Mental Health and Primary Care: The Case for Integration

Medicine has a problem with mental health. I realized this during my first year in medical school when discussing a patient case with a group of classmates and a physician mentor. The case involved an elderly man admitted to a Veterans Administration hospital for signs of liver failure, the result of a long life of heavy drinking.

Our physician mentor asked our group, “What do you want to do first for this man?” My classmates began listing lab tests, imaging scans, and other procedures to order for the man. When it was my turn, I said I wanted to know what was going on in this man’s life to lead him to such chronic alcoholism. I was met with an awkward silence.

Apparently, an inquiry into the man’s emotional life had no place in a discussion of how to work up liver failure. “Real” medicine, I was told, seeks efficiency in diagnosing, treating, and discharging sick patients; it has no time to dwell on the psychological factors at work in each patient. Perhaps I “should go into psychiatry” if I wanted to “talk about someone’s feelings.”

Such an attitude paints a false dichotomy between the mind and the body. Contrary to this physician’s words, “feelings” actually have a lot to do with alcoholic liver failure.

Trying to Control Weeds Without Pulling Out their Roots

Medicine’s unwillingness to acknowledge the influence of behavior on health is leading to suboptimal outcomes in our patients and costing the healthcare system billions of dollars every year. Recent studies also reveal just how intertwined diseases of the mind and the body are. For example:

• The Journal of Clinical Psychiatry reports that the incremental economic burden of individuals with depression has increased 21.5 percent, from $173.2 billion in 2005 to $210.5 billion in 2010 with most of the cost resulting from comorbid physical disorders exacerbated by depression.¹
• Up to 70 percent of physician visits are for issues with a behavioral health component.²
• Patients with chronic health problems with a mental health diagnosis are 3 times more likely to be medication non-compliant.²
• Nearly one in five people in the United States has a mental health condition.³
• The disease burden of mental health and substance use disorders was higher than for any other condition in 2015, reports the Journal of the American Medical Association.⁴

By focusing solely on the treatment of chronic medical problems at the exclusion of behavioral health, physicians systematically ignore the psychological factors that fuel many of these problems in the first place - as if they were gardeners trying to control a weed problem without pulling out the roots.

The Escalating Shortage of Mental Health Professionals

An astounding 59 percent of patients with mental health needs receive no treatment. Even when patients make their needs known, two out of three primary care providers have difficulty referring patients for mental health care.⁵ Among those who are referred, 15 to 30 percent never make an appointment, highlighting the structural disconnect between primary care providers and mental health professionals.⁶

One explanation of the provider shortage involves health economics. A 2017 report on physician reimbursement rates notes that mental health providers are reimbursed less than physical health providers, leaving institutions sometimes struggling to cover salaries. This low valuation of mental health services fails to consider the rising costs of neglecting it. The National Council for Behavioral Health reports that patients going to emergency departments for psychiatric services rose by 42 percent over a recent three-year period.⁶ Consider the potential monetary savings to both patients and society if more behavioral health problems could be addressed early in their course, rather than escalating to this level of crisis!

A Solution in Integrated Care Models

Evidence suggests that if more mental health problems could be screened and addressed in the primary care setting, there would be payoffs in mental health outcomes, patient satisfaction, control of chronic disease, and annual cost savings. Several models have emerged in the past few years to implement this.

The best studied model is known as the Collaborative Care Model (CCM), which is a multicomponent model that systematically links patients with mental health and primary care providers in a joint management effort.⁷ In essence, this model uses care managers to work with Primary Care Providers (PCPs) to help manage medications and coordinate care across multiple providers, including psychiatrists and counselors. The team implements a measurement-guided care plan based on evidence-based practice guidelines, and focuses particular attention on patients not meeting their clinical goals.

A 2015 report from the Institute for Clinical and Economic Review found that the CCM⁸:

• Saves between $26.3 and $48.3 billion a year
• Patients were 54 percent less likely to have an emergency room visit
• Patients reported less opiate use and substance abuse
• Patients had a lower mean total health care cost compared to those receiving standard care

A leader in this field is the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington. This center has seen promising results from embedding psychiatrists in primary care practices, where they oversee cases, provide consultation, and see only the most challenging patients.

Another is Project ECHO (Extension for Community Healthcare Outcomes) at the University of New Mexico Medical School, which connects specialists with PCPs seeking guidance on behavioral health treatments. While these ideas differ slightly in their approach, they represent an emerging consensus: behavioral health integration with primary care is currently the best model to achieve better mental health outcomes, provide a better experience for patients, and reduce system-wide health care costs.

Necessary Policy Changes

Shifting the paradigm of mental healthcare towards one of prevention has numerous advantages to our current system. But to make these changes a reality, there are several policy hurdles that must be considered.

1. America must continue to move away from fee-for-service models towards value-based reimbursement with risk-adjusted capitation. Such a shift would provide insurers and providers with the incentive to maximize the efficiency of their treatments to lower their costs. The collaborative care model would become an appealing, evidence-based solution in such a situation. But for some high-risk populations with greater needs, the risk to the provider should be adjusted by government subsidies to account for the higher costs of treating such populations.
2. Change billing requirements. This allows more primary care providers to bill for mental health services, expand billing codes for case management, remove specialist level copays for mental health providers, and provide billing options for telehealth (for mental health professionals to remotely consult a patient through video conference software).

As I reflect back on the encounter with my physician mentor and the liver failure patient, I know he would probably smirk if he knew that after all this time, I am actually following his advice by planning to specialize in psychiatry. But far from merely “talking about feelings,” I anticipate the field of mental health care to continue to move towards erasing the arbitrary divide between mental and physical health by replacing it with a model that integrates the mind and the body. This paradigm shift will require expansion in the ways mental healthcare is delivered. Integrating aspects of behavioral health with primary care is one evidence-based policy solution that could be a powerful first step towards meeting America’s unmet health needs.

Author Bio

Adam Borecky is a student at Loma Linda University School of Medicine who is simultaneously working on a master’s degree in clinical bioethics. Upon graduating in 2019, he hopes to enter a residency program in psychiatry.

References

1. Greenberg, Paul E., Andree-Anne Fournier, Tammy Sisitsky, Crystal T. Pike, and Ronald C. Kessler. "The economic burden of adults with major depressive disorder in the United States (2005 and 2010)." The Journal of clinical psychiatry 76, no. 2 (2015): 155-162.
2. Tice  JA, Ollendorf  DA, Reed  SJ,  et al. Integrating Behavioral Health into Primary Care. June 2, 2015. https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101679435-pdf.
3. Bose, Jonaki, Sarra L. Hedden, Rachel N. Lipari, Eunice Park-Lee, Jeremy D. Porter, and Michael R. Pemberton. "Key substance use and mental health indicators in the United States: results from the 2015 National Survey on Drug Use and Health." Substance Abuse and Mental Health Services Administration website. https://www. samhsa. gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015. pdf. Published September (2016).
4. Kamal, Rabah, Cynthia Cox, and David Rousseau. "Costs and Outcomes of Mental Health and Substance Use Disorders in the US." JAMA 318, no. 5 (2017): 415-415.
5. Malek, Stephen P., Daniel Perlman, and Stoddard Davenport. “Addiction and Mental Health vs. Physical Health: Analyzing Disparities in Network Use and Provider Reimbursement Rates.” Milliman Research Report, December 2017.
6. Parks, et al. “The Psychiatric Shortage: Causes and Solutions.” 2017.
7. Gerrity, Martha. "Evolving models of behavioral health integration: Evidence update 2010–2015." (2016).
8. Tice  JA, Ollendorf  DA, Reed  SJ,  et al. Integrating Behavioral Health into Primary Care. June 2, 2015. http://cepac.icer-review.org/wp-content/uploads/2015/01/BHI_Final_Report_0602151.pdf.