Integrating mental health into primary care practice settings needs both research and a payment structure that works.

  • Primary care practices screen too few patients for mental illness, missing many cases.
  • Researchers evaluated the global budget model, which is a capitated system that can enhance the integration of mental health services in primary care.
  • The global budget exercise has resulted in more patients being seen by the mental health clinicians.

A growing national trend to better integrate mental health into primary care practice settings needs two components to make it a feasible model for healthcare organizations.

The first component is research, and the other piece involves paying for these integrated services — a challenge in America’s fragmented delivery system, says Benjamin Miller, PsyD, chief policy officer for Well Being Trust of Oakland, CA, and senior advisor for Eugene S. Farley, Jr. Health Policy Center at the University of Colorado School of Medicine in Denver.

Because of the fragmented payment system, mental health and primary care services have evolved separately, which has been a mistake from a healthcare quality perspective. “Only 4% of primary care physicians screen patients for depression,” Miller says.

He cited a study published in July 2017 in the journal Psychiatric Services. Researchers found that the overall rate of depression screening was 4.2%, with African-Americans being screened half as often as whites.1

The United States’ overall major depressive episode prevalence for adults is 6.7%, with women at 8.5%, according to 2015 data by the National Institute of Mental Health.2

There is a disconnect between what’s needed to help patients improve their health and the screening and services available, he says. One factor involves how healthcare is paid. The predominant system now used is fee-for-service, in which there is retrospective payment for each item of service provided, based on billing codes submitted to payers.

The Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) model, formed by a partnership of Colorado healthcare organizations, has evaluated an alternative: the global payment model. This capitated system model pays a predetermined rate per person to healthcare organizations, allowing the organizations to determine which services to deliver.

Four years ago, Miller was part of the collaboration to test a prospective payment model that allowed mental health clinicians to perform their jobs without the constraints of fee-for-service payment.

The study involved patients from primary care settings. Each setting had an onsite mental health clinician. The study compared outcomes between two different types of reimbursement for primary care services in those settings. One type was the traditional payment model in which primary care clinicians sent patients to the embedded mental health clinician when necessary. The others used an alternative payment model in which funding was given to treat patients, including those needing mental health services.

“The facilities received a global budget that took into account the cost of the mental health clinician,” Miller explains. “They didn’t have to bill for their own services, but could do whatever the practice determined was appropriate to do.”

Researchers wanted to know whether payment model type affected primary care clinicians’ ability to treat and identify patients with mental health needs. If it proved that a global budget improved mental health screening and resulted in more patients being treated, then the next question was whether this resulted in cost avoidance.

“We didn’t do any training [of primary care staff] because we wanted to see what would naturally evolve within these practices once the payment model allowed them to have what they wanted,” Miller says.

“We learned a lot along the way,” he adds. “There is a story, in particular, about the training that’s necessary to have a successfully integrated practice, and that led us to create competencies and other projects outside the scope of the program.”

They found that the the global budget exercise resulted in more patients being seen by mental health clinicians, and more patients were identified than were those under the traditional payment system, Miller says.

“Identification is very important because we don’t do a good job of identifying mental health at all,” Miller says.”

The main mental health issues observed in the study were depression, anxiety, and substance abuse. “There was a statistical increase in these diagnoses when we removed the fee-for-service handcuffs,” Miller says.

The hope was to find that treating individuals’ behavioral care issues sooner would, down the road, reduce the need for costly hospitalizations, ED visits, and pharmaceutical use.

The study showed the alternative payment model resulted in cost avoidance.

“It’s a little different from cost savings because we’re predicting cost avoidance based upon trends that the services traditionally used are now avoided,” Miller explains. “We were able to see cost avoidance on three factors, which is actually quite profound,” he adds.

The cost avoidance was more than $1 million. The research is expected to be published soon.

“This research has profound implications for anyone doing anything on delivery, financing, or policy,” Miller says. “Integrating care is smart business, but it needs financial support.”

Investing dollars into mental healthcare will help organizations achieve better outcomes at lower costs, he says. “To move the needle on cost, you need clinical delivery reform and, simultaneously, financial reform.”

Global payments make it possible for behavioral health to become a critical facet of comprehensive healthcare. It also allows behavioral health providers to not be trapped in a volume-based payment workflow.

In the policy domain, healthcare leaders should consider dropping policies that limit patients’ ability to gain access to mental health services in primary care, Miller says. Once patients have immediate access to mental healthcare, their outcomes improve and costs are avoided.

“It’s a team approach to whole health. That’s the model, and that’s what we’re trying to espouse nationally,” Miller says. “The reason we don’t see this model happening more often — although it’s one of the leading innovations in the industry — is because of the financing.”


  1. Akincigil A, Matthews EB. National rates and patterns of depression screening in primary care: results from 2012 and 2013. Psychiatr Serv. 2017;68(7):660-666.
  2. National Institute of Mental Health. Major Depression Among Adults. Available at: http://bit.ly/2nDfKc1. Accessed Nov. 1, 2017.