Improving Access to Behavioral Health Services with Workforce, Primary Care, and Telehealth Solutions

Access to behavioral health services has long been a barrier, with some areas of the country having few or no behavioral health providers available

By Christina Koster and Christina Rodich, Guidehouse 

As winter approaches and those with seasonal depression join the thousands of people already experiencing exacerbated mental health and substance use disorders, now is the time for state authorities to seriously evaluate access to behavioral health services.

Access to behavioral health services has long been a barrier, with some areas of the country having few or no behavioral health providers available.

The pandemic creates an opportunity to comprehensively pinpoint and address access barriers, and embed solutions in the workforce, across primary care settings, and through the increasing use of telehealth. While some temporary fixes have been established, communities across the country need transformations that will support both near-term and future behavioral health needs.

The Workforce

Historically, high turnover rates, aging workers, and low compensation have contributed to behavioral health shortages. According to Mental Health in America’s Access to Care, 22% of adults with a mental illness were unable to receive the care that they needed, due to reasons such as:

  • Overall undersized mental health workforce.
  • Lack of available treatment types (i.e., inpatient treatment, individual therapy).
  • Limited insurance coverage of mental health services.

As more individuals experience increased behavioral health symptoms, COVID-19 will further challenge the limited supply of behavioral health providers. With Medicaid paying for 25% of mental health services and 21% of substance use disorder services as of 2014, Medicaid agencies have a critical role in assuring there is a workforce that can meet increasing behavioral health needs.

A comprehensive needs and gap analysis can provide important insights for strategies, priorities, and future behavioral health workforce investments.

Improving Access to Behavioral Health

Many behavioral health providers have taken a large financial hit due to COVID-19, with 54% of behavioral health organizations that had to close programs as a result of the pandemic. It is key to consider current and long-term impacts, such as workforce availability and capabilities to provide services across the behavioral health continuum, to ensure individuals receive the intensity of services appropriate to their needs, in the most appropriate setting.

Additionally, investments in grassroots and community-based approaches, such as Mental Health First Aid, can help to broaden awareness and identify individuals with mental health and substance use issues. Many people are no longer visiting their doctors or professional therapists, underscoring an important role for individuals outside of the formal healthcare delivery system (e.g., grocery store clerks, hairdressers, bank tellers, apartment managers) to identify when someone may be in crisis and help refer them to appropriate services.

Mental Health First Aid—or similar evidence-based training—promotes community awareness of behavioral health, destigmatizes obtaining professional help, and mobilizes those who regularly interact with at-risk individuals in the community to facilitate referrals based on risk factors identifiable by a layperson.

Primary Care

Primary care practices will likely see increased demand for behavioral health services due to COVID-19. Integration of physical and behavioral health has long been identified as an effective approach to addressing behavioral health issues.

It is important for Medicaid agencies to equip primary care practices with the capabilities necessary to identify behavioral health needs and connect individuals to the right service.

This means encouraging providers to:

  • Screen for behavioral health issues in the primary care setting using an evidence-based screening tool that can identify mental health and substance use symptoms.
  • Develop a consistent behavioral health provider referral process for those individuals with positive screens.
  • Use multidisciplinary care/treatment teams to provide whole person care that addresses the variety of issues patients present.
  • Track and report on population health metrics to monitor the progress of individuals needing behavioral health services over time (e.g., movement in PHQ-9 depression scores).

Medicaid agencies can further support primary care and behavioral health integration by offering value-based prospective per member per month payments and performance incentive payments to reward high-performing providers for the time and labor required to evolve their care delivery models. This allows for a more predictable stream of revenue for providers—revenue that has become a more apparent need as volume has decreased for many during the pandemic. States can also tie incentive payments to providers achieving National Committee for Quality Assurance Distinction in Behavioral Health Integration.

When done right, primary care and behavioral health integration programs have led to both quality improvements and cost savings. In fact, Guidehouse helped TennCare, Tennessee’s Medicaid agency, achieve positive outcomes with its primary care and behavioral health transformation programs, in which primary care providers earned more than $11 million in outcome payments.


The use of telehealth services, including telepsychiatry, has rapidly increased during the pandemic for individuals seeking physical and behavioral health services. Telehealth can help to more rapidly expand access to behavioral health services to respond to the anticipated surge in demand for behavioral health services.

Telehealth services may be delivered real time or in store-and-forward modalities, which allow for secure electronic transmission of medical information to providers who provide services outside of a live interaction. Telehealth can also mitigate common barriers that prevent individuals from seeking behavioral health treatment, including the stigma associated with receiving behavioral health care and transportation challenges.

Guidehouse conducted an environmental scan of states’ policies regarding telehealth and determined states have made four primary changes to their telehealth policies:

  1. Loosened restrictions on allowable originating and distant sites, or the sites at which the Medicaid beneficiary and Medicaid provider are located, respectively.
  2. Reduced the requirements for eligible technologies or modalities through which telehealth services may be delivered, including via telephonic-only communication.
  3. Allowed the establishment of a patient-provider relationship through telehealth.
  4. Expanded the types of services delivered through telehealth. 

At least 41 states now allow telehealth delivery of behavioral health services. However, many states’ telehealth changes are temporary and set to expire after the end of the pandemic/public health emergency. An analysis of lessons learned during the pandemic can inform future telehealth policies. Areas for states to consider in future planning include, but are not limited to:

  • Effectiveness of telehealth to provide certain behavioral health services.
  • Options for individuals without access to the internet or technology devices.
  • Privacy concerns, which are heightened for behavioral health services.

Upon assessing lessons learned, states can better determine which behavioral health services to offer long-term via telehealth and review and update Medicaid reimbursement methodologies to correlate with changes in service delivery. States may also consider broader reimbursement policies that encourage more widespread, long-term use of telehealth for behavioral health services. For example, prior to COVID-19, only five states had implemented telehealth parity laws for private payers.

As the cold months come and “pandemic depression” increases, the importance of state agencies’ roles in addressing access to behavioral health services only increases.

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