November 7, 2018
Integrated Care – More Than Just Hype
At WeCounsel, we’re supporters for behavioral health integration, and we’re not alone. Practices of all sizes and locations have benefitted from Behavioral Health Integration (BHI). It’s nearly a magic pill, perfect for all practices that are searching for improved outcomes and a way to manage increased demand for behavioral care. As the primary care field is changing, BHI is a strategy that is set to last.
Identifying Issues Before They Present
US Preventative Health Care Task Force has preventative measures in place specific to behavioral healthcare. In medicine, vaccinations are the most well-known type of preventative medical care. However, there is a need for a more comprehensive preventative approach to improving outcomes for any and all diagnoses. The sooner preventative behavioral interventions begin for chronic conditions or substance abuse, the sooner comprehensive care starts. With comprehensive care, it is possible to mitigate destructive behavior or exacerbation of symptoms. None of this can happen though, without a mental health evaluation.
Prevention doesn’t reduce the prevalence of mental and behavioral disorders, nor is that the goal, as numerous mental health issues are unpreventable. Prevention does, however, address risk factors including trauma, family history, and chronic conditions, and how any combination can increase the likelihood of developing mental health issues. Acknowledging these traumas and other risk factors early-on is physically and sociologically beneficial. Access to preventive care can reduce the development of physical symptoms, encourage early symptom management, and lead to a longer lifespan.
Comprehensive Patient Health
An appointment with a primary care physician is typically scheduled to address a physical ailment, like a cough or back pain. Patients have symptoms, so they see their primary care doctor in order to get better. Primary care physicians can also act as a gateway to a specialist, such as an endocrinologist or a cardiologist, but their trajectory stops at behavioral healthcare, stunting a patient’s treatment.
Consider healthcare like car repairs. If someone is driving a car as it’s overheating, there are two major problems. First, there was a pre-existing problem with the car before it started to overheat. Second, they shouldn’t continue driving the for fear of increasing damage. Without addressing the reason or the car overheating, the car is at greater risk for future, costly repairs. It’s a telltale case of chronic health conditions and mental health comorbidity. The body keeps running, but without addressing the mental health, patients are significantly less likely to properly manage their physical chronic conditions, resulting in higher risks and care costs.
BHI incorporates mental health services into primary care to address all symptoms, regardless of their origin. Eliminating the sole focus on the physical body helps patients receive full, comprehensive medical care, addressing all ailments. Consistent studies show that comprehensive care results in healthier patients and significant reductions in the total cost of care. Considering that Healthcare is nearing 20% of GDP, that’s a big deal.
Comorbidity is Critical
Oversight in care can be detrimental, as comorbidity between physical and mental health issues is common and serious. Let’s look at diabetes – on average, 40% of diabetes patients present with signs of depression. Diabetes patients are extremely sensitive to external triggers, such as lifestyle or environmental changes. Triggers can change their glucose levels and increase susceptibility to developing depression. Depression patients are also more likely to develop Type II diabetes, even from the slightest lifestyle changes. Hence, the separating the treatment process for these types of care can be more harmful than helpful.
Comorbidity awareness and addressing mental health can actually resolve a patient’s physical ailments. For example, one in five Americans suffers from Irritable Bowel Syndrome (IBS). Comorbidity with IBS is commonly associated with anxiety and depression, which can be a ‘chicken and egg’ scenario. IBS symptoms can cause stress and anxiety, or stress and anxiety can cause IBS symptoms. Addressing the mental health diagnosis can stop this cycle and help alleviate both the physical and mental ailments for patients.
Acknowledging comorbidity is important for patients as they may be unaware of their symptoms. Centers for Medicare & Medicaid Services ran an FFS Medicare-Medicaid enrollee study with a sample of 5.3 million people. Of that population, 77% presented with two + conditions, 60% presented with three +, etc. Over 4 million people presented with mental and physical comorbidity – meaning it is very common, but over 50% of patients lacked awareness. Considering that chronic care accounts for 75% of US healthcare costs, these statistics are hard to ignore.
Smaller practices have fewer resources to work with, but that doesn’t mean they can’t make a sizable impact. All that is truly needed is a primary care physician with extra behavioral training or a simple partnership with a behavioral provider group. It’s much easier for a patient to see two physicians at once or one dual-trained healthcare provider than it is to schedule two separate appointments. Plus, it guarantees a higher rate of patient compliance.
On that note, with BHI, communication between providers becomes more streamlined and efficient. As mental and physical health requires evaluation for a complete, integrated exam, both perspectives are needed before a diagnosis. While sometimes providers are in the same practice, other times they are not, which introduces the virtual option. Virtual BHI is the practice of implementing BHI when one provider, or patient, is at a remote location. It runs as smoothly as a typical phone call, without the time wasted waiting for notes to process or debating prescriptions. Virtual BHI ensures all providers are on the same page, at the same time. Increasing provider communication stops the cycle of patients becoming dependent consumers of the healthcare system while avoiding costs and addressing underlying conditions. Breaking this cycle with preventative behavioral can save upwards of $406B in healthcare costs.
Improving Patient Outcomes
Access to care is a huge barrier that BHI directly tackles. By making it easier to access a mental health professional, access ceases to be a barrier and care is “routine”. Patients no longer have to wait weeks to see a provider, and the stigma issue subsides. Behavioral care becomes another normal service provided by their trusted primary care provider. Normality as a concept is crucial as many people consider “stigma is a really big deal in behavioral health”.
Integrating behavioral health services into primary care appointment increases the opportunity for treatment. As mentioned earlier, patients may not know there is an issue until they visit their doctor. The correlation between an emotional trauma and back pain may not be obvious to the patient. To trained professionals, however, it’s a no-brainer that has to be delicately articulated. The patient’s access to mental health providers allows for holistic care and reduces demand for healthcare because patients are healthier and need fewer resources.
The Results Thus Far
Integrated care is a culture change. It redefines the concept of “health” to be more inclusive of mental, physical, and spiritual health, and social elements. But the change is being embraced in a big way – BHI has broad support in the healthcare community and Congress. Plus, there isn’t a single group or institution fighting against it. The National Alliance for Mental Illness and patient groups love it because it increases access and destigmatization. With this type of support, integration of behavioral healthcare in commercial-payer and Medicaid Accountable Care Organizations (ACOs) is only predicted to grow in the years ahead.
With all new innovations, come challenges. BHI is no exception, but no challenge is insurmountable. For example, the debate to extend or limit Medicare and Medicaid spending is constantly changing. Yet, Medicare has already expanded Reimbursement Opportunities, introducing 4 new codes in 2018. These codes make BHI more easily reimbursable under traditional BHI, and a newer model, the Psychiatric Collaborative Care Model.
The Medicaid Innovation Accelerator Program launched various programs focusing on mental health, one of which is the Physical and Mental Health Integration (PMH). This program assists enrollees who suffer from mental health issues, to:
- Improve the behavioral and physical health outcomes and experience of care of individuals with a mental health condition(s).
- Create opportunities for states to link payments with improved outcomes for Medicaid beneficiaries with these comorbid conditions.
- Expand or enhance existing state physical and mental health integration efforts to customize for specific populations and/or spread integration efforts to new areas of the state or to new types of health professionals.
Currently, the federal government and the Affordable Care Act support initiatives like BHI. Yet, they can’t guarantee any money for it. If Medicare and Medicaid are making strides to support BHI though, it’s feasible that the competition could spur private-payer insurers to follow suit. After that, it’s only a matter of time until it’s supported throughout all insurance markets.
The New England Journal of Medicine says BHI is a huge step forward and predicts widespread implementation will result in millions of beneficiaries and millions of dollars in savings. Experts agree, that sheer interest in BHI is growing among ACOs and will likely be even more prevalent in the years ahead. The U.S. may reach a point where integration is the standard of care. Then we’ll strive towards the next innovation while taking care of the entirety of every patient.