One in four adults in the United States experiences mental illness in a given year, and more than half receive no treatment, according to the National Alliance on Mental Illness. Given patients’ limited access to mental health treatment, the primary care system must often fill the gap. Up to 70 percent of primary care visits are driven by psychosocial factors, and 25 percent of patients have a diagnosable mental disorder, The Permanente Journal says.
Integrated behavioral healthcare presents solutions. By delivering mental healthcare in primary care settings, patients can receive treatment for common behavioral health problems such as depression, anxiety and substance use disorders.
The Need for Integrated Health Services
Historically, behavioral healthcare has been largely separated from the primary care system. Two decades ago, the Institute of Medicine concluded that this divide was leading to inferior care. “In the intervening years, evidence has continued to mount that having two, mostly independent systems of care leads to worse health outcomes and higher total spending, particularly for patients with comorbid physical and behavioral health conditions ranging from depression and anxiety, which often accompany physical health conditions, to substance abuse and more serious and persistent mental illnesses,” The Commonwealth Fund says.
Up to 80 percent of patients who come to primary care practices and emergency departments have behavioral health problems, but many providers only have the time, training and staff to treat physical health problems. An estimated 60 to 70 percent of these patients will not receive treatment for their behavioral health condition, increasing the likelihood of having trouble recovering from their medical conditions. Also, when primary care providers refer patients to specialists such as psychiatrists or therapists, patients may not follow through.
Concurrent medical and behavioral health conditions are associated with decreased patient adherence, higher complication rates, earlier mortality, doubling of the total annual cost of healthcare, and greater disability.
At the same time, the majority of patients in behavioral healthcare settings have chronic medical conditions, yet they also have challenges accessing medical services for economic and geographic reasons, according to the American Journal of Managed Care. “Concurrent medical and behavioral health conditions are associated with decreased patient adherence, higher complication rates, earlier mortality, doubling of the total annual cost of healthcare, and greater disability,” the journal explains. These patients are more likely to be hospitalized for medical conditions and readmitted to the hospital more frequently.
The financial consequences for failing to treat behavioral health conditions are significant.
- Approximately 14 percent of the total population covered by Medicare, Medicaid and commercial insurance was treated for behavioral health conditions in 2012, yet they accounted for nearly a third of total health resources.
- Patients with medical conditions and behavioral health conditions, including mental illness or substance abuse problems, typically cost two to three times as much on average as patients with no behavioral health condition, according to a report commissioned by the American Psychiatric Association. Due to these costs, the report suggested that integration programs offer “significant potential for savings in medical costs.”
- Depression in patients with chronic medical illness is associated with greater costs, as documented by General Hospital Psychiatry. For example, the total annual medical cost of a middle-aged patient with depression alone is about $3,000, and the cost of a middle-aged patient with diabetes is about $6,000. But the cost of a middle-aged patient with both diabetes and depression is more than $9,000.
Moving Toward Integrated Behavioral Healthcare
“Payment is the heart of the problem,” Roger Kathol, physician and president of a consulting firm that advocates for integrated behavioral healthcare, told The Commonwealth Fund. The multitude of different requirements for reimbursement from payers present complications for a team-based approach to healthcare. Primary care practices considering behavioral health services must deal with low reimbursement rates and restrictions on the services they can bill for.
Another barrier to integration is the way the arrangement changes how sets of providers normally work. Primary care providers typically refer patients with mental illness or substance abuse problems to specialists, due to time constraints and multiple priorities. On the other hand, behavioral health specialists will need a new skill set to practice in primary care settings. “As part of a team, behavioral health providers have to deal not only with depression and anxiety but also heart failure and diabetes,” Michael Hogan, former commissioner of mental health for New York state, told The Commonwealth Fund. Integrated models of care allow both types of healthcare providers to work as a team to provide what the patient needs.
A popular approach to integrated care includes the collaborative care model. The collaborative care model involves psychiatrists consulting with primary care providers to focus on patients who aren’t making progress or who have more serious mental illnesses. Collaborative care also makes use of behavioral health specialists and workers, such as case managers and counselors.
Collaborative care has demonstrated success in achieving the “triple aim” of improving access to care, improving quality and outcomes of care, and reducing total healthcare costs, according to General Hospital Psychiatry. For instance, four trials found that collaborative care for chronic medical issues and depression was more effective than usual primary care in improving quality of depression care and depression outcomes over a two-year period. All trials pointed to how the increased mental health costs for collaborative care were offset in total medical costs over a two-year period; two of the four trials examined long-term costs, demonstrating continued savings of collaborative care for up to five years.
Implementing collaborative care for the 20 percent of Medicaid patients diagnosed with depression would save the Medicaid program approximately $15 billion per year, a report for the Centers for Medicare & Medicaid Services (CMS) estimates. Research on collaborative care for patients diagnosed with depression demonstrates cost savings for every category of health savings examined, including pharmacy, inpatient and outpatient medical, as well as mental health specialty care.
Although barriers remain, new payment policies are encouraging different implementation models for integrated behavioral healthcare. For instance, health insurance sold through the Affordable Care Act’s marketplaces must now include behavioral health benefits. Other payment approaches are seeking new ways to augment standard fee-for-service billing by primary care providers, according to the report for CMS.
Enhancing Behavioral Healthcare
As the healthcare system evolves, behavioral healthcare professionals will be in a better position to increase access to care and quality of care. Alongside primary care providers in particular, behavioral healthcare professionals can assume an even more important role in helping patients.
Alvernia University’s online B.A. in Behavioral Health prepares students for graduate studies or work in hospitals, rehabilitation centers and other environments. The program takes place in a convenient online format to accommodate students’ work and personal schedules.