Redesigning behavioral health care: The time is now


Richard Antonelli, MD, is a primary care pediatrician and medical director of Integrated Care and Physician Relations and Outreach at Boston Children’s Hospital.  He also co-chairs the Task Force on Care Coordination for Children with Behavioral Health Needs, a group within the Massachusetts Child Health Quality Coalition. Laura Chandhok, MPH, Physician Partnership Liaison at Boston Children’s Hospital, contributed to this post.

The recent shootings in Newtown, Conn., have revived the long-standing debate about gun control in the United States and rightly put a spotlight on media and video-game violence. Importantly, this tragic event has also raised questions about the adequacy of our nation’s behavioral health system and whether troubled children, adolescents and their families have access to needed diagnostic and management services.

These questions aren’t new. And as care delivery models evolve in response to the demands for better care at lower costs, we have an opportunity to improve our behavioral health services. Broadly defined, behavioral health encompasses mental health, substance abuse and dependence, and risk behaviors ranging from eating habits to risky sexual activity.


Right now, the behavioral health system delivers unacceptable outcomes. I partnered in a recent Massachusetts study led by the Parent/Professional Advocacy League (PPAL) and funded by the U.S. Maternal and Child Health Bureau. Parents of children with behavioral health needs described their frustration in PPAL’s report (PDF):

“I feel like there is really no coordination between medical providers, mental health providers and school, except what is done by me.”

“We’ve been unable to find another psychiatrist in our network who treats teenagers. The insurance company puts up road blocks that had to be overcome and his new psychiatrist is 1¾ hours away.”

“We’ve found unnecessary barriers such as requirements to use emergency services rather than going to the clinician’s office.”

These parents’ experiences are not unique. Consider these statistics:

  • Almost 20 percent of U.S. children are dealing with some form of mental illness,1 and only one in five gets treatment.2
  • Thirteen percent of 8- to 15-year-olds have mental illness severe enough to disrupt their day-to-day lives.3
  • Half of all mental illnesses begin by age 14; three quarters by age 24.4
  • From the time symptoms first emerge, it take an average of 8 to 10 years for a child to receive appropriate intervention.5

Early detection and intervention can make a huge difference. In 2008, total expenditures for treating children’s mental illness topped $12 billion,6  not counting the costs of treating chronic medical conditions like asthma and diabetes, which often have worse outcomes in these children.

86 percent of parents said they had sole responsibility for coordinating their child’s mental health care.

Right now, our health care system isn’t configured to provide good behavioral health care. Screenings are not universally applied. Formal diagnoses are often late to happen. Access to behavioral health specialists is inadequate. Finally, families and providers often are reluctant to “label” a child because of the stigma associated with behavioral health diagnoses.

And once a child is identified as needing help, families often have trouble accessing the services they need. The PPAL study demonstrated that only 38 percent of parents whose child needed mental health care received help in getting that care from the pediatrician. Two-thirds had to wait three months or more to see a psychiatrist. And 86 percent said they had sole responsibility for coordinating their child’s mental health care.

What other medical condition requires this degree of self-navigation by families?

Shortages of behavioral health appointments aren’t likely to change anytime soon. What we can do, though, is to bolster behavioral health screening and management capacity within community-based primary care, by employing new family-centered integrated care models.

In these models, primary care providers and behavioral health providers become close collaborators. When children enter the primary care setting for routine check-ups, or for specific behavioral complaints, the primary care team conducts a behavioral health assessment and works with patient and family to create a care plan that may include referral to a behavioral health provider. When that referral is made, the family has clear expectations for their child’s outcomes and follow-up care.

Research funded by the Agency for Healthcare Research and Quality (PDF) indicates that integrated mental health care saves the system money. Costs per patient go down, utilization of specialty services goes down, emergency room use goes down, psychiatric admissions and length of stay go down and medical hospitalizations are shorter.

For these integrated models to succeed, we need a policy environment that sustainably supports them and measures their performance. That means devoting resources to training families and providers, compensating pediatric primary care providers for time spent coordinating care and compensating behavioral health providers for their participation as a care partner, rather than an exclusive provider.

We are hopeful that new performance expectations, coupled with innovative funding mechanisms, will be an important part of the Massachusetts Medicaid Comprehensive Primary Care Payment Reform. Though final wording has not been announced, we have every indication that reforms will include payment for primary care providers to participate in integrated behavioral health models that include expectations for appropriate screening and care coordination services.

A likely part of the new expectations will be a requirement for authentic patient and family engagement in their health care—which will be an important driver of change. More on that to follow.

Join the Children’s Advocacy Network to be a voice in improving children’s access to quality mental health care.


1. National Research Council and Institute of Medicine (2009); 2. Mental Health: A Report of the Surgeon General (1999); 3. National Health and Nutrition Examination Survey (2010); 4. NIMH, Mental Illness Exacts Heavy Toll: Beginning in Youth (2005); 5. NIMH (2005); 6. Agency for Healthcare Research and Quality (2011); 7. PPAL report (PDF) (2012).