When someone with diabetes also has depression, they will likely have more trouble keeping their diabetes under control than a diabetic who is not depressed. Physical and mental health, in other words, are inexorably linked. Yet in general, American health care is divided in two: medical care on one side, mental health care on the other. And, although experts have for decades made the case for joining the two together at the primary care office, where most people seek help when they face mental health issues, progress has been slow.
A key obstacle, said Benjamin F. Miller, PsyD, chief strategy officer for Well Being Trust, is the way we pay for health care.
“Health care is paid for out of two pots of money, physical and mental,” he said. “Integrating mental health into primary care is about a team of clinicians working in concert with a patient to give them what they need in a timely manner. But our payment system pays for individual clinicians and not a team, and it doesn’t support primary care physicians and mental health specialists working together.”
Already, up to 60 percent of mental health treatment happens in primary care. Looked at the other way, 1 in 5 visits to primary care is related to mental health, a number that likely should be higher since many mental health conditions go untreated. Yet, when mental health care comes in the form of a referral, many patients fail to get the additional help they need. Those who do get care, often don’t get the best evidence-based treatment.
Miller believes more health care institutions would launch efforts to combine behavioral health and primary care if they could easily show those who pay for care — insurers, Medicaid, Medicare —how much they could save on other aspects of health. So, he asked Denver-based actuary Steve Melek, of the global actuarial firm Milliman, to design a tool that can project exactly that.
“We want health care systems to be able to tailor solutions to their unique setting and population: how old their patients are, their payer mix, their staff,” Miller said.
Melek built the tool using commercially-insured, Medicare and Medicaid claim and membership data and patient outcomes in effective integrated programs. By averaging the impact effective integrated care programs have on healthcare costs, the tool projects healthcare cost savings over a five-year period. In the projections, users can simulate how an effective integrated care program’s positive results might grow over time. The tool reveals savings in pharmacy costs, emergency room visits, and inpatient and outpatient visits for both physical and mental health care.
“Some healthcare costs will go up,” Melek said. “If you integrate, you’re going to spend more time on some elements of healthcare in primary care settings. But then you get patients healthier, so you spend less in high-cost facilities and emergency rooms.”
Melek’s tool illustrates how the complex interaction between mental and physical health conditions drives cost across the health care continuum, said Philip K. Capp, MD, Medical Director of Providence Health Plans, in Seattle.
“Accurately describing the cost impact of new delivery models is difficult due to how the money works,” Capp said. “The Milliman tool shows where savings might accrue if mental health care was embedded at multiple levels in the system. The most important setting is the medical home.”
Eventually, health care systems could use the tool to change the conversation around health care payment, he said.
“Carriers and clinicians understand that untreated mental illness and substance use lead to avoidable expense,” he said. “Sustainable care models addressing the whole person are predicated on reimbursement that incentivizes the same. This tool can start a reasoned fiscal conversation tuned to regional need to drive innovative care. The money is the money. It is what we prioritize that matters.”
Ultimately, the goal for health systems is to meet patients’ behavioral health needs wherever they go for care, said Robin Henderson, PsyD, Providence St. Joseph Health’s clinical liaison to the Well Being Trust.
“We have years of research showing integration helps patients do better,” she said. “But progress has not been swift enough. Now we’re making the business case to bring better care to patients sooner, rather than later.”