Providers have increasingly integrated behavioral health care into primary care to improve patient outcomes and decrease the likelihood of costly, acute health events.

Federal health plans have jumped on board with integration efforts, paving the way for more collaborative care models. But government plans have unevenly adopted value-based care, which is often associated with integrated models like collaborative care, industry insiders said at Behavioral Health Business’ VALUE event.

“In Medicaid, there was a trend around carving out behavioral health, so that you had separately managed benefits,” Seth Zuckerman, chief business officer of Upward Health, said. “I think more and more states have looked to carve it in. That’s helpful in integrating primary care and behavioral health.”

Venture-backed Upward Health is an in-home care provider focusing on whole-person care, including behavioral health, physical health and social determinants of health. Hauppauge, New York-based Upward operates in six states in partnership with Medicare and Medicaid health plans.

Integrating behavioral health into primary care benefits patients and can prevent costly acute behavioral health events like emergency department visits.

Research has demonstrated that integrating behavioral health care into primary care does not raise overall health care costs among Medicare patients and can significantly lower overall costs. 

“What we often see is, through better management of some of those behavioral health conditions, you see better outcomes on the medical side and overall kind of lower cost of care,” Zuckerman said.

When acute behavioral health events do occur, Upward implements a rapid follow-up.

But integrating behavioral health care into primary care is “incredibly difficult” when operating on a fee-for-service model, Katherine Suberlak, senior vice president of population health at Oak Street Health, said.

Chicago-based Oak Street Health is a primary care network for Medicare beneficiaries. The provider operates more than 200 centers in 28 states and operates on a full-risk basis. CVS Health (NYSE: CVS) bought Oak Street in 2023

“What makes [building out collaborative care] possible is early investment to have that longitudinal impact with your patients that you’re trying to prevent more downstream,” Suberlak said.

Oak Street typically sees costs decline after year three or four after implementing a value-based, collaborative care model.

For Suberlak, value-based care involves taking full risk on total cost of care and providing care across the health spectrum, including behavioral health events.

Medicare, Medicaid integration efforts

Federal health plans have increasingly sought to integrate behavioral and primary care. The Centers for Medicare & Medicaid Services (CMS) introduced a new program called the Innovation in Behavioral Health (IBH) Model specifically to connect adults with mental health conditions or substance use disorders (SUDs) to physical, behavioral and social supports. 

In the fall of 2023, CMS allowed more mental health workers, including marriage and family therapists and mental health counselors to bill Medicare for their services. 

The agency also expanded behavioral health codes to include collaborative care, which brought more recognition for the care management that is required for patients with serious mental illnesses (SMIs) or SUDs, Suberlak said.

While CMS is increasingly seeking to integrate behavioral health care, the agency’s value-based care efforts are not as aggressive.

Medicaid’s behavioral health moves toward value-based care, which often goes hand-in-hand with behavioral health integration, have lagged behind Medicare, however. But progress is still being made, Zuckerman said.

“I remember in 2020 I was working on what was seemingly the first value-based contract, or at least the first with downside, with a large national Medicaid payer,” Zuckerman said. “Contrast that four years ago with now, we’re at the start to see arguably the largest Medicaid payer in the nation having a template for a value-based contract.”

The increased Medicaid action creates opportunities for payers and providers interested in offering value-based care, Zuckerman added.

Medicaid does participate in value-based care, Suberlak said, but it “looks a little different.”

“I’ve seen challenges in some of the contracting or the templates getting too specific in the quality measures that lead to some sort of value but not fully there yet because then the operators or the providers tend to go to tactics that are not well connected,” Suberlak said. “There are components of full longitudinal care management, but not quite there, and then when you segment it, you end up losing a ton of the investment.”

Patients who are eligible for both Medicaid and Medicare represent an opportunity to maximize the advancement of Medicaid into value-based care, Suberlak said. Approximately 40% of Oak Street’s patients are dual-eligible.

Medicare’s expanded opioid use disorder (OUD) treatment access has also created opportunities for behavioral health care in other settings, Suberlak said, such as mobile services.