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Cheat Sheet

Understand the key stakeholders in behavioral health

For patients, navigating the U.S. behavioral health system is often a confusing and disjointed experience. They're not alone—many industry leaders feel similarly unequipped to make strategic decisions within the behavioral health sector because of the complexities of how patients and money move throughout the system.

Take, for example, a patient whose needs escalate while under the care of their PCP. After visiting the ED in crisis, the patient is admitted to an inpatient setting with the goal of transitioning to long-term specialty care. That means four (often) separate entities must work together to share data, communicate care plans, and ultimately smooth transitions in care. And those four entities may have entirely different financial models, some of which may operate outside of the health insurance system altogether.

Ultimately, this system-wide fragmentation is a driving reason for why there is no easy fix for the current behavioral health crisis. It's why many health plans carve out behavioral health services from their operations altogether. And this complexity also makes it challenging for new entrants and would-be innovators, like digital health vendors, to find staying power.

Use this resource library to better understand the roles of the primary stakeholders in the behavioral health care sector—including organizations that deliver and pay for care. Each installment includes an overview of the stakeholder's primary behavioral health services, target patient/member population, and financial model.


Organizations that deliver behavioral health care

Primary care

The primary care setting is often a patient’s main access point for health care, positioning primary care physicians (PCPs) particularly well to identify and treat mild to moderate behavioral health needs. Primary care professionals can support lower-acuity management and connect patients to specialty care.

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Specialty outpatient care

Specialty outpatient behavioral health programs are offered by a range of organizations including hospital outpatient clinics, health systems, clinics, treatment centers, and private practices. This care option is a good fit for patients who have mild to moderate symptoms, patients transitioning out of inpatient treatment, and patients who do not have the capacity to be in inpatient treatment.

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Digital health vendors

Digital behavioral health vendors provide a range of therapeutic services delivered remotely to patients. However, the success of the interventions is largely reliant on consumers having access to the appropriate technology and the skills to use it, which creates barriers for some patients.

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Community-based care

Community-based behavioral health care organizations provide services that address both the clinical and non-clinical needs that impact behavioral health outcomes. Challenges to sustainable funding limit the ability for these community-based organizations to invest in the infrastructure needed for growth.

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Crisis care

Crisis response services are often patients’ first entry point for behavioral health care. Patients who receive crisis response services are often receiving care at the last possible moment. A more equitable system would provide the most marginalized and at-risk patients with more accessible, affordable options prior to escalation.

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Inpatient care

Inpatient behavioral health programs are run by medical facilities including psychiatric hospitals and residential treatment centers. There is both short-term and long-term inpatient treatment programs, and treatments often include a combination of services.

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Organizations that pay for behavioral health care

Private health plans

Health plans manage behavioral health services for two different types of customers: private entities, and state and federal government agencies. A private health plan’s coverage for behavioral health services is highly dependent on state regulations and the plan’s determination of medical necessity.

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Federal law requires Medicaid to cover certain behavioral health services, including specific outpatient and inpatient services. With recent federal policy focus on expanding Medicaid coverage, many states have committed to initiatives designed to expanding tele-behavioral health coverage, community-based service access, substance use support, and crisis intervention programs.

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The Commonwealth Fund estimates about one of every four Medicare beneficiaries have a mental health condition. Medicare provides behavioral health coverage in four parts, including limited inpatient services, certain outpatient services, prescription medication, and additional purchased services.

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