Perspective on Practice
As the focus on health-care reform intensifies, psychology needs to turn its attention to a broader role for our profession in the health-care system—one that must focus increasingly on integrated care.
Why integrated care? Over time, health, mental health and substance use treatment systems have evolved in silos and independent from each other, as if the mind and body were two separate and unrelated systems. The physical health-care system was not designed to address behavioral health-care issues, and the mental health and substance abuse systems were not designed to adequately address physical health issues. Our health-care systems often fail to detect important aspects of an individual's overall health, resulting in significant costs to the individuals, their employers, the health-care system and society.
At least half of the care provided for common psychological disorders is delivered in primary-care settings, not in specialty behavioral health settings. This is especially true for persons of color. Patients tend to present with psychological disorders of mild to moderate severity, a level that makes them much more amenable to treatment that can prevent more severe or chronic disorders. The consequences of unmet mental health treatment needs, which can contribute to or worsen a variety of physical health problems, are too costly to ignore.
Unfortunately, the first line of primary-care treatment for psychological disorders is usually medication without the appropriate referral for psychotherapy. Prescription drugs are viewed as cost-effective, are widely accessible and associated with less stigma than other mental health treatments. These factors, combined with greater access to primary-care providers, have increased the use of and spending for psychotropic medications.
Patients who access the primary-care system could benefit tremendously by having prescribing psychologists as an integral part of their health-care team. Prescribing psychologists use a biopsychosocial model of care and have much more training regarding psychological disorders and psychotropic medications than any other prescribing health-care professionals aside from psychiatrists. But there is a dearth of psychiatrists and their ranks continue to diminish. Psychologists are the logical providers to fill these dire gaps in care.
Individuals with common medical disorders also have unusually high rates of co-morbid behavioral health problems, particularly depression. When these behavioral health issues are not adequately treated, health outcomes worsen because the individuals are not able to adequately manage their illness or follow prescribed treatment. They have higher medical costs and higher mortality than those without co-morbid psychological disorders. Alarmingly, individuals with severe mental illness die of physical ailments an average of 25 years earlier than people without severe mental illness.
So how do we know that integrated care works both for the patient and the health-care system? As early as 1971, data indicated that 50 percent to 80 percent of all medical visits involved patients with no identified physical health problem. Overutilization of medical care by patients with co-occurring physical and psychological complaints has been clearly documented. A meta-analysis of some 91 studies demonstrated a decrease in medical utilization following psychological intervention for 90 percent of those studied.
APA member Parinda Khatri, PhD, director of integrated care at Cherokee Health Systems in Tennessee, reports data from her health-care system that offers dramatic evidence for the cost-effectiveness of integrated care, including increased efficiency of primary-care services delivery, an average 30 percent medical cost offset, improved patient adherence and referrals to specialty mental health care. Patient and provider satisfaction increased when a psychologist participated on the treatment team. Integrated care systems utilizing psychologists can produce better outcomes for fewer dollars.
This is the first of two columns adapted from Dr. Nordal's address during the State Leadership Conference. The second column will appear in the July/August issue.