During a recent policy forum in Washington, Benjamin Miller, Psy.D., says the traditional separation between physical and mental health is an artificial one that does not serve patients' interests. He noted that many patients first bring their mental health issues to the primary care setting.
For years, the prevailing notion in medicine held that the body is treated in a physician's office and the mind in a separate mental health facility.
That view is slowly changing, however, as a growing number of medical professionals and others contend that such separation leads to ineffective treatment that does not answer patients' needs.
"When you take mental health out of primary care, you get poor outcomes and you pay more for it," said Benjamin Miller, Psy.D., director of the Eugene S. Farley Jr. Health Policy Center, an initiative of the Department of Family Medicine at the University of Colorado Denver School of Medicine. The majority of patients who are diagnosed with mental illness are initially seen and treated in a primary care setting, he noted.
Miller spoke during a recent forum hosted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, "From Fragmentation to Integration: A Triple Aim Imperative." During the event, panelists addressed how the notion that a patient's mental health can be separated from his or her physical health is an outdated one.
- Speakers at a recent policy forum explained that the notion of a division between physical health and mental health is outdated.
- Patients with mental health needs seek out their primary care physician before considering a visit to a mental health facility.
- The current payment structure for medical care discourages physicians from providing the kind of comprehensive care that would include a mental health component.
Unfortunately, said Miller, the majority of patients who receive a referral from their primary care physician to a mental health specialist do not make the visit. He suggested that one reason for the lack of follow-up is the unwillingness of patients to describe their mental health to another professional with whom they are not familiar after having already detailed their concerns to a physician they trust.
"People are saying, 'When I go for primary care, I want my mental health needs to be addressed there," said Miller.
Parinda Khatri, Ph.D., chief clinical officer at Cherokee Health Systems, a comprehensive community health care organization with 56 clinical sites in 13 counties in Tennessee, recalled a woman who recently visited a clinic after her son died in an accident. The day after the accident, the woman went to see her primary care physician to discuss her situation. If she had instead tried to make an appointment with a therapist, she might have faced a six-week waiting period.
"We need to be on the path that patients have decided to walk," said Khatri.
According to Miller, policymakers and private insurers have sufficient reason to combine mental and physical health care because there is a market incentive to reduce overall costs and a public health mandate to improve patient outcomes.
Still, those in the general population don't place a premium on taking care of their own health, Khatri observed, perhaps because they don't receive strong enough encouragement to do so.
Former Colorado Gov. Bill Ritter Jr. says advocates for primary care need to demonstrate how any increase in investment will improve care and lower costs.
The result? "We are reinforcing paying for those who are not taking care of their health," she said. "If you have that kind of a system, it will be expensive and not very satisfying."
The panelists agreed that changes are needed in both medical education and at the practice level if the medical community is to create an integrated health approach that includes both physical and mental health in a single location.
"Just placing professionals together doesn't lead to collaboration," said Susan McDaniel, Ph.D., director of the Institute for the Family in Psychiatry at the Rochester University School of Medicine and Dentistry in Rochester, N.Y. "Primary care physicians need training on psychosocial health."
One attendee asked the panel if the medical community needs a new paradigm modeled after the principles outlined in the Flexner report that would address the integration of physical and mental health care needs. McDaniel said some programs are beginning to teach students about the importance of mental health, but the respective curricula of these fields remain unintegrated.
"Many medical schools are light on psychosocial health, and many mental health programs are light on biology," she said.
Meanwhile, efforts to increase investment in primary care and mental health are proving effective for one health insurance plan. Patrick Gordon, associate vice president of Colorado-based Rocky Mountain Health Plans, shared statistics that compared the insurer's traditional practices with more advanced practices that receive greater financial support for primary care and include a mental health component.
The traditional practices in the network continue to operate on a fee-for-service basis, whereas the advanced integrated practices also receive a monthly payment for each patient ranging from $5 to $15. After four years, the integrated practices are costing about 4.5 percent less per patient than the traditional plans.
Still, given the volatility that continues to surround health policy, convincing elected officials to spend more on health care remains a concern. Former Colorado Gov. Bill Ritter Jr. told attendees that when making a case for changes in care delivery to policymakers, the emphasis should be on how an increase in investment can lead to lower overall costs.
"When you are talking about the cost of care, you are not just talking about the cost of primary care," he said. "You are talking about the cost of human services and the cost of jails."
In Colorado, for example, it costs $33,000 annually to house one prisoner, an expense Ritter said would be better devoted to education or other societal needs.
He told attendees that when meeting with legislators, they must be prepared to show how an increased investment in primary care will lead to better outcomes and eventually reduce other societal costs.
"People say that when you expand some kind of service it has to cost more," said Ritter. "You have to come armed with data that shows it can be cost-efficient."