Why behavioral health is the new frontier in primary care

While primary care physicians provide most mental healthcare, few of those in private practice are integrating behavioral health providers into their groups, due largely to the lack of financial support for it in the fee-for-service world.

But that situation is likely to change. 

As value-based pay replaces fee-for-service, mental health integration is becoming more commonplace and expected. 

Behavioral health conversations regarding a patient’s well-being-asking about their mental state, about substance abuse, and whether there’s a gun in the house-“is going to become part of the standard of medical care,” predicts Michael Caudle, MD, an ob/gyn at Cherokee Health Systems, which operates a network of federally qualified health centers in Tennessee. “You’re not going to be able to avoid asking these questions in practice, or you’re not going to have proper reimbursement. And when you find answers to those questions, you’ll need some way to deal with it.”

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Furthermore, as a recent editorial in the Journal of the American Medical Association noted, “Integrated [team-based care] is clearly superior to [traditional management] for patients with complex mental illness and chronic medical disease…It would be unethical…to randomize this type of high-risk patient to usual care when integrated care has been shown in many studies and many types of health systems to be superior to traditional care.”

With this kind of endorsement, it’s likely that integrated care will continue to gain ground. So whether a primary care doctor is employed by a hospital or is in private practice, he or she will probably work in an integrated setting in the future

Poor training, poor care

About a third of U.S. adults who have medical conditions also have mental health disorders, according to 2011 research by the Robert Wood Johnson Foundation, and 68% of adults with mental illnesses also have medical conditions.

Patients with behavioral health problems-which include both mental illness and substance abuse disorders-cost two to three times as much to care for as those without them, the Commonwealth Fund discovered in 2014. A prime reason is that they often don’t take care of themselves.

Parinda Khatri, Ph.D., chief clinical officer at Cherokee Health Systems, notes that 40% of patients with diabetes are depressed, and that many of them won’t get their blood sugar under control unless clinicians address their depression. 

“If you give someone a prescription and ask them to take it regularly, you’ve asked them to change about seven health behaviors,” she points out. “They have to fill the prescription, they have to take it home, they have to build it into their regimen. They may or may not have to modify their diet. All of that requires significant health behavior change.”

Primary care physicians write about 80% of the prescriptions for psychotropic medications. However, most of them don’t treat mental illness very well, says Marci Nielsen, Ph.D., president and chief executive officer of the Patient-Centered Primary Care Collaborative, an advocacy group for medical homes. They’re not trained adequately to deal with it, and they don’t have much time to take care of these issues, she observes, because they’re compelled to see a certain number of patients each day.

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Primary care doctors “treat people all the time [for mental illness], but in suboptimal ways,” agrees David Woodlock, president and chief executive officer of ICL, a nonprofit firm that operates a network of mental health clinics in New York City. “They’re writing a prescription for Prozac when the evidence is quite clear that anti-depressant medication and psychotherapy are the optimal treatments for depression.”

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Woodlock partly blames lack of access to behavioral health specialists for the overreliance on primary care physicians. Low insurance reimbursement means patients often can’t afford mental health care, and some health plans make it difficult for doctors to refer patients, he says.

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There’s also a stigma attached to seeing a counselor, he notes. Even when patients are referred to a psychologist or a licensed clinical social worker (LCSW), they keep their appointments only about half the time.

Some healthcare systems and community health centers  try to overcome these barriers by co-locating behavioral health providers in primary care practices. But while this approach can avoid the stigma of seeking help for mental conditions, merely placing different kinds of providers near each other doesn’t necessarily improve care.

To make a significant difference in outcomes, experts say, primary care providers and behavioral health professionals must act as a single care team, communicate through electronic health records and collaborate in developing care plans. They must also have access to psychiatrists as a backup resource.

Counseling in the exam room

Cherokee Health Systems, which includes 23 community clinics in 14 Tennessee counties, has been integrating primary care and behavioral health care for 30 years. “Integration is a core aspect of our clinical approach, primarily because we’ve found that we cannot provide good primary care without addressing the behavioral health issues,” notes Khatri.

The ratio of PCPs to behavioral health providers at Cherokee is about four to one (three to one in pediatric practices), she says. The clinical psychologists and LCSWs are embedded in the primary care teams, and the physicians use screening tools to determine which patients might benefit from counseling. If a patient consents to see a therapist, his or her doctor will have the therapist meet with that patient in the exam room.

“We do the assessment right there,” Khatri says. “Our experience is that if people have to come back for that, you’ve added a barrier.”

Cherokee’s PCPs and behavioral health professionals work off the same electronic health record (EHR) system and create patient care plans together. Any provider who pulls up the record sees a dashboard that includes a snapshot of the patient’s care, including care gaps. If Khatri, a psychologist, notices that a patient hasn’t had a test for asthma or another chronic disease, she’ll tell the patient she needs to get one and will set it up. 

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If a patient has a serious mental health condition, he or she can be referred to one of the psychiatrists who regularly work with Cherokee. Primary care doctors also can consult with these psychiatrists about medication management. But the primary care teams handle 90% of behavioral health problems, Khatri says.

Cherokee’s Caudle observes that some patients’ physical symptoms may be related to mental health conditions. Frequently, he  sees patients who present with generalized pelvic pain or who fake pregnancy because the physical symptom is more acceptable than admitting that they have other problems. Sometimes, when women come in with unspecified pelvic pain, “It’s a sign that they’re depressed or have a history of some kind [unrelated to their medical conditions]. I’ll say, ‘Would you like to talk to somebody about this?’ And often they say yes.”

The initial assessment of the person’s problem may lead to later visits with a mental health professional, he says. In that case, the patient can see the psychologist or LCSW when she returns for ob/gyn follow-up or can see the therapist on her own. In some cases, he adds, the counselors notice care gaps and follow up on their own.

“That’s one of the big values of this approach,” Caudle says. “As we eliminate the barriers between the doctors and the mental health professionals, I learn some psychology, and they learn about medicine. And they become better at it, so they can advocate for things like birth control.”

Large group approach

Even more than Cherokee, Intermountain Healthcare, based in Salt Lake City, stresses primary care in its 15-year-old approach to behavioral health care integration. All of Intermountain’s 62 primary care clinics are integrated. They are also patient-centered medical homes, which requires them to emphasize behavioral health. Primary care physicians work with mental health specialists on care teams that provide essential support to the doctors. 

Intermountain’s care teams screen for depression, anxiety and other mental health conditions during annual visits and on every visit by a patient with a chronic disease. But the integrated approach has been flexible from the start, says Brenda Reiss-Brennan, Ph.D., APRN, the healthcare system’s mental health integration director.

“If you were there for a sore throat and you weren’t sleeping and weren’t working and couldn’t get out of bed, it became a normal routine thing to check for depression or anything else that was going on,” she says.

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When a screening questionnaire indicates that a patient may have a mental health issue, the doctor offers him or her the options of medication, education and/or psychotherapy. “In any of those categories, the primary care physician would provide the care,” Reiss-Brennan notes, in the form of light mental health counseling. 

If the patient needs more extensive counseling, they’re referred to a behavioral health provider in the clinic. But that isn’t routine, as it is in some other groups that have co-located mental health professionals, she points out. “In our system, 80% of the mental health care is provided by the primary care doc.”

To compensate for deficiencies in the doctors’ training, she adds, mental health experts coach them on such topics as anxiety, depression, motivational interviewing and cognitive behavioral therapy. For further guidance, they can follow mental health protocols similar to those for diabetes and asthma. If a patient’s condition is of moderate complexity, he or she is referred to a counselor. Complex or urgent cases are sent to a psychiatrist.

During a study period from 2010-2013, Reiss-Brennan notes, the cost of the program to the Intermountain Healthcare system was $22 per member per year, and the Intermountain health plan saved $115 per member per year. This return on investment makes it easy to justify the additional expense of integrating behavioral care.

Financial sustainability

Cherokee adopted integration because of its mission, which includes providing superior primary care and filling the need for mental healthcare in rural areas, which might otherwise go unmet. While the network is starting to get value-based-reimbursement contracts from health plans, its population is heavily skewed toward Medicaid and self-pay patients. That means Cherokee has to limit costs so it can afford to serve those who can’t pay.

“It would have been more profitable for us if we hadn’t gone this route,” Khatri says. “But we didn’t want to do that, because we see ourselves as stewards of limited healthcare resources.”

Private practitioners also find it difficult to get financing for integration, notes Ben Miller, PsyD, director of the health policy center and associate professor in the department of family medicine at the University of Colorado School of Medicine.

“There’s very little incentive for small and medium-sized primary care practices to onboard or integrate a behavioral clinician, because the payment structure doesn’t support that,” he points out. 

One group that has made it work is the Westminster Medical Clinic, a primary care practice in Westminster, Colorado, that includes three physicians, two physician assistants and a nurse practitioner.

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Led by Robert Scott Hammond, MD, the practice finally hit upon the right formula to help patients by partnering with a community mental health center five years ago. That center now pays the salaries of the psychologist and the LCSW who are embedded in the practice. Without that financial support, Hammond says, the practice could not afford these professionals. 

Over the years, he says, the practice has had to make financial sacrifices to continue providing mental health services. The partners took cuts in pay, and staff salaries were frozen for a long time. Yet the group is still united in its vision. 

“We don’t feel we can provide quality primary care without addressing mental health issues, which impact 40%-50% of our patient visits,” he explains. “It’s like going in to see a patient without a stethoscope. 

Hammond and his colleagues screen patients at every visit for depression, anxiety, substance abuse and other issues. If the brief initial screen is positive, patients are asked to complete a longer questionnaire that helps the doctors diagnose them. The patients are then divided into two groups according to the severity of their conditions. If they are in moderate distress, doctors can address it.

In high-acuity cases, the physicians can make a referral to an onsite therapist through their EHR, to which the mental health professionals have access. Although the behavioral health providers use a different EHR than the PCPs, they can enter notes from their counseling sessions into the doctors’ EHR, following an agreed-upon template.

“We don’t get every bit of information, but we’ve developed a nice bidirectional information flow that’s useful,” Hammond says. “So when we make a referral, they get the information they need and we get the information we need.”

Severe cases are referred to a psychiatrist whom the doctors access through the community mental health center. The physicians can also consult with a psychiatrist about psychotropic medications before prescribing them.

A study of the group’s outcomes showed that the integrated approach reduced the prevalence of depression and anxiety by about 50%, Hammond says. The researchers also found a positive trend in the HbA1c results of diabetic patients, but the sample was too small for statistical significance. Provider and patient satisfaction are also up, he adds.

But Hammond is realistic that absent grant funding or an initiative that provides support, primary care practices will encounter obstacles in following his practice’s footsteps. Nonetheless, as more opportunities emerge, he stresses that integration is a crucial element of healthcare reform. 

“We cannot move forward without mental health integration,” Hammond says. “It’s such a critical part of our care delivery. It’s unimaginable that we don’t have it.”