The case for holistic delivery of physical and mental healthcare

Healthcare organizations can meet growing demand when whole-person care models integrate behavioral health and primary care services.

Physical and mental health often are symbiotic. Depression, for example, is linked to asthma, diabetes, cancer, cardiovascular problems, sleep issues and more, One-third of people with serious medical conditions experience mental health issues.

Yet, particularly in the US healthcare system, there’s little coordination between primary care clinicians and behavioral health providers. Further, with the fragmented availability of behavioral health services, two-thirds of primary care physicians say they’re unable to connect their patients to outpatient mental health services.

The gap also leads to further negative consequences, such as the potential for adverse drug interactions when there’s no single point of coordination for all treatments prescribed to patients with behavioral and physical co-morbidities. The risk of undiagnosed conditions also grows when primary care and mental health specialists cannot coordinate their care.

One study found the US healthcare industry could save $185 billion annually by integrating behavioral health services into primary care. While investing in the necessary systems and offering additional benefits would increase costs initially, the projected returns are considerable, as much as $3 for every $1 of investment in integration.

There is enormous market opportunity for healthcare organizations that integrate primary and behavioral care. By rethinking their operations and supporting them with modern capabilities, health organizations can deliver holistic strategies and whole-person care models that deliver efficiencies and cost savings, as well as better care outcomes.

Stage is set for integrated behavioral and primary care services

A mix of cultural, regulatory and technological incentives have intertwined to create a compelling business case for integrating mental health, crisis management and addiction services into primary care. These forces include:

• Demographic needs. The elderly are susceptible to depression and anxiety, often as a result of their medications and physical health changes. As the US population ages, an integrated care model will help clinicians recognize and mitigate these issues. Meanwhile, studies and surveys show increasing anxiety and depression among adolescents, representing a growing need for services among this population, as well.
  
  
• Cultural shifts. Increased public awareness of mental health challenges, including celebrities and athletes sharing their experiences, has encouraged more individuals to seek help with less fear of being stigmatized.
  
  
• Expansion of digital health services. Telehealth and digital mental health platforms can make primary and mental healthcare more accessible and convenient. Digital channels often are the preferred choice for younger people.
  
  
• Regulatory requirements. The 2024 final rules relating to the Mental Health Parity and Addiction Equity Act are designed to protect healthcare insurance plan participants, beneficiaries and enrollees from facing greater restrictions on accessing mental health and substance use disorder benefits than they do with medical or surgical benefits. The rule doesn’t require insurers to offer mental health services but creates the expectation that such services will be easy to access and covered by benefits.
  
  
• Empowered healthcare consumers. A recent Gallup poll found 57% of Americans think mental health service access, cost and quality are much worse than medical services. With dozens of new entrants in the mental health space, and consumers increasingly free to choose where they spend their healthcare dollars, some of these new approaches may disrupt traditional delivery models.
  
  
• Technology innovation. Generative AI, machine learning, automation and data analytics make it possible to more easily coordinate holistic care while also improving overall operations efficiency. “As a service” models can enable healthcare organizations to tap modern technology more cost effectively. Federal interoperability regulations and application programming interfaces (API) based on FHIR®* standards should enable more fluid data flows that enhance care coordination, improve data accessibility and support comprehensive care.

These shifts are driving demand for behavioral health services, with state governments, school districts, employee assistance programs and pharmaceutical companies looking for care partners. The challenge is how best to deliver integrated primary and mental healthcare.

A tale of two models

Many large payer organizations are experimenting with two different models for blending primary and behavioral healthcare. One popular approach is the delegated model, where a health plan taps a third-party vendor or partner to manage administrative services, care navigation, treatment services, member awareness and engagement campaigns.

While the delegated model requires less initial investment, it is not member-centric. Member medical records are unlikely to be integrated across behavioral and physical care providers and depending on the number of vendors or partners involved, records may be even more fragmented. Much of the member experience is beyond the payer’s control, limiting the ability to develop new holistic products and services. That limits potential returns.

In contrast, an integrated model seamlessly merges physical and behavioral healthcare service delivery. Primary care physicians, medical and behavioral health case managers, nurses and consulting psychiatrists all collaborate to treat patients. Medical records, including prescription drugs, are integrated across behavioral and medical services. The behavioral benefits in the health plan are on par with medical benefits, as are reimbursement levels.

This model puts the member-patient first. It requires more investment and is less mature, but the potential returns are greater. Controlling the member experience is critical to delivering better outcomes and greater satisfaction. The winners will retool their value chains, from benefit design through reporting, with the right capabilities to support affordable, accessible holistic care.

A new value chain for integrating primary and behavioral healthcare

To succeed with an integrated holistic care model, healthcare organizations need to simplify and modernize key steps throughout the value chain. This streamlining will benefit all lines of the business and create a foundation for serving new markets with holistic health benefits. Here are just a few examples based on our client work.

• Enhancing operations. Building behavioral health benefits into primary care coverage has ripple effects all along the value chain.  Product strategy, actuarial analysis, benefits design and risk adjustment are obvious areas for retooling. Beyond these areas, there are also impacts on downstream operations. When a client launched behavioral health services, we helped develop a strategy for how the plan could deliver encounter and provider extracts to the state, explanation of benefits and check payments to providers, and track the claim paid amounts. We also redesigned the plan’s care administration and advocacy functions.
  
  
• Speeding enrollment. A client offering behavioral health services quickly realized it had to streamline its existing onboarding processes. Doing so required mapping all the applications and systems related to onboarding and using bot-driven automation to speed configuration data and customization processes.
  
  
• Claims management. Holistic care delivery can create new challenges for processing claims and ensuring accurate payments and member accumulators. This was proving difficult for a client operating multiple claims management systems built on obsolete technology. By migrating to a single platform, the client eliminated costs and inefficiencies, reduced total cost of ownership and was able to build a holistic view of its members’ behavioral and primary care experiences.

These are just a few examples of how value chains must evolve to support holistic primary care that combines physical and mental health services. It’s a necessary evolution for healthcare organizations that want to maximize opportunities to serve new customers and expand member bases with whole-person care.

By investing in new benefits and underlying operations support, payers can ultimately reduce medical costs and boost member and provider satisfaction. In the near term, modern systems reduce operating costs and improve experiences across all plans. That’s a holistic improvement to accompany whole-person care.

*HL7® and FHIR® are the registered trademarks of Health Level Seven International and their use of these trademarks does not constitute an endorsement by HL7.