“Big Eight” Recommendations for Improving the Effectiveness of the U.S. Behavioral Health Care System

The Affordable Care Act (ACA) requires most individual and small-group health insurance plans that are sold on the health insurance marketplace to cover mental health and substance-related services. It is estimated that more than 60 million individuals now have new health care coverage for the treatment of mental and substance use (hereafter referred to as behavioral health) disorders (1).

The increased demand for health care services has created challenges for the existing health and behavioral health care systems. For example, the general health, mental health, and substance use services systems have traditionally each been distinct and separate. Separate training, funding streams, and separate vendors for electronic health record (EHR) systems have limited providers’ ability to offer integrated, whole-person care (2).

With the challenges come opportunities. The American health care system is poised for innovation that can help address the great need for services, accountability, and effectiveness of behavioral health care. Innovation has been brewing in pockets throughout the United States, and much of it has emerged as a response to the need for effective services in the context of limited funding.

The purpose of this Open Forum is to highlight strategies that can be advanced by federal agencies that address health and human services. The strategies are aimed to improve the delivery of effective behavioral health care services in the public and private sectors. The recommendations were selected because they can be accomplished through existing funds or authorities allocated to federal agencies and do not require additional funding.

This Open Forum is derived from an exploratory study undertaken to highlight strategies that can be used by federal agencies to remove barriers to the delivery of effective behavioral health care; align policies across federal programs and agencies; ensure consistent application of effective strategies; and define specific technical assistance, consultation, or other types of active facilitation. The goal was to identify strategies that could be implemented through existing funds and would not require new funding. The full study report included an extensive environmental scan, literature review, and 25 strategies, with several options for how to implement each strategy. The report was informed by in-depth semistructured interviews with national experts on innovative and effective methods for the provision and financing of evidence-based behavioral health services. A separate panel of national experts on federal funding, programs, and policy was convened three times in 2014 to ensure feasibility of strategies, and provided feedback regarding implementation of strategies.

For this final report, we culled the list of recommendations to the ones that we feel are the most relevant and promising—the “Big 8.” Each of the recommendations presented in this brief report assumes that the objective of behavioral health care is to focus on delivery of services that are evidence based, culturally sensitive, and likely to improve lives. The order of the recommendations does not reflect our view of their comparative significance.

The “Big 8” Recommendations

Recommendation 1: incentivize beneficial behavioral health care.

The health care financing system should ideally support and incentivize the delivery of beneficial and evidence-based behavioral health care. Performance-based incentives should be promoted to improve the quality of care. Performance-based incentives are defined as providing financial or nonfinancial (such as public recognition on a Web site) incentives to providers for quality improvement efforts that demonstrably improve patient experience or outcomes (3). Incentives might include classes or levels of accreditation—for example, in the way that the National Committee for Quality Assurance’s Patient-Centered Medical Home recognizes medical homes that integrate behavioral health care (4). Preferably, however, incentives can be explicitly linked to improved patient experience or outcomes. Incentives might involve differential payment rates (3).

Recommendation 2: provide flexibility within financing vehicles to support integration of care.

There is growing recognition of the benefits and evidence for integrating behavioral and general health care. The research has spurred implementation of a range of integrated care models, both in Medicaid and in private insurance contexts. There is potential for integrating behavioral and general health care within patient-centered medical or health homes, accountable care organizations, federally qualified health centers, and community mental health centers. In these settings, care integration is far from universal and payment methodology is a major barrier. The financing mechanisms for these health care settings should be creative and flexible enough to accommodate and encourage the adoption of integrated behavioral and general health care (5). Payers and managed care entities should address finance-related obstacles, such as allowing payment for psychiatric consultation in collaborative care situations, allowing payment for outreach and engagement activities that take place outside a clinical building, and avoiding unduly restrictive credentialing requirements, among others.

Recommendation 3: promote measurement-based care and quality improvement systems.

Measurement at the client, provider, organization, and population levels is an essential part of effective decision making and quality improvement. For example, a provider should measure response to treatment in an ongoing fashion and adjust treatment based on the individual’s preference and on whether individuals receiving care show improvement on predefined outcomes (6). Clinicians should use clinical outcomes measures with demonstrated validity and reliability, such as the nine-item Patient Health Questionnaire, the seven-item Generalized Anxiety Disorder Scale, and the Alcohol Use Disorders Identification Test, among others. The surveys conducted by the Agency for Healthcare Research and Quality’s Consumer Assessment of Healthcare Providers and Systems provide useful data on consumer experience across a range of clinical settings (7).

Recommendation 4: maximize use of shared, integrated EHRs and clinical registries.

Shared and integrated EHRs that are accessible to all providers working with an individual (that is, behavioral health, primary care, specialty care, and emergency department and hospital) can help enhance communication, enable safe care transitions, and generally improve the quality of care (8). The use of clinical registries to track progress for groups of clients with specific conditions is an essential element if we are to improve population health. Unfortunately, behavioral health organizations were not included in the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was enacted as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology. Therefore, behavioral health organizations have been slow to adopt EHRs as part of routine practice. Furthermore, integrating EHRs across provider organizations remains challenging given diverse health information technology systems, EHR designs that fail to include important behavioral health data elements, lack of registry functionality, and limited interoperability. Federal agencies should include behavioral health data, registry functionality, and more effective interoperability as future requirements for meaningful use and include behavioral health specialty organizations in the incentive program. Even as meaningful use incentives decline, the behavioral health field needs to increase involvement in EHR development and use, despite the special privacy challenges that the field faces.

Recommendation 5: encourage workforce development around integrated care methodologies.

With the movement toward integrating behavioral health and general health care, there is a need to train the provider workforce to contribute as part of an integrated team. Workforce development needs to be considered for those who are currently working, those who are new hires, and those who are at colleges and universities and will become part of the provider workforce. Federal agency leadership could encourage and incentivize educational institutions to train providers to function as care coordinators and in other roles as part of an integrated care team. Educational programs should include strong emphasis on quality assurance and how to use data to improve practice.

Recommendation 6: support patient- and family-centered care.

The Institute of Medicine defines patient-centered care as active involvement of individuals who are receiving care and their families in the design and in decision making in regard to the individual’s options for treatment and services. Patient- and family-centered care puts responsibility for important aspects of self-care and monitoring in the patient’s hands, along with the tools and support to carry out the plans (9). Federal rules, regulations, and communications should strongly support the use of shared decision-making tools and approaches and require consumer participation in health care organization boards and advisory committees (as they do currently for federally qualified health centers).

Recommendation 7: integrate providers of alcohol and drug abuse treatment into the patient-centered care team.

There is a shortage of trained alcohol and drug abuse treatment providers with higher education degrees. Furthermore, many psychologists and primary care physicians are not trained in the use of methods for treating substance use disorders. In the post-ACA marketplace, providers of substance abuse treatment need to be trained in integrated care and evidence-based services—including medication-assisted treatments—and oriented to the culture of integrated health settings (2). Training for the full care team should include the use of motivational interviewing (10) and SBIRT (screening, brief intervention, and referral to treatment for alcohol or drug use disorders).

Recommendation 8: protect patient confidentiality but remove barriers to sharing information within the care team.

It is critically important that we continue to protect patient confidentiality, but failure to share information within the full care team can create conditions in which the health and even the life of a patient are endangered. The substance abuse privacy regulations, 42 CFR Part 2 Confidentiality of Alcohol and Drug Abuse Patient Record, have unnecessarily blocked sharing of critical information and should be amended (2). Although HIPAA need not prevent sharing of information for treatment, largely incorrect interpretations of HIPAA have created barriers to good communication. Federal agencies should consider working together to amend 42 CFR Part 2 and provide clear guidance in regard to work flows and forms to obtain informed patient consent and share essential health information across the care team (2,11,12).