By IHPL - May 9, 2018

What is the scope of mental illness in the United States?

Mental illness can range from depression and anxiety to substance abuse and serious illnesses that interfere with daily activities. According to the National Alliance on Mental Illness, 18.5 percent of American adults have a mental illness, and only 41 percent of them receive mental health services during a given year.1 Less than 5 percent of patients are screened for depression during their primary care visits.2 Additionally, out of all patients that are referred to outpatient behavioral health clinics by their primary care providers, somewhere between 30 and 50 percent do not make it to their appointment.3 Barriers to prevention and treatment include lack of awareness (for both patients and providers) of effective treatments, high cost of care, shortage of the mental health workforce, and social stigmatization of mental illness.4

Data from 2013 shows that direct medical spending for mental health services cost 10 percent ($201 billion) of all medical spending.5  When mental health conditions accompany other medical conditions, the health costs can often be much higher as patients utilize care in costly settings, such as the emergency department, that are not well-equipped to handle serious mental illnesses. Given the need to control the excessive costs of medical care while ensuring adequate care, integrating mental and behavioral health services into the primary care setting is paramount to increasing access and providing cost-effective care.

What does integration look like?

According to the Integrated Behavioral Health Partners, there are five levels of integration:

  • Level 1: Minimal Collaboration
  • Level 2: Basic Collaboration at a Distance
  • Level 3: Basic Collaboration On-Site
  • Level 4: Close Collaboration in a Partly Integrated System
  • Level 5: Close Collaboration in a Fully Integrated System6

At the most basic level, community health workers and primary care physicians refer patients to one another and discuss mental health and behavioral health care options to encourage patients to seek care and maintain well-being.

In an ideal setting, a patient who was visiting his/her primary health care provider would receive a general checkup as well as mental health screening7 to identify the risk of depression, substance abuse, or serious mental illness. If the patient screens negative, the physician can inform the patient about the importance of mental well-being and provide any relevant resources. If the patient screens positive, the physician would refer the patient to an on-site behavioral health worker who would evaluate the patient and provide psychotherapy. If the patient required medications, the primary care physician could use telehealth to coordinate care and prescriptions with a psychiatrist. This way, the patient would receive full care in a team-based setting, and the patient’s entire health profile would be monitored with every visit.

What are the barriers to achieving integration?

Unfortunately, the most significant barrier is the current payment structure. Health insurance reimbursement for mental and behavioral health services remains low despite the passage of the Mental Health Parity and Addiction Equity Act of 2008 which requires insurance companies to provide coverage for mental health services that are comparable to physical health.8,9,10 Thus, many psychologists and psychiatrists don’t accept private or public insurance and people are left to pay out-of-pocket. Likewise, there are restrictions on the number and type of services that providers can bill for as well as rules that behavioral and physical health providers cannot bill for services on the same day.    

Moreover, integration requires a team-based model of care and task-shifting for primary care physicians as well as mental health providers. In essence, primary care physicians must add prevention and treatment of mental illness to their “to-do” list, which requires an institutional change. A further impediment to the team-based approach is the Health Insurance Portability and Accountability Act (HIPAA) which places restrictions on data sharing between clinicians when it comes to sensitive issues such as treatment for substance abuse.

There is also an issue of stigmatization and health care inequity with studies indicating that racial and ethnic minorities have less access to mental health services and worse quality of care compared to non-Hispanic, white Americans.11 Although efforts have been made to improve staff sensitivity to these correlations, behavioral health workers can be better equipped to work with disadvantaged populations.

What programs have achieved successful integration?

Many states have led demonstration projects to study the health benefits and cost savings that result from care integration. These programs rely on grants, Centers for Medicare and Medicaid Services (CMS) waivers, or are self-funded.12

Three noteworthy programs have brought down costs and improved prevention and treatment of mental and behavioral conditions:

  1. Colorado’s Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE)-Run from 2012-2015, SHAPE was a multi-organizational partnership that utilized a global payment system in which the care groups received a fixed cost per person to care for the individual’s health needs, including mental health. Compared to the fee-for-service based control group, the program saw cost savings of 4.8 percent with the global payment system and improved detection of mental health conditions.13
  2. Missouri’s Community Mental Health Case Management (CMHCM)- The program builds upon the mental health infrastructure by adding trained providers and analytic tools to community mental health centers. Case managers and primary care nurses work with patients who receive mental health treatment in the centers to provide screening for health conditions such as obesity, diabetes, hypertension, and high cholesterol. The program not only helps with the development of social skills and assistance finding housing or jobs but also provides prevention programs such as smoking cessation and medication adherence.14
  3. Intermountain Healthcare’s Mental Health Integration (MHI) program in Utah- The pilot program was a ten-year program that enrolled 113,452 individuals throughout 113 primary care settings. Mental health checkups were provided as part of the primary care services, and a team of healthcare workers provided care. The study showed higher screening rates for depression, greater adherence to diabetes care plans, and better control over blood pressure. Emergency department visits dropped by 23 percent and the health insurance company noted a 3.3 percent savings.15 Based on the success of MHI, Intermountain Healthcare launched a healthcare company known as Alluceo earlier this month. Alluceo offers consultation services and technology to help hospitals integrate mental health services into the primary care setting.

What can be done moving forward?

Mental illness can affect anybody. Moreover, the cycles of poverty, homelessness, criminal activity, and incarceration are deeply intertwined with some mental illnesses. Thus, removing the stigma from receiving care should be the number one priority in improving mental health outcomes. Moreover, the shift from fee-for-service to value-based, whole-person care can be integral in forcing providers to learn to work together and promote better integration of care. Moving forward, all primary care providers should be encouraged and incentivized to incorporate discussions of mental health in their clinical settings. Medicare and Medicaid should be leaders in setting appropriate reimbursement rates for mental health services and pushing for the development of an inclusive list of billable codes for mental health and behavioral health services. By promoting mental well-being and adequately supporting those with mental illnesses, our society will be healthier, happier and more productive.

Author bio and photograph:

Priya Vedula is a health policy analyst at the Institute for Health Policy and Leadership. Her work involves examining health policies and regulations with a focus on oral health, mental/behavioral health, and hunger. She received her Master of Public Health degree from Columbia University.