Making Care Primary: An Important Advance for Integrated Behavioral Health Care

There is an ongoing behavioral health crisis in the United States. Behavioral health care is costly, difficult to access, and not equitably provided. These challenges cannot be addressed with the behavioral health specialty care workforce alone, owing to insufficient number of providers, particularly in rural areas. To equitably meet the needs of people with mental health and substance use disorders, behavioral health care must be integrated with primary care to ensure that people get access to effective care quickly and in an accessible and trusted setting.

A New Approach to Primary Care

Recently, the Center for Medicare and Medicaid Innovation (CMMI) took an important step toward supporting high-quality primary care by launching Making Care Primary (MCP), a model that focuses on bringing more providers into value-based payment arrangements and supporting behavioral health integration. Using a tiered payment approach, CMMI has laid out incremental steps to enable providers unfamiliar with value-based payments to build infrastructure and gain experience with risk sharing. The model also presents an opportunity to scale and spread behavioral health integration.

Solving Key Challenges in Behavioral Health

Primary care integration expands access to behavioral health care by treating patients where they are already seeking care — that is, their primary physicians’ offices. In one evidence-based approach, the Collaborative Care Model, primary care providers identify and treat behavioral health needs with the support of a consulting behavioral health specialist and a care manager. As a team, they provide short-course psychotherapy, prescribe medications as appropriate, track progress of symptoms, and refer patients to higher levels of care as needed.

While the evidence is strong, primary care integration has been slow, owing to challenges like lack of capital for effective implementation and inconsistent billing and reimbursement across providers. Further policy changes to address these challenges and promote integration between primary care and behavioral health care is needed.

MCP addresses critical issues that primary care practices face in implementing and sustaining integrated care, including:

• Financing. MCP offers upfront and consistent payments that allow providers to implement integrated behavioral health care that fits their practice and patient population. The new initiative also will offer behavioral health performance improvement bonuses based on depression screening and depression remission. MCP also allows providers more options to bill for interactions with behavioral health specialists.
• Equity. MCP encourages smaller and less resourced practices to participate in the model by offering these clinicians the ability to take on financial risk incrementally. These practices are often more likely to serve patients that are low income, rural, or people of color. Practices can receive additional funding for care coordination and integration, which will promote more equitable access to integrated care. By supporting integration, the model allows primary care clinicians to provide behavioral health care in a familiar setting and one that is preferred by patients.
• Sustainability. By aligning financing and engaging commercial payers, in addition to Medicaid, providers will have resources to make the practice changes necessary for effective behavioral health integration. Practices can also receive specialized technical assistance and peer-to-peer learning opportunities to support behavioral health integration activities. The model’s 10-year period ensures practices have enough time to effectively implement integration.

Long-Term Promise for Behavioral Health and Primary Care

Making Care Primary provides a path forward for expanding equitable access to integrated behavioral health care in the United States by addressing many of the key barriers primary care providers face when implementing integrated care.

Many challenges to integration may remain, including the shortage of behavioral and primary care providers and lack of culturally appropriate care. However, evaluations of the model moving forward will offer critical insights into how payment reform can enable widespread integrated care. Policymakers, payers, and providers can use these findings to advance behavioral health integration and expand access to care.