Meeting the Mental Health Need
July 28, 2020
Photo by Eboni Winford
With our mental health care system stigmatized and stretched thin, could primary care meet the country’s rising mental health needs?
Listen to the full episode below, read the transcript or scroll down for more information.
NOTE: An additional post-script was added to the end of this story when it re-aired on Dec. 17, 2020. That update can be found in the episode transcript.
The Basics: Meeting the Rising Mental Health Need
In the midst of a pandemic and an economic recession, the U.S. is also facing a rising tide of mental distress. The number of adults reporting symptoms of anxiety or depression has tripled since last year. Calls to crisis lines have skyrocketed, and overdoses are up, too.
Research shows many people with a mental illness won’t go on to get treated or even diagnosed. For those who do get treated, about half get help in primary care, where providers are short on both time and mental health expertise.
Most other patients see specialty providers, like psychologists and psychiatrists, which can be stigmatized and hard to find, especially for patients in rural areas and the safety net.
¹Holly Andrilla, Davis Patterson, Lisa Garberson, Cynthia Coulthard and Eric Larson. “Geographic Variation in the Supply of Selected Behavioral Health Providers.” American Journal of Preventive Medicine, 2018.
²Hefei Wen, Adam Wilk, Benjamin Druss, et al. “Medicaid Acceptance by Psychiatrists Before and After Medicaid Expansion.” JAMA Psychiatry, 2019.
³Philip Wang, Michael Lane, Mark Olfson, et al. “Twelve-Month Use of Mental Health Services in the United States.” JAMA Psychiatry, 2005.
The Idea: Bringing Behavioral Health Into Primary Care
One way to increase access to mental health (as well as other behavioral health) expertise is to bring it into primary care practices, where patients are already going. This is an approach known as integration, and some versions of it have been around since the 1980s.
In a truly integrated primary care practice, behavioral health providers and primary care providers, who traditionally practice in silos, become part of a single team. They collaborate fully in a patient’s care, from writing notes in the same electronic health record to jointly developing care plans that meet all of the patient’s needs.
Integration can be defined and implemented in many different ways, which are often plotted along a continuum like this figure from the SAMHSA-HRSA Center for Integrated Health Solutions:
Click on the graphic for a more in-depth breakdown of the various levels of integration
One recent study found that that 44% of primary care practices have a behavioral health provider co-located, but co-location far from guarantees integration. One expert told us likely less than one-quarter of those practices are using a truly integrated model.
Generally, experts in the field believe that some integration is better than none, but there is minimal evidence that lesser levels of integration can meaningfully impact patient outcomes or costs.
The Evidence: Improving Outcomes, Saving Money
Given the wide range of ways in which practices implement integration, studies of the approach can be hard to generalize. Nonetheless, the field has produced more than three decades of evidence, including more than 90 randomized controlled trials. Many of the field’s most robust studies have evaluated a particular kind of integrated care known as collaborative care, but it is not the only model in use.
Within the literature, established benefits of integrated care include:
Better mental health
Studies show that patients receiving integrated care have better depression and anxiety outcomes compared to those receiving usual primary care, where providers often lack the time and expertise to properly diagnose, treat and monitor mental illnesses.
Better physical health
Nearly 7 in 10 people with a mental illness also have at least one medical condition. Studies show that integrated care can also improve outcomes for chronic medical conditions, such as diabetes, in patients that also suffer from depression.
Lower health costs
Because mental illnesses can make medical ones harder and more expensive to manage (and vice versa) estimates show that integrating care for patients with both medical and mental illnesses would reduce health costs by between $40 and $80 billion per year.
A Patient's Experience: Robert
Robert (whose last name we are omitting for privacy) is a patient at Cherokee Health Systems, a safety-net provider that runs 24 integrated primary care clinics in eastern Tennessee. He started going to Cherokee 12 years ago for medical care, but once he revealed his struggles with depression, he started receiving mental health care, too.
Robert recalls being skeptical and slow to share at first, “A lot of stuff was eating at me [but] you gotta really want help first.” Now, he sees the benefits and has become a strong advocate for mental health care among his family and friends. Robert’s care team also helps manage his arthritis, diabetes and a new multiple sclerosis diagnosis, but it’s the mental health care he’s most grateful for.
“It means a lot. I’ve got somewhere to go and take my veil off, where I ain’t got to be macho,” says Robert, recalling the many times he’s cried on his provider Eboni’s shoulder. “She tells me what to do to get me feeling better and I can go on to the next episode.”
To hear more of Robert’s story, listen to the full episode.
The Barriers: Payment and Workforce
Although nearly half of practices now have a behavioral health provider on-site, adoption of truly integrated care lags behind. There are several barriers, and two of the most significant are:
Payment
Because integrated care blurs the lines between medical and behavioral health care, billing for it is difficult. CMS rolled out a handful of billing codes unique to integrated care in 2017, hoping other payers would follow suit. Even with some payers offering the codes, uptake has been slow, with many providers struggling to implement them.
Some experts point to the unique systems leading the way on integrated care, like the VA, Kaiser and federally qualified health centers, as evidence that the model scales better outside of traditional fee-for-service settings. Others believe the fee-for-service financials can work, but the model must first become cheaper and easier to implement. Some private companies have emerged to meet that need, essentially remotely “renting” out the necessary staff and expertise.
Workforce
In order to grow a workforce for integrated care, both medical and mental health providers need more training in how to work together to meet patients medical and mental needs at the same time and in the primary care setting. The availability of that training has grown some over the last few decades.
About half of psychology programs report offering training in primary care, and the majority of family medicine programs train residents in integrated care. However, provider shortages in both behavioral health care and primary care persist in many areas.
To help increase overall provider capacity, experts have also advocated for giving more training and responsibilities to other workers like community health workers and peer specialists. Other countries with severe shortages in mental health workers have shown that with sufficient supervision, people with a wide range of education levels can be trained quickly to deliver impactful, evidence-based mental health care.
The Tradeoffs: Integrated Care
With 60% of Americans with mental illness going untreated and mental distress on the rise during COVID-19, the need for better access to mental health care is clear. Expanding the role of primary care is one compelling solution. There are many different approaches to integrating care, and each has its own unique tradeoffs.
In general, integrated care cannot always address all behavioral health needs, and for some patients, more specialized psychiatric care models may be more appropriate. Some providers also prefer to practice in specialty settings. It is also important to recognize that the U.S. health care system already expects a lot from primary care, and practices are under new financial pressure as a result of COVID-19. As a result, they may not be able to handle the investment and work that integration requires.
This episode was produced as part of a series on health workforce issues funded by the California Health Care Foundation.
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Episode Resources
Select Research and Reports on Integrated Primary Care:
Integrated care: When physical and behavioral health professionals team up (Denise-Marie Ordway; Journalist’s Resource at Harvard Shorenstein Center on Media, Politics and Public Policy; 8/2/2020)
Factors Influencing Physician Practices’ Adoption of Behavioral Health Integration in the United States (Angèle Malâtre-Lansac, Peggy Chen, et al; Annals of Internal Medicine; 7/21/2020)
Integrating Clinical and Mental Health: Challenges and Opportunities (Bipartisan Policy Center; January 2019)
Potential economic impact of integrated medical-behavioral healthcare: Updated projections for 2017 (Stoddard Davenport, Katie Matthews, Stephen P. Melek, Doug Norris and Ally Weaver; Milliman; 2/12/2018)
Integration of behavioral health and primary care: current knowledge and future directions (Mark E. Vogel, Kathryn E. Kanzler, James E. Aikens and Jeffrey L. Goodie; Journal of Behavioral Medicine; February 2017)
Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost (Brenda Reiss-Brennan, Kimberly D. Brunisholz, Carter Dredge, et al; JAMA; 8/23/2016)
Evolving Models of Behavioral Health Integration: Evidence Update 2010-2015 (Martha Gerrity; Milbank Memorial Fund; 5/12/2016)
Integration of Behavioral and Physical Health Services in Medicaid (MACPAC; March 2016)
AHRQ Integration Academy Playbook (AHRQ Academy; 2016)
Collaborative care for people with depression and anxiety (Janine Archer, Peter Bower, Simon Gilbody, et al; Cochrane Library of Systematic Reviews; 10/17/2012)
Episode Credits
Guests:
Sandy Blount, EdD, Founding Director, Center for Integrated Primary Care at the University of Massachusetts Medical School
Richard Frank, PhD, Margaret T. Morris Professor of Health Economics, Harvard Medical School
Parinda Khatri, PhD, Chief Clinical Officer, Cherokee Health Systems
Eboni Winford, PhD, Director of Research and Health Equity, Cherokee Health Systems
Robert, Patient, Cherokee Health Systems
Music composed by Ty Citerman, with additional music from Blue Dot Sessions and the U.S. Forest Service
This episode was reported and produced by Leslie Walker. It was mixed by Andrew Parrella.
Additional thanks to:
Journalist’s Resource at Harvard’s Shorenstein Center on Media, Politics and Public Policy
Ben Miller, Febe Wallace, Peggy Chen, Garrett Moran, Judiann Jones, Sarah Farley, Cathi Grus, Doug Tynan, Alex Ross, Scott Kodish, Diane Powers, Heather Klusaritz, Kyle Grazier, Angela Beck, Greg Simon, the Tradeoffs Advisory Board…
…and our stellar staff!