Dr Lori Raney Outlines the Advantages and Limitations of Treating Mental Health Disorders in Primary Care Settings

Lori Raney, MD, principal, Health Management Associates, explained that integrating mental health care into primary care settings can eliminate the need for a referral and potentially avoid stigmatization, but there still needs to be a better payment model for integrated care.

What are the advantages and limitations of treating mental health disorders in a primary care setting?

The advantages are certainly finding a large population of patients who have gone untreated for so, so long. Sixty percent of people with a behavioral health condition are getting absolutely no treatment whatsoever. Many of them are not being discovered in the primary care setting because we don’t have adequate screening. Many of them, their need for behavioral health is discovered, but the access to behavioral health is so poor across the country it can be anywhere from 2 to 3 months to a year to actually get in to see a psychiatrist for an appointment, and the same is true for therapy and other services.

We have a very limited workforce to help us with treating behavioral health conditions, so primary care has very few resources for referring. If we can actually provide that care within the primary care setting, then we don’t have that need for referral and we’re able to get people the care they need.

Stigma also prevents people from leaving the primary care practice and following through on the referral from their primary care provider. They don’t want to be seen as having a mental illness or really dealing with the struggles of stigma of being diagnosed with a behavioral health condition, so it really does prevent people from getting the care that they need. A huge advantage is getting that care in your primary care medical home with a trusted primary care provider.

The disadvantages have certainly been a lack of a really good payment model for integrated care. A number of integrated care programs for the last decade have really run off grants: local grants, SAMHSA [Substance Abuse and Mental Health Services Administration] grants, all kinds of different grants have been used. And not having a good financial model for paying for integrated care has certainly been a problem.

Most recently we have new CPT [Current Procedural Technology] codes for the collaborative care model of integrated care. The codes can be a bit of a challenge to implement but once implemented can really provide a nice funding source for integrated care. Again, the issue, one of the issues with that is we don’t have all the payers on board, and in particular Medicaid payers, so being able to have a good financial model is important.

The other thing is, some of the integrated care models don’t work as well for more severe mental illness. The goal would be that we would see those patients in specialty behavioral health, the best setting to see them, but again we have referral issues around that, so the primary care providers really want help with more severe illness, and most of our integrated care models currently aren’t designed as much to deal with more severe mental illness.
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