Investigating the Adoption of Behavioral Health Integration

Announcer:
You’re listening to Perspectives with the AMA on ReachMD, produced in partnership with the American Medical Association.

Here’s your host, Dr. Jennifer Caudle.

Dr. Caudle:
The integration of behavioral and physical health care has long been identified as one of the more effective solutions to increasing access to treatment for many mental health conditions, but despite it’s proven effectiveness, sustained behavioral health integration, or BHI for short, is still not present in a majority of practices to date. So, to find out why that is, the American Medical Association partnered with the RAND Corporation in 2019 to examine the motivators, facilitators and barriers to BHI from the perspectives of physician practices with firsthand experience, and now, those results, recently published in the Annals of Internal Medicine, are ready to be shared.

Welcome to Perspectives with the AMA on ReachMD. I’m your host, Dr. Jennifer Caudle, and joining me to discuss the results of the study that is entitled: Factors Influencing Physician Practices’ Adoption of Behavioral Health Integration in the United States, A Qualitative Study, are Drs. Kathleen Blake and Peggy Chen. Dr. Kathleen Blake is Vice President for Healthcare Quality in the AMA Physician Satisfaction and Practice Sustainability Strategic Initiative Group and one of the co-authors of the study. Welcome to you, Dr. Blake.

Dr. Blake:
Thank you and good to be here.

Dr. Caudle:
Dr. Peggy Chen is a physician policy researcher at the RAND Corporation. She’s also a board-certified pediatrician and a senior author of the BHI study. Great to have you with us, Dr. Chen.

Dr. Chen:
Thank you so much, Dr. Caudle. It’s great to be here.

Dr. Caudle:
To kick us off, Dr. Blake, what prompted this investigation? And why is it important for physicians to consider integrating behavioral health care into their practice?

Dr. Blake:
So, in 2018, the AMA engaged a number of influential stakeholders representing physician practices, health systems, payers, employers, and patients, among others, to discuss the opportunities to empower patients, physicians, and practices to thrive in a value-based care environment. One of the main conclusions from those discussions was that there was really a pressing need to address the significant gaps here in the United States in the delivery of behavioral health care.

What did we find out? We found out that health data strongly suggests that 1 in 5 adults has a mental illness with a significant number of those individuals, 20% of our population, failing to receive treatment, so we realized that behavioral health integration as a general model would allow physicians and their patients an opportunity to more consistently, more effectively identify and address concerns about those conditions. We also found out that there are lots of resources that currently exist, but knowing how to use those resources and integrate behavioral and mental health care into practice can be challenging and sometimes confusing. We’ve now come to realize that the COVID-19 pandemic will almost assuredly exacerbate the existing problems around delivery of this kind of care, and so it was on that basis that we reached out to our colleagues and coinvestigators at the RAND Corporation to conduct this study.

Dr. Caudle:
Thank you for that, Dr. Blake. Turning to you now, Dr. Chen, as a researcher for the RAND Corporation and a senior author of this study, can you give us an overview of the approach used? And what were the key findings?

Dr. Chen:
For this study, our goal was to describe and characterize the various factors that influence physician practices’ implementation of behavioral health integration. Because this is an area that has not been widely studied in an empirical way, we didn’t know what we didn’t know, so we used a qualitative approach conducting semi-structured phone interviews with clinicians and leaders in practices that had adopted behavioral health integration. We supplemented those interviews with additional interviews with experts and vendors in behavioral health integration to add additional context and nuance to those interviews with physician practices. In total we interviewed 47 physician practice leaders and clinicians, representing 30 unique physician practices. We also spoke with 20 experts and 5 vendors. Physician practices were sampled for diversity on a number of characteristics, such as specialty, size, affiliation with parent organizations, geographic location, and behavioral health integration model, such as whether they were co-located or collaborative. We audio-recorded all interviews and had them professionally transcribed. Then our analytic team coded those transcripts line by line using the cyclical coding approach to classify various text excerpts to identify codes or concepts and the relationships between them. Those codes or concepts were then rolled up into recurrent and unifying themes providing the overall picture of our phenomenon of interest.

Our study identified 4 major themes. First, practices reported a wide variety of motivations for integrating behavioral health care into their practice. These motivations included expanding access to behavioral health services, improving clinicians’ abilities to respond to patients’ behavioral health needs, and enhancing the practice reputation. Second, there weren’t any plug-and-play solutions. Practices tailored their implementation of behavioral health integration to their local resources, financial incentives, and patient populations. Third, practices described a wide variety of barriers to behavioral health integration. This included cultural differences between behavioral and nonbehavioral health clinicians and challenges with incomplete information flow between behavioral health and nonbehavioral health clinicians. This was perceived too often be due to organizational misinterpretations of patient privacy regulations. Respondents also described challenges navigating the complexities of billing for behavioral health integration encompassing every aspect of the process from getting set up to be permitted to submit a bill to including the billing process in the practices’ regular workflow. Finally, few practices in this sample reported positive financial returns from behavioral health integration. Most reported losing money and moreover weren’t able to calculate how much money they had lost. Further, they were able to describe advantages and disadvantages to both fee-for-service and alternative payment models.

Dr. Caudle:
For those of you who are just tuning in, you’re listening to Perspectives with the AMA on ReachMD. I’m your host, Dr. Jennifer Caudle, and today I’m joined by Dr. Kathleen Blake from the AMA and Dr. Peggy Chen with the RAND Corporation on the topic of their peer-reviewed study on behavioral health integration recently published in the Annals of Internal Medicine. So, Dr. Chen, now that we know more about the study’s findings, how can they be used to help facilitate greater adoption and sustainability of behavioral health integration?

Dr. Chen:
That’s a great question, Dr. Caudle. We learned that in order to facilitate greater adoption of behavioral health integration, it’s really not enough to just identify a behavioral health integration model and adopt it wholesale. It’s important to have a champion of behavioral health integration within the practice who can bridge both the behavioral health and the physical health side of the practice. Support from practice leadership was also found to be really vital, particularly because so many models for financial success require substantial up-front financial investment. Also, practices should be prepared to tailor aspects of any behavioral health integration model to suit their local needs and contexts. Some practices reported that the ability to marshal resources such as behavioral health integration consultants could really help guide practices through this process and make the whole experience much smoother.

And then, in terms of sustaining behavioral health integration, there are 2 major takeaway lessons from this study. First, the financial aspect of sustainability is really at the forefront of all our concerns about long-term sustainability of the behavioral health integration model. It’s really telling that few respondents were able to report a positive or even a neutral financial impact of behavioral health integration on their practice. In order to shift the balance there, it’s really important to make sure that there are consistent funding streams for behavioral health integration, whether that’s through fee-for-service or alternative payment models. And then, secondly, ensuring the behavioral health integration codes remain classified under medical care as opposed to behavioral healthcare will really help facilitate their use by allowing practices to avoid these mental health carve-outs that we heard a lot about. These carve-outs really hinder other aspects of behavioral health, and it’s important that behavioral health integration is able to sidestep those barriers. It’s also important that practices have access to resources that can help them implement billing for behavioral health integration and ensure that those practice processes fit into their practice workflow.

Dr. Caudle:
Great. Thank you for that. And before we wrap up, I want to come back to you, Dr. Blake, for the closing word on the AMA’s next steps in BHI. So, what’s on the horizon?

Dr. Blake:
So, what’s on the horizon is very much guided by the study that Dr. Chen has just reviewed with you, and the AMA is looking forward to supporting opportunities in collaboration with others to accelerate the integration of behavioral health care into medical practices and that will obviously require that we increase its long-term sustainability. For more information, our listeners can check out the AMA’s webpage on behavioral health integration. We plan to update it on a regular basis. If you’re interested in more information on the study methods and the results, we’d encourage you to check out the peer-reviewed publication in the Annals of Internal Medicine. Furthermore, if you are interested in actual practices’ experience with BHI, we’d encourage you to check out our earlier episode on ReachMD that’s titled: “Behavioral Health Integration: Exploring its Effect on Clinical Practice.”

Dr. Caudle:
Well, with that, I’d really like to thank my guests for today’s discussion. Dr. Blake and Dr. Chen, it was wonderful having you both on the program today.

Dr. Blake:
Thank you.

Dr. Chen:
Thank you very much.

Announcer:
The preceding program was produced in partnership with the American Medical Association. To revisit any part of this discussion and to access other episodes in this series, visit ReachMD.com/AMA. Thank you for listening. This is ReachMD. Be Part of the Knowledge.