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Integrating mental health into primary care: an idea ready for the mainstream

Friday, November 8, 2013

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CIHS infographic
Image courtesy of thenationalcouncil.org

At Ginger.io, we hope for a future where mental health is central to managing a community’s health. As we discussed in our last post, addressing mental health is particularly crucial for helping patients manage other chronic diseases like diabetes, lung disease and cancer. Our dream is for our technology to be a part of the revolution integrating behavioral health as an essential component of any well-functioning primary care system.

If you follow our blog posts, you probably already know how much we care about mental health. It’s still sobering to think of how broadly mental health problems affect our country: a 2008 report estimated that 26% of Americans suffer from a mental health disorder, and that 6% have a severe disorder. This adds up to nearly 60 million people in America with a mental health disorder. That’s staggering.

These statistics aren’t just faceless numbers, either. I encounter the reality of the burden of mental illness in my clinical work every day. It’s the young man with untreated multiple sclerosis with progressive pain and weakness because of an undiagnosed mental illness manifesting as uncontrollable irritability and anger that no physician had tried to treat before. Or the middle-aged Dominican woman with depression and knee arthritis who didn’t treat either problem and bounced from primary care practice to primary care practice because no one could find her a Spanish-speaking therapist. A common story I hear from patients is that it was just too hard to find a mental health professional, so they stopped looking.

The most credible proposal to fix the problem of mental health access is fundamentally changing how mental health care is delivered. Instead of piecemeal access for whoever is lucky enough to have a psychiatrist, psychologist or social worker nearby, health systems across the country are transforming their primary care infrastructure to integrate mental health care directly into primary care. This makes sense for a number of reasons:

1) In the US, Primary care providers are the frontline for medical care. They are better suited than anyone to address mental health in their communities. It has been estimated that up to 70% of primary care visits stem from psychosocial issues. In addition, diagnosing and treating mild or even moderate mental illness is not too complex for primary care physicians. However, it makes practicing much easier to have the support of a behavioral health infrastructure to back up your decisions and help with complicated cases.

2) Payment reform and the Accountable Care Organization movement means that treating mental health doesn’t mean losing money. In most markets today, mental health care reimburses poorly, leading to closure of psychiatric facilities and prompting health systems to avoid developing a strong mental health infrastructure. However, payment models are increasingly switching from purely “fee-for-service”, where physicians get paid for every service they provide, to a “bundled payment” model, where physicians get paid a fixed sum to take care of a large population of patients. At a high level, the overall incentive in the bundled payment model is for physicians to save money by improving their populations’ health to reduce avoidable health care use. And it turns out that treating mental illness is a very effective way to avoid excessive health care utilization.

3) There is also accumulating evidence that primary care and behavioral health can do amazing things when they work in the same place. The most widespread model is the IMPACT program, which involves integrating a psychiatrist and population care manager into primary care to manage depression.  This team, together with the primary care physician, can provide much more comprehensive management and follow-up for patients with depression. The model has spread to over 500 clinics across the country.

4) There’s also legislation to help increase mental health access for all: in Massachusetts, a bill is being proposed the would compensate psychiatrists for electronic visits at the same rate as an in-person visit, which could be transformative. There are also pilots of electronic psychiatry visits, or “telepsychiatry” being piloted in over 40 states.

I’ve seen all of these factors in play firsthand. My clinic happens to be one of those great places where primary care and behavioral health can work together. On my clinical team, there’s a social worker who meets with our population manager and a psychiatrist weekly to coordinate care for all of our patients with mental health needs. If I meet a new patient who has a mental health need (and many do), I have them fill out a comprehensive form and then our social worker helps to find the right place for their mental health care. Together with the social worker on my team, we have helped almost all of my patients with serious mental health needs into the loop of the best mental health professional they needed. And once that loop is established, we are in continuous contact about how to thread together our patients’ mental and medical health care. By integrating behavioral health into primary care, we are able to treat the whole patient, not just the symptoms.

How do you integrate mental health into primary care? Join the discussion on twitter by letting us know at @ginger_io!