COVID-19 Highlights the Dire Need to Integrate Primary and Mental Health Services

Across the country, helpline calls for people with mental health and substance use issues are increasing at an alarming rate because of COVID-19. According to a new survey by the Census Bureau, one third of Americans are showing signs of anxiety or depression since before the pandemic. This staggering statistic highlights an urgent need to address a crisis that has largely been unmet in the United States. Moreover, COVID-19 is not only disproportionately affecting communities of color but also exposing racial and ethnic disparities in access to mental health care. According to SAMHSA, nearly 67% of Latino and 69% of Black Americans did not receive treatment for mental illness in 2018 compared to 56.7% of the general population.

As more Americans use emergency rooms and primary care providers to access mental and physical care services, we recommend policymakers focus on promoting integrated models of care that have proven successful in reducing health disparities and providing comprehensive services to those struggling with mental health conditions.

The Agency for Healthcare Research and Quality defines integrated behavioral and primary care as a team of primary providers and behavioral health clinicians working together, along with patients and their families, to provide patient-centered care. Research shows that integrating these services improves access to care and treatment outcomes, lowers rates of mortality, and potentially reduces healthcare costs by $38 billion to $68 billion annually. However, there have been significant inequalities in the treatment and insurance coverage of mental health compared to physical health in the U.S., creating a fragmented system.

To be sure, the effects of social distancing, economic insecurity, and uncertainty about the future course of COVID-19 are taking a toll on Americans’ mental health and well-being. The Centers for Disease Control and Prevention warns that the pandemic is causing fear and worry about one’s own health or the health of loved ones, changes in sleep and eating patterns, worsening of chronic health and mental health conditions, and an increased use of alcohol, tobacco, or other illicit drugs. In fact, the Substance Abuse and Mental Health Services Agency Disaster Distress Helpline received 11 times more calls in April 2020 than in April 2019.

The psychological effects of the pandemic are further straining our nation’s health care system, which continues to grapple with insufficient access to care for those with existing mental health issues. However, many Americans will experience mental health and substance use disorders for the first time. Prior to the pandemic, one in eight emergency room visits were related to mental health or substance use issues, a proportion which will certainly increase.

Those who have not experienced mental health conditions previously may not be aware of the physical symptoms that might also be present. For example, anxiety may come with palpitations, sweating, or nausea. Some may not recognize that these symptoms can be caused by an underlying mental health issue and may seek care from primary care providers or emergency rooms for their physical symptoms.

Integrated care has the potential to meet these demands and help provide better access to mental health services to those who predominantly use primary and ER services. Non-integrated care settings may not have adequate behavioral health resources, and, in these cases, people can miss out on the help they desperately need.

Integrated care ranges from coordinated care to co-located care and system-level integration. For instance, co-located care has both primary care clinicians and behavioral health providers working in proximity but does not go as far as system-level integrated care, which completely combines workflows, payment streams, and care delivery. If a patient presents with physical symptoms, such as palpitations, sweating, or nausea, the health care team in an integrated practice is more likely to identify an underlying mental health condition if present and be more prepared to provide the necessary care.

But while integrated care is an important part of the solution, without appropriate payment models and resources, many health care providers will have a hard time scaling up these models nationwide.

Recently, the Bipartisan Policy Center launched a task force to tackle policy barriers to the integration of primary and behavioral health care. Led by former Sen. John Sununu, Jr.; former Rep. Patrick Kennedy; Shelia Burke, fellow, BPC; and Richard Frank, professor of health policy, Harvard University, the work of the task force will continue through 2020. However, the group realized the immediate need for quick action in response to COVID-19 and released interim recommendations to expand access to telehealth and bolster training for an integrated care workforce. They recommended that:

• Congress and states should align commercial insurance and Medicaid telehealth policies with Medicare telehealth provisions in the CARES Act and recent Trump administration waivers.
• Congress should provide funds to the Health Resources and Services Administration (HRSA) to support fast-tracked targeted training opportunities for health care providers.

Expanding telehealth will increase access to behavioral health care for many vulnerable Americans. Moreover, our health care system needs a much more robust behavioral health workforce to meet increased need. Behavioral health training for physicians, social workers, nurses, and peer and recovery support specialists will lead the way towards a health workforce that is more prepared to deliver integrated care and address behavioral health needs due to COVID-19.

Addressing our nation’s current crisis calls for an integrated health care workforce and a health system that is better prepared to deliver both primary and behavioral health care. BPC’s task force will release a final report with recommendations later this year.