Mike Franz, MD, executive medical director of behavioral health at Cambia Health Solutions, told Becker’s a layered approach that combines multiple established care models can improve access, upskill providers and keep behavioral health patients within the primary care setting.
“I see an optimal level of [behavioral health] integration into primary care occur when we have multiple validated models layered,” he said. “Layer[ing] them one on top of each other really provides some synergy to at its best support the primary care team, starting with the primary care provider.”
The five layered care models represent what Dr. Franz describes as an “optimal environment” for integrated behavioral health in primary care — “the North Star, the Holy Grail.”
The models include:
Primary care behavioral health model: An embedded behavioral health clinician works directly within the primary care team, sharing treatment plans, conducting real-time assessments and performing “warm handoffs” during patient visits. The model emphasizes immediate access to behavioral care within the clinic and requires protected time for unscheduled, in-the-moment interventions.
Collaborative care model: A team-based, largely asynchronous model where a psychiatrist, care manager and primary care provider collaborate. The care manager and psychiatrist review cases regularly, often without direct patient interaction, and provide treatment recommendations based on measurement-driven criteria, with the goal of improving outcomes and graduating patients from the program over time.
E-consults: A primary care provider-initiated, one-time consultation with a psychiatric specialist for complex cases. The specialist conducts a detailed chart review and provides target recommendations, including medication adjustments or psychosocial strategies, with the option for future re-consultation if needed.
Psychiatric access lines: State- or institution-supported phone consultation services that allow primary care providers to receive real-time guidance from psychiatric specialists while the patient is still in the clinic. These interactions enable immediate clinical decision-making and are typically followed by written recommendations.
Project ECHO: A virtual, hub-and-spoke education model where specialists train and mentor primary care providers over a series of sessions, often lasting around 12 weeks. Through case discussions and didactics, the model builds primary care capacity to manage complex behavioral health conditions independently.
These models increasingly keep patients in primary care, where many prefer to receive care, rather than being referred elsewhere and needing to travel or schedule another appointment.
Although, implementing all five models is more of a vision than a reality on the ground, with most systems operating with partial adoption of one to three models, he said. The layered approach benefits the health system since effective primary care integration can keep specialized behavioral health clinics for individuals with complex conditions.
All the models allow primary care providers to become “mini specialists,” where they can care for more challenging and complex cases, feeling more comfortable managing those without having to refer out.
Cambia supports integrated behavioral health models through reimbursement structures, including both general behavioral health services across care settings and specific models like e-consults and collaborative care.
At the same time, limitations in fee-for-service reimbursement are noted, particularly for integrated models such as the primary care behavioral health model that rely on real-time collaboration, care coordination and unscheduled provider interactions, he said.
Dr. Franz pointed to the need for alternative payment models, noting that providers would need to make significant operational changes — including staffing, workflows, performance metrics and reimbursement structures — to participate. However, because any single payer represents only a portion of a provider’s patient population, these changes are often not feasible unless a larger share of patients is included under the same model.
“There’s going to be a relatively higher threshold where the provider rationally is going to say, ‘I’d love to do that, but I can’t do that just for you. I need to have 40%, 50%, 60% of our patients enrolled in that kind of a model to really make it economically and practically feasible,’” he said.
Dr. Franz said Cambia is involved in “initial starts” with collaboratives, where a neutral convener brings together multiple payers and providers to develop alternative payment models for integrated behavioral health. These collaborations focus on aligning around care delivery approaches and structure — rather than pricing — to ensure compliance while creating consistency across stakeholders.
The goal is to establish payment models that support integrated care approaches and tie reimbursement to defined outcomes, particularly for services that are not easily reimbursed under traditional fee-for-service structures.
At the Becker's Fall Behavioral Health Summit, taking place November 4–5 in Chicago, behavioral health leaders and executives will explore strategies for expanding access to care, integrating services, addressing workforce challenges and leveraging innovation to improve outcomes across the behavioral health continuum. Apply for complimentary registration now.
