White House Gives a Shot in the Arm to Collaborative Care

‘A wide range of excellent suggestions to advance integrated care’

The White House package for extensive new mental health interventions puts the Psychiatry-based collaborative care model (CoCM) at its centerpiece.

CoCM, alongside additional funding and raised reimbursements, are the key components proposed in a 122-page supporting document Tackling America’s Mental Health and Addiction Crisis Through Primary Care Integration produced by the Bipartisan Policy Center.

ACLP president-elect, Maryland Pao, MD, FACLP, clinical director of the Mental Health Intramural Research Program at the National Institutes of Health, says: “That document has a wide range of excellent suggestions to advance integrated care, including putting behavioral measures in a package of measures for primary care, and loan repayments for all professionals in these settings.”

The document sets out how individual providers should be incentivised to participate in integration. It suggests:

• Creating a novel payment model that allows primary care providers to cover the full range of primary care and mild-to-moderate behavioral health services under enhanced risk-adjusted capitated payments in traditional Medicare. It is estimated that this recommendation would serve between 200,000 and 800,000 Medicare beneficiaries and cost the federal government $2.9 billion over 10 years.
• Providing funding for a loan program to assist individual providers and small primary care practices with the upfront costs of implementing behavioral health services.
• Including additional behavioral health integration measures into Medicare’s Merit-based Incentive Payment System to incentivize behavioral health provider participation in integrated care.
• Removing barriers to the adoption of CoCM. It is estimated that this recommendation would cost the federal government approximately $224 million over 10 years.

The American Psychiatric Association (APA) says that the strategy elevates national attention to improve the nation’s mental health and devotes federal resources to policies that will ensure millions of Americans have access to the care they need.

“To see the mental health crisis elevated to this level by the President is truly an encouraging sign,” says APA president Vivian Pender, MD. “The mental health crisis is, indeed, something that affects us all, regardless of politics, geography, race, or ethnicity: there is no health without mental health. Now we need action to put new measures and funding into place, while also ensuring that we are implementing any policies in a way that decreases inequity in the provision of care.”

Presidential pledges

In his first State of the Union, President Joe Biden outlined policy which has historically been supported by both Republicans and Democrats. He said: “Our country faces an unprecedented mental health crisis among people of all ages. Two out of five adults report symptoms of anxiety or depression. And, Black and Brown communities are disproportionately undertreated—even as their burden of mental illness has continued to rise. Even before the pandemic, rates of depression and anxiety were inching higher. But the grief, trauma, and physical isolation of the last two years have driven Americans to a breaking point.”

At the heart of the crisis, he said, is a severe shortage of behavioral health providers. “More than one-third of Americans live in designated Mental Health Professional Shortage Areas, communities that have fewer mental health providers than the minimum their level of population would need. Even outside of these shortage areas, the fragmentation of the current system makes it hard for mental health providers to meet people where they are. We must dramatically expand the supply, diversity, and cultural competency of our mental health and substance use disorder workforce—from psychiatrists to psychologists, peers to paraprofessionals—and increase both opportunity and incentive for them to practice in areas of highest need. Our crisis response infrastructure must also be strengthened to ensure that those facing acute behavioral health challenges can be seamlessly connected to necessary services.”

The President committed to invest in proven programs that bring providers into behavioral health. “Doctors, nurses and other clinicians cannot do this work alone.” Investment in training will increase the number of community health workers and other health support workers in underserved communities. “The President’s FY23 budget will also propose major, new, multi-year funding to develop provider capacity and support mental health transformation.”

New funding will also build a national certification program for peer specialists which will accelerate adoption of the peer mental health workforce and promote the mental health of frontline health care workers. Together with the launch of a 988 crisis response line, certified community behavioral clinics will be expanded, and investment made into research on new practice models.

Significantly, the President commented that less than half of Americans with mental health conditions receive treatment. “Those with mental illness are often misunderstood, mistreated, mislabeled, and misdirected to services. It is imperative that we promote better pathways to care and make it as easy as possible for all Americans with behavioral health needs—including common and pervasive conditions like anxiety and depression—to access the resources that will improve their well-being.”

The President promised to double funding for primary and behavioral health integration programs in his 2023 budget through:

• Integrating mental health and substance use treatment into primary care settings.
• Equipping primary care providers with tools to identify, treat, and manage behavioral health conditions.
• Supporting whole-person care through behavioral health integration.
• Investing in tele- and virtual mental care options—saying that telehealth had proved itself to be safe and effective during the pandemic while it had also reduced barriers to care.

But, the President acknowledged: “We cannot transform mental health solely through the health care system. We must also address the determinants of behavioral health, invest in community services, and foster a culture and environment that broadly promotes mental wellness and recovery. This crisis is not a medical one, but a societal one.”

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