Benjamin Miller, Psy.D., director of the Eugene S. Farley Jr. Health Policy Center and an assistant professor in the Department of Family Medicine at the University of Colorado School of Medicine, says mental health needs are not being met in today's health care environment.
The movement to integrate primary care with mental health is a prime example of how it takes more than wide recognition of an idea's merit to overcome a lack of funding and institutional support.
Panelists at a recent event(allhealth.org) that was co-hosted by the Alliance for Health Reform and The Commonwealth Fund discussed some solutions to this problem.
The need for integration is great, said Benjamin Miller, Psy.D., director of the Eugene S. Farley Jr. Health Policy Center and an assistant professor in the Department of Family Medicine at the University of Colorado School of Medicine (UCSOM). He cited some sobering statistics to illustrate his point.
For example, Miller noted, 20 percent of primary care visits have a mental health component, and 35 percent of children with reported mental health conditions are treated only in pediatric settings. And although 46 percent of adults will have a mental health or substance abuse need at some point in their lives, two-thirds of them do not receive the necessary care.
- Panelists at a recent event co-hosted by the Alliance for Health Reform and The Commonwealth Fund discussed ways to successfully treat mental health issues in a primary care setting.
- Patients are most likely to discuss mental health with their primary care physician because they already have an established relationship.
- Community support to address social determinants of health will assist care integration.
"Whose responsibility is it when the patient says, 'I'm depressed?'" asked Miller. He called this a fundamental question that health professionals need to answer.
Miller said the situation is stated well in a line from Frank deGruy III, M.D.,(www.nap.edu) chair of the Department of Family Medicine at UCSOM: "Primary care cannot be practiced without addressing mental health concerns, and all attempts to do so result in inferior care."
Patients are most likely to discuss mental health with their primary care physician because they already have an established relationship. Therefore, said Howard Goldman, M.D., Ph.D., professor of psychiatry at the University of Maryland School of Medicine, payment protocol should be designed to allow physicians to provide both primary care and mental health care on the same day. AAFP leaders recently made the same argument during a visit with members of Congress.
Primary care physicians often make referrals for behavioral health needs, but several panelists pointed out that method means patients who do not follow through with the referral do not receive necessary treatment.
Goldman has long advocated equipping primary care settings with the support they require to care for patient with mental health needs on-site. One such collaborative care initiative, led by the University of Washington, has been tested in eight states. Despite having been proven highly effective, it has not expanded because of limited funding and payment difficulties entrenched in the fee-for-service model. The model requires a nurse care manager to supervise patients receiving mental health care, as well as time for the on-site psychiatrist, physician and care manager to consult, Goldman said.
Community support to address social determinants of health also will assist care integration, said Jeff Richardson, M.B.A., executive director for Mosaic Community Services in Maryland. His organization, for example, helps by delivering a range of services across 120 locations, including 500 beds for permanent housing, employment assistance, family counseling and pharmacy access.
"You can provide an intervention, but if you don't provide a range of community-based support, it's going to fail," said Richardson. "We do the kinds of things that fee-for-service does not pay for. It's connective tissue."