If care is clinically inappropriate it fails. If care is not operationalized properly, it also fails. If care does not make reasonable use of resources, the organization, its patients, or society eventually go bankrupt and thousands of patient-clinician relationships are disrupted.

-The Three-World View of Healthcare (Peek, 2008)

President Kennedy’s focus in the 1963 Community Mental Health Center Act was to “return mental health care to the mainstream of American medicine” (Kennedy, 1963). Then again in 1979, the US Surgeon General Julius B. Richmond argued in his report for the integration of medical and mental health services. However, achieving and sustaining their shared goal has proven elusive.

As with most major changes in health care services, integrated behavioral health care began with a clinical theory that evolved into an operational model and only later took into serious consideration the financial infrastructure to support and grow it. In fact, in 1993, when the intellectual founders of integrated behavioral health care initially met to create strategy to develop integrated behavioral health care, they intentionally left financial considerations out of their vision statement: “No matter how financed, what should a thoroughly modern health care delivery system look like at the clinical level?” (Collaborative Family Healthcare Association [CFHA], 2012). While probably inevitable, the decision to focus on clinical services and operational models before financial sustainability was in place has deeply shaped the evolution and growth of integrated behavioral health care in the US health system.

This book’s operational definition for integrated behavioral health care was provided by C.J. Peek in Chap. 2 of this book. Integrated behavioral health care is “a team with a shared population and mission using a clinical system supported by an office practice and financial system and continuous quality improvement and effectiveness measurement.” This chapter will focus almost exclusively on the “financial system” of this definition. We will start with a historical context of public health funding and analyze the development of integrated behavioral health care across several states. We will then examine financial aspects of integrated behavioral health care in vertically integrated and nationwide systems. We will finish this chapter by highlighting the impact of very recent initiatives that might sustain integrated behavioral health care and how they might rollout in the near future.

Although the 1979 US Surgeon General, Julius B. Richmond, highlighted in his report a national interest in integration, much of the energy has remained at the local and state levels, until recently. State foundations and local nonprofits realized that waiting for private payer and federal support would not respond to communities’ needs quickly enough. While examples of all states are not included in this chapter, some of the more prominent programs and pilots (also reviewed in Butler et al., 2008; Collins, Hewson, Munger, & Wade, 2010) are included to provide a sampling of the power of community influence and the critical backing of local and state foundations to support advancements in health care. The local perspective is important because of the following features:

In this milieu, integrated behavioral health care has also developed in state-­specific patterns. In order to allow for both a deep and broad presentation of state-­level variation, an in-depth integrated behavioral health care history from one state (Colorado) will be presented, followed by an analysis of common developmental themes across multiple states.

Colorado. Grand Junction, Colorado, is named after the confluence of the mighty Colorado and Gunnison Rivers near the city’s artsy downtown. However, in Colorado’s integrated behavioral health care circles, Grand Junction is known more for pioneering the merger of medical care and mental health care. The history of integrated behavioral health care in Colorado begins with the leaders of a little-­known safety net clinic whose vision went viral across the state.

In 1998, Marillac Clinic (Mauksch et al., 2001) was a small medical center in the heart of rural western Colorado. In an attempt to better meet the high psychosocial needs of their patient population, the Executive Director, Janet Cameron, serendipitously invited a family friend, Larry Mauksch, to come out for a sabbatical. Unbeknownst to her, Larry was a faculty member in the University of Washington’s medical school who had published widely on collaborative care. Marillac Clinic proved to be an ideal laboratory for him to train clinicians and test his models. At the end of his nine months in Grand Junction, Larry was awarded a grant from Robert Wood Johnson Foundation, which, along with a local match, provided ­sufficient funds to hire a collaborative care supervisor, two collaborative counselors, and a case manager. This team was in place by 2000 (full disclosure: Randall Reitz, coauthor of this chapter, was the first hire of the RWJ grant).

From the outset, Marillac’s staff and leadership maintained a missionary zeal for sharing the model. They created a countywide collaborative care consortium, presented frequently at the Collaborative Family Healthcare Association conference, and published research on their findings (Mauksch et al., 2007). Representatives from many other Colorado clinics traveled to Grand Junction to see the model and attempt integration in their settings. By 2004, collaborative projects were increasingly common throughout Colorado.

At the same time, a group of five Colorado foundations pooled funds to assess the current status of mental health treatment in Colorado. Their 2003 report identified “lack of integration” as one of the largest barriers to improving mental health services (TriWest Group, 2003). These same foundations funded a five-year statewide mental health integration project beginning in 2005. This initiative heralded collaborative care as a Colorado standard and jump-started many other initiatives. Increasingly, the rise of collaboration was spurned by the rise of The Colorado Health Foundation (TCHF). The foundation was formed in 1995 and has since grown to be one of the largest health foundations in the United States. Most of Colorado’s collaborative clinics have benefitted from TCHF support.

In 2008, the Collaborative Family Healthcare Association held their national conference in Denver. This event included a policy summit, which convened leaders from around the state to coordinate a plan to advocate for necessary changes. The conference also highlighted the work of the Salud Clinics and other large Federally Qualified Health Centers in the Denver area.

In 2011, TCHF partnered with the Collaborative Family Healthcare Association to create the Colorado Promoting Integrated Care Sustainability (PICS) project. Through PICS, these organizations conducted an assessment of collaborative care in Colorado and promoted policy changes to financially sustain collaborative services. Fifty-six integrated sites completed an online survey, and 29 sites participated in key informant interviews. While these sites represent only a percentage of the collaborative care sites in Colorado, their data provide a clear picture of collaboration in the state. Findings include the following:

The PICS project assessed financial barriers and made recommendations for financial next steps. The researchers discovered that, while there is great diversity in Colorado’s collaborative clinics, there is considerable uniformity in the financial obstacles that still limit the growth of integrated behavioral health care and its movement into the sustainable mainstream of health care services. The PICS ­assessment of collaboration revealed the following:

Key informant interviews provided additional richness to the quantitative data. The PICS project manager conducted recorded interviews with key staff from 29 clinics that participated in the initial survey. Analysis of the interviews corroborates the findings of the survey. Many respondents expressed concern over the insurance practice of “carving-out” mental health coverage as a disincentive to integration. Interviewees expressed a high level of interest in scrapping traditional fee-for-service insurance models in exchange for other models that they hoped would align incentives to support integrated behavioral health care (i.e., patient-centered medical home [PCMH] enhanced payments, pay-for-performance, capitation, and case rate models).

Based on the survey and interview findings (The Colorado Health Foundation, 2012), leaders of the PICS project proposed five recommendations for enhancing the financial sustainability of integrated behavioral health care:

The PICS group asserted that the first three recommendations were short-term fixes that would provide initial financial support for integrated behavioral health care. However, they would be wholly insufficient without the systemic changes envisioned in recommendations four and five.

Perhaps the most important success story from the Colorado legislature was the 2011 passage HB 1,242. This law reads, “(c)urrent reimbursement policies for providers providing physical and behavioral health care services on the same day are complicated and the policies create a barrier to the seamless integration of these services for the well-being of the patient.” The law mandates that the Colorado Medicaid office review state policies that create obstacles to integration and propose solutions to them in 2012. The law specifically identifies the PCMH model and Accountable Care Organizations as possible solutions.

Other state-level successes. The growth of integrated behavioral health care and the development of its financial supports across the United States share many similar themes from Colorado’s story. All states with highly developed collaborative models reflect several of these core elements: pioneering clinics and foundations, legislative victories, frequent convening, and a supportive commercial insurance environment. The following sections highlight these themes from multiple states.

Pioneering clinics and foundations. State successes in pioneering behavioral health integration in primary care share two categorical things in common: a variety of funding mechanisms for support and a variety of models for implementation. In just about every case, their voyage into the unknown of integrated behavioral health care was financed by a philanthropic foundation that provided the financial resources to jump-start these initiatives. For Colorado, it was Marillac Clinic, the Robert Wood Johnson (RWJ) Foundation, and later a consortium of foundations. As noted in the Colorado section, many Colorado clinics continue to require foundation support for ongoing collaborative operations. The fact that integrated behavioral health care services are not self-sustaining presents one of the largest financial obstacles to the model.

Maine. The health care system in Maine has benefitted from a pairing between clinical sites and the Maine Health Access Foundation (MeHAF). Based on early pilots with Penobscot Community Health Care, Maine Medical Center, and TriCounty Mental Health, the foundation invested $10 million in integrated care initiatives starting in 2007. These funds benefited over 43 projects covering 100 different sites (B. Boober, personal communication, March 29, 2012). Another entity, MaineHealth, the largest health care system in Maine, has been a recipient of MeHAF grants for integration (N. Korsen, personal communication, April 24, 2012). MaineHealth is a nonprofit integrated health care delivery system serving 11 counties in rural Maine (www.mainehealth.org). MaineHealth is supporting a service line, which helps practices implement and sustain integrated services. The health system currently funds services such as care management through a mixture of sources, including departmental funding, PCMH-incentive dollars, and direct patient care (J. Schirmer, personal communication, May 11, 2012). To this end, MaineHealth integration staff has worked with a variety of types of practices, including hospital-owned practices, FQHCs, rural health clinics, and private practices. While some practice types have reimbursement rates that are more favorable for integrated services, MaineHealth’s financial models suggest that not only can integration be financially sustained in any of these practices and pay for itself with a reasonable expectation for productivity; it can also generate funds to support its service line.

California. Several California clinics have integrated care for decades. The Haight-Ashbury Free Clinics and Walden House function as a combined FQHC. This system has over 200 paid staff and 500 volunteers providing services to over 15 facilities and 19,000 clients, with some facilities specifically designed for integrated care. The vast majority of their revenues come from state and local government general funds, with most of it being public health community behavioral health service funding (Butler et al., 2008; K. Linkins, personal communication, April 24, 2012). California has an organization, Integrated Behavioral Health Project (IBHP)—which has the financial backing from the California Endowment and is a project of the Tides Center. IBHP is a nonprofit organization dedicated to accelerating and elevating integrated behavioral health care throughout California (www.ibhp.org). IBHP’s initial goal was to accelerate integrated care by providing training and grants to primary care clinics to broaden their behavioral health services and increase intra-clinic collaboration. To date they have funded three rounds of initiatives. In 2007, phase I supported “vanguard clinics” that had co-location of BH and primary care. Phase II funded a larger group of “learner clinics” to train and guide enable those that were newly embarking on integration. In Phase III, with the availability of federal and Mental Health Services Act grants in California, the public mental health sector rather than the primary care centers have been more active with integration initiatives. Most of their efforts, though, have focused on collaborating with primary care to ensure identification and treatment of chronic physical problems for their populations with serious mental illness. Many local mental health departments have also provided psychiatric consultation for local primary care clinics. Thus, to simplify the movement in this state, the thrust of primary care has been to expand the mental health services they provide internally to their patients and the thrust of mental health has been to secure physical health services to their own clients. Both systems seem to prefer to operate on their own turf (B. Lurie Demming, personal communication, May 24, 2012). The funding criteria and funded projects are listed on their website (www.ibhp.org).

Texas. The Hogg Foundation for Mental Health began their investment in ­integrated care in 2006 by funding 2.6 million in three-year grants to bring the “collaborative care” model of integrated health care to several clinics in Texas (L. Frost, personal communication, April 16, 2012). In 2009, a staff member from the Hogg Foundation was appointed to the Texas Integration of Health and Behavioral Health Workgroup created by House Bill 2,196 to recommend best practices in policy, training, and service delivery to promote the integration of health and behavioral health services in Texas. Members were appointed by the Texas Health and Human Services’ executive commissioner and represent stakeholders, such as consumers, family members, advocacy groups, providers, health care workers, and state agencies. In 2012, the foundation launched a second round of grants to promote integration, focusing on 1-year planning grants and 2-year implementation grants for agencies across Texas. The Hogg Foundation continues to commit funding to the advancement of integration of health and behavioral health and has become a national figure in advocacy and public policy efforts.