5 minute read

The behavioral health field is failing to fulfill one of its essential social roles.  Our main function is to help people resolve behavioral health issues, but our longstanding inability to make care accessible diminishes our social value.  This is an issue of equity.  People should be able to access behavioral care as easily as care for physical problems. 

Solutions are available if payers fund system reforms.  For example, expanding integrated care, defined minimally as placing more behavioral clinicians in primary care, is a clear avenue for better access.  Care integration is compelling as a clinical approach, but this social perspective gives it urgency.  Integration can help us achieve parity in care access. 

Many clinicians have long been committed to integrating medical and behavioral care, but framing it within a social mission fosters a re-examination of our clinical models.  We must ground expansion in models that balance the urgency of the care access crisis with an imperative for clinical quality.

The State of Care Integration

A key requirement for solving population-level issues like care access is scalability.  The access crisis is broad, encompassing problems ranging from mild to severe.  The slow and varied expansion of existing integration models (e.g., CoCM, PCBH) should prompt a review of how they scale.  Currently, integration varies by funding stream, and it skews toward patients with greater complexity and symptom severity.

Beneficiaries under Medicaid or the Department of Defense are more likely to access integrated care than the general population.  Many FQHCs (treating 9% of pop.) use integrated models, yet integration is less available for the commercially insured (> 60% of pop.) and for seniors covered by Medicare (> 17% of pop.).   Moreover, across all funding streams, integration leans toward major clinical disorders.

Increasing funding for integration will be a battle, and compelling business arguments are needed.  PCPs might welcome behavioral clinicians into primary care, but the priority for many is preserving their own profession.  The business case for integrated care is strongest when tied to the urgency of the behavioral care access crisis.  Distressed consumers are demanding services, and payers cannot simply ignore them. 

Diagnostic Screening Excludes Needed Services

The lack of easy access to care even extends to people with severe mental health and addictive disorders.  However, the crisis is not defined by diagnostic categories.  Many people suffer from sub-clinical problems.  Unhealthy behaviors are destructive without being pathological.  We need early intervention for all types of problems.  Diagnostic screenings should not be the basis for solutions.

Behavioral issues are pervasive and potentially insidious.  Our goal should be to prevent problems from escalating.  Primary care facilitates early intervention and the ability to resolve non-clinical issues (e.g., diet, medication adherence, life stressors) that impact overall health.  Our field could even redirect existing funding to these services—benefits like EAP could be reconstituted for primary care use.

Diagnostic screening may be unsuitable for this access fight, but outcomes research provides another approach to psychometrics.  Evidence-based treatments are widely touted today, but research contradicts some commonly held beliefs.  Praise for therapy models dissipates as one understands the findings on “therapist effects.”

Meta-analysis shows that therapy techniques do not drive results; instead, therapists are the agents of change driving most clinical improvement.  We should trust them while validating their outcomes, and the path to validation is Measurement-Based Care (MBC).

Measurement-Based Care (MBC)

The staffing goal for integrated care settings should be to scale behavioral services to meet population needs. A lesser goal essentially accepts how care delivery has evolved historically, and we should develop optimal systems rather than acquiesce to the status quo. 

Another critical feature of a best-in-class system is measuring results.  Clinical outcomes should be measured rather than presumed positive.  We must embed MBC into care delivery to assess clinical needs, detect risks, and measure outcomes. 

MBC relies on clinical measures that are valid, reliable, and sensitive to change.  Clinical measures should also include normative data on how patients change during outpatient treatment.  These norms provide a benchmark for evaluating clinical change from care’s beginning to end.  MBC enables a comparison of actual clinical change with norms for expected change.

MBC should be an integral part of any behavioral care system, whether standalone or integrated.  Several commercial MBC products exist today, but all could benefit from administrative simplification.  High-volume integrated settings will especially benefit from automating tasks like data collection and clinician feedback.  MBC is under-utilized today, and this may speed its adoption. 

MBC is especially valuable for severe problems that warrant ongoing monitoring—an optimal system collects data between visits and tracks clinical changes.  MBC is an egregious gap in our field’s quality profile today, but it can be rectified with needed investments.  Let us respond to the urgency of our social mission by expanding care integration with a system of accountability for results.