Each year in the U.S., hundreds of billions of dollars are spent on ineffective treatment of comorbid behavioral health conditions. Integrating behavioral health and primary care services has been shown to lower costs and improve quality of care, but navigating reimbursement remains a challenge for most provider organizations.
There are several significant obstacles to the financial sustainability of integrated behavioral health programs. Providers often struggle with complicated billing requirements, low reimbursement rates, and variable coverage policies under commercial and public payers. For that reason, the majority of integrated behavioral health programs tends to rely on grant funding.
While the business case for an integrated behavioral health model is strongest in populations covered under risk-based contracts, providers can successfully apply the integrated model under fee-for-service to generate financial returns. For example, improved behavioral health treatment for Medicaid and uninsured patients can reduce low-value downstream services such as avoidable medical admissions or readmissions.
How to improve care management for three Medicaid populations
A comprehensive pro forma is a valuable tool for identifying breakeven targets for cost-effective, sustainable behavioral health integration. To create an effective integrated behavioral health pro forma, the model should minimally include the following components.
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