Need to see a mental health provider but don’t know where to start? You may be able to get connected to one through your regular doctor.
It’s becoming increasingly common to see primary care doctors getting involved with mental health care — whether by connecting patients to same-day appointments with psychologists, or teaming up with mental health providers to keep track of a patient’s mental health challenges.
The model of care, known broadly as “integrated mental health,” gives patients an entry point to behavioral health care in a setting they’re already familiar with — their own doctor’s office. Doctors can quickly refer patients to mental health treatment and can be kept in the loop about the patient’s status. The goal, mental health professionals say, is to make those services more accessible and reduce the stigma of seeking mental health care for people who otherwise wouldn’t.
“I think of us as the jack-of-all-trades Swiss Army knives of mental health,” said Rob Bailey, a psychologist with UW Medicine’s Northgate Primary Care clinic who provides integrated care. “We can do a little bit of everything, especially mild to moderate issues.”
Heather Riley, a social worker at UW Medicine’s behavioral health integration program, said these programs can be helpful for people who’ve never done counseling before.
“This is a good place to start because they trust their doctor,” she said.
Some patients say they’ve seen increased access and improved health as a result. But others say the initial connections with mental health providers haven’t translated to the long-term solutions they seek. And some have said navigating those services can be difficult depending on their insurance provider.
Providers acknowledge that these models of care are more suited toward short-term concerns. More acute or severe mental health cases are still best treated directly through specialty care, although Bailey said integrated care can still be an entry point for those types of cases.
But behavioral health professionals say that while there is room for these types of programs to grow, the core concept has already connected people to much-needed services.
“When you’re struggling with behavioral health concerns, you’re often already overwhelmed and trying to problem solve a complex system is hard,” said Anna Ratzliff, the co-director of the University of Washington’s Advancing Integrated Mental Health Solutions Center. “If you’re not sure how to get help, just go to your primary care provider and they now have more capacity to support you.”
The concept of merging physical and mental health services isn’t new. The University of Washington has been training other clinics to integrate primary and behavioral health care services for about 20 years through the Advancing Integrated Mental Health Systems program. The university began providing those services at its own clinics about a decade ago.
One model of integrated mental health care does “warm handoffs,” offering patients direct and immediate consultations with a mental health professional when they go to their regular doctor. During a checkup, doctors will ask patients if they have any mental health needs or concerns, or patients can raise those issues on their own. If so, the doctor will ask if they want to see a mental health provider that day. Patients can then have a brief appointment with a psychologist, like Bailey, who can offer an assessment and give them some immediate strategies.
“That’s true clinical integration — in person, at the clinic,” said Jason McGill, the assistant director of Medicaid programs for the Washington State Health Care Authority. “But not everyone’s Harborview. So there have been a number of different community health clinics that have good models of care.”
Others, he said, have incorporated telehealth, where a psychologist may not be on staff, but can contract with a primary care provider to help. Some behavioral health clinics also offer assistance in the other direction — connecting patients with primary care clinicians during their appointments.
The collaborative care model, which was developed at UW, involves psychiatric providers working in tandem with primary care providers and a behavioral health manager, keeping track of the patient’s mental health and progress over time.
The behavioral health integration program refers patients to social workers like Riley, and typically focuses on helping patients with moderate depression or anxiety. She offers cognitive and dialectical behavioral therapy, as well as problem-solving skills, to help patients develop coping skills.
Mara Page, a Seattle resident, said she was first offered mental health care through her primary care provider in 2022, when she went for an annual checkup at her doctor’s office, Swedish Medical Center’s Ballard clinic.
She mentioned she was experiencing some stress at work, and her doctor told her the clinic had several resident doctors specializing in behavioral health. The doctor asked if she wanted to see one, and she was able to schedule the appointment through the same office.
“It felt very unintimidating,” she said. “It was the same location I was already going to. I felt like if I had to go to a different place, I probably wouldn’t have done it because I didn’t consider my issue to be that important.”
A few months later, she was going through a period of grief and had symptoms including loss of appetite. She met with her primary care provider, who told her if things didn’t clear up in a few weeks, she should consider talking to a behavioral health provider again.
“It was cool to have that option as a first line of remedy,” Page said.
Bailey said mental health services at the primary care clinics can help address several common challenges, including anxiety and depression, or even help with coping skills for chronic pain or quitting smoking or drinking.
During his meetings with patients, he’ll try to provide suggestions for how clients can recognize patterns or thoughts that are causing problems, and change them to get a different result.
The goal, he said, is to provide the maximum efficiency and impact in just a few sessions.
“We experience something anxiety-provoking and exit the situation,” Bailey said. “It could be leaving, it could be using a substance to help manage the moment. What I’ll explain is that we find the anxiety will reduce, but it’s kind of like giving candy to a screaming kid. It works in the short term, but it only teaches the child that if they make enough noise, they’ll get what they want.”
Those who have more chronic mental health issues might need more specialized care, and could be referred to longer-term treatment.
Insurance challenges
As health care providers increasingly merge mental and physical health services, one question often emerges: How does insurance cover it?
The state Legislature in 2016 changed Medicaid coverage so that anyone using the government-funded health care plan could be covered for behavioral health, physical health and substance use disorder all through one system. Previously, different state agencies covered each of those areas.
Merging insurance coverage of those services hasn’t overwhelmingly increased patients’ use of them, however. McGill said the system was integrated just before the pandemic, and he thinks that, combined with a shortage of mental health care workers, slowed people’s access to these services.
And private insurance doesn’t have specific rules for covering integrated mental health services. Stephanie Marquis, a spokesperson for the Office of the Insurance Commissioner, said most insurers use collaborative care-specific codes to track those services.
Coverage of integrated care varies based on each person’s plan, said Ratzliff, the UW psychiatrist. Some services may be billed as primary care, while others may incur a second bill directly from the mental health provider.
Because private insurance billing data is not readily available, it’s hard to track how much people are actually using those services, said Ratzliff.
Many patients also still encounter broader challenges accessing mental health care, even when referred through their primary providers.
Walter Hekala was referred to several mental health providers by his primary doctor but ran into roadblocks because of his insurance coverage.
The Bellingham resident said he attempted suicide after being accidentally exposed to a toxic chemical that affected his cognition.
He was taken to the hospital and put under observation, but said the hospital didn’t have room to keep him longer.
“They told me ‘We’ll release you, but you have to seek mental health help within 24 hours,’ ” Hekala said.
His primary insurance was Medicare, but he had secondary coverage with Regence Blue Cross Blue Shield. As he tried to find mental health providers that could take him, each told him they would only do so if he paid cash out of pocket.
“It is a complete desert finding mental health care that will take Medicare,” Hekala said. “In the meantime, the only one I’m talking to is my [general practitioner], who’s doing the absolute best he can.”
Eventually, Hekala said Blue Cross Blue Shield agreed to cover his care, but it took him more than a month to be able to sit down with a counselor.
Medicare is supposed to cover a variety of mental health services, including the majority of costs for outpatient services and therapy. But it doesn’t cover residential treatment. And some providers don’t accept Medicare, noted Ratzliff.
Ratzliff said there are areas for improvement with models of integrated care, like better systems to track how widely patients are using the programs and developing more services that connect mental and physical health.
She said that as the state continues to think about primary care quality, behavioral health is becoming a more essential part of that conversation.
“There’s increasing recognition that primary care is one of the places that this is happening,” she said, “and that we should be expecting a different level of quality within behavioral health within primary care.”
