Experts Call for Integration of Primary Care With Mental Health, Substance Abuse Services

The patient-centered medical home should purposefully include mental health and substance abuse services to improve patient care and reduce costs, said the director of the AAFP's Robert Graham Center during a primary care forum here on March 29.

"Making room for mental health and substance use in the medical home should not be a question," said Robert Phillips, M.D., M.S.P.H., director of the Graham Center, during a forum on integrating primary care with mental health and substance abuse services. "How can you be patient-centered without it?"

In addition, public and private payers need to reconfigure payment systems to integrate mental health care and substance abuse into the medical home, said child psychiatrist Mary Jane England, M.D., President of Regis College in Weston, Mass., at the same forum. Payers need to "understand the connection between the mind and body," she said.

In some countries, England added, insurers pay physicians for keeping patients healthy and out of the hospital, creating a payment system that emphasizes prevention and the integration of services.

The patient-centered medical home does not "dissect patients by organ or disease"; rather, it focuses on the whole person, thus providing an array of services that should include mental health and substance abuse services, Phillips said. There is overwhelming evidence that the integration of primary care, mental health and substance abuse services reduces patient complications, leading to a reduction in costs and an improvement in patient care, he said.

Yet, public and private payers, for the most part, have not sought to integrate primary care with mental health and substance abuse services, added Phillips.

England pointed to a 2005 Institute of Medicine report that concluded the only way to achieve true quality in the health care system is to integrate primary care with mental health and substance abuse services. The report also concluded that all three areas are interrelated and that improving care delivery and outcomes for any one of the three services depends on improving care and outcomes for the other two.

Phillips also pointed to research that indicates 50 percent of the nation's residents with "poor mental health" see only a primary care physician; 17 percent do not visit a primary care doctor. Only 13 percent of the nation's residents with a "poor mental health" diagnosis visit both a primary care and mental health care provider, and a scant 5 percent see a mental health care provider only, Phillips said.

The outlook for integrating these services may be changing, however. Both the House and Senate recently passed legislation requiring health plans that offer mental health coverage to provide the same benefits for mental illnesses as they do for other conditions.

The House bill, H.R. 1424, (at the THOMAS Web site, type "H.R. 1424" in the search box after selecting "Bill Number") requires out-of-network benefits for mental health coverage if out-of-network benefits are offered for other surgical and medical conditions; the Senate bill, S.B. 558, (at the THOMAS Web site, type "S. 558" in the search box after selecting "Bill Number") requires mental health services parity only if a plan offers out-of-network mental health coverage. House and Senate members currently are working on a compromise between the two bills.