Treating mind and body

Sixty-eight percent of adults with mental health conditions also have medical conditions, and 29 percent of adults with medical conditions have mental health conditions. "If that's not a reason to integrate mental and behavioral health care into primary care, I don't know what is," said Rebecca B. Chickey, MPH, director of the American Hospital Association's section for psychiatric and substance abuse services.

Fortunately, health-care reform is encouraging hospitals and health systems to do just that, Chickey and others told participants at the State Leadership Conference in March in a workshop co-sponsored by APA's Div. 31 (State, Provincial and Territorial Psychological Association Affairs). The health plans offered in the new state-based and federal insurance exchanges, for example, must include mental health and substance abuse services and comply with the federal parity law that stops larger health plans from imposing treatment or financial limitations on mental health benefits that are more restrictive than limitations on medical benefits.

Health-care reform is also bringing new payment mechanisms that encourage integration of psychological and physical health services, said Frank V. deGruy, MD, chair of the department of family medicine at the University of Colorado School of Medicine. While hospitals have traditionally seen admissions as the path to higher revenues, new models — such as bundled payments and global caps — mean that hospitals fare better financially the better their patient outcomes are, he said.

Health-care reform is also promoting primary-care-based patient-centered medical homes in which multidisciplinary teams of providers offer holistic, coordinated care to individuals. Emphasizing prevention rather than focusing on acute care problems such as urinary tract infections and ear infections is key, said deGruy. "You can't wait until diabetic people can't see or need their foot amputated," he said. "You have to get people into a program of care before they're physically or psychologically symptomatic."

To improve chronic disease care, the first generation of patient-centered medical homes used care managers, quality improvement techniques and registries of patients with particular diseases designed to identify gaps in care. But to achieve the triple aim of better health care, improved health and lower costs — what deGruy calls the "primary-care effect" — patient-centered medical homes must also focus on the whole person. "You can get a big leg up on comprehensiveness by doing one thing: making sure your patient-centered medical home has incorporated behavioral health care into the fabric of its operation," said deGruy.

Primary care isn't the only setting where behavioral health services are needed, deGruy added. Specialty care facilities such as neurology labs and pain clinics can benefit from adapting the lessons learned from behavioral and primary-care integration. Reverse integration — bringing primary care into specialty mental health settings — is important, too, deGruy said.

Integration can also happen system-wide, said Robin Henderson, PsyD, executive director of the Central Oregon Health Council. The council oversees Oregon's coordinated care organization, which develops initiatives demonstrating that integrating physical and behavioral health care can improve health outcomes and lower Medicaid costs.

"How are we going to get paid in the future?" Henderson asked. "For the outcomes we produce." The coordinated care organization receives a lump sum for all the care it provides to Medicaid patients, then shares in any savings it achieves.

The coordinated care organization has launched several transformation initiatives, all of which involve psychologists providing behavioral interventions to people with medical conditions. In the obstetrics department, psychologists help women comply with pre-term regimens, overcome addiction and cope with postpartum depression, for example. In the neonatal intensive care unit — "the most expensive place in any hospital," said Henderson — psychologists have helped reduce lengths of stay by working with families. Psychologists have also worked with pediatric asthma patients, teaching better asthma control behaviors as a way of keeping patients out of costly emergency rooms.

Many initiatives target the 12 percent of individuals responsible for 82 percent of costs, who typically have chronic diseases. But embedding psychologists in primary care can also help with prevention, said Henderson, explaining that the health-care system needs to get better at identifying people on their way to developing chronic conditions.

The coordinated care organization is also doing things the other way around, by putting primary-care clinicians into clinics for people with serious mental illness. Henderson predicts that in 15 or 20 years, such clinics won't even exist. Instead, people with severe mental illness will receive treatment in primary-care settings. "That will be the new normal," she said.

Rebecca A. Clay is a writer in Washington, D.C.