Behavioral Health Policy Changes and Primary Care Integration

The greatest opportunities in the healthcare industry will be found by integrating mental health providers into primary care practices.

Thanks to federal regulatory and policy updates in the last two years, it has never been easier to find a strong business ROI for integrating behavioral health into primary care and implementing technology solutions to support those efforts.

Integration of behavioral health into primary care holds the potential to revolutionize healthcare spend and outcomes.

Behavior Change and Health Outcomes

A physical therapist by training, I learned very early in my career that professional success would not merely depend on identifying the source of an individual’s impairments or what treatment progression would be best to reach achievable goals. For technical reasons, those are the skills I would need to master first, perhaps.

Think things like:

• The genesis of musculoskeletal weakness, the source of pain, the type of gait impairment, the source of balance deficit and level of fall risk

• The manual and therapeutic exercise techniques and progression that would lead to resolved symptoms

• The ideal frequency to treat the patient in-person and what treatments would best be carried out at home

But all of these are my behaviors, not what my patient has to do to make progress. Patient engagement is important in all of healthcare, but it’s an obvious needed lever in mental and physical therapy.

I can set up a treatment plan and modify it over time, but for most patients to recover and maintain what they achieve, they themselves commonly must:

• Trust my diagnosis and recommended course of treatment

• Add new habits to their days (showing up for therapy, following the home exercise plan, avoiding exacerbating activities)

• Be able to prioritize their treatment plan among all the other responsibilities and activities in their lives

• Attend to and internalize takeaways from our interactions and build engagement in their care

In other words, my skills as a therapist are only a fraction of the recipe for success in providing high-quality patient care and patients realizing the outcomes that are possible.

To be great at my profession, I need to be a skilled communicator, salesperson, cheerleader, and anticipator. I need to influence behavior change, which takes time.

I must create individualized plans that not only account for my treatment plans, but that also incorporate anticipated barriers to ongoing commitment to behavior change, developing new habits, and addressing other outside factors that could prevent recovery.

The Big Picture

At a high level, all medical professionals first evaluate to develop a working diagnosis, then develop a plan to treat the acute or chronic condition. They “evaluate and manage” patients.

But how we have historically reimbursed professionals for that work does not take into account the time it takes to effectively communicate and engage with patients in their treatment plan. Getting patient buy-in and commitment is critical.

A general medical example we can all relate to:

My daughter developed a sore throat, pus on her tonsils, headache, and significant fatigue. I considered the possible diagnoses and knew the differential couldn’t be determined by a telehealth visit because she would need a throat culture for strep, at the minimum. It was Sunday, so we hit an urgent care.

Rapid strep, flu, COVID, all negative, I asked them to do a mono spot test. It was negative. We went home, and she continued to sleep a lot and have the same symptoms. Her throat was getting worse.

She saw the pediatrician the next day, we re-tested the strep and ordered bloodwork. I also knew the mono spot may not have picked up mono and that a blood test might be needed, and the pediatrician did order that.

The diagnoses: mononucleosis and significant anemia, possibly a side effect of the mono. The pediatrician called, prescribed Slow Fe with vitamin C, and explained the typical course of mono and avoiding certain activities because of the risks to her spleen in the short term.

I knew the mono stat might not pick up mono and that a venipuncture should be done if her symptoms didn’t improve. The doctor at the urgent care didn’t tell us anything other than “it’s viral.” No one called to check on her after. There was no other discussion other than “do you need a note for school or work?”

Why does it matter?

Yes, mono typically runs its course without complications. But mono symptoms last weeks. She has to be cautious about certain activities, and because this physician didn’t know her, couldn’t know her risk level if the mono stat was a false negative (common) or a few more days were needed for the test to pick it up.

Feeling sick and fatigued for weeks can cause depression in some people, and knowing there is a reason and an end in sight can help significantly. She also happened to suffer the side effect of significant anemia and required treatment. To top it off, she could transmit mono to someone else for 2-4 weeks or more.

How this relates to time

What I do know about the fee-for-service visit to the urgent care: payment wasn’t hinging on the amount of time she spent with my daughter or how effectively she communicated with her. Nor was her payment hinging on what happened after we walked out of the urgent care.

I’m a healthcare practitioner with the education and experience to know that the differential diagnosis given to my daughter was not conclusive, and there could be value in additional testing in this particular case. But should it be my responsibility to know these things?

In reality, there are many other things at play here, like the low value placed on non-transactional medical care. We have not valued communication with patients or the time communication takes in the vast majority of reimbursement structures.

What does this story have to do with mental health policy?

Mental and Behavioral Healthcare

Primary care is a pivotal point of opportunity to improve the health of a population. I could write a 5,000 word essay on this topic alone and barely scratch the surface.

As recent policy changes (such as the ones in my brief, linked below), regulatory updates, and innovative programs create the foundation for successfully re-imagining advanced primary care, the industry has a chance to act on these new incentives.

Early adopters are catching on to behavior health integration in primary care because of a series of other updates and the impacts of a pandemic. Widespread adoption will depend on the ability to recognize and analyze opportunities, and to be flexible enough to act on the right ones.

As I explain in my brief, new codes and provider classifications, changed in regulations and statute, open the door for mental health care providers to improve health at the primary care level.

Mental healthcare at the primary care level will facilitate some obvious improvements, like radically improving access to care and the likelihood that a patient will follow-up and receive treatment, once referred. But that’s only where it starts.

When a physician or non-physician provider sees any patient for any reason, a new, low friction solution may be available that would improve the likelihood of that provider thoroughly evaluating for behavioral health concerns.

Behavioral Health providers embedded within the primary care practice.

A common concern is that when non-medical findings may indicate a need for intervention outside of medicine, they are less likely to be evaluated for in the first place. If there is no way to address a problem and no reimbursement structure for the time it would take to research solutions and make direct connections to solutions, what’s the incentive to evaluate?

Some findings indicating a referral to the behavioral health provider in the practice will be straightforward, like classic depression, anxiety, or substance abuse. For those patients, while medication may be an important part of the treatment plan and may be addressed by the medical provider, the option to first be evaluated promptly by a mental health specialist is down the hall. Collaboration with the mental health provider is now simple and integrated.

What about for those with chronic health conditions whose treatment requires significant behavior change from things like long-term poor habits, poor health literacy, untreated long-term anxiety, poor self-image, and more? These individuals have a complicated road ahead to achieve medical goals like reducing exacerbations of heart failure or consistently managing their blood sugar in diabetics.

In primary care team-based care environments, professionals’ skills sets and expertise can be leveraged in the ways that are most aligned with their specialized value. Integrated care facilitates improved health outcomes and high-value care.

With a mental health provider as part of an advanced primary care team, behavior change, patient mastery of managing their conditions, and ongoing support and patient connection can be facilitated and rewarded.

As I described earlier about PTs’ need to be expert communicators to ensure patients were actively contributing to their treatment plans, mental health providers’ patient care depends almost exclusively on their ability to communicate and connect with patients and ideally other team members supporting their care.

These providers can also develop and train others in the practice on patient engagement techniques, and work with the same staff that are outreaching to the practice’s patients to achieve sustained progress on primarily medical impairment.

Patients generally trust and respect physicians, but may be wary or fearful of outreach to a mental health provider. When a physician invites mental health providers to be part of their primary care team, it creates a new paradigm for the value of mental healthcare in medical healthcare. It’s now not a stigma, but a necessity recommended by their primary care provider.

Behavior Change and Developing New and Sustained Health Habits are Non-Negotiables for Improving the Health of those with Chronic Conditions

This is most profound for diseases influenced by lifestyle.

The practices and organizations that understand how habits are influenced by processes and technology..

The ones that simplify and reward providers’ efforts towards evaluating and managing mental health and substance use disorder..

The ones who incorporate mental health providers into their practices..

The ones who automate prompts to outreach and provide critical feedback to patients…

The ones who make it easy and comfortable to connect with their practice anytime, day or night…

The ones who embrace technology that makes connecting at the right time with the right person simple…

The ones who adopt alternative payment models and prospective payment and invest in transforming how they provide care

Will be places where patients can receive the most comprehensive care

and…

these will be places where providers feel more satisfied, fulfilled, appreciated, and connected to the patients in their care.

Habits and Health

This weekend, I binged James Clear’s Atomic Habits on Audible. If you haven’t taken in this delightful and thought-provoking content, it’s not something you will regret. It’s an inspiring book that reminds readers that most success in all aspects of life ultimately depends on our habits.

And one of James Clear’s most famous quotes: