Plan sponsors, payers, and third-party administrators owe it to our members and physician partners to encourage further behavioral/physical health integration in our practice networks.
Editor's note: Nancy Klotz, MD, is the chief medical officer at Brighton Health Plan Solutions.
If the pandemic has taught us nothing else, it's the importance of mental and behavioral health to overall well-being. The World Health Organization says the global pandemic triggered a 25% increase in the prevalence of anxiety and depression worldwide. In 2020, the latest data available, U.S. deaths associated with alcohol, drugs, and suicide reached 187,673, and substance misuse deaths reached their highest level ever, according to the Trust for America's Health.
Based on these statistics alone, it's clear that behavioral and physical health go hand in hand and poor mental health has recently contributed to physical suffering and death on an unprecedented scale. So why do we continue to treat behavioral and physical maladies as independent of each other?
Where the behavioral and physical intersect
Even though the Mental Health Parity and Addiction Equity Act requires health plans to offer behavioral health benefits on par with medical and surgical benefits, patients obtain these services in discrete ways. With few exceptions, physical and behavioral health care are not integrated.
The reasons behavioral and physical health services are so separate are complex and too numerous to highlight here, but they begin with the now-antiquated notion that patient disorders in thinking, emotion, and behavior are an indicator of moral weakness or that they result from poor personal decision-making. In other words, this thinking goes, while physical health problems are out of the patient's control, they bear some responsibility for their behavioral or mental issues. Never mind that science and the general public relegated this overly simplistic view of mental health to the dustbin years ago; how practices are traditionally organized is its legacy and inertia is a big hurdle.
The evidence is compelling that change is needed. As noted in the statistics above, physical health is often a predictor of mental health and vice versa. Physical maladies such as cancer, or chronic illnesses such as heart disease and diabetes contribute to the risk of physical injury or death. Mental illnesses contribute to worsening of physical problems through substance abuse or apathy due to depression, for example.
Parity should encourage new models
Patients don't fall neatly into the "physical" or "behavioral" health classification. Rare is the patient who has only physical or behavioral needs. In fact, up to three-fourths of primary care visits include behavioral or mental health components, including behavioral factors related to chronic disease management, substance use (including tobacco), and exercise, just to name a few examples. But these are often addressed in an unsystematic way by professionals whose practice is aimed at physical health. Primary care physicians often don't feel equipped or properly compensated for tackling mental health issues beyond making a referral outside their practice.
But new practice models that integrate behavioral health and primary care have shown promise and the benefits accrue to both patients and their physicians.
One primary care integration model uses a behavioral health consultant—whether a psychologist, licensed clinical social worker, or other behavioral health professional—as a member of the healthcare team. In such models, behavioral or mental healthcare is not referred outside the practice. Rather, the patient is guided to a behavioral health professional "co-located" at the practice, who then works directly with the primary care physician in support of the patient's broader health goals. Another collaborative care model incorporates a behavioral health specialist as part of the team managing individual patients. In some states, advanced practice nurses can practice psychiatry on their own, offering another opportunity for integration for health systems.
Finally, options for better integrating behavioral health are widening beyond the physician office. The social isolation the pandemic required contributed to behavioral issues as well as encouraged the development of virtual behavioral health. Patients are migrating to fast-growing companies in the telehealth arena that pledge to integrate both physical and behavioral health. Many patients prefer to receive mental or behavioral health care virtually already—perceiving it as more discreet.
While payers, plan sponsors, and health plans may wish to avoid dictating how physicians should organize their practice, it's past time for them to encourage practice changes that facilitate the integration behavioral and physical health services. This can be done via incentives to the practice to add these capabilities or by steering patients toward practices that have implemented them.
Integrating physical and behavioral health is also better for physicians. According to a study that surveyed physicians about integrating a behavioral health specialist in primary care, 93.8% believed integrated care improves patient care, and 90.1% said integrating a psychologist in their practice reduced their personal stress level. And they'll likely support employer or payer efforts to help them integrate behavioral health. Eight physician organizations recently issued a call to action supporting such integration efforts.
For these reasons, plan sponsors, payers, and third-party administrators owe it to our members and physician partners to encourage further behavioral/physical health integration in our practice networks. The evidence is clear: integrating behavioral and physical health services reduces suffering, potentially lowers costs, and improves health.
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Nancy K. Klotz, MD, MBA, FACP, is chief medical officer at Brighton Health Plan Solutions, where she is responsible for clinical strategy across the company's various business segments. Previously, she served as chief clinical officer at HealthCare Partners, and Heritage NY Medical, PC.