By NextBestFitStepped care and integration into primary care
Self-referral to talking therapies, collaborative care in primary care, crisis lines.
Large capacity at low cost.
Review ledgerHow this path connects
Addresses
Mental health care is hard to getThis path
Stepped care and integration into primary care
Creates or worsens
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Allow self-referral to talking therapies
- Fund collaborative care in primary care
- Fund crisis lines
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Mental health care is hard to get
Self-referral to talking therapies, collaborative primary care, and crisis lines provide substantial capacity at low cost. Patients can refer themselves without a doctor visit.
What it creates or worsens
- Longer waits if demand grows faster than capacity
Stepped care can leave patients waiting for higher-intensity mental health care.
12 paths soften this
Legal wait-time guaranteesLonger waits if demand grows faster than capacityChosenBuild capacity before demand risesLonger waits if demand grows faster than capacityChosenPay for activity on top of budgetsLonger waits if demand grows faster than capacityChosenFund more residency slotsPhysician shortage, especially in primary careChosenFull practice authority for NPs, PAs, pharmacists, dental therapistsScope-of-practice limits waste capacityChosenTeam-based care with physician oversightScope-of-practice limits waste capacityRejectedFee-for-service at public fee scheduleU.S. prices are far higher than in other countriesChosenKeep means testing, but expand home careLong-term care requires spending down to povertyChosenAllow private insurance for covered servicesTwo-tier care: a private fast lane for those who can payRejectedBudgets adjust automatically for population, age, and volumeFixed budgets can ration careChosenBase budget plus activity paymentsFixed budgets can ration careChosenWaiting-time guarantees as a backstopFixed budgets can ration careChosen - Targets and quality metrics invite gaming
Outcome targets in stepped mental health care can be gamed.
Who's affected
Who gains
- People needing mental health care
- Mental health care is hard to get: Shortages and limited insurance acceptance make mental health treatment hard to obtain.
- Family caregivers and affected families
- Mental health care is hard to get: Shortages and limited insurance acceptance make mental health treatment hard to obtain.
- Hospitals, clinics, and care organizations
- Mental health care is hard to get: Emergency departments board psychiatric patients who cannot access other care.
- Targets and quality metrics invite gaming: They can benefit by changing referral dates, avoiding sick patients, or upcoding.
- People with ongoing or specialist care needs
- Mental health care is hard to get: Self-referral to talking therapies, collaborative primary care, and crisis lines provide substantial capacity at low cost. Patients can refer themselves without a doctor visit.
Who loses
- Cash-pay and private care practices
- Mental health care is hard to get: Limited insurance acceptance supports cash-pay treatment.
- Health insurers, brokers, and their shareholders
- Mental health care is hard to get: They benefit from avoiding behavioral health costs.
- People with employer coverage
- Longer waits if demand grows faster than capacity: They are seen fastest today and would share one queue with everyone.
- People with ongoing or specialist care needs
- Longer waits if demand grows faster than capacity: They need specialists and procedures most often.
- Targets and quality metrics invite gaming: Gaming wait-time and quality measures undermines their intended protection.
Where it has been tried
- NHS Talking Therapies: Self-referral, stepped care model.