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Behavioral health's future includes integration challenges

November 04, 2015

Planning for the future is no small task. Behavioral health executives are chipping away at long-term visions, such as integration, operationalization and new technology application. Individual organizations are seeking to build out not just limited projects but foundational infrastructure across their enterprises in the next three to five years.

Integration

One of the larger infrastructure goals for behavioral health delivery is the advancement of integration. Many believe the best way to provide comprehensive care to consumers is to seamlessly mesh mental health and addiction medicine with medical specialties, particularly primary care. However, in real-world practice, implementation is wrought with logistical and philosophical barriers.

Even though most stakeholders know what the future should look like, the adoption of the integrated model is currently quite rare, according to C. Scott McMillin, consultant and principal with Recovery SI.

“It really is a vast challenge,” McMillin says. “We talk about integration, but it’s so far into the future, it’s almost an impossible dream. You find isolated examples of real integrated care, but you drive 50 miles in any one direction, and you see the complete absence of that.”

Too often, the best a primary care patient with behavioral needs can often hope for is a handout from a family doctor that lists phone numbers for local addiction and mental health providers. McMillin envisions a “no wrong door” approach in the future, in which those seeking health services can receive comprehensive care regardless of the access point.

For example, there is a growing number of federally qualified health centers (FQHCs) that have achieved degrees of integration, often in the form of two providers co-located or in close proximity that mutually can offer warm handoffs. In some cases, local providers count on grant money to drive integration, but efforts risk fading away when the funding dries up, McMillin says.

SAMHSA has allocated various grants for a variety of projects, including technology integration and co-location of service providers. For example, the administration offers grants to establish projects to coordinate services with primary and specialty care providers in community-based behavioral health settings.  The Primary and Behavioral Health Care Integration  grant program also offers tools for provider communities to help them figure out how to implement the integration vision on the ground.

Robert Wergin, a family physician in Milford, Neb., and board chair of the American Academy of Family Physicians (AAFP), says integration is indeed happening—right now. Primary care providers want to include the behavioral element of care because they’re driving toward the medical home model that offers them financial rewards for comprehensive care. Such care is incomplete without addressing behavioral health.

“Integrated behavioral health is the thing of the future, and as we move to value-based payment, I think it’s going to be accelerated,” Wergin says. “But it’s already happening now.”

For most treatment centers,  a co-location arrangement isn’t possible. In that case, the way to foster integration is to grow a patient-centered medical community, he says.

AAFP created its “Joint Principles” of behavioral health integration last year which include recommendations for co-location or patient-centered medical communities as an alternative. The principles also recognize that behavioral health providers should be paid as valuable members of the medical home and the comprehensive care team.

Likewise, the advent of accountable care organizations (ACOs) with their neighborhoods of cooperating, risk-sharing provider networks could signal an opportunity for behavioral health to integrate with comprehensive health systems. At the moment ACOs, whether driven by Medicare or commercial payers, are still getting their footing. Behavioral health components could be a later iteration for many communities.

“I have been in this field since 1970, and I see many efforts take hold and be abandoned,” McMillin says. “I’ll watch ACOs just like the rest of the country to see what kind of programs will be sustained—not just initiated or advanced, but sustained.”

He recommends that behavioral health providers start by breaking down the silos that separate them from other providers in their communities and begin a conversation—something they haven’t done often enough.

Operationalization

As private equity drives ready cash into the behavioral segment, more providers will have the opportunity to grow from single-site, mission-driven treatment centers to larger, structured enterprises with streamlined care delivery and centralized back-office operations. Frequently thought of as a cottage industry, behavioral health will see operationalization as well as consolidation in the next three to five years.

Kevin Ryan, member of the firm Epstein Becker Green, says more providers are operationalizing and seeking novel approaches that diverge from the older industry models as they position themselves for the future.

“There will be far more consolidation or affiliation between behavioral health providers,” Ryan says. “The single or two-person behavioral health practice will not disappear, but you’ll see some big changes and more affiliations. Whether it’s through management service organizations or independent practice associations, you’ll see more people practice as part of one program or a united program for contracting with third-party payers.”

The traditional grant-based models will endure, of course, as will the self-pay models.

“You’ll also see a lot of behavioral health providers take insurance that they previously had not participated in,” he says.

And many treatment center operators are moving forward in efforts to streamline their businesses and become more strategically minded. In many cases, such operationalization is the prerequisite for growth.

“The ‘cottage industry’ brings with it certain benefits but also potential downfalls,” says A.J Schreiber, CEO of Sunspire Health.

Sunspire launched in 2011 with one facility in Florida and now operates nine treatment centers with private equity backing. Additional locations are in the pipeline currently.

Schreiber believes the organization’s smaller-sized facilities “maintain the positives of the cottagelike atmosphere” meanwhile, centralized management operations keep the business side on track across the enterprise. The organizational backbone also offers economies of scale and allows executive directors at individual facilities to focus on the community and the mission instead of, for example, human resources or billing, he says.

For organizations looking to grow in the future, Schreiber cautions that expansion must be strategically executed—rather than growth for the sake of growth.

“If you are part of an organization that’s making  acquisitions or looking for growth, do it for the right reasons,” he says. “Make sure your primary concern while doing that is that you don’t sacrifice quality for growth.”

Because the environment changes so rapidly, Schreiber says, providers must plan for how they intend to do business 12 or even 36 months into the future. Everything from service offerings to payer mix to marketing strategy should be considered in the context of the emerging business atmosphere.

“Make sure you don’t jump at everything that comes through the door because it will change tomorrow,” Schreiber says. “The key is to set yourself up and plan for the various iterations of change that will come down the pike.”

Technology

Tools of the trade increasingly include EHRs and data analytics on the back end, as well as telehealth and mobile apps on the clinical side. Adoption of tech-based assets will continue to drive program performance and sustainability.

The adoption of EHRs across all of healthcare rose from 30 percent of clinicians using them to 70 percent since 2008, says Jody Ranck, independent digital health consultant and analyst with Chillmark Research. According to a Behavioral Healthcare technology survey from earlier this year, the figure is similar in the behavioral space with 79.8 percent of those responding saying they use EHRs. The findings are also similar to those reported late last year by OPEN MINDS

Ranck says adoption is high, but most providers are still bogged down by the practical implementation because EHR systems don’t fit naturally into the clinical realities of care delivery. It’s not just the workflow that is hampering daily use but some of the clinical nuances that are hard to record with standardized inputs.

For example, in the rush to drive evidence-based care, EHRs are increasingly adding decision support tools that are sourced from swaths of aggregated data.

“It’s epidemiological and based on randomized, controlled trials,” Ranck says. “But physicians are not dealing with a population average when they have an individual patient in front of them. It’s an ‘n’ of one. When dealing with that individual patient, that physician is going to look at the family context and social status.”

Unique patient needs including the personal and socioeconomic supports that are so pivotal in behavioral health aren’t figuring into tech tools, he says. Neither are the trial-and-error processes that are inherent in patient care.

Ranck believes improvements in even the most intractable technology issues will come in time, however. For example, value-based care is contingent on data sharing, but interoperability of the data has a long way to go.

“We’re still in the early days,” he says. “It’s easy to see things as messy and uncoordinated.”

The use of sophisticated technologies doesn’t encompass just the tools themselves but also business models and bureaucratic policy as well, Ranck says.

For example, care that gets reimbursed is care that gets delivered. As payers of all types increasingly pay for new treatments—such as online video visits between a patient and provider—such treatments will gain traction.

Thanks to advances in technology, telehealth is in fact gaining ground. Part of the benefit for consumers seeking behavioral health services is the increased access, especially in rural areas or communities where providers are in short supply.

“You’ll see new innovative approaches to behavioral health to reach audiences and patients who in past have been reluctant to walk into an office or just didn’t have access to it,” Ryan says. “And with mobile apps, there is an expansion of services to patients through mobile devices.”

He says there are legal concerns about delivering care remotely, including federal HIPAA rules, state laws and professional licensing limitations. Some laws also place limitations on how the organizations themselves can be structured if the employees deliver clinical care.

But delivery of telehealth for behavioral providers is possible with the right amount of due diligence, Ryan says.

“There are people out there doing it, but it’s not easy,” he says. “And that’s why you may not have seen many organizations out there, but there are approaches to address the issues and if you do them up front, the organization can be structured to provide the services. They are out there, and they’re contracting with payers.”

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