There are many complexities associated with the financial and structural barriers to integration in mental and behavioral healthcare. For example, there has been considerable discussion about whether behavioral healthcare should be “carved-in” or “carved-out” when states or other purchasers make purchasing decisions. Some “carve-out” models have been customized to support clinical integration efforts, while some “carve-in” models have had the effect of reducing overall levels of behavioral healthcare spending and services, especially for the population with serious mental illness.

Treating depression in a Primary Care setting is a key factor in the financing issue. Many privately funded, national programs have been created with the goal of increasing the use of effective models for treating depression in primary care settings. Importantly, these programs addressing the impact that financial and structural issues that are being proposed will affect Medicare and Medicaid, as well as other clinical models. Many of the issues these programs raise speak directly to the financial and policy barriers in our existing behavioral healthcare system.

The clinical interventions that have been so successful in controlled research environments have proved difficult to sustain in the rough and tumble of daily practice. Existing financial and organizational arrangements are thought to impede incorporation of evidence-based depression care into routine practice. Common problems include the inability of primary care providers to bill for depression treatment (in the context of behavioral health care carve-out programs) and the absence of payment mechanisms for key elements of the collaborative care model such as care management and psychiatric consultation services. Also, since appropriate care of people with depression typically involves more time than the average case, primary care providers reimbursed on a capitated basis or rewarded for the number of patients seen may opt to refer patients to specialty care that could be treated successfully in primary care. Fragmentation in financing and delivery of care due to managed behavioral health carve-out contracts, multiple health plan contracts, and separate prescription drug budgets contribute to and reinforce tendencies to avoid attending to cases of depression using evidence-based practice.

» Read more: Overview of Financial Barriers to Integrated Behavioral Healthcare Reform