Integrated Care No Longer an Afterthought at APA

In 2010, the topic of integrated care in mental health was still at the edges of practice, so much so that the topic only merited a single workshop at the meeting of the American Psychiatric Association (APA) in New Orleans.

This year, at the APA’s 167th annual meeting, held at the Jacob K. Javits Center in New York City, the need to understand the interplay between mental health diagnoses and other problems, such as diabetes, covered an entire track across 20 sessions, said Lori Raney, MD, a child and adolescent psychiatrist in Colorado.

Dr Rainey’s introduction to “Leveraging Psychiatric Expertise: Integrated Care and Healthcare Reform,” evoked a theme that permeated the sessions: mental healthcare can no longer be relegated to a separate silo; for the good of patients, physicians treating persons with mental health disorders such as depression or anxiety must grasp how that affects a person’s overall health. For example, will a person with depression follow nutrition guidelines or take medication to control type 2 diabetes mellitus (T2DM)? Or is a different type of support needed?

Joining Dr Rainey were Roger Kathol, MD, president of Cartesian Solutions; Jürgen Unützer, MD, MPH, and Wayne J. Katon, MD, both of the University of Washington; and Ben Druss, MD, of Emory University. Dr Rainey said that as psychiatrists and primary care physicians (PCPs) move toward integrated care models, one challenge is integrating different cultures of practice. Psychiatrists and PCPs operate differently, and, in fact, it’s the psychiatrists who have taken longer to come around. “What we’re learning is that this work is hard,” she said. “The team dynamic determines if it’s going to work.”

But the walls must come down, the panelists agreed, because healthcare reform calls upon medicine to improve population health. Psychiatrists and PCPs who fail to embrace integrated care models will suffer financial consequences, as payment will be tied to whether patients’ health is improving. Payers have taken note of how much persons with mental health issues tax the system in other ways, as outlined in the 2014 Milliman report prepared for APA. That report estimated that integrated care could save the healthcare system at least $26 billion a year.¹

Dr Kathol reviewed some sobering statistics from the report: In 2012, 14% of the enrollees on commercial plans had mental health claims, but those patients accounted for 28.7% of the total medical spending in the plans. Mental health patients make up 9% and 20% of the enrollees in Medicare and Medicaid, respectively, but they accounted for 26.3% of the medical spending for the plans.

How does this happen? Dr Kathol said that the first step in understanding the need for integrated care is realizing that most behavioral healthcare is not delivered by psychiatric specialists, but by PCPs. “This is where we really need to be,” he said.

Yet there are many barriers to integration, involving everything from patients’ transportation challenges, to the fact that plans treat mental health separately from medical claims, to the fact that psychiatrists have historically not been “embedded” in emergency departments, where persons with mental health problems so often land.

“Right now, we do reactive consults,” said Dr Kathol about emergency rooms. “We now have data that show if you are part of the hospitalist team, you have much better outcomes. Proactive consultation is needed.”

What are the “core ingredients” of integrated care? Dr Kathol said they are:

• Moving toward payment for behavioral health services through the medical/surgical side of health benefits.
• Consolidating medical and behavioral health electronic health records (although some state regulations make this difficult).

Dr Unützer said that the time is now to pursue these changes, because persons with mental health issues will gain greater access to coverage under the Affordable Care Act (ACA). “If it plays out the way the ACA intends, 60 million Americans will have new or better health coverage. But it will also create tremendous challenges,” he said, including not enough mental health professionals.

The patient-centered medical home (PCMH) model provides an opportunity for psychiatrists to offer integrated care alongside PCPs, he said. New standards for PCMH certification will require on-site capacity for mental health services.

Dr Katon discussed results from a 2012 study of a “multicondition” intervention involving patients with both mental health and cardiometabolic issues.² An earlier intervention on depression symptoms only with this population had produced better quality of life, but not improvements in measures like blood pressure or glycated hemoglobin. But a collaborative effort with specially trained nurses, which targeted both mental health problems and T2DM or coronary heart disease, produced improved scores on depression as well as improvements in cardiometabolic health measures.

“Depression frequently starts in teenage years,” Dr Katon said. Patients start smoking and become more sedentary, so it’s little wonder that depression is a predictor of obesity and metabolic syndrome, and is associated with other health conditions. “People with depression don’t adhere to medications very well, so they tend to have more problems,” he said.

Dr Druss, who practices in Georgia, where half the counties have no psychiatrist, said the poor distribution of psychiatrists nationally is one of the challenges the field will confront in a move toward more integrated care. Part of the problem is coverage: because of reimbursement differences, only 43% of psychiatrists accept Medicaid, compared with 73% of all physicians.

Thus, well-trained social workers and peer specialists will have to be part of the picture, he said. But psychiatrists must be ready to embrace new roles as well, going beyond “the patient in front of you.”

Healthcare reform calls on psychiatrists to take on a public health role, to address the patients who have not shown up for care. It calls on the field to embrace the role of the behaviorist, to help patients quit smoking or deal with obesity. And, Dr Druss said, healthcare reform calls on psychiatrists to advocate for disadvantaged populations, and to be leaders, “especially in community settings.”

References

1. Melek SP, Norris DT, Paulus J. Economic impact of integrated medical-behavioral healthcare, implications for psychiatry. American Psychiatric Association website. http://www.psychiatry.org/integratedcare. Published April 4, 2014. Accessed May 4, 2014.
2. Katon W, Russo J, Lin EH, et al. Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. Arch Gen Psychiatry. 2012;69(5):506-514.