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Few ACOs Pursue Innovative Models That Integrate Care for Mental Illness and Substance Abuse with Primary Care

Doctor patient healthcare


Evidence shows that integrating primary care and behavioral health services can improve patients’ physical and mental health outcomes while also helping to control costs. Accountable care organizations (ACOs) have built-in incentives to integrate these services. According to new survey data, however, only 14 percent of ACOs have achieved complete or nearly complete integration. And while most ACOs are on the hook for certain behavioral health care costs, more than one-third have no formal relationships with behavioral health care providers. Certain factors—such as the design of ACO contracts and the general availability of behavioral health services—appeared to influence the extent of integration within ACOs.

The Issue

More than one-quarter of U.S. adults have at least one behavioral health condition, such as depression or substance abuse. People with behavioral health issues are not only at greater risk for acquiring additional illnesses, they may have difficulties accessing health care and adhering to recommended treatment. But closer cooperation between primary care providers and behavioral health care providers has been shown to improve physical and behavioral health outcomes for these patients, and it has the potential to reduce the overall costs of patient care as well. Despite its promise, such integration is not common in health care delivery, though new payment models like ACOs—which assume responsibility for addressing the full range of health needs within a patient population—may help drive integration. In this study, Commonwealth Fund–supported researchers surveyed ACO leaders to learn how their organizations are focusing on behavioral health care and the extent to which these services are integrated with primary care.

Key Findings

  • Most of the respondents (84%) reported their ACO had at least one contract, covering both commercial and public payers, that specifies responsibility for behavioral health care within the total cost of care.
  • Fewer than 15 percent of ACOs reported full or nearly full integration of primary and behavioral health care within their organizations. Forty-three percent reported some integration, while another 43 percent reported little or no integration.
  • Two of five of ACO leaders (42%) said their organizations contained behavioral health provider groups. But 37 percent said they had no formal relationships with behavioral health provider groups, and 21 percent said they contracted with such providers from an outside organization.
  • ACOs that offered comprehensive chronic care management, as well as those that included at least one participating federally qualified health center, were more likely to have integrated behavioral health and primary care. Those with greater integration were more likely to employ health coaches and case managers to support primary care providers and their patients.
  • Certain factors appeared to drive higher rates of integration: high numbers of individuals with behavioral health care issues in the patient population; a low supply of behavioral health providers in the surrounding area; pay-for-performance contracts that used quality measures related to behavioral health, such as depression screening rates; and inclusion of behavioral health costs in the ACO contract.

The Big Picture

“Unmet behavioral health needs can compound patients’ difficulties in accessing care and adhering to treatment recommendations. Lack of access to these services may contribute to chronic or ongoing health problems and to increased health care expenditures.”

Most ACOs that have attained some level of primary care and behavioral health care integration have done so by expanding behavioral health capabilities in the primary care setting through consulting arrangements with off-site behavioral health providers—like psychiatrists, psychologists, or social workers— or by locating behavioral health and primary care providers within the same clinic or location. Only a few have introduced primary care providers into a behavioral health office.

About the Study

The researchers conducted the National Survey of Accountable Care Organizations among 257 ACOs that were in existence as of August 2013. Respondents included leaders of ACOs in the Centers for Medicare and Medicaid Services’ Pioneer program, Medicaid ACOs, ACOs led by commercial payers, and participants in Medicare’s Shared Savings Program. Sixteen of these organizations were interviewed further to learn additional details about their structure, behavioral health care providers and services, integration with primary care, and challenges related to improving behavioral health services.

The Bottom Line

Accountable care organizations have the potential to improve access to behavioral health care by integrating it with primary care. Including certain incentives and quality measures in ACO contracts may encourage faster integration, leading to better health outcomes for patients and reduced health care costs overall.

Publication Details



Valerie Lewis, Assistant Professor, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine

[email protected]


V. A. Lewis, C. H. Colla, K. Tierney et al., “Few ACOs Pursue Innovative Models That Integrate Care for Mental Illness and Substance Abuse with Primary Care,” Health Affairs, Oct. 2014 33(10):1808–16.