Delivery of physical medical care and behavioral health services is too often uncoordinated, operating in silos with little or no communication between physicians and other providers providing a patient with primary, specialty, acute, and pharmacy services and behavioral health professionals proving that same patient with mental health care or substance abuse treatment.  Naturally, the presence of a serious mental health condition, such as bipolar disorder, major depression, or schizophrenia, or an addiction to alcohol or drugs, is a tremendously important factor in treating physical diagnoses- and vice versa.  Ultimately, the lack of integration between physical and behavioral health care leads to poor clinical outcomes, higher costs, and unnecessary services.

Addressing this is especially critical in Medicaid.  State Medicaid programs are the nation’s largest buyers of behavioral health services (inpatient and outpatient medical health care and residential and outpatient substance abuse treatment) and the second largest buyers of physical health care, including primary and specialty physician services, pharmacy benefits, inpatient and outpatient hospital services, and emergency room visits.

As Medicaid has expanded to cover a greater portion of lower-income consumers, the need for integrating behavioral and physical treatments has correspondingly increased. The low-income group of patients newly covered under Medicaid – disproportionately childless adults with no medical home – has a greater concentration of co-occurring mental and physical disorders.  An informative analysis of multi-morbidity patterns by the Center for Health Care Strategies, a respected non-profit research and technical assistance shop supported by foundations, “confirms the overwhelming pervasiveness of physical and behavioral health comorbidity among Medicaid’s highest-cost beneficiaries.”

Unfortunately, efforts to treat these patients in a holistic way are hindered by the historic separation of mind and body, with state Medicaid programs and Medicaid health plans reimbursing mental and physical health care through wholly different channels. Even as states recognize the fiscal imperative of integrating care, they are blocked by the extreme fragmentation of behavioral health care providers, many of who are organizationally and administratively far less sophisticated than most of their physical health counterparts.

In recognition of this problem, new strategies are being developed to address care delivery for patients with comorbid health conditions. An in-depth report from the Commonwealth Fund provides granular quantitative data as well as illustrative individual narratives to showcase issues. An executive summary of the report is also available from Commonwealth.

Why is Behavioral Treatment Needed for Medical Care?

Behavioral health problems, which encompass mental illness as well as substance abuse, coexist with many physical disabilities and medical conditions. It’s clear, for example, that treating a chronic illness such as asthma or diabetes will have a limited effect if the treatment does not also address the fact that the patient is schizophrenic or alcoholic. The Commonwealth Fund study reports that treating patients with comorbid conditions costs 60 to 75 percent more than treating chronic physical health issues in mentally healthy patients. Furthermore, among Medicaid patients with disabilities, more than 99 percent have co-occurring conditions and problems.

Why was Behavioral Care “Carved Out” from Physical Care?

Historically, policymakers concerned about controlling Medicaid costs were faced with political and practical pressures. In many states, advocates (genuine advocates for persons with mental illness or substance abuse problems, as well as provider advocates, many perhaps acting in the guise of consumer advocates) lobbied hard to keep behavioral health care out of Medicaid managed care.  There were concerns that the diagnosis and delivery of mental health care would be impossible to bring under the Medicaid umbrella dominated by physical health care delivery. In many states, these “carve-out” separations – behavioral health care carved out of Medicaid health plans’ scope of responsibilities and turned over to separate vendors, either on a capitated or fee-for-service basis – continue to this day, despite evidence that they generate additional expense for taxpayers and obstacles to effective, accessible, timely care for patients.  Like Medicaid carve-outs of pharmacy services, behavioral health care outs are inadvisable.

The Need for More Types of Providers

Another impediment to providing cost-effective behavioral health care is found in states’ licensure regulations. While outcome-based research indicates that the use of non-traditional providers such as community health workers and peer counselors provides good value for the dollar, state regulations often pose a tangled web of restrictions that prevent these providers from entering the field.  Again, states face opposition from licensed providers understandably worried about lower standards and increased competition, especially from practitioners who don’t have to meet the same stringent, costly educational and training requirements.

The Information Problem

While the provision of physical health care has been stringently guided into digital record-keeping over recent years, this is not equally true of behavioral health care. Electronic record keeping in that field is sporadic at best and non-standardized, so a conversion period is needed even after a state decides to integrate its sectors of care. Such a decision requires acquiring new funds for implementing digital mental health records and establishing policy guidance for information-sharing.

The (Lack of) Evidence and Measures Problem

Much of health care is bedeviled by a lack of evidence on what works best for patients.  In recent years, government and influential health plans have invested in building up our knowledge base on the absolute and comparative effectiveness of therapies, procedures, drugs, biologics, and diagnostics.  But this remains a work in progress and, even in the presence of evidence, many physicians do not routinely follow evidence-based practice guidelines (or when they do, they don’t document it).  Meanwhile, great strides have been made in the measurement of the clinical performance of health care providers, particularly physicians and hospitals but this has been growing to encompass other major providers such as pharmacies, nursing facilities, and home health agencies.  Much more is needed, especially in the measurement – and public reporting – of patient outcomes, rather than mere measures on process and structural factors or patient satisfaction.  It is a complex but essential process, with the ultimate goal being the linking together of evidence-based medicine, data-driven measures of patient outcomes and provider efficiency (together, the value of care), performance-based provider payment methods, and transparent, public reporting of providers’ performance.

However, we have barely begun in the fields of behavioral health – mental health care and substance abuse treatment.  To be sure, there is evidence and there is little doubt that high-quality behavioral health is needed and that providers convey value.  But compared to physical health therapies, there has been little invested in assessing effectiveness, outcomes, efficiency, or satisfaction.  Studying the topic of mental health care is extraordinarily complex, there is little funding or data for evidence development, treatment sites and practices vary tremendously, and wide disagreement on best practices makes focusing sparse evaluation work very difficult.  Of the quality measures that have been proposed for mental health care, a new study by the Agency for Healthcare Research and Quality (AHRQ) says “none are used consistently across all treatment sites or all forms of SMI (serious mental illness).”  The AHRQ study on the Relationship Between Use of Quality Measures and Improved Outcomes in Serious Mental Illness confirms that mental health outcomes are difficult to measure and there are yet no valid and reliable quality measures for mental health usable in real-world settings.

Unfortunately, the field of substance abuse treatment is in an even worse position.  Again, substance abuse treatment is as an essential part of health care benefits but what patients receive, when, why, and how varies widely, is not consistent or readily comparable by setting or type of treatment or patient characteristics, is comparatively light on evidence, and lacks valid and reliable measures of outcomes and cost effectiveness.

While progress is limited in assessing behavioral health treatments and measuring quality or outcomes, innovative primary care practices have been working to integrate primary care with behavioral health care through, for example, local care teams and coordinated workflows.  AHRQ explains how “integrated behavioral health care is an emerging field with the potential to improve health outcomes for patients and health care delivery within practices. Integrated behavioral health care can systematically enhance a primary care practice’s ability to effectively address behavioral health issues that naturally emerge in the primary care, prevent fragmentation between behavioral health and medical care, and create effective relationships with mental health specialists outside the primary care setting.”

Steps to Integrating Physical and Behavioral Care

Different states have very different approaches to integrating mental health care. Some states that are continuing a “carve-out” strategy are establishing new linkages between their different reimbursement streams. Other states are finding ways to integrate the varied aspects of treatment within their single managed care system, which is sometimes limited to individuals with the most severe mental illnesses. Furthermore, a few regions are revising credentialing procedures so that patients can have some of their basic needs met at a lower cost by peer helpers and community workers.

Despite the high use of mental health and substance abuse treatment among Medicaid beneficiaries, Medicaid patients with multiple morbidities and dual physical-behavioral diagnoses driving much of total Medicaid spending, and the clear benefits to patients and taxpayers of integrated care delivery, obstacles and resistance to full integration of physical and behavioral services remain. Each state has a unique political and policy landscape, so there is no single pathway that will work in every region.

Instead, it’s imperative that individual states develop their own methods for allowing Medicaid patients to receive integrated care in an efficient manner – and hopefully increasingly edge toward integrated physical and behavioral health delivery, ideally through health plans, with evidence-based guidelines, valid and reliable measures of patient outcomes and provider efficiency suitable for real-world care, performance-based provider reimbursement, and public reporting of provider and plan performance.