes are better when a behavioral health provider is brought into primary care that “looks and feels” like they are part of the clinic. Still, some patients want care done, and some care can be provided virtually, he said.
In-person care can be a differentiator when selling to large health systems that need behavioral health integration assistance. This has been evolvedMD’s experience. At least one of the company’s partners went with it because of the in-person care.
“Systems have told us that they understand virtual care but that they want someone there with their people to actually work on these things,” Minor said.
EvolvedMD partners with primary care providers to establish the collaborative care model (CoCM). This care system, developed at the University of Washington, calls for frequent contact with primary care providers, a behavioral health care manager, and as-needed engagement with a psychiatrist.
Other providers see a mixed bag between in-person and virtual behavioral health care within the CoCM. Spencer Hutchins, co-founder and CEO of San Diego-based Concert Health, said his company hasn’t seen a difference in engagement or outcomes between the two.
Concert Health raised a $42 million Series B funding round in 2022 to scale its business to more states.
In practice, CoCM tends to be more virtual. “Good models,” Hutchins said, see 70% of patient engagement and care when the patient is not at the clinic by using more frequent and shorter interventions.
“The deadweight loss of waiting, driving into the office, parking, and getting there is greater if you’re talking to patients more frequently, for 20 minutes rather than an hour-long session.”
He also warned that clinics can still drift away from what makes the CoCM work without vigilant leadership. Without it, primary care providers may lose sight of behavioral health providers as their peers in providing care and see them more as “secretaries.”
Still, Concert Health sees 65% to 75% in service engagement. The primary care provider’s ability to build patient trust makes the model work.
“Whether [the service] is co-located or not, building rapport and trust through the primary care provider makes it so you can draft off of that momentum,” Hutchins said. “It opens the aperture for the type of people you can get to and support.”
Still, trust can be a challenging part of getting CoCMs established in the first place.
The top hurdles include getting primary providers to buy into greater behavioral health integration and navigating administrative issues.
“There are these philosophical hurdles where primary care providers believe that mental health care doesn’t belong in the primary care office or where clinicians believe that they already know how to treat their patient’s mental health needs but need to see collaborative care as a step beyond that,” Minor said.
On the administrative side, it can take years to complete a sales cycle with large health systems or primary care groups. It took evolvedMD to secure a partnership with Banner Health, the largest health system in Arizona, Minor said.
Often, providers can get clinician buy-in to behavioral health integration by pointing out the need for more support for primary care providers and demonstrating patient improvement from the model, Hutchins said. Primary care providers prescribe about 40% of all medication related to any mental illness and about half of all medications for anxiety and depression, according to one study.
“As an industry, we talk about behavioral health integration as something new: Anybody that’s been practicing primary care is like, ‘What are you talking about? I’ve been doing this nonstop every day,'” Hutchins said. “They are dealing with the downstream implications of all that.”
Also, some primary care providers are interested in building CoCMs internally. In that case, Concert Health can bring its business services into the equation to be an “easy button” for that growth.
The status quo helps a little bit with billing and financial barriers for behavioral health integration. Hutchins said nearly all Medicare and Medicare Advantage plans cover services provided within the CoCM. However, serious gaps remain within Medicaid. Very few cover CoCM, and fewer still cover it in a sustainable way, Hutchins said.
“I think payers need to put real carrots and sticks in their plans as opposed to talking about it,” Hutchins said. “Partly, our belief is that the outcomes are clearly superior to a lot of traditional outpatient psychotherapy practices.”