Behavioral Health Integration (BHI) is a model of care that places behavioral health staff and resources directly into health care settings such as primary care. This makes it easier for patients to access physical and behavioral health care in the same location, delivering a more seamless experience and better outcomes. With approximately 80% of Americans seeing primary care physicians annually, this approach delivers a more patient-centered system of care that is also more efficient, supports better patient and provider satisfaction, and increases equitable access to care while bending the cost curve.

Despite these clear benefits, provider organizations can face significant operational and financial challenges trying to implement integrated models of care. To address these specific issues, Blue Shield of California joined up with the California Quality Collaborative (CQC), Sutter Health, and Providence to complete a Connecting for Better Health Community Design Studio. Community Design Studios bring together cross-functional teams to co-create solutions to complex challenges in just a few weeks, with the resulting outcomes delivering clear next steps to make tangible change in our health care and social services systems.

Addressing Barriers to Integration

This group specifically focused on addressing the barriers that make it challenging to implement BHI models in the real world, using the Collaborative Care Model (CoCM) as the working example. To begin, the group analyzed and set out to address three specific layers of challenges:

  • Data barriers: Electronic health record (EHR) gaps that are not optimized for integrated care models and data infrastructure gaps make it more challenging to ensure that data is actionable, affecting the ability to refine and monitor performance and workflows as well as streamline claims and claim denials processes.
  • Billing and Reimbursement barriers: Historically, challenges with CoCM billing have led to higher claim denials rates, increased administrative costs, and complex clinical workflows. Improper denials and/or delays occur due to inconsistent payer rules, misaligned billing models, and limited data integration, causing difficulties delivering this model within primary care.
  • Operational barriers: Operational barriers are both      systemic and unique to each provider organization, depending on staff and resources. Billing is more complex, creating more administrative burden on providers and workflows. Due to the intersection of health care and behavioral health, these claims are often misunderstood, leading to a high denial rate.

Leveraging User Experiences to Deliver Solutions

Once these barriers were identified, the Design Studio anchored its work around a future vision: How might we improve billing and reimbursement for CoCM services so that more practices will embrace and be able to sustain the model, helping make integrated behavioral health the default in primary care rather than the exception?

Blue Shield brings unique experience to answering this question. Blue Shield has collaborated with other health plans and providers for the last five years to identify and improve health plan processes to improve timely and accurate reimbursement. With this knowledge and experience in place, they were able to help contribute to the deep analysis required to articulate the needs of these stakeholders into workflows. Using these insights from Blue Shield and other group members, the Design Studio turned existing experiences into concrete billing guidance for CoCM, giving practices and health plans a shared roadmap to reduce denials, cut administrative burden, and make CoCM financially viable.

To identify opportunities and challenges, the group developed a persona, or an example of a typical patient, and “walked” them through every step of the current state of accessing and receiving care in a CoCM. By taking this approach, the Design Studio was able to identify each of the specific issues that emerged for the various entities involved, including the patient, provider, practice, payer, etc. These key insights and their impact allowed this cross-functional team to then collaborate on recommendations that would address the specific barriers as they emerged.

 

Accessible Recommendations for Change

The Design Studio participants brought together their considerable knowledge, expertise, and reach to identify specific recommendations to overcome challenges when implementing CoCM — from EHR workflows and user experiences that would improve visibility to revenue cycle management (RCM) system workflows. By delivering a clear guide and blueprint for addressing these challenges, Blue Shield is participating in collaborative, cross-functional activities that will support its long-term impact.

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