Mental Health and Primary Care Integration - PCPCC Letter to Senate Finance Committee

Dear Mr. Chairman and Ranking Member Hatch:

As a large and diverse stakeholder group committed to health system transformation, the leadership of the Patient-Centered Primary Care Collaborative (PCPCC), thanks you for this opportunity to provide our feedback on your August 1, 2013 request for recommendations to improve the nation’s mental health system. Further, we commend your attention to this critical topic, and encourage you to call on us in the future to articulate the importance of integrating primary care and mental health, particularly within a patient-centered medical home.

The current mental health system faces a number of challenges that require a myriad of complex solutions. The Centers for Disease Control and Prevention (CDC) estimates that one in four Americans reported a mental health issue in the previous year, at a cost of more than $300 billion, including the cost of care and productivity loss. Further, over a lifetime, half of all Americans are expected to experience a mental health disorder.[i]

Given the redundancies and fragmentation in our current health system, the call for better integration of mental and behavioral health with primary care will continue to be a key part of health care delivery reform into the foreseeable future. Research demonstrates that integrated models of primary care and mental health improve access to mental health services and treatment,[ii],[iii] increase adherence to treatment and medication,,[iv] ,[v] and result in better health outcomes.[vi] When offered in a primary care setting, researchers of a multi-site and multi-state study found that patients had 50% better access to mental health care services.[vii]  In addition, several states are actively implementing integrated models and are showing impressive improvements in cost and health outcomes such as Colorado’s SHAPE program that projects costs savings of $656 Million and Massachusetts’s MCPAP program that has improved health services to children with mental health problems.  North Carolina’s ICARE program, Utah’s Intermountain Healthcare, and the multi-state IMPACT trial are just a few of many states leading the nation in efforts to study and integrate behavioral and mental health care with primary care (access more state program results here).

According to an expansive report published in 2010 by the Milbank Memorial Fund, Evolving Models of Behavioral Health Integration in Primary Care, there is a strong correlation between mental health and physical health related problems as documented in the research literature over the past 25 years.[viii]  The report outlines an orientation to the field of mental and behavioral health integration with primary care and provides a compelling case for tiered levels of integrated or coordinated care across the continuum - including minimal, partial, and full integration – depending on the practice and community’s needs and capacity.  It also includes an impressive summary of the peer-reviewed evidence for different models of integrated care, as well as the implementation and financial considerations of each, and offers examples of each model from both the public and private sector.  The report ends with recommendations for health care delivery system redesign to support integrated care taking into account the difficult budget and fiscal constraints that will require an incremental approach to integrated care.

That a strengthened primary care model that better integrates mental and behavioral health is acknowledged as a key solution to the US health conundrum makes intuitive sense.  Most individuals are closely connected to the health system via their primary care practice, and their primary care provider is often viewed as an entryway to the complicated world of health and health care for patients, families, and consumers alike, especially those with chronic illness. The research identifies several reasons for integrating mental health into primary care, including:

• The significant burden of mental illness and the fact that mental and physical health burdens are interwoven;
• The gap for mental disorders is significant and integration helps to increase access for mental health services;
• Delivering mental health services in primary care settings can help reduce stigma and discrimination; and
• The majority of individuals with mental health disorders treated in collaborative primary care have good outcomes and result in cost-effective care.[ix]

Policy Recommendations

In order for Congress to support the integration of behavioral and mental health care in primary care settings, we recommend the following strategies to address legislative and administrative barriers that currently prevent or discourage Medicare and Medicaid recipients from obtaining the care they require. In general, the current fee-for-service payment system does not adequately compensate and reimburse services provided in the medical home that promote care coordination, including communication and consultation between clinicians and providers, alternatives to traditional face-to-face visits (e.g., remote monitoring, e-consults, etc.), wellness and prevention services, and innovative technologies that promote continuity and access to care (e.g., electronic health records, patient portals, and mobile technologies). Therefore, it is essential that CMS acknowledge and allow for payment models that encourage, rather than obstruct, integration of primary care and mental health.

Adopt payment reform incentives that support care integration. Alternative payment models such as global payments and shared savings, and reimbursement changes should be adopted that enable and reward clinicians, employers, and states to deliver team-based, whole-person, coordinated care that emphasize mental and behavioral health needs – even if the financial benefit for that effort accrues to other parts of the total system of care. Payment systems should be able to reward integrated primary care clinics for improving quality, patient experience, and cost that is realized elsewhere such as via reduction in unnecessary hospitalizations, re-hospitalizations, emergency care, repeated specialty services and fragmentation of care along a medical-mental health split.

Promote payment reforms that support team based care. An integrated health model also calls for increased collaboration among the primary care team, behavioral and mental health care providers, and support services and networks in the local community. Such team-based care, as seen in patient-centered medical homes, may involve various disciplines, including primary care, behavioral health, allied health professionals, social workers, care coordinators and patient navigators. Payment systems must in some way cover the financial and staffing resources necessary to facilitate teamwork among all these professionals in order to provide more behavioral and mental health services within medical homes and help patients navigate through the medical neighborhood. This includes facilitating communication between providers; exchange of health information; and informing and engaging patients and families in self-management of their behavioral health conditions.  A number of examples of team-based care are described at the SAMHSA-HRSA Center for Integrated Health Solutions – a joint initiative between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) - http://www.integration.samhsa.gov/integrated-care-models.

Forty percent of deaths are caused by behaviors that could be modified by preventive interventions, many in a primary care setting.[x] These include behaviors such as smoking, violence, physical inactivity, poor nutrition, and substance abuse,[xi] which our current health care system addresses unreliably or not at all. [xii]  Inclusion of behavioral and mental health services in primary care is primarily focused on the substantial portion of mental health and substance abuse problems that patients present in primary care. This does not intend to move the essential work of community and other mental health clinics into primary care—rather it puts important behavioral and mental health resources into primary care where so many people first bring their mental health concerns as a regular part of seeing their doctor.

Encourage utilization of health information technology strategies as a means for creating connections between clinicians (e.g., primary care, specialists, hospitals, home health, mental health), and community organizations that encourage healthy living, wellness, and safe environments (e.g., YMCAs, schools, faith-based organizations, employers, and public health agencies).  Through these connections and use of health information technology (health IT), providers can more readily identify patients that are in need of interventions. Health IT offers structure to help primary care practices in and across the medical neighborhood provide better access to care, better communicate, and enhance teamwork.[xiii] In fact, health IT has tremendous potential to identify health trends in local communities, exchange information across provider organizations, coordinate care as patients transition between providers, and to enable secure communications between providers and their patients and families.

PCPCC Support for Policy & Payment Reform

The PCPCC has long supported policies and payment reforms that better integrate and coordinate mental and behavioral health with primary care.  Early in our organization’s evolution, the PCPCC established a Behavioral Health Group, which has had a long-time following of clinicians and other allied health professionals, academics, advocates, as well as representatives from primary care organizations, government and industry.  Led by a team of primary care and behavioral health care experts, this group has identified several strategies and key components for improving the health care and mental health care system through patient-centered, coordinated, team-based primary care and this letter reflects their recommendations.

Founded in 2006, the PCPCC is dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home.  Today, PCPCC’s membership represents more than 1,000 organizations and individuals throughout the U.S., working in partnership to advance public policy that supports care delivery and payment innovations across a broad range of stakeholders and in support of improved health outcomes.

Integrating mental health services into primary care through a patient-centered medical home offers a cost-effective, well researched, and effective means to ensure that Americans have access to needed mental and behavioral health services.  As Congress considers various behavioral and mental health reform proposals to improve the current system, we appreciate the opportunity to underscore the need for increased and enhanced support for the various models of care integration.

Sincerely,

Marci Nielsen, PhD, MPH
Chief Executive Officer, Patient Centered Primary Care Collaborative

[i] Reeves, W., Strine, T., Pratt, L., Thompson, W., Ahluwalia, I., et al. (2011, Sept 2). Mental Illness Surveillance Among Adults in the United States.  Morbidity and Mortality Weekly Report, 60(03), 1-32. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/su6003a1.htm?s_cid=su6003a1_w

[ii] Kilbourne, A. Piggarlia P., Lai, Z., Bauer, M., Charns, M., et al. (2011, Aug). Quality of General Medical Care Among Patients With Serious Mental Illness: Does Co-Location Matter? Psychiatric Services, 62(8), 922-8.  doi: 10.1176/appi.ps.62.8.922 

[iii] Druss, B., von Esenwein S., Compton, M., Rask, K., Zhao, L., et al. (2010, Feb). A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral and Evaluation (PCARE) Study.  American Journal of Psychiatry, 167: 151-159. doi: 10.1176/appi.ajp.2009.09050691

[iv] Mertens, J., Flisher, A., Satre, D., & Weisner, C. (2008, Nov 1). The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients. Drug Alcohol Dependence, 98 (1-2):45-53. doi: 10.1016/j.drugalcdep.2008.04.007.

[v] Roy-Byrne, P., Katon, W., Cowley, D., & Russo, J. (2001, Sep). A Randomized Effectiveness Trial of Collaborative Care For Patients with Panic Disorder in Primary Care. Archives of General Psychiatry, 58(9): 869-76.

[vi] Rost, K., Pyne, J., Dickinson, M., & LoSasso, A. (2005, Jan 1). Cost-Effectiveness of Enhancing Primary Care Depression Management on an Ongoing Basis.  Annals of Family Medicine, 3(1):7-14. Retrieved from http://www.annfammed.org/content/3/1/7

[vii] Bartels, S., Coakley, E., Zubritsky, C., Ware, J., Miles, K., Arean, P., et al. (2004, Aug). Improving Access to Geriatric Mental Health Services: A Randomized Trial Comparing Treatment Engagement with Integrated Versus Enhanced Referral Care for Depression, Anxiety, and At-Risk Alcohol Use. American Journal of Psychiatry,161(8): 1455-62.  Retrieved from http://psychiatryonline.org/data/Journals/AJP/3763/1455.pdf

[viii] Collins, C., Heuson, D., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. Milbank Memorial Fund. Retrieved from http://www.milbank.org/uploads/documents/10430EvolvingCare/EvolvingCare.pdf

[ix] Ivbijaro, G., & Funk, M. (2008, Sept). No mental health without primary care. Mental Health in Family Medicine, 5(3):127-8. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2777569/

[x] Mokdad, A., Marks, J. Stroup, D., & Gerberding, J. (2004, Mar 10). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291(10):1238–1245.

[xi] Berwick, D., Nolan, T., & Whittington, J. (2008, May).  The Triple Aim: Care, Health and Cost.  Health Affairs, 27(3): 759-69. doi: 10.1377/hlthaff.27.3.759

[xii] McGinnis, J., Williams-Russo, P., & Knickman, J. (2002, Mar). The Case for More Active Policy Attention to Health Promotion. Health Affairs, 21(2):78-93. Retrieved from http://www.hdassoc.org/pdf/Active_Policy_Attention.pdf

[xiii] Schoen, C., Osborn, R., Squires, D., Doty, M., Rasmussen, P., et al. (2012, Dec).  A Survey of Primary Care Doctors in 10 Countries Shows Progress in Use of Health Information Technology, Less in Other Areas.  Health Affairs, 31(12): 2805-16. Retrieved from http://www.commonwealthfund.org/Publications/In-the-Literature/2012/Nov/Survey-of-Primary-Care-Doctors.aspx