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March 10, 2022
Primary Care Transformation Mental Health
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California, like the nation, is facing a behavioral health crisis. Nearly one in six Californians experience mental illness, with the majority of serious mental illness appearing before the age of 25 during adolescence.
The COVID-19 pandemic has increased mental health care needs while simultaneously restricting access. In early 2019, 1 out of 10 adults in the United States reported symptoms of anxiety or depressive disorder. In 2021, about 4 out of 10 adults reported these symptoms. Likewise, the fraction of adults reporting unmet mental health care needs rose from 9.2% in August 2020 to 11.7% in February 2021. Nationwide mental health clinician shortages intensify barriers to care for many communities, especially rural populations.
The issue of mental health has been particularly pronounced for youth, for whom US Surgeon General Vivek Murthy issued an advisory declaring a mental health crisis in December 2021. In 2020, the proportion of mental health–related emergency department visits for those aged 5 to 11 years saw a 24% increase, and those aged and 12 to 17 years saw a 31% increase, from 2019.
The National Academies of Science, Engineering, and Medicine’s (NASEM) 2021 report “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care” describes a vision of high-quality primary care: whole person care that accounts for the mental health of a person in addition to other needs. The report emphasizes that “[w]hole-person health focuses on well-being rather than the absence of disease. It accounts for the mental, physical, emotional, and spiritual health and the social determinants of health of a person.” The NASEM plan identifies and defines five objectives for achieving high-quality care:
On February 24, during Innovation and Integration: Addressing the U.S. Mental Health Crisis through Primary Care Partnerships, the second event in Blue Shield California and Milbank Memorial Fund–sponsored Primary Care Payment Innovation series, participants discussed how partnerships, payment innovation, and digital health in primary care can help to address mental health. This conversation built off our first event, which illustrated how payment innovation can advance health equity, as well as an op-ed by Shruti Kothari, Director of Industry Initiatives at Blue Shield California and Christopher F. Koller, President of the Milbank Memorial Fund. The second event, moderated by Shruti Kothari, included panelists Gil Addo, Chief Executive Officer, RubiconMD, Nina Birnbaum, Medical Director, Blue Shield of California, Jessica Cruz, California Executive Director, National Alliance on Mental Illness, and Karan Singh, Chief Operating Officer, Headspace Health.
1. Mental health and physical health are intertwined, so integrated care is essential
“Primary care should be the foundation of a well-run health care system, and we need to provide the right support to primary care to enable them to quarterback care for the patient.” – Gil Addo, Chief Executive Officer, RubiconMD
The first place that most people turn to for care is their primary care provider. It is critical that prevention and early intervention needs are served in the primary care setting. Treating patients with behavioral and health conditions can cost more than twice times as much as other patients, often because of how poorly these conditions are managed. Payers and other stakeholders must provide direct support to primary care teams to help develop capacity to treat mental health conditions where appropriate and coordinate care by specialists when necessary.
2. Workforce capacity needs to be strengthened, with the promotion of coordinated team-based care
“As with [nurse practitioners] and [physicians assistants] historically within primary care, there are opportunities within mental health care to start to introduce new levels like coaches that can be part of the care team.” – Karan Singh, Chief Operating Officer, Headspace Health
The existing health care infrastructure is not sufficient to meet the demand for mental health care. Health care workers report high rates of burnout, with many leaving the field altogether. To provide compassionate and equitable mental health care, meeting workforce needs should be a priority. This includes training and payment to developing multidisciplinary teams in primary care teams. A collaborative care team has members who can screen for symptoms of mental health disorders, coordinate care, case manage, provide resources, and deliver treatment to patients. This model of care is not only safer and more efficient, but also leads to better outcomes and a more equitable system.
Clinicians and leaders should also remember that patients and families are a critical part of the care team. Policies should also explore reimbursement pathways for family caregivers. Research shows that patient outcomes improve when families play an active role in mental health treatment decisions. NAMI California advocates for a patient- and family-centered approach, in which the patient and their loved ones participate in planning, implementing, monitoring, and evaluating treatment. Primary care providers should provide patients and caregivers with education and resources to support shared decision-making.
3. Value-based care and multipayer collaboration strengthen primary care and behavioral health integration
“We have to find a way to get to multipayer alignment because practices can’t take the risk of doing things differently unless they have a reasonable guess that they can achieve financial stability under these new models.” – Nina Birnbaum, Medical Director, Blue Shield of California
Rather than working within a system that rewards the volume of services, we need to develop payment systems that incentivize financial and human investments in integration. For a value-based care model like Oak Street Health to scale, credit for primary care needs to be built into the model so that providers have the coverage to do more. Other payment partnerships and models, like Ginger and Headspace, can also support this integration. These applications provide access to a full care team, including coaches, therapists, psychiatrists, as well as an underlying data infrastructure. Headspace increasingly partners with health plans, where payments cover an episode of care or are paid on a per member per month (PMPM) basis.
One payer alone cannot make an impact: we need multipayer investment with program alignment to make this vision reality. As an example, Blue Shield of California is working with the Integrated Healthcare Association and Purchaser Business Group on Health to convene 10 of the largest health plans in California to move toward voluntary participation in advanced primary care models that provide for behavioral health integration.
4. Digital health plays an integral role in providing behavioral health to communities
“Technology is a mechanism to start to unlock affordable access for far more people… It’s a combination of great technology, new care models, and covering new kinds of care like coaching, content, and other resources that traditionally have not been considered part of mental health.” – Karan Singh, Chief Operating Officer, Headspace Health
Digital health mechanisms help empower consumers and their caregivers by easing access to care, especially in underserved rural areas and communities of color, and should be supported by payers. Apps like Headspace Health offer behavioral health coaching, meditation, and mindfulness content, and provides access to care to patients that the traditional health care system may not address.
Lack of access to technology is a social determinant of health, and digital tools promote patient engagement have the potential to lead to better health outcomes. While affordability and digital literacy pose challenges to scaling access across populations, these barriers can be overcome through intentional investment and support, guided by communities and by using a patient-centered approach. Considerations should include ensuring patient privacy and cultural elements like language access.
5. Community voice is critical to designing a system that meets mental health care needs
“At the end of the day, the treatment is affecting the individual and their families.” – Jessica Cruz, Executive Director, NAMI California
Payers, providers, and policymakers need to solicit family and community voices when it comes to treatment, governance, and the prioritization of decisions and policies. Community input can and should influence provider services, such as behavioral health integration. For instance, the community health center model of community governance surfaces patient needs and creates provider accountability. Policymaking needs similar community input. For example, Medi-Cal’s current payment structure is a barrier to integrating behavioral health and physical care due to mental health and substance use service delivery carve-outs from Medi-Cal Managed Care. Organizing, channeling, and amplifying community input is necessary for the policies that will make the kind of care discussed in the panel possible.
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