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According to the National Institute of Mental Health, mental disorders affect tens of millions of Americans each year, and only about half of those individuals receive treatment. One barrier is the lack of reliable mechanisms in healthcare settings that ensure patients connect with mental health services.
As the industry aims to deliver higher-quality care at a lower cost, healthcare providers are recognizing the need to better integrate behavioral health care with primary care to make sure all patients get the treatments they require to sustain long-term health outcomes. In this edition of the Healthcare Challenge Roundtable, senior provider and health plan leaders examine strategies for achieving such integration.
Participating are Michael Alwell, vice president, revenue cycle for RWJBarnabas Health, West Orange, N.J.; Michael Plopper, MD, chief medical officer, Sharp Behavioral Health Services, San Diego; and Hyong Un, MD, chief psychiatric officer, Aetna.
Hyong Un: First, most people seek treatment for a mental health condition in the primary care setting because their primary care doctor is usually their most trusted physician. Although many behavioral health issues can be successfully managed as part of primary care, it is helpful to have behavioral health resources—psychiatrists, therapists, counselors, social workers, and so on—readily available should the patient’s problem surpass the primary care physician’s abilities.
In addition, chronic medical disorders—including coronary artery disease, diabetes, and musculoskeletal issues—regularly have a behavioral health component. In many cases, there will be depression associated with these disorders, which can impact patients’ abilities to adhere to medication regimens and self-manage their conditions. It is crucial that organizations be aware of and treat the underlying behavioral alterations of physical comorbidities.
Overall, assimilating behavioral health into primary care is important to maintain the health of a patient population. Especially as organizations take on responsibility for more-holistic patient care that emphasizes value, they are starting to appreciate the criticality of behavioral health resources. Let’s face it, you can’t manage chronic illness, limit unnecessary emergency room visits, and reduce avoidable readmissions without these kinds of resources.
Michael Alwell: When behavioral health care and primary care are integrated, primary care physicians can quickly refer patients to the appropriate behavioral health practitioners to meet the patients’ needs. Not only does this approach ensure that patients receive the level of care they require, but it also avoids placing the primary care providers in a position where they must address a condition that might be outside of their comfort zone. Also, if you can bring both types of care into a single practice location, it saves time on the billing side because you may not need to obtain additional authorizations and potentially refer the patient outside of the network.
Michael Plopper: The coordination of behavioral health care and primary care has been an underdeveloped component of healthcare delivery in the United States for a long time. Although providers have talked about the need for integration for at least 20 years, the country is not at a place where it could say it has accomplished this goal—other than in a few locations.
Oftentimes communication is quite poor between mental health and primary health delivery systems. The traditional siloed care models have led to subpar interactions and missed opportunities. Due to the stigma associated with mental health, the dearth of payment mechanisms for these types of services, and psychosocial factors such as lack of transportation and family support, patients who are seriously ill—and even those with less severe illnesses—can struggle to receive appropriate and adequate mental health care.
Un: Behavioral health specialists and primary care physicians approach patient diagnosis and care differently, and this has historically presented some roadblocks to integration. For example, primary care physicians tend to see patients at a fairly rapid rate, and weaving behavioral health into the primary care office workflow could be problematic, particularly if the behavioral healthcare delivery model follows traditional behavioral health workflows. Therapists are accustomed to seeing their patients for 30 minutes to an hour, and that may or may not work in a primary care setting where doctors see patients every 10 to 15 minutes.
There have also been issues around financing. For the longest time, behavioral health was carved out as separate from the rest of a person’s medical health benefits. In fact, Aetna was one of the first companies to integrate behavioral health and medical health and have the financing come from one source. Not every payer takes this approach, and that can add complications to the behavioral health-primary care dynamic.
Ultimately, bringing behavioral health and primary health together requires marrying two different delivery systems and two different financing systems. That coupled with the variations in practice style and workflow makes integration challenging. Things are starting to change, but it’s going to take a while.
Alwell: Another barrier has been the reluctance of some behavioral health providers to participate in managed care networks. Historically, the payment rates tied to these networks have been quite low for behavioral health professionals.
To overcome this issue, some large hospitals and health systems, like RWJBarnabas, are employing behavioral health professionals, enrolling them into various managed care plans and placing them in offices side by side with primary care providers—thereby improving access for patients who need the services. That said, it becomes quite costly for healthcare organizations to employ these providers. However, we view it as part of a much larger primary care strategy that encompasses this kind of care.
Un: I think organizations should look at three different metric domains: structure, process, and outcomes measures. Structurally, you must have behavioral health resources that are available for integration—enough psychiatrists, therapists, care managers, and so on. You also need the ability to create and manage a registry.
Once you have a sense of the structure, then make sure you’re following solid processes. Are you consistently screening for mental illness, such as depression? Are you referring those patients who screen positive to a mental health provider? Is there two-way communication between the primary care office and the mental health provider?
In addition to process measures, study patient outcomes. For patients with depression, does their average depression score decrease? Are suicide rates dropping? Are there fewer emergency room visits? Finally, review patient satisfaction scores for patients with a diagnosed mental illness. Do they feel their needs were addressed? Were providers compassionate?
Alwell: The integration of behavioral care and primary care should result in a reduction in emergency department (ED) visits and reduced psychiatric admissions. Through integration, providers may be able to monitor whether patients are compliant with their medications for both the mental illness and any chronic conditions. If the behavioral health issues are not being managed properly, there’s a good possibility the patients aren’t going to be compliant with any of their medication regimens and will end up back in the hospital or ED for medical conditions in addition to behavioral health problems.
Plopper: Another metric to examine is follow-up after initial screening. Right now, primary care offices are starting to effectively screen for conditions such as depression. However, it would be smart to look at what happens after these patients are screened and found to have depression or another mental illness. Are they provided services? Are they referred to a specialist? Are they compliant with medication? Is there improved attention once the disorder is identified?
It also might be beneficial to study severe negative outcomes, such as suicide rates or hospitalizations for mental illness. The literature supports the notion that patients who commit suicide have sometimes seen a primary care doctor in the recent past. There’s an opportunity to better provide services for people who are ill and contemplating this drastic act. Similarly, some hospitalizations could be avoided if patients were better served on an outpatient basis.
Plopper: Even though the industry has been talking about integration for 20 years, there aren’t many great models out there. One that is effective is called the Collaborative Care Model and emerged from Dr. Jurgen Unutzer at the University of Washington. It’s moderately robust and has been in place for a number of years, demonstrating improved outcomes and care quality at lower costs. The model mostly involves ready access for primary care offices to psychiatric consultation—either in person or through telemedicine.
Un: The University of Washington model is probably the best one. There are numerous quality studies that indicate it works. To be effective, an integrated program must have care management, registry use, and measurement-driven care, and Dr. Unutzer’s model has all those components.
Alwell: At RWJBarnabas Health, we are working on a program in which we will place a psychiatric advanced practice nurse (APN) in a primary care physician’s office. The primary care provider will screen for depression and other cognitive impairments and refer any patients who screen positive to the APN, who can further assess the patient’s cognitive needs or behavioral issues and prescribe therapy or medications as appropriate. Because the APN is located on site, we believe there will be greater interaction between primary care and behavioral health.
Plopper: Most of the models I’ve worked with are self-funded or funded through grants. For integration to take hold, it is going to require global payment policies in which payers and providers are accountable for the total cost of care and patient outcomes. I think there should be a stronger effort by public-sector payers to lead the way. As healthcare systems, we have many different masters in terms of our payment sources, and that can lead to complexity and confusion. The more we can come together and break down barriers, the more we can make some meaningful change.
Alwell: We are in discussions with one of the largest payers in New Jersey about integrating behavioral health and primary care, looking to increase the referrals from primary care to behavioral health and streamline that process.
For many health plans, an important first step should be finding ways to incentivize primary care to refer patients for early screening by behavioral health professionals. Some of these primary care physicians are afraid to refer out of their practice for fear of being penalized by the insurance plan for overutilization of resources. With an integrated system, the referral and initial treatment could reside within the practice if the plan allowed the primary care physician to have an APN or other psychiatric professional within the practice.
Another step would be to break down the silos between reimbursement channels. A number of payers still carve out patients’ behavioral health benefits from their medical benefits, and that separation often causes confusion for both patients and providers, sometimes resulting in delays in treatment.
Un: I’ve been at this for 15 years, and I think in the past three to four, things have really started to move forward. The Centers for Medicare & Medicaid Services just approved a set of codes related to collaboration and integration, and they are also more focused on care management. The American Psychiatric Association has a large project to retrain psychiatrists in a model that is more collaborative.
Much of the improvement we’ve seen so far has stemmed from different organizations realizing that behavioral health is essential to value-based contracting. With that and a shortage of psychiatrists, organizations are beginning to understand the benefits of offering some level of behavioral health care in the primary care setting.
There always will be a need for specialist psychiatrists. We have seriously ill patients with mental health conditions who will need to be managed by a psychiatrist, but there’s a sizable number of patients who through a collaborative care model can be monitored without having to see a psychiatrist because they can be managed successfully in the primary care setting.
Kathleen Vega is an HFMA contributing
writer and editor.
Interviewed for this article: Michael Alwell, vice president,
revenue cycle, RWJBarnabas Health, West Orange, N.J.; Michael
MD, chief medical officer, Sharp Behavioral Health Services, San Diego; Hyong
MD, chief psychiatric officer, Aetna.
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