Primary care settings have been identified as a gateway for many patients with mental health/substance use (behavioral health, or BH) disorders and primary care needs. This point of access is well known to CAP member physicians, their staff, and their organizations, who meet patients and their families at intersections of need and frustration. According to the Centers for Disease Control and Prevention (CDC), the numbers of people seeking BH services each year are in the millions, whether they come to a physician’s office, a community health clinic, or a hospital’s emergency department.
To gain a perspective on the need for care, the challenges to accessing and receiving care, and possible ways forward, we spoke with Dr. Roger G. Kathol, president of Cartesian Solutions, Inc.™ in Burnsville, Minnesota. He is board certified in internal medicine and psychiatry and has developed integrated programs for patients with concurrent general medical and BH disorders for hospital systems, health plans, and government agencies for more than 30 years. In the coming months, Dr. Kathol will lead the development of national standards for accrediting primary care BH entities by URAC in Washington, D.C.
CAP: Dr. Kathol, thanks so much for taking time to speak with us. To get us started, give us a context for understanding the need for integrating primary care and BH.
RGK: Well, the challenge to patients is simple and profound: they want treatment but may not be able to get it. The vast majority of BH patients never get to the BH clinical area. These folks understandably fear the stigmatization associated with being in that setting. But BH payers, common in most U.S. states, wish to pay only for BH services in BH areas.
CAP: As great as the need is, accessing care and getting reimbursed for providing care are challenges that are inextricably linked. You’ve been at this a while. How did we get here?
RGK: The separate payment system, for medical health as opposed to BH, originated as managed care and was created in the 1980s. This separation persists since BH payers resist efforts to integrate into medical care. So, 70 percent of BH patients are seen primarily or only in the medical sector. Of this group, only 10 percent receive evidence-based BH treatment. They – which include probably 50 percent of patients with serious and persistent mental illness – end up costing buckets of money.
CAP: Our members are dedicated to giving appropriate care but have understandable concerns about incurring liability if they appear to be practicing outside their scope. What is your take on navigating that concern in a primary care setting when there is an expectation of providing BH services?
RGK: BH care is not outside primary care physicians’ scope of practice. However, it is often outside their scope of comfort. There are simply too few psychiatrists and other BH professionals to meet the needs of patients with BH problems or to provide assistance to primary care doctors. Most psychiatrists practice in BH settings where they get paid and focus on treating BH issues. This is similar to the role that physicians in medicine take. They treat conditions with which they are familiar, i.e., medical, in the medical setting and quite often avoid taking responsibility for assessing and managing BH issues, largely by asking few BH questions.
CAP: Is there a practical, realistic way forward?
RGK: There are many examples of successfully integrated programs. For instance, one Midwestern metropolitan network of over 10 general medical hospitals introduced psychiatric assessment and treatment into their “medical” emergency departments. The result was a 25 percent decrease in the total cost of emergency department care and admissions compared to when they used stand-alone BH emergency departments. But the most promising approach has come from the Centers for Medicare and Medicaid Services’ (CMS) recognition of value through collaborative care – the integration of BH into primary care settings. There are over 80 randomized controlled trials that prove depressed patient outcomes improve and costs go down for years when this model of integrated medical and BH care is tried.
CAP: That sounds like a no-brainer.
RGK: To those of us who have been working in the field, it does since the model reflects a specific, researched model of BH integration. In the model, a psychiatrist is introduced into the outpatient medical care setting, reviews cases regularly – every fourteen days or so – and recommends the treatment to be given by the primary care physician. After this, patients are followed and assessed by the BH team and primary care doctor, and either treatments are adjusted or patients are discharged from collaborative care (when improved). In this setting, the psychiatrist and primary care physician are professional colleagues, working together. CMS approved payment about two years ago. In 2018, specific CPT codes will be used to report BH integration services. Interestingly, medical, not BH benefits pay for BH services through the primary care clinic – a major advance for patients who would otherwise receive no treatment.
CAP: Telehealth has been identified as a care delivery system that can be effective and make mental health services accessible. Can you comment on that?
RGK: There are a number of very good studies now showing that telehealth is as effective as face-to-face encounters. The patient gets the services he or she needs, delivered by a BH professional. As an example, cognitive behavioral therapy delivered via telehealth using standard guidelines is as good as going to
the therapist. This approach directly tackles the
maldistribution of BH professionals.
CAP: That sounds like another step forward and an advantage for patients. And it’s a positive note on which to end our conversation. Many thanks for sharing your experience and vision with us. I hope we can talk again about further progress in primary care behavioral health integration.
Carole Lambert is CAP’s Vice President, Practice Optimization, and Residents Program Director. Questions or comments related to this article should be directed to clambert@CAPphysicians.com.