• The future of mental health treatment begins with primary care

    The following is a response to Austin’s post by Benjamin F. Miller, Director of the Office of Integrated Healthcare Research and Policy in the Department of Family Medicine at the University of Colorado School of Medicine.

    In 2009, with mental health parity on the horizon, Dr. Peter Cunningham surveyed 6600 primary care physicians to assess how this change in insurance would impact their practice. His findings then, as they are now, are symptomatic of a larger problem in healthcare that goes far beyond insurance parity for mental health.

    Essentially, with a focus on outpatient mental health care, the survey asked the physicians: “During the last 12 months, were you unable to obtain any of the following services for your patients when you thought they were medically necessary?” The results were staggering. Two thirds of the physicians surveyed indicated that they could not gain access to specialty mental health care.

    Before I go further, let me back up and clarify an assumption about these data: We assume that just because a patient is identified with a mental health condition in primary care that they have a desire to go to a “specialty mental health” setting. In fact, evidence suggests that most patients would rather receive care for mental health in the setting that more often identifies the problem – primary care.1-3 Further, even when referred, most patients do not follow up on their referrals to mental health from primary care.4-6

    Playing this logic out:

    If, patients are identified more often with a mental health condition in primary care, and IF, data suggests most of these patients do not follow up on a referral to outpatient specialty mental health, THEN comments that the mental health system will be inundated in light of expanded mental health coverage may not be entirely accurate.

    What these data do suggest is that having more complete models of primary care that include mental health providers may provide a unique opportunity to meet community demand for mental health services AND provide more timely access to problems as they present not weeks down the road.

    Simply put: integrating mental health INTO primary care defragments healthcare in a way that can immediately impact the majority of individuals who have a mental health condition.

    But there are barriers and cause for concern.

    Currently policies, both Medicaid and Medicare, treat and finance mental health services as if they are uniquely different from physical health. This leads to a place where regardless of how effective mental health, behavioral health, and substance use integration can be in primary care, there is a substantial barrier to financially sustaining these innovative models.7,8 To increase the likelihood of getting care to people earlier and engaging them in care more effectively, any effort to improve funding for mental health should include a clear focus on improving the integration of mental health into primary care. This is the first step in enhancing better policy for the mental health community.

    There remains a profound need to address mental health in our communities. While coverage expansion will indeed bring new patients into the system who have mental health issues, what happens if our attempts to address these patients are misdirected? What happens if we consider that more patients with mental health are seen in primary care than in any other healthcare setting?

    Using health center staffing  data and behavioral health service patterns from the 2010 Uniform Data System and the 2010 National Survey on Drug Use and Health, our team estimated that the number of patients likely to need mental health care in Federally Qualified Health Centers.9 We found:

    More than 2.5 million patients, 12 or older, with mild or moderate mental illness, and more than 357,000 with substance abuse disorders, may have gone without needed behavioral health services in 2010. This level of need would have required more than 11,600 full time providers. This translates to approximately 0.9 licensed mental health provider FTE, 0.1 FTE psychiatrist, 0.4 FTE other mental health staff, and 0.3 FTE substance abuse provider per 2,500 patients.  These estimates suggest that 90% of current centers could not access mental health services or provide substance abuse services to fully meet patients’ needs in 2010. If needs are similar after health center expansion, more than 27,000 full time behavioral health providers will be needed to serve 40 million medical patients, and grantees will need to increase behavioral health staff more than four-fold.

    Beyond access and workforce issues, there remains a need to discuss the clinical implications of fragmentation. Consider the negative impact of mental health, behavioral health, and substance use issues on physical health.10 As one example, when depression and diabetes are both addressed, positive diabetic and depression outcomes are generated.11  More so than the impact of other comorbid chronic diseases, the effect goes in both directions: Depression worsens chronic disease and chronic disease worsens depression.12  This association between depression and poorer functioning with chronic disease13-15 and clinical improvements in depression are associated with clinical improvements in aspects of chronic disease.15,16 However, when patients present to primary care with multiple chronic diseases that include depression, the depression is often not treated.17

    So, should we be paying attention to the impact mental health coverage expansion will have on our mental health system and providers? Absolutely! However, we should not stop there. We should consider what our patients have been telling us for years – mental health and primary care are inseparable and any attempts to separate the two leads to inferior care.10 We should consider that the system that will be “overwhelmed if not inundated” may not be the mental health system but rather the first point of entry for almost every patient in healthcare: primary care.

    References

    1. Blount A, Bayona J. Toward a system of integrated primary care. Families Systems Medicine. 1994;12:171-182.

    2. Kessler R, Stafford D, eds. Primary care is the de facto mental health system. New York: Springer; 2008. Kessler R, Stafford D, eds. Collaborative Medicine Case Studies: Evidence in Practice.

    3. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. June 1, 2005 2005;62(6):593-602.

    4. Collins C, Hewson DL, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care. 2010.

    5. Trude S, Stoddard JJ. Referral gridlock: Primary care physicians and mental health services. Journal of General Internal Medicine. 2003;18:442-449.

    6. Mitchell AJ, Selmes T. Why don’t patients attend their appointments? Maintaining engagement with psychiatric services. Advances in Psychiatric Treatment. November 1, 2007 2007;13(6):423-434.

    7. Kathol RG, Butler M, McAlpine DD, Kane RL. Barriers to Physical and Mental Condition Integrated Service Delivery. Psychosom Med. July 1, 2010 2010;72(6):511-518.

    8. Mauch D, Kautz C, Smith SA. Reimbursement of mental health services in primary care settings. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration;2008. HHS Pub. No. SMA-08-4324.

    9. Burke B, Miller B, Proser M, et al. A needs-based method for estimating the behavioral health staff needs of community health centers. BMC Health Services Research. 2013;13(1):245.

    10. deGruy F. Mental health care in the primary care setting. In: Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America’s Health in a New Era. Washington, D.C.: Institute of Medicine; 1996.

    11. Golden SH, Lazo M, Carnethon M, et al. Examining a bidirectional association between depressive symptoms and diabetes. Journal of the American Medical Association. 2008;299:2751-2759.

    12. Fortin M, Bravo G, Hudon C, Lapointe L, Dubois M-F, Almirall J. Psychological Distress and Multimorbidity in Primary Care. Ann Fam Med. September 1, 2006 2006;4(5):417-422.

    13. Andrews G. Should depression be managed as a chronic disease? BMJ. February 17, 2001 2001;322(7283):419-421.

    14. Luber MP, Hollenberg JP, Williams-Russo P, et al. Diagnosis, treatment, comorbidity, and resource utilization of depressed patients in a general medicine practice. International Journal of Psychiatry in Medicine. 2000;30(1):1-13.

    15. Theme-Filha MM, Szwarcwald CL, Souza-Júnior PRBd. Socio-demographic characteristics, treatment coverage, and self-rated health of individuals who reported six chronic diseases in Brazil, 2003. Cadernos de Saúde Pública. 2005;21:S43-S53.

    16. Noel PH, Williams JW, Jr, Unutzer J, et al. Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-being. Ann Fam Med. November 1, 2004 2004;2(6):555-562.

    17. Piette JD, Richardson C, Valenstein M. Addressing the needs of patients with multiple chronic illness: the case of diabetes and depression. The American Journal of Managed Care. 2004;10:152-162.

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    • The “Helping Families in Mental Health Crisis Act” (HR 3717) takes a stab at fixing some of the disparities in Medicaid. Specifically, it allows states to receive funds for free-standing IMDs that average less than 30 days length of stay. It eliminates provisions that are being read to prevent medicaid reimbursement for mental health and physical health services received on same day, and it elminates the ability of states to establish needlessly restricted formularies for the treatments used to treat serious mental illnesses like schizophrenia.
      DJ Jaffe
      Executive Direct
      Mental Illness Policy Org
      http://mentalillnesspolicy.org

    • Not suggesting this is insurmountable but many primary care providers are unsure how to integrate BH/MH into their practices even if they want to. Should they just be co-located with integration of eMRs and staff? Should they essentially be “on call” so the primary care provider can warm refer a patient identified with a need for MH/BH care?

      The model quoted suggests nearly 2 additional FTE per 1-2 PCP (depending upon how many medical extenders the office has). That means at least 2 more rooms when most offices are already maxed out.. What impact does the additional staff – with a whole different set of policies and procedures have on the front desk and other support staff.

      Answering these questions will go a long way toward achieving integration of MH/BH and primary care.

      OTOH, in addition to the benefits cited above, there is reason to believe good implementation of integrated practices will increase the utilization of MH/BH. There is still a stigma to MH/BH for many people. If these people can simply go to “the doctor’s office”, sit in the same waiting room and be called behind the same door for their appointments, they aren’t as vulnerable to that stigma.

    • Note also that in just 8 days the decades old discrimination against mental health in the outpatient Medicare benefit is eliminated, giving it parity (80% reimbursement) with all other services.

    • Once again, healthcare reform must assure that Primary Health Care is available to and accessible by each citizen, community by community. Primary Health Care must also have the “skill-set” necessary to offer the health care for Basic Healthcare Needs and to coordinate this healthcare with any Complex Healthcare Needs.

      For mental health, then, what are the training needs throughout the spectrum of under-graduate and post-graduate medical education necessary to promote the optimal mental-health skill-set by a Primary Physician? In practice now for 38 years, mental health is the #1 chronic illness in my office. This challenge will not be accommodated without a Public Health dimension to healthcare reform for Primary Health Care. And, our nation’s healthcare will not become efficient and effective without it.