Primary Care, mental Health

A young woman's diagnosis of infertility leads her to commit suicide a short time later much to the horror of her caring and well-intentioned doctor, who never saw it coming. He thinks it may have been avoided if there had been a mental health professional on his staff. This is one of many stories recounted in a Mental Health Forum and Town Hall held by the Agency for Healthcare Research and Quality (AHRQ) at its September annual meeting. A large panel of experts discussed the importance of integrating mental health professionals into primary care practices. The goal of integration is to reduce the fragmented and inadequate care of mental health problems in primary care patients.

Primary care clinicians are not fully trained to diagnose or treat mental health problems, yet people with these conditions typically are seen in primary care more than any other setting. To make matters worse, referrals to community-based mental health providers are a persistent problem. "Studies show that well over half of primary care docs are not successful in referring patients to mental health professionals in the community for a variety of reasons, " says Charlotte Mullican, M.P.H., senior advisor for mental health research at AHRQ. "This could be due to insurance and payment barriers, limited availability of mental health providers and other access problems, as well as stigma."

The result? Depression and other mental health problems are undiagnosed or inadequately treated, inappropriate psychotropic drugs are prescribed with little followup, and the contribution of these mental health problems to chronic disease symptoms is often overlooked.

While family medicine doctors get some training in mental health as residents, other primary care doctors may not, according to Frank DeGruy, M.D., chairman of the Department of Family Medicine at the University of Colorado. He told Research Activities, "The majority of family docs will tell you that they wish for more behavioral health expertise in their practice. The training in mental health for primary care physicians is very superficial and it's not very deep. Family docs don't want to spend the time, they don't want to deal with anything but the most straightforward mental health problems, and they don't know what to do if anything goes wrong. That's pretty much our story." What many primary care physicians would like, he says, and what patients would benefit from, is the help of mental health professionals.

Barriers to integration

Yet few mental health providers are trained to work in the primary care setting and neither primary care nor mental health physicians are trained to work as a primary care team. "These workforce and culture issues are a barrier to integration of mental health in primary care, " adds Mullican. "Problems with reimbursement of mental health services in the primary care setting is another major barrier to integration. Unfortunately, the bottom line is inadequate care for patients with mental health problems. We need to change that."

The current system is fragmented and doesn't promulgate successful models of team-based care, asserts Benjamin Miller, Psy.D., assistant professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine.

Miller envisions the future role of clinical psychologists and other mental health professionals like him as embedded in a primary care practice collaborating with the other primary care providers to provide comprehensive care to the patient. These providers would be seamlessly integrated in one primary care practice and regularly see patients for 5, 7, or 15 minutes for a host of mental health issues, many of which may be affecting their chronic health problems. But the way the current health system is set up, integration of the mental health professional in primary care is not financially sustainable. That's because mental health and "physical" health are paid out of different pots of money.

"What happens if I go into the room to see the patient with the physician?" asks Miller. "Who is going to pay for that? That's where sustainability starts to rear its ugly head. What happens when I am the one who starts to do an intervention around mental health or health behaviors? There will not necessarily be a billable code to classify what I just did. It's all in the codes. The codes force you to do what they value versus what the patient sitting in front of you is telling you they value."

There is growing recognition that many health problems are affected by mental health problems. Day in and day out, primary care clinicians see a significant proportion of common symptoms such as fatigue, abdominal pain, and back pain for which they don't find a cause. "If we understood people's psychosocial stressors, their adverse childhood experience, and we were better at identifying common mental and behavioral conditions such as depression, anxiety, and substance use, we'd understand a lot more about what's driving those symptoms, " noted Neil Korsen, M.D., medical director at MaineHealth, at the Forum. Embedding mental health professionals in primary care could enhance a more patient-centered approach to care.

Promising models of integrated care

The Forum panelists all agreed that payment drives practice and how services are reimbursed will have to be changed if mental health is to be integrated in primary care. That's what has happened in Maine and it's making a difference.

In the State of Maine, to participate in the patient-centered medical home (PCMH) pilot project, a primary care practice has to integrate mental health or behavioral health services. "We've been working hard on improving care for diabetes, care for people with heart disease, and you can't do that if you're not addressing the mental health components, " says Korsen. "Primary care clinicians can do some of that work, but we need help. Increasingly, health care is a team sport and we need help from people who have more expertise. So in Maine, the patient-centered medical home equals integration."

Maine is a good example of how changes in reimbursement start to change how care is delivered, explains Miller. "Look at the payment structure of the PCMH. Let's say you get $7 per patient per month in the PCMH and then you get a financial incentive for integrating mental health care by getting paid more per patient per month. This may be the money you need to offset the cost of bringing in the mental health provider to take care of these patients."