The case for integrated mental and primary care

The connection between a person’s wellbeing and physical health is indisputable. Texans deserve to expect this holistic understanding applied to all their health care, not just for the treatment of major physical illness.

Whether a mental health need such as depression is triggered by a medical condition, or a chronic illness such as diabetes develops due to a medication side effect or difficulty accessing primary care because of the symptoms of a mental illness, Texans can never be as healthy as they can be until our medical delivery systems begin to address the whole person. That includes mental health care delivered within primary health care for those with routine needs and primary care in mental health care settings for those with the most severe needs.

Approximately one-in-four Texans have mental health needs every year. Fifty percent of mental illness begins by age 141. Early intervention and treatment are essential to prevent behavioral health needs from getting worse. Beginning in 2005, multiple studies have correlated high levels of comorbidity and high levels of premature mortality among the severely mentally ill.

Consider the following findings compiled for The Meadows Mental Health Policy Institute:

Texans with severe mental illness die by age 49.5 on average; the national average for this population is age 56. Primarily preventable and treatable diseases including diabetes, cardiovascular diseases, chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), and infectious diseases drive these premature mortality rates. Texans with serious mental illness have over 2 times the rate of diabetes (22 percent) and heart disease (18.4 percent) than Texans without mental illness. The health cost per person with severe mental illness is 3 to 10 times higher, costing billions of dollars annually.

Behavioral health and medical clinicians in communities across Texas are piloting programs to put integrated care models into practice. Under the Texas 1115 Medicaid Demonstration Waiver, there are 139 behavioral health DSRIP (Delivery System Reform Incentive Payment) projects dedicated to co-occurring behavior health (BH) and primary health (PH). Representing approximately one-third of all the behavioral health DSRIP projects and more than $200 million a year in Medicaid spending, these pilot programs are projected to serve more than 200,000 individuals a year by the end of the Waiver period in 2016. While sustaining these programs after the waiver period ends in 2016 will be a challenge, they have helped catapult Texas delivery systems forward in terms of integrated capacity development.

Integrated BH/PH programs generally involve co-locating providers either in the behavioral health or primary care setting. For the most severely mental ill individuals, primary care providers are brought into the mental health clinic to address comorbid medical needs. For people with more routine mental health needs, primary care practitioners bring psychologists, social workers and other behavioral health clinicians into their clinics for a range of services that – in best practice situations – includes innovations like joint sessions to develop integrated treatment plans.

There is early evidence that some of the Texas programs are showing success, but there are two significant challenges. One is training. Our health training systems still educate our physicians and mental health providers to work in fragmented systems that separate the body and head. Primary care and behavioral health care providers need training in how to work with each other from the first day of graduate training. The second challenge involves the reimbursement mechanisms for outpatient care. Public and private billing systems often disallow claims made at the same time or same day by two different practitioners. We need to reorient our health care delivery systems to better train and incentivize practitioners to deliver integrated care.

The Meadows Mental Health Policy Institute is funding a study by Texas A&M University to look at ten of the 139 DSRIP BH/PH projects in more depth to see what is successful, with particular emphasis on adults with serious mental illness with high rates of comorbid diseases (and related mortality).

In addition to saving lives, successful BH/PH integrated care programs stand to save billions of dollars in preventable hospitalization costs for the treatment of comorbid conditions among the severely mentally ill. The Texas Department of State Health Services spends $1.16 billion a year on mental health and Medicaid spends at least $1.2 billion a year (and potentially over $2 billion annually). The 1115 Waiver is funding over $500 million a year in behavioral DSRIP projects, representing a significant part of Texas’ mental health budget, funding which may be lost if the waiver is not renewed in 2016. However, studies suggest that the medical costs associated with mental illness are many times higher, impacting both the state Medicaid program and local hospital districts and inpatient providers serving people without insurance.

Our Institute believes that Texans deserve behavioral health care that is accessible, understandable, efficient, and effective. Early intervention and treatment are essential, and behavioral health care should be readily available in every doctor’s office and health care setting. To ensure access to treatment before tragedy, we need a minimum standard of availability and knowledge of effective and efficient practices in every Texas community. And we need both behavioral health and primary care providers to be fairly paid, with more emphasis on outcomes of care, not just quantity, with incentives to innovate and improve.

The Meadows Mental Health Policy Institute is a nonpartisan, nonprofit organization that supports the implementation of policies and programs that help Texans obtain effective, efficient mental health care when and where they need it. The Institute's vision is for Texas to be the national leader in treating people with mental health needs.

Sources: 1 Texas Mental Health Landscape, 2014, The Meadows Mental Health Policy Institute, 2 Reynolds RJ, Becker EA, Shafer AB. Causes of Death and Comparative Mortality in Texas Public Mental Health Clients, 2006-2008. Ment Health Clin. 2013;3(1):52; TriWest Group. (2011). The Status of Behavioral Health Care in Colorado – 2011 Update. Advancing Colorado’s Mental Health Care: Caring for Colorado Foundation, The Colorado Health Foundation, The Colorado Trust, and The Denver Foundation: Denver, CO; Serious and Persistent Mental Illness in Texas Medicaid: Descriptive Analysis and Policy Options Final Report, February 2015. Prepared for The Texas Institute for Healthcare Quality and Efficiency, The Meadows Foundation, by UT School of Public Health Faculty Paul J. Rowan, Charles Begley and Robert Morgan, and UT School of Public Health Doctoral Students Shuangshuang Fu, and Bo Zhao.

PhD, President/CEO Meadows Mental Health Policy Institute

Dr. Andy Keller is President and Chief Executive Officer of the Meadows Mental Health Policy Institute