Effect of the ACA on Access to Behavioral Health Care for Rural Populations

Jay Getten | Sep 7, 2021 | 38 min read


The Patient Protection and Affordable Care Act (ACA) of 2010 dramatically shifted the healthcare landscape. So much so its effects were felt from America's population centers to its most remote communities. Since the 2016 election the ACA's future has been in doubt. Many elements of the law have been removed or changed, yet after a decade ACA remains the driving force in the US healthcare system.

The overarching goal of the ACA is to achieve what is called the Triple Aim. The Triple Aim's goal is to simultaneously expand affordable insurance coverage, reduce healthcare costs, and improve healthcare outcomes (Obrien, Acri, Campanelli, Cerniglia, & McKay, 2018). Several key provisions within the ACA include prohibiting the exclusion of patients due to pre-existing conditions and requires all insurance plans to cover ten categories of essential health benefits which include mental health and substance abuse care. The act also expanded Medicaid eligibility to all non-elderly adults with incomes up to 138% of the federal poverty level (The Henry J Kaiser Family Foundation [Kaiser Foundation ], 2017).Montana is one of 35 states that has elected to expand Medicaid and about 25% of Montanans are covered by Medicaid or CHIP programs (Help Act Oversight Committee, 2018).

To reduce healthcare costs and improve patient outcomes the ACA authorized states to amend their Medicaid state plans to offer Health Home services. Under Medicaid Health Home program states can provide enhanced care coordination for patients with multiple chronic comorbid conditions (NACHC, 2016).

In 2013 Montana passed the Patient Centered Medial Home (PCMH) Act to expand upon comprehensive and coordinated care as demonstrated by the ACA and Health Home program. The Act set participatory, reporting, and payment standards for healthcare providers and insurers. PCMH is healthcare directed by primary care providers offering patient/family centered, culturally effective, coordinated, comprehensive, and continues care in the patient's community and integrated across all systems (Loveland, 2016). The Montana PCMH Act ended in 2017 and handed off oversight duties to national governing bodies like National Committee for Quality Assurance (NCQA).

Integrated behavioral health (IBH) recognized by federal, state, and independent PCMH governing bodies as best practice. For some governing bodies community health centers must submit evidence of IBH programs to become PCMH certified. IBH models increase access, reduce costs, and improve outcomes for patients with comorbid medical and mental health conditions by embedding a licensed behavioral health provider (BHP) within a primary care team. The BHP works with the primary care team to provide immediate interventions for acute life stressors, crises, mental health/substance use disorders, stress related physical symptoms, ineffective patterns of healthcare utilization, and referral to higher level of behavioral health services as needed (Raney, Lasky, & Scott, 2017).

Social, Economic, Ethical, Legal, and Political Influences on Integrated Care Legislation

Throughout the US access to behavioral health care is often difficult and this is especially true for those in rural communities. Rural populations are disproportionately at risk for suicide, substance abuse, and chronic illness (Selby-Nelson et al., 2018). Based on a 2013 Risk Factor Survey one in five Montanans report having a depressive disorder or a depressive episode. Twenty percent of adult in Montana report binge drinking compared to 16% nationally and 7% of adults in Montana are classified as heavy drinkers compared to 6% nationally (Loveland, 2016). The adult suicide rate in Montana is consistently double the national level and in 2013 Montana had the highest suicide rate in the US with nearly 24 per 100,000 compared to 13 per 100,000 for the country. Under diagnosis of mental illness and high rates of substance abuse contribute to the suicide crisis in Montana. Of those who die by suicide only 40% have a mental health diagnosis at the time of death (Loveland, 2016).

Majority of rural areas have few if any behavioral health providers with 60% or rural Americans living in mental health professional shortage areas (Selby-Nelson et al., 2018). A 2012 study found that residents in 19 Montana counties 34.0% of the population have three or fewer licensed behavioral professionals. In all, 78.0% of Montana's behavioral health workforce resides in just eight counties (Loveland, 2016). Currently Montana has twenty-five state approved mental health centers. However, the state's community mental health centers are in peril because they do not receive federal grants or enhanced reimbursement rates to offset the high levels of uncompensated care. This places them in a vulnerable position and contributes to workforce shortages due to their inability to pay behavioral health providers competitive wages and keep offices open (Loveland, 2016).

Even when behavioral health services are available rural populations are unlikely to use them because the stigma attached to receiving mental health services is a significant barrier. To protect anonymity rural residents are more likely to use primary care providers for behavioral health services than their urban counter parts (Selby-Nelson et al., 2018).

Historical Foundations, Core Assumptions, and Values Affecting IBH Legislation

Since 2005 behavioral health visits have grown by nearly 200%, dramatically outpacing growth in medical and dental visits (National Association of Community Health Centers [NACHC ], 2016). This growth and the decline of community mental health centers has inundated primary care clinics with patient populations they are unused to treating. Research suggests that nearly 70% of primary care appointments include issues associated with psychosocial factors (Selby-Nelson et al., 2018). A recent national study found that almost one in five Americans had comorbid medical and mental health conditions (Loveland, 2016). As a result, primary care providers are often undertrained and ill equipped to manage the complexity of mental health concerns presented by patients.

Disconnection between state and federal regulations frequently create barriers for individuals seeking behavioral health services. For many states, the laws regulating healthcare services are exceedingly siloed. A 2015 National Association of Community Health Centers assessment found that state's siloed behavioral health licensure and certification systems are major obstacles that impact FQHCs ability to provide behavioral health services and were viewed as being at odds with federal initiatives like health homes (NACHC, 2016).

Montana's current behavioral health system is disjointed with separate administration, funding, and service facilitation for mental illness and substance abuse disorders. Theses separate systems create barriers for organizations that wish to increase access to mental health care by implementing integrated behavioral health services. As a result, patients with complex comorbid medical and behavioral health concerns are often required to receive care through multiple agencies, often through the criminal justice or school systems which are equipped to provide comprehensive care (Loveland, 2016).

Purpose and Scope of the ACA and its impact on Integrated Behavioral Health Care

The ACA provided several opportunities and incentives for expanding accessibility and sustainability for behavioral health services in the US. This includes avenues for increased adoption of integrated behavioral health care via increased access to care through expanded insurance coverage and mental health parity (Kwan, Valeras, Levey, Nease, & Talen, 2015).

As part of the ACA changes in reimbursement that support behavioral health care due to increased Medicaid and Medicare payments from primary care health homes that support patients with mental health conditions, accountable care organizations, and colocation of primary care and behavioral health services in community based health centers. The ACA also supports several structural, financial, and workforce development changes for FQHCs to adopt and sustain integrated behavioral health programs (Kwan et al., 2015).

The ACA's introduction of innovative models like IBH have influenced healthcare organizations to acclimate to a changing healthcare system (Obrien et al., 2018). While service reimbursement models under the ACA such as pay for performance and accountable care organizations have reformed the incentives for chronic disease treatment delivery and may benefit IBH adoption, implementation, and sustainability (Kwan et al., 2015).

Integrated care has key implications for meeting the primary aims of the ACA. Specifically, reducing healthcare costs and improving healthcare outcomes (Obrien et al., 2018). Studies have found patients integrated care interventions resulted in improved behavioral health outcomes overall and had 12% lower total healthcare costs during a four-year period (Loveland, 2016). While benefits of IBH on a national level are clear.

Review of Literature

The ACA's impact on health coverage for those in rural communities has been profound especially in states that expanded Medicaid. Roughly half of rural patients in those states are on Medicaid or other public insurance like CHIP (Watanabe-Galloway, Valleley, & Rieke, 2016). The ACA and ensuing Medicaid expansion has benefited low-income populations by increasing their access to healthcare. Specifically, the ACA promoted an increase in primary care utilization among these groups and as a result an observed decrease in income-based disparities in access to care and utilization of services (Kino & Kawachi, 2018).

Findings from the Literature on the ACA's Impact on Rural Behavioral Health Care

Under the ACA mental health and substance abuse treatment are recognized as essential health benefits. Additionally, Medicaid patients with a severe mental health condition or substance use disorder are considered as a medically frail population that are provided with benefits with variety of evidence-based services that exceed original benchmark equivalent standards (Wen, Druss, & Cummings, 2015). A study on the impact of the ACA on rural substance-using women found a fifty percent increase in coverage following the implementation of the ACA. It also found the ACA had a noteworthy impact on increased access to healthcare for this highly vulnerable and underserved population (Dickson et al., 2018).

Rural states that participated in the ACA's expansion of Medicaid saw an increase in Medicaid coverage by nearly 5%. Medicaid expansion was also associated with improved health system performance and decreased the likelihood of closure. Especially, in rural communities which had many uninsured adults prior to Medicaid expansion (Iglehart, 2018). Keeping the doors open for many rural safety net clinics indirectly improves access to behavioral health services. Some access to behavioral health care is better than no access to care.

Rural populations have transportation barriers, limited mental health providers, and often have stigmas attached to mental health services. Rural patients benefit from coordinated and comprehensive care in primary care settings. Provisions within the ACA benefited rural populations by providing financial incentives to improve coordination between primary care and behavioral health services through patient centered medical homes (PCMH), accountable care organizations (ACO), and subsidiaries of Medicare/Medicaid that support provider innovation (Andrews et al., 2015).

Analysis of the Effect of the ACA on Rural Communities Access to Behavioral Health Care

Prior to the ACA behavioral health carve-outs were prevalent arrangements in many state Medicaid programs. Medicaid behavioral health carve-outs created additional barriers for rural and underserved patients by shifting payments for BH services to other payers, further fragmenting care. Payment reforms in the ACA has encouraged more states towards carve-ins or integrated Medicaid managed care programs to finance and administer different types of services for patients under a single managed care plan (Xiang et al., 2018). The shift to carve-ins by public insurers increased access to rural BH services by allowing patients to receive all their care in one location.

Implementation of the ACA and Medicaid expansion was also associated with increasing the likelihood of individuals receiving mental health or substance use disorder treatment. Conversely, states that did not expand Medicaid were shown to have disproportionately high number of uninsured adults with behavioral health conditions (Wen, Druss, & Cummings, 2015). The lack of insurance adds to barriers for rural populations to receive care which often exasperates existing behavioral health problems and adds tension to other societal systems. One study found a meaningful impact of Medicaid expansion on the mental health of low-income adults and families, with significant reductions in psychological distress among states with medium and large expansions (McMorrow, Gates, Long, & Kenny, 2017).

Rural states that expanded Medicaid saw benefits to those involved with the justice system. Especially, people who were ineligible for Medicaid and could not afford private insurance had access to health care coverage. Nearly 90% of prison inmates in states that expanded Medicaid were eligible for coverage following the ACA's implementation. Inmates having health care coverage after release have been shown to decrease the odds of re-arrest, especially, among female inmates (Dickson et al., 2018).

Underlying, Assumptions, Values, and Biases within the Literature

Prior to the ACA the behavioral health system experienced rounds of budget cuts and as a result suffer from insufficiencies in geographic, infrastructure and workforce. Fears that the behavioral health system will be stretched beyond capacity under full implementation of the ACA's Medicaid expansion has led some policy makers to leverage funding resources to increase care coordination and integrated systems (Wen et al., 2015).

Early studies have shown that behavioral health services are cost effective and improve outcomes when delivered as part of an integrated primary care practice. These studies have led policy makers and health officials to believe increasing the investment in integrated primary care practices will improve patient outcomes and help bend the health care cost curve (Nielsen & Levkovich, 2019).

Existing Gaps in Access to Behavioral Health Care for Rural Populations

A major problem with innovative programs like IBH encouraged under the ACA is that innovation on the ground outpaces changes in health policy at the local, state, and federal level which limits scalability and adoption of these programs (Miller, 2015). The misalignment between state payment policy and efforts to integrate care disrupts key goals within the ACA that were designed to move US healthcare forward in a way that improves access to care and manages medical care concurrently with behavioral health needs (Roby & Jones, 2016).

As stated above close to half of rural patients are covered by Medicaid. However, there are percentage of rural patients have found coverage in the ACA Marketplace. Plans within the Marketplace have also created barriers to accessing behavioral health services. A 2016 study found that provider networks within the ACA marketplace were far narrower than those for primary care. This was demonstrated by lower rates of network participation by mental health providers compared to primary care providers. For example, ACA Marketplace plans have shown that psychiatry was one of the most restricted specialties with only 15% of the plans offering fewer than five in-network psychiatrists within one hundred miles. Rigid administrative rules and lower reimbursement rates have influenced the lack of participation of behavioral health providers in Marketplace networks (Zhu, Zhang, & Polsky, 2017).

Even though addiction treatment was listed as an essential service within the ACA rural patients with substance use disorders (SUD) still have a difficult time accessing necessary care. Challenges exist within the current addiction treatment delivery system. This is due to SUD treatment programs have historically operated separate from the rest of the healthcare system with different institutional values, capacities, and funding streams which pose barriers to integrating SUD treatment with the mainstream healthcare system (Andrews et al., 2015).

For many rural and low-income populations disparities remain despite increased healthcare coverage. Healthcare infrastructure inequalities in rural areas persist. This is evident in the limited amount of high-quality medical and mental health resources in many low-income, minority, and rural communities. Social determinants of health such as lack of public transportation, second-rate housing, and unhealthy physical environments have profound effects on the overall health of rural communities (Sommers, McMurtry, Blendon, Benson, & Sayde, 2017).

Effectiveness of the ACA on Addressing Existing Gaps in Rural Behavioral Health Care

To increase access and reduce costs the ACA temporarily increased federal grant funding for health centers to increase healthcare innovation and infrastructure in underserved areas (Sommers et al., 2017). One example is Sanford Health a large integrated health system that was awarded 12 million dollar CMS Health Care Innovation grant to implement a new practice based quality improvement intervention to improve patient outcomes with specific behavioral health and chronic health conditions in primary care settings in the Dakotas and rural Minnesota (Zurovac et al., 2019).

Federal grant funding for health centers, broader primary care networks, and higher primary care participation create an important supplementary access point for low-income and rural populations. Further, demanding greater attention on integrated healthcare systems (Zhu et al., 2017). Unfortunately, many states are still utilizing fee for service reimbursement models which impacts the sustainability of IBH services. This is due to non-reimbursable staff providing care in integrated systems (Roby & Jones, 2016). For example, Medicare does not recognize certain licensed behavioral health providers. Specifically, licensed professional counselors and licensed marriage and family therapists who are often apart of integrated care teams.

Innovation and efficiency in implementing integrated care is only truly possible when alternative payment models such as bundled or capitated contracts are available and practical (Nielsen & Levkovich, 2019). An example of alternative payment models within the ACA are Medicaid accountable care organizations. ACO's replace fee for service payments with incentivized value-based care. The model demonstrates that sharing substantial financial risk offers powerful incentives to design integrated care models that meet the needs of complex patients by linking social services, behavioral health, and medical care. One study of an integrated ACO health system found a reduction in emergency department and hospital use. The study also found an increase in primary care use, especially with low-income and high-utilizing patients (Vickery et al., 2020).

To increase access for patients struggling with substance abuse the ACA provided financial assistance for state addictions treatment programs to increase collaboration with community mental health centers and federally qualified health centers. However, only three states have allocated funds to facilitate ACA implementation within the SUD treatment system. Federal funds may be exhausted before all the details of the ACA's provisions on SUD treatment are worked out by state SUD treatment programs. This could cause states to miss out on opportunities to expand the quality and quantity of SUD services if they underinvest in the adaptation of addiction treatment to the provisions within the ACA (Andrews et al., 2015).

The ACA and Medicaid expansion reduces socioeconomic inequality found within rural populations through increasing the ability to afford health insurance, having a primary care provider, and attending routine checkups which are important as a safety net (Kino & Kawachi, 2018). However, it is does not contribute to the reduction in rural inequality directly impacted by social determinants of health that effect access to behavioral health services, treatment adherence, and ability to engage in preventative mental health screenings. Additional study is needed to identify strategies that can bridge gaps between the ACA and larger societal issues that impede access to behavioral health care for rural communities.

Analysis of Social, Economic, Ethical, Legal, and Political Effects on Integrated Healthcare

The cost of healthcare in the US is near 18% of the nation's GDP and rising (Baucher, 2019), with a small percentage of patients accounting for most of the total healthcare costs. The 5% of Medicaid recipients with complex health needs account for 54% of total Medicaid expenditures and 1% account for 25% of total program costs (Edwards, 2017).

To reduce costs, prevention has become the new medical necessity and it has been viewed as one of the most lasting legacies of the ACA (Obrien, Acri, Campanelli, Cerniglia, & McKay, 2018). Patients with comorbid physical and mental health conditions account for nearly 90% of total health care spending (Zurovac et al., 2019) provisions within the ACA incentivized health systems to integrate primary care and behavioral health services to aid with early identification and treatment of behavioral health conditions that increase patient acuity.

Underserved populations are disproportionately at risk of experiencing factors which increase patient acuity. Rural populations on average have lower household incomes, higher percentages of youth living in poverty, fewer adults with college education, more uninsured residents, and higher rates of mortality (Warshaw, 2017). Rural populations have fewer healthcare resources then their urban equivalents and often present with the same complexity (Peterson, Turgesen, Fisk, & Mccarthy, 2017). While rural Native American communities are four times more likely to experience traumatic events in their lifetimes than other populations (Hiratsuka, et al., 2016).

The complexity of rural and underserved populations demonstrates the need for IBH programs to improve access to behavioral health services for these populations through providing collocated services. One study has shown that nearly 20% of IBH patients are classified as underserved. These patients often identify a high need for services across a broad spectrum of behavioral health concerns (Bridges et al., 2017).

Impact of Values and Beliefs in Setting Healthcare Priorities and Resource Allocation

Many policy makers believe rural primary care settings are an ideal context to improve access to behavioral health services through IBH. Primary care offices are widely dispersed geographically, are familiar to families, and offer the opportunity of discussing sensitive issues in a safe environment (Arora, Godoy, & Hodgkinson, 2017). Federally qualified health centers (FQHC) which emphasize IBH models are key portals of access to medical and behavioral health services in underserved communities (Jones & Ku, 2015).

Experts believe that between 26 and 48 billion dollars could be saved annually in the US healthcare system if effective IBH systems were implemented nationwide (Loveland, 2016). Potential cost savings influenced policy makers to include seed funding within the ACA for health systems to develop and implement IBH programs.

The Center for Medicare and Medicaid's Comprehensive Primary Care Plus Program provides seed funding for health centers to implement system wide IBH programs (Stoeckle, Cunningham, & Arenson, 2018). Similarly, the Health Resources and Service Administration demonstrated the importance of IBH services by awarding over 100 million dollars in 2014 and 2015 to support over 400 health centers with implementing IBH programs (National Association of Community Health Centers [NACHC ], 2016).

Current Gaps in Healthcare Policy on Behavioral Health Access in Rural Communities

Prior to the ACA 40% of primary care providers (PCP) in the US were collocated with behavioral health consultants (BHC). Following the implementation of the ACA this number increased to 44%. Of this percentage only 26% of PCPs are collocated with BHCs in rural areas. Rural practices are less likely to have collocated services due to fewer BHCs to integrate with PCPs (Richman & Lombardi, 2020).

Some states inability to adopt bundled or value-based reimbursement systems within the ACA create barriers to care for underserved populations. Fee for service (FFS) payment models incentivize BHCs to deliver more direct patient care, which supports volume instead of value. This excludes services like health behavior change interventions, prevention services, consultation, and care coordination, forcing BHCs to bill for patients with diagnoseable mental illnesses that are seen face to face (Herbst et al., 2018).

Disconnection between reimbursement methods and federal programs also created hurdles for rural communities to access behavioral health care. FQHCs are often the first option for underserved populations to address mental health issues. Yet, FQHCs are not allowed under Medicare to receive payment for services furnished remotely and are only eligible to serve under Medicare as telehealth originating sites, but not has telehealth distance sites (NACHC, 2016).

Provisions within the ACA offered incentives to better utilize health information technology (HIT) in providing comprehensive integrated care. However, many healthcare organizations electronic health record systems (EHR) lack features essential to support IBH functions such as longitudinal data tracking, shared care plans, patient registries, and template-driven progress notes for common behavioral health conditions (Cifuentes et al., 2015).

The ACA did not define what successful IBH programs look like. Instead leaving it up to the states to determine what makes an IBH program worthwhile. In Montana there is not a consensus on what behavioral health outcomes health systems should be tracking. This makes it difficult to demonstrate the viability and sustainability of integrated programs (Loveland, 2016).

Effects of the ACA on Rural Integrated Behavioral Health Care and Stakeholders

Due to increased access and wholistic approach, integrated care models have proven useful in reducing depression/anxiety symptoms, improved primary care outcomes related to diabetes/heart disease in patients with comorbid depression, and improved outcomes because of reductions in negative health behaviors (Obrien et al., 2018).

Policy makers have recognized that effective use of HIT can increase access to behavioral health services and improve outcomes. Provisions within the ACA encouraged and incentivized HIT. Intermountain Healthcare a health system that serves rural and urban populations in Utah recognized the value of HIT. Intermountain developed an integrated model that combines research-based treatment with innovative informatics tools that track patient progress and navigation of the health system. The health system's effective use of HIT allowed them to meet their goals of enhanced detection of behavioral health conditions, monitoring and management of mental and physical health conditions, patient engagement, treatment monitoring, and real time adjustment of interventions (Kwan, Valeras, Levey, Nease, & Talen, 2015).

Location and nature of services substantially increases the reach of integrated systems. IBH provides patients with same day access to BHCs with visits lasting between 15-30 minutes. This approach means service delivery capacity for IBH programs can be as high as 200-300 patients per month. These numbers greatly exceed what is expected from professionals working in specialty mental health clinics (Bridges et al., 2017).

By increasing reach IBH provides access to behavioral health services to populations that would not normally seek mental health care. In one study a sizable number of patients surveyed stated they prefer to receive behavioral health care in a primary care setting. Most of the patients in the study indicated that they would not seek care for mental health concerns if behavioral health services were not available in primary care. Half of the patients in a health system where specialty mental health care is covered and reasonably accessible prefer integrated behavioral health in primary care (Ogbeide, Landoll, Nielsen, & Kanzler, 2018). Participants in another study highlighted appreciation for the availability of BHCs for ongoing, as needed support, as part of their primary care (Koehler et al., 2019).

Integrated care allows for flexible service delivery which is beneficial for rural settings as each rural community may have unique needs, cultural traditions, and accessibility considerations (Selby-Nelson, Bradley, Schiefer, & Hoover-Thompson, 2018). The ACA's efforts to increase access to behavioral health services to underserved populations has proven to be fruitful. This is especially apparent through the blending of primary and behavioral health care. However, with only 26% of rural PCPs collocated with BHCs, untapped opportunities to increase access to behavioral health services for rural populations remain.

Impact of Healthcare Policy Processes on the Delivery of Healthcare Services

Medicaid has become the single largest payer for behavioral health services. Through its expansion under the ACA Medicaid has become the behavioral health safety net for the most disadvantaged and impaired populations. During times of financial crisis states often reduce behavioral health expenditures before cutting other programs. Many states inability to fund behavioral health services is further compounded if they did not expand Medicaid. Non-expansion states are unable to take advantage of provisions within the ACA to bolster behavioral health services (Mechanic, 2014).

Even if it is not a perfect system the ACA offers a constructive framework to build a more meaningful behavioral health system that is more allied with medical care and social services (Mechanic, 2014). Integrated behavioral health embodies the ACA's goal of synthesizing medical care with psychosocial interventions. According to research integrated care models are twice as effective as specialty care for depression. Specifically, IBH provides measurement-based treatment to target, which monitors patient outcomes with standardized measures and adjusts treatment when a patient is not improving. Integrated care teams provide population-based care by providing outreach to all patients in a defined population and not just those who show up to the health system (Bauer et al., 2018).

Healthcare Policy Gaps and Initiative Proposals to Address Deficits

The American healthcare system faces two fundamental challenges in the delivery of behavioral health care. The first challenge is capacity. Nearly all US counties have unmet needs regarding specialty behavioral health services. The second challenge is equity. There is a large inequitable geographic distribution of behavioral health providers in the US. Rurality is strongly correlated with the lack of behavioral health providers and lack of access to behavioral health care at the county level (Fortney et al., 2015). The disparities in the availability of well-trained behavioral health professionals nationally is especially evident with psychiatric providers. In recent years, the US has seen a 14% decline in graduates from psychiatry programs and nearly half of psychiatric providers are over fifty-five years old (Mechanic, 2014).

Telehealth technology is becoming more apparent in behavioral health service delivery among rural communities. Telehealth has the potential to increase geographic access and compensate for behavioral health workforce shortages. According to several studies' diagnostic assessments, psychiatric/psychological treatments, and psychotherapy delivered via interactive video appears to be equally effective as face to face encounters (Fortney et al., 2015). Incorporating telehealth with integrated care models have shown to improve outcomes in patients with comorbid conditions. A study examining the effectiveness of integrated telehealth treatment of depression and insomnia with rural patients found significant reduction in symptoms among participants (Scogin et al., 2018).

Telehealth not only increases access and improves outcomes; it has also shown to be effective in reducing healthcare costs. One study found that for every dollar spent in telehealth, $11.50 was saved in travel and childcare expenses, without any decrease in quality of care. While some researchers estimate that general healthcare costs can be reduced by nearly 36 billion dollars per year by the effective use of telehealth through the improvement in productivity and efficiency of healthcare providers (Kruse et al., 2016).

The effective use of health information technology can increase patient access to care and help maximize the limited behavioral health workforce in rural areas. Conversely, inefficient use of HIT creates obstacles to care and increase costs. Electronic health record systems are an important aspect of HIT. EHRs can enable teamwork, communication, and task delegation through instant messaging, task management, and population specific data collection. However, EHRs may be a barrier to IBH because many systems lack functionality and interoperability that supports care management and population-based care through the application of shared care plans and patient registry management tools (Cifuentes et al., 2015).

Patient registry capability is a critical component of integrated care and assist with the effective management of an entire patient population. Effective registry use supports IBH workflows through reminders for proactive outreach and follow up for patients who are not engaging in care. It also flags patients who have not improved and could benefit from changes to treatment interventions (Bauer et al., 2018).

Many integrated health systems are incorporating innovative technologies into their practice to increase their reach and better manage patient populations. One approach is to utilize smartphone technology. Behavioral health smartphone apps can support integrated care delivery in primary care settings through patient generated data that is securely transmitted to BHCs. Smartphone apps also assist patients with self-management of chronic behavioral health conditions. Data collected is integrated with the registry, enhancing measurement-based care through timely remote symptom monitoring. The ability to interface with patient registries provides a convenient method for patient/provider communication and has shown to improve patient engagement (Bauer et al., 2018).

To maximize population level effectiveness given a fixed capacity of behavioral health providers, rural health systems would benefit from incorporating necessary HIT to allow for remote delivery of IBH models. This would allow primary care providers manage patient panels with curbside consultations or case reviews from tele-psychiatrists (Fortney et al., 2015). Remote care delivery would allow offsite BHCs to devote all their time and energy to patient outreach and follow up. Remote BHC encounters can be effectively conducted via phone or secure messaging through patient portal mobile apps, increasing patient access through convenient and timely communication (Fortney et al., 2015).

Federal policy also limits access to behavioral health services for rural populations. Medicare has not updated its qualification requirements for behavioral health providers since 1989 when clinical psychologists and clinical social workers were included (Wiley et al., 2019). Several key frontline mental health providers are excluded from Medicare policy. Most notably licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs).

Rural Medicare beneficiaries are unable to access behavioral health services provided by LPCs and LMFTs who are designated as critical mental health professionals and are granted the ability to diagnosis and treat mental illnesses by states and the federal government. Yet, Medicare does not recognize LPCs or LMFTs as qualified providers.

Many rural communities do not have clinical psychologists or social workers within driving distance, while many of these communities have LPCs. Older patients cannot access their services because of Medicare restrictions leaving them to seek mental health services from their primary care providers. Even with more primary care clinics adopting integrated models many Medicare beneficiaries are unable to access care if the onsite BHC is licensed as an LPC or LMFT (Wiley et al., 2019).

Studies suggest that excluding LPCs and LMFTs from Medicare reimbursement increases obstacles for older patients seeking mental health care. This is especially true in rural contexts. Revisions to Medicare policy allowing LPCs and LMFTs to provide treatment to beneficiaries would lessen disparities in access to behavioral health care and strengthen integrated care systems by expanding the eligible workforce (Wiley et al., 2019).

Effect of Social, Economic, Ethical, Legal, and Political Forces on Healthcare Services

Rural populations face complex challenges in meeting their health care needs. This is particularly true for rural Native American communities who demonstrate the highest rates of substance abuse/dependence in the nation and possesses the highest mortality rates from alcoholism, accidents, homicide, and suicide than all other Americans. Yet, health systems serving these communities are underfunded and their resources are spread much thinner than their urban counterparts (Kruse et al., 2016).

Currently close to 8 million older adults with cooccurring physical and mental health disorders live in rural areas that largely underserved because inaccessible care (Scogin et al., 2018). It is estimated by 2030, the total number of Medicare beneficiaries will exceed 80 million and nearly 26% of them will have a behavioral health diagnosis (Wiley et al., 2019). Without the inclusion of LPCs and LMFTs, health systems that are already stretched beyond capacity will be woefully unequipped to support an aging population with comorbid mental and physical health conditions.

Rural behavioral health care challenges of equity and capacity cannot be fixed with a single piece of legislation. However, if policymakers could provide a greater focus on embedding behavioral health providers in primary care settings, including all qualified behavioral health providers in Medicare policy, efficient use of HIT, and maximizing behavioral health provider reach through telehealth technologies health systems could remove many barriers that prevent rural populations from receiving care.


To address complex behavioral health issues facing rural and underserved populations the US must adopt a safer more effective system, it will need to rebuild the behavioral health workforce, embrace evidence based treatments, focus on more timely access to care, improve coordination of care, and adoption of HIT that allows better self-management of care (Mechanic, 2014). Integrated behavioral health's focus on patient access, evidence-based treatment to target, population health, care coordination, and effective utilization of HIT makes it an ideal candidate to lead the charge in reshaping the US behavioral health system.


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