There is little doubt that integrating behavioral health care into primary care is a good idea – mental and physical health are intimately associated.
Depression increases the risk for type 2 diabetes and heart disease. Chronic disease often triggers depression and anxiety. Given these associations, it makes sense to treat these conditions concurrently.1
A multiconditional collaborative care model not only improved depression outcomes, but also improved glucose, blood pressure, and cholesterol – while reducing costs at the same time, results of a 2010 trial published in the New England Journal of Medicine indicate.2
“There is no doubt that integrating care improves outcomes dramatically and saves money,” said Marc Avery, MD, clinical associate professor and associate director for clinical services of the Advancing Integrative Mental Health Solutions (AIMS) Center at the University of Washington in Seattle, and Psychiatry Advisor Editorial Board member.
“Those results have now been validated in over 80 studies. The model works. The research has now shifted to how to apply the model.”
Evolution of Integrated Care
Models of integrated or coordinated care for psychiatry and primary care have been around for a long time, but early models were hampered by the fragmentation inherent in the U.S. healthcare delivery system.
“Primary care doctors would screen for depression, and patients were streamlined into a mental health referral. But patients either did not go to the referral or never followed up. Since mental health does not respond to brief interventions, outcomes did not improve,” Avery said.
Today’s model may include mental health screening by a primary care doctor and a practice care coordinator who provides patient education, tracks outcomes, and gets weekly oversight from a psychiatrist. The trio makes up the integrated care team.
Another potential model is to embed a psychiatrist or psychologist directly into the primary care site. This is being tested in Massachusetts, where a plan called Primary Care Payment Reform recognizes three levels of mental health and primary care collaboration.
“At the highest level, a psychiatrist works on site for one day per week supporting the [primary care physicians] and full-time behavioral health clinicians at the primary care office,” explained Alexander Blount, EdD, founder of the Center for Integrated Primary Care at the University of Massachusetts Medical School in Worcester.
“The most effective model of integrative care is one treatment plan with behavioral health and primary care on the same team. The concept has been around for a long time, but we are still at the beginning,” he added.
Barriers to Integrated Care
There are two main barriers to integrating behavioral health and primary care. One is that our healthcare system, although changing slowly, is still fragmented. Neither primary care doctors nor mental health doctors are used to working as a team.
Another barrier is financial – billing codes are currently fee-for-service, a system that is not designed to accommodate integration.2
But several forces are also working in favor of integrated care. One is the mountain of evidence showing better outcomes for less cost, and another is the Patient Protection and Affordable Care Act (ACA).
“We hope that the ACA will expand and transform payment. We hope it will allow us to circumvent regulatory issues of the current system that stand in our way,” Blount said.
Healthcare reform, if it continues to evolve, will incentivize integrated care. Accountable care models, population-based care, and measurement-based care all lend themselves to integration of care.2
Physician resistance will not be much of a barrier, according to Avery. “Primary care doctors already see and treat the majority of patients with depression. An integrated care team makes their job easier. They can even expand to treat mild to moderate bipolar disorder.”
The Future of Integrated Care
Integrated mental health and primary care models represent an estimated 5% to 10% of the U.S. healthcare system, according to Avery.
Currently, six major insurers in Minnesota have agreed to pay for collaborative care, and the Centers for Medicare & Medicaid Services is implementing the model, as is the Veterans Health Administration.
One early implementer, Cherokee Health Systems in Tennessee, began mental health and primary care integration back in 1984. They use an embedded behavioral health provider as part of their care team. Their largest payer is Medicaid, and they have a good history of improved patient outcomes with an estimated 20% reduction in costs.
Accomplishing more widespread implementation of integrated care teams will be a slow and steady process, according to Blount. Moving too fast could result in failures that could cause people to lose faith in the models.
“Think of our healthcare system as a big battleship. Trying to turn it around is not quick or easy,” Blount said.
Chris Iliades, MD, is a freelance medical writer.
Medically reviewed by Pat F. Bass III, MD, MS, MPH.