Primary Care Integration: Alternative Workforce Strategies for Community-Based Behavioral Health Service Organizations in the Era of Physician Shortages

It has been many years since the surgeon general report declared that vastly poor health outcomes for persons suffering from behavioral health disorders was a public health crisis. Lives filled with long term disability and early mortality caused, in part, by service fragmentation within the U.S. healthcare system. (Parks, J., Svendsen, et al Morbidity and mortality in people with serious mental illness. Technical report of the National Association of State Mental Health Program Directors. 2006.) Among those in the behavioral health field, this report became widely referenced as it conveyed the changing core principles of care; that mental health and primary care integration is a necessary and basic tenet for this population. Despite that call to action, the provision of integrative services may likely continue to be unequal nationwide for community-based, nonprofit, behavioral health providers, in part due to shrinking public funding and the competing high costs of employing primary care physicians.

Alternative Models of Care: Primary Care Physicians Shortage, Funding Limitations.

Compounding these service delivery limitations is a growing shortage of primary care physicians. In a study conducted by the AAMC (American Association of Medical Colleges), it is projected that by 2030 there will be a shortfall of between 14,800 and 49,300 primary care physicians. This is largely due to three reasons: the growing U.S. population, which by 2030 is expected to grow 11%, the aging of the “baby boomers,” with the over 65 population expected to grow by 50% by 2030, and the shortage of medical residents interested in pursuing a primary care practice over a lucrative career as a specialist. (Academy of Family Physicians. Family physician, scope, philosophical statement. In AAFP Reference Manual. Leawood, KS: AAFP; 2012). This year alone, the number of U.S. medical school graduates entering primary care, family medicine, internal medicine and pediatrics residencies combined totaled 2,730. (Peikes, D. The Comprehensive Primary Care Initiative: Effects on Spending, Quality, Patients, And Physicians. Health Affairs. 2014;37(6).

This is a significant shortfall that does not even come close to addressing the predicted deficiencies in the primary care provider pool, which is expected to reach 23,640 by the year 2025. On the contrary, according to the Bureau of Labor Statistics Occupational Outlook Handbook, the projected percent of change in employment for nurse practitioners from 2016 to 2026 is up to 31%. Projected growth in physician’s assistants is 37%, resulting in an increased supply for both occupations with higher than average growth rates.

Coupled with this labor force reality is the unequal distribution of funding available to the nonprofit sector to support integrated service delivery models. We know that the largest portion of resources available to this sector came through the Substance Abuse and Mental Health Services Administration (SAMHSA) 2009-2016 Primary and Behavioral Care Integration (PBHCI) Program grant funding which averaged $400,000 per year per organization, renewable for up to 4 years. This program was developed to address community-based service capacity issues, but what remains unclear are the sustainable effects from the service systems’ ability to continue cost-effective primary care models in the era of reduced funding.

Consequently, with the limited supply of physicians and existing economic challenges for nonprofit providers, we propose a departure from the traditional model of physician-based primary care. We advocate for the adoption of a universal industry standard that allows for Nurse practitioners or Physician Assistants to be given full regulatory approval by each state to act as the patient’s primary care professional. Historically community-based providers have been contractually obligated to engage a minimum of physician services, limiting alternative solutions to meet their patients’ primary care needs, especially when these other qualified medical providers are often better suited to meet the demands of this population and are much more cost effective. As advocacy leaders and champions of our mission, we have realized the benefits of primary care integration within our industry and advocate to adopt federal regulatory changes which include strategies for alternative medical providers within community-based nonprofit settings. In light of the diminishing physician supply, alternative models of care are not just a good idea but have more than ever become necessary. These long-standing barriers to integration, financial pressures, and lack of federal funding are now making every provider wary of further decreases in the pool of patient care revenue. Primary care providers will be cautious about losing potential reimbursement to increased mental health services unless they feel they can benefit from the cost savings in the utilization of primary health care. Comparably, the groups that control mental health revenue tend to protect their shrinking pool of dollars rather than face the unknown of collaboration with primary care providers. These struggles contain the opportunity for a renewed recognition of the interaction between the physical and mental life of patients, as well as the need for the reintegration of care. Access to comprehensive, quality health care services is important for promoting and maintaining health, preventing and managing diseases, reducing unnecessary disability and premature death, and achieving health equity for all Americans.

Research in Progress: National Survey to Behavioral Health Providers on the Adoption of Integrative Practices

Policymakers must focus on particular subgroups that are most at-risk for high cost and poor quality, such as the one proposed our ongoing study. This is necessary to improve the quality of health care and reduce costs. If rectified, it could provide community-based organizations with more patient-centered, cost-effective models of care coordination that broaden organizational vision and mission to include holistic care. Decades of economic strain for an already inadequately funded safety net of providers has hastened the need for public policy leaders and researchers to support alternative models that provide quality primary care services for all. To that end, data is currently being gathered through a national survey being distributed to nonprofit community-based providers to examine in greater detail how physician shortages with reduced funding and unequal regulatory requirements, have impacted integrative practices.

Special Request: Short Survey

on Behavioral Health and Primary Care Integration Funding


Dear Nonprofit leader,

We are conducting a short survey at The University of New Haven on primary care integration funding within the nonprofit, behavioral health sector. The results of this survey will enable us to analyze funding needs, and the support required for these essential services. Please feel free to take and forward this survey to any of your nationwide nonprofit colleagues. If you have any questions regarding this survey, please contact me directly at or at (203) 479-4704.

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