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Am Fam Physician. 2008;77(6):757

Most people with poor mental health are cared for in primary care settings, despite many barriers. Efforts to provide everyone a medical home will require the inclusion of mental health care if it is to succeed in improving care and reducing costs. Major primary care organizations have reached a consensus regarding the desirability and the feasibility of a medical home.1 The whole-person orientation of the medical home posits that the personal physician is responsible to provide for the patient's health care needs and to integrate care across settings and problems.

Currently, there are payment policy barriers that prevent the full integration of the behavioral and physical health needs of patients. These will need to be resolved if the medical home is to be a comprehensive and coordinated system of care. This movement would also enable key recommendations of the Institute of Medicine (IOM) to improve mental health and substance-use care.2

Patients with severe mental illnesses, treated primarily in the mental health sector, are at a great risk of developing life-threatening physical ailments. One study shows that public mental health patients die 25 years younger than the national average, mainly due to the lack of appropriate primary care.3 Compelling evidence indicates that more should be done to facilitate the treatment of patients with mental and substance-use conditions in primary care. Most people with poor mental health are cared for in primary care, and many rely on primary care physicians for mental health treatment. Rates of mental health problems are significantly higher for patients with certain chronic conditions (e.g., diabetes, heart conditions, asthma). Failure to treat both physical and mental health conditions yields poorer outcomes and higher costs (see accompanying table).

Cost without mental health conditionCost with mental health condition
All adults*$1,913$3,545
Heart condition4,6976,919
High blood pressure3,4815,492

Carve-outs of mental health benefits (i.e., only paying for mental health care delivered by mental health professionals), high copayments for mental health treatment, and inadequate reimbursement are barriers to effective collaboration and disincentives for primary care physicians to screen for and adequately treat mental health. Fixing disparities, removing mental health carve-outs, and creating blended payment systems could improve mental health treatment in primary care. This would support integrated, patient-centered mental health care that is consistent with the principles of the medical home.

The information and opinions contained in research from the Graham Center do not necessarily reflect the views or the policy of the AAFP.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Graham Center Policy One-Pagers published in AFP is available at One-Pagers are also available at

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Copyright © 2008 by the American Academy of Family Physicians.

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