NHMH NO HEALTH WITHOUT MENTAL HEALTH A 501(c)(3) non profit   San Francisco - Washington DC Director’s blog


A WAY FORWARD   January 27, 2016

The burden of delivering mental health care for the preponderance of mental health patients in the U.S. is continuing to fall on primary care physicians (PCPs) and those who support the primary care setting.  

This at a time when those practices are overwhelmed with other fundamental transformative changes in how primary care is delivered and reimbursed.  Anyone seriously interested in ensuring that more Americans receive mental health treatment early and effectively, must of necessity focus on primary care and how primary care practices an be supported to deliver effective behavioral health services.

Confusion and lack of knowledge persists in the public debate on behavioral (i.e. mental health and substance use) care:   what are the different types of behavioral disorders,  what treatment do they require, by whom; where, what is the role of technology, what is most cost-effective, etc.

The reality is that there exists a wide spectrum of mental disorders requiring very different types of care by different professionals in different settings.   Labeling any particular disorder “mild” or “severe” can be problematic as it may depend on the person and his/her course of illness.  Behavioral health conditions are not so much different from other medical conditions in this regard.  For example, there are all types of cancer and patients may have cancer that is easily managed by a primary care provider, while others may have severe forms that are best handled by medical specialists, at least in the early treatment phase.   Similarly in mental health, where some people with bipolar disorder are very stable and easily managed by PCPs while some need ongoing treatment by a specialist.

The key issue is being able to have linkages and collaboration between PCPs and behavioral health specialists, in both directions, behavioral into primary care, and medical into mental health care.

The spectrum of behavioral disorders can run from common and mild disorders, such as depression, anxiety, phobias, etc  to severe and  persistent disorders such as schizophrenia, bipolar, and major depressive disorder. The behavioral needs of patients along the entire spectrum need to be addressed if we are to improve mental health care.

Patients with serious mental illness are a very small fraction of the general population, just 1-3%, i.e. 1-3 million. Although only 1-3% of the population, many are likely to require a large amount of both mental and medical care services, given the chronic nature and severity of their symptoms and treatment needs.  Rep. Tim Murphy’s (R-PA) important “Helping Families in Mental Health Crisis” bill (HR 2646) now before the U.S. Congress, primarily addresses this patient group’s needs.  We will likely always need some form of special funding for community mental health centers for this very vulnerable population.  And, they also often lack adequate effective medical services so that there is a great need to integrate medical services into the places where they are seen.   

The great majority of people with behavioral health disorders, 20-35% of the general population, or 30-45 million, are followed in the primary care setting.  Many people who are seen in primary care are insured and could go to specialty mental health providers, but they prefer to receive their care in primary care.  However, they receive little or no mental health care in this setting.  Also, importantly, many seriously mentally ill go to primary care to avoid the stigma, shame, fear associated with mental health clinics, or because no specialty mental health services are available in their area.  So primary care is seeing both mild and severe behavioral health conditions.

Why are patients in primary care not receiving needed behavioral health services?

One reason is because PCPs have not been trained well in how to assess and treat mental health care.

Another is that primary care settings often cannot afford to hire clinicians who may have expertise in treating these disorders.  While individual primary care clinics cannot do this, larger medical groups have begun hiring at least master’s level mental health clinicians to meet the need.

Patients in growing numbers continue to appear in primary care with behavioral health issues.   PCPs commonly prescribe antidepressant medications to many of their patients with depression, with little or no follow-up to see if patients remain on them, or if they are even working as intended.   The use of medications, where given alone, may constitute less than adequate treatment.  Some patients may benefit from therapy without the risk of medical side effects from medications.

Untreated mental disorders worsen not only the patient’s behavioral condition, but also aggravate and impede improvement of the patient’s physical conditions.   The cumulative result is unnecessarily higher healthcare costs for everyone.  Thus, all of us have a stake in ensuring effective mental health care is available in the primary care setting.

Payers, i.e. the federal and state governments through Medicare or Medicaid and private insurance companies, acknowledge untreated behavioral health conditions dramatically increase their medical claims costs.  They have started to encourage patients having all of their health issues addressed in a coordinated fashion in primary care or in “health homes” to drive down costs.

Against this backdrop, a major transformation in primary care itself is underway:  in how doctors work, deliver care,  and get paid.  The healthcare system is moving slowly away from paying physicians under a fee-for-service model, and towards reimbursement for quality care and improved patient outcomes (e.g. better weight, blood pressure, blood sugar control, etc etc).   A driving force is Medicare which covers the  costs of a large patient population the majority of whom have multiple chronic medical and behavioral conditions.

More thought needs to be given to how we can make it easier to provide adequate behavioral health services in the primary care setting.   Ways to do this could include further development of collaborative care models that are feasible in various settings;  use of telehealth services to provide specialty services in areas where such services are not now available; and innovative payment  models incentivizing doctors and health systems’ focus on prevention and early identification of behavioral health problems.

Grady Health in Atlanta, Georgia, is a good example of linkages and collaboration between PCPs and behavioral health specialists.  Grady is a provider of healthcare services to an urban underserved population.  It has initiated a medical care clinic in their outpatient mental health department to provide medical services onsite to those with severe mental disorders.  In addition, they are expanding behavioral health services into their community primary care clinics through the use of telepsychiatry.  According to Dr. Gray Norquist, Chief of Grady Behavioral Health Services and a Professor at Emory University, they are already seeing improvements in the general health of the patients they serve in their outpatient programs, as well as reductions in the need for costly additional medical services.

We need more evidence-based models of mental health treatment interventions that are feasible to use in primary care settings as primary care practices across the country are so hugely varied.  PCPs need to have the freedom and flexibility to choose what mental health care model works best in their practice and are feasible for implementation.   The one essential is that all integrated care models should have a proven, evidence base supporting their effectiveness.   

Telepsychiatry offers enormous potential to deliver effective mental health care in primary care settings, including rural and remote settings, in an efficient, cost-effective way.  Clinics may simply contract for a mental health professional’s time, thereby multiplying the access to scarce behavioral health specialists. NHMH is participating in a very important PCORI-funded telepsychiatry large pragmatic clinical trial with tremendous potential (see www.nhmh.org).

Since 2007 NHMH has been a leader in patient advocacy for effective integrated med/psych care.  Our focus will continue to be on development of multiple effective models of behavioral health care in the primary care setting and medical services in the mental health sector.   The key is to develop linkages and collaboration between the medical and behavioral health fields such as described above.