Preventive Services Covered by Private Health Plans under the Affordable Care Act

Integrated Care Opens New Doors To Mental Health, Addiction Care

In every American community — wealthy or poor, rural or urban, young or old — at least 1 in 5 people live with mental health disorders. And yet no American community has an adequate supply of mental health clinicians who can provide timely, affordable, high-quality care for the people who need it.

Untreated mental illness has a profound toll: poor health outcomes, missed work, high costs of care, and premature death. Only half of individuals referred for treatment are actually seen by a mental health care provider and, when they are, the average number of visits is just two. Only half of psychiatrists accept insurance, and less than half of U.S. Counties have any psychiatrists at all.

Why is there such a mismatch between supply and demand for mental health care?

The main reason is that the U.S. Health care system has for years driven a wedge between care for the mind and care for the body. With separate insurance, different methods and amounts of payment, and silos between clinicians, mental health care has been isolated from the rest of the health care system, making it hard for people to access.

But that divide is beginning to erode, thanks to a movement called integrated mental health care. Integrated care places mental health clinicians side by side with physical health clinicians in other specialties, like primary care and oncology. With mental health expertise and services integrated into these practices, patients can be quickly connected to well-coordinated whole-person care. Even for individuals without other health issues, accessing mental health care through their primary care provider is more convenient and less stigmatized.

We launched an integrated care program at Penn Medicine in January 2018. It is based on a model called Collaborative Care, originally pioneered at the University of Washington in the late 1990s. It embeds clinical social workers in primary care practices to proactively monitor and treat patients with mental health issues. We anticipated the program would see 500 patients in its first year. Instead, more than 13,000 have been referred into the program in the first two years, roughly 10% of whom reported having thoughts of suicide.

Here's how the program works: When patients come to one of our primary care offices, they are screened for depression with two simple questions. If the screen is positive, or if a patient or primary care doctor identify other mental health concerns, a more detailed assessment is offered.

For common problems like depression, anxiety, and some substance abuse issues, patients are enrolled with social workers in our practice who do frequent check-ins over a three- to four-month period. Psychiatrists provide behind-the-scenes support and guidance to social workers and primary care doctors as they work directly with their patients. This team-based, protocol-driven approach allows us to spread psychiatrists — a scarce resource — over a much bigger population than they could see on their own.

Patients who do well "graduate" from the program and continue with regular primary care follow-up. For those who continue to struggle, the integrated team tries other strategies or connects them with mental health clinicians with additional expertise.

For more complex problems, like bipolar disorder or post-traumatic stress disorder, we help patients find mental health clinicians outside of our practice and follow up later to ensure they have been seen.

The Collaborative Care model has been proven effective in dozens of studies in various settings. Not only do measures of mental health improve, but medical conditions like diabetes also improve and use of the hospital and emergency room goes down. Integrated care also saves money. For every $1 spent on collaborative care, a seminal study found a $6 savings in overall medical costs.

Integrated care is gaining traction nationally. In 2017, Medicare created new payments to support integrated care. In August 2019, Illinois became the first state requiring all insurance companies to cover these payments. Democratic presidential candidate Pete Buttigieg's mental health policy plan includes several integrated care initiatives. In September, Walmart opened its first store-based primary care clinic offering mental health services.

Still, more can be done to help spread integrated care. First, insurance companies and employers who provide insurance to their employees should end the practice of separating mental health insurance from medical insurance. Second, Medicare and insurance companies should cover payments for integrated care without any copays or deductibles for patients. Third, training programs for physicians, nurses, social workers, and others must begin teaching the skills these clinicians will need to deliver integrated care. Fourth, physicians, hospitals, and health systems should embrace integrated care as enthusiastically as they would a new wonder drug or innovative surgical procedure and immediately implement integrated care in their practices.

Mental health is a complex issue, and integrated care is no panacea. But it's a practical, patient-centered solution with proven benefits, which is not easy to come by in American health care. By opening the doors of medical care to include mental health, we will help meet one of our communities' most urgent needs.

Matthew Press, M.D., is interim chair of family medicine, associate medical director of the primary care service line, and associate professor of medicine in the Perelman School of Medicine at the University of Pennsylvania. He was previously employed by the Centers for Medicare and Medicaid Services and worked on payment for integrated mental health. Cecilia Livesey, M.D., is the chief of integrated mental health, associate residency training director, and clinical assistant professor in the department of psychiatry in the Perelman School of Medicine. The opinions expressed here are the authors' and do not necessarily represent those of the University of Pennsylvania Health System or the Perelman School of Medicine.

Pediatric Behavioral Health Improves With Integrated Primary Care

Expanding pediatric behavioral health care to include integrative services that encompass meetings with behavioral health clinicians (BHCs) and psychotropic prescriptions led to reductions in scores on the 17-item Pediatric Symptom Checklist (PSC-17), indicating improved overall behavioral health outcomes, according to new research.1

Contributions from meetings with community health workers (CHWs) were also evaluated, but were not shown to make a statistically significant difference in the children in the study cohort compared with the children in the control group. These results were published online today in JAMA Network Open.

The study authors used electronic medical records from June 2020 through April 2023 from 4 federally qualified health centers that implemented the Transforming and Expanding Access to Mental Health Universally in Pediatrics, or TEAM UP, model of integrated behavioral health care. For study inclusion, children had to be aged 4 to 18 years, have completed the PSC-17 at the time of or after their index screening for a behavioral health concern, have at least 1 follow-up PSC-17 between 6 and 18 months later, and have a note in their record of a behavioral health concern from their primary care physician.

A score of 15 or higher on the PSC-17 indicates concerns, with total scores ranging from 0 to 34 and each item being scored a 0 (never), 1 (sometimes), or 2 (often).

These investigators explain that despite calls for greater availability of integrating behavioral health care services for a pediatric population with their primary care services, data demonstrating current resources are insufficient for these patients, and considering previous research on the effectiveness of integrated behavioral health care,2-5 indirect evidence is still needed "that supports the "minimal, sequential clinical assumptions that must be verified using empirical evidence."1

Overall, 368 children had behavioral health encounters and were matched to a control cohort of 528 children. Of this group, 58.4% were female patients, their mean (SD) age at the baseline visit was 11.7 (3.5) years, most were Hispanic (43.8%) or non-Hispanic White (27.7%), the primary language was English (51.9%), and the top 5 health concerns were depression (32.9%); anxiety (31.0%); hyperactivity, inattention, or disruptive behavior (29.6%); parent or caregiver mental health concern (17.9%); and emergency services (15.5%). Food was the most common health-related social need in 7.9%.

Just 2.4% reported a previous encounter with a CHW and 1.6%, prior use of psychotropic medication.

The children with behavioral health encounters were older than the control cohort (11.7 vs 10.9 years), more likely to speak Spanish as a primary language (29.9% vs 19.5%), and more likely to have behavioral health concerns identified by a health care practitioner (32.9% vs 14.0%, depression; 31.0% vs 12.9%, anxiety).

There were 3 regression analyses in regard to changes measured by the PSC-17, and each compared results between children who did and did not receive the treatment, respectively. Baseline PSC-17 scores were 2.06 points (95% CI, 1.03-3.09) higher for at least 1 BHC encounter, 1.46 points (95% CI, 0.29-2.63) higher for at least 1 CHW encounter, and 4.06 points (95% CI, 2.76-5.36) higher with at least 1 medication prescription. Improvements by way of a 1.51 (95% CI, −2.65 to −0.37)–point reduction from least 1 BHC encounter and a 2.21 (95% CI, −3.89 to −0.54)–point reduction with prescription receipt were seen in the treated group. The point reduction from a CHW encounter was 0.53 points (95% CI, −1.86 to 0.80).

Children in the control group did not see any significant changes in their PSC-17 scores.

The study authors also considered total BHC and CHW encounters. Having at least 2 BHC encounters was linked to a PSC-17 improvement of 2.17 points (95% CI, –4.03 to –0.31) and 3 or more encounters, 1.70 points (95% CI, –3.03 to –0.37). Again, the results for the control group were not statistically significant.

Externalizing scores also improved in the treated group of patients vs the controls: by 0.77 points (95% CI, –1.26 to –0.28) for at least 1 BHC encounter and by 0.92 points (95% CI, –1.63 to –0.03) for receipt of medication, with the authors noting, "Descriptive analyses suggest that symptom improvements generally aligned with the type of presenting concern and treatment received."

The authors explain that their findings back efforts of integrating pediatric behavioral health care at federally qualified health centers and that there is a dose effect, too, for BHC encounters. Their study is also the first to use a nonrandomized trial to evaluate the impact of integrated pediatric behavioral health care services on behavioral health symptoms. Additional study strengths are that their findings on the TEAM UP model echo previous research on the effectiveness of psychotherapy and psychotropic medications and they focused on specific elements of behavioral health care.

However, there are also limitations. The electronic medical records did not include information on outside health care received, results could be biased from regression to the mean, clinical significance was difficult to estimate because the PSC-17 does not have a minimal clinically important difference, and results were included on all children identified as having behavioral health concerns, not just elevated screening scores.

References

Kim J, Cole MB, Rosenberg J, Morris A, Feinberg E, Sheldrick RC. Integrated behavioral health services and psychosocial symptoms in children. JAMA Netw Open. 2025;8(9):e2532020. Doi:10.1001/jamanetworkopen.2025.32020

Kolko DJ, Campo JV, Kelleher K, Cheng Y. Improving access to care and clinical outcome for pediatric behavioral problems: a randomized trial of a nurse-administered intervention in primary care. J Dev Behav Pediatr. 2010;31(5):393-404. Doi:10.1097/DBP.0b013e3181dff307

Kolko DJ, Campo J, Kilbourne AM, Hart J, Sakolsky D, Wisniewski S. Collaborative care outcomes for pediatric behavioral health problems: a cluster randomized trial. Pediatrics. 2014;133(4):e981-e992. Doi:10.1542/peds.2013-2516

Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis. JAMA Pediatr. 2015;169(10):929-937. Doi:10.1001/jamapediatrics.2015.1141

Wolfe I, Satherley RM, Scotney E, Newham J, Lingam R. Integrated care models and child health: a metaanalysis. Pediatrics. 2020;145(1):e20183747. Doi:10.1542/peds.2018-3747

Newsletter

Stay ahead of policy, cost, and value—subscribe to AJMC for expert insights at the intersection of clinical care and health economics.

Dr Lori Raney Defines Integrated, Collaborative Care For Behavioral Health

Lori Raney, MD, principal, Health Management Associates, provided a definition and examples of integrated care for physical and behavioral health, in addition to explaining the strengths of the collaborative care model.

Transcript

How would you define integrated care, and what are some examples?

Integrated care is when you design a healthcare system to address the physical health and the behavioral health of a particular patient or in a particular patient population. We talk a lot about the integration of behavioral health into primary care settings, but we also talk about integrating primary care into behavioral health settings so that we get whole-person care.

Other examples would be addressing behavioral health conditions in intensive care units, on medical/surgical inpatient units, in emergency rooms, and in other clinics, but mostly what you'll hear people talking about when they mention integrated care is really thinking about addressing behavioral health in primary care settings.

What is the collaborative care model and how can it deliver evidence-based behavioral health care?

The collaborative care model is a very robust model of integrating primary care and behavioral health, primarily in the primary care setting. In this model, behavioral care managers, who are typically licensed social workers, psychologists, therapists, work with the primary care provider and the patient to come up with a treatment plan to address their behavioral health conditions. Supporting that is the work of a psychiatric consultant, so they're reviewing the patient's care, their treatment plan, and making suggestions to the primary care provider for how to change or intensify or adjust their treatment if they're not getting better.

The model really works off some core principles, such as measurement-based treatment to target, so we are able to treat someone's depression to remission, to clinical improvement, just as we would with something like diabetes.

Newsletter

Stay ahead of policy, cost, and value—subscribe to AJMC for expert insights at the intersection of clinical care and health economics.

---