Survey Snapshot: Integrated Care Makes Sense — but Barriers Remain

Over the past 5 years, Parinda Khatri, PhD, Chief Clinical Officer at Cherokee Health Systems, a nonprofit provider of primary care, behavioral health, and addiction services to more than 70,000 poor and uninsured in East Tennessee, has noticed much greater awareness of the need to integrate primary care and mental and behavioral health services. Where once her health system stood out as an anomaly for blending these critical services, it now was being sought after for advice.

“We used to go around the country and explain why integration is important — really having to explain the need. Everyone now knows why; they just want to know how,” Khatri says.

Since its start 3 decades ago, Cherokee Health has provided comprehensive care but has struggled to get payers to catch up to its unique models, sometimes accepting a financial loss in favor of efficiently and effectively treating a patient, Khatri says.

Take, for instance, having a patient be seen for primary care and mental health care on the same day. “Many insurance companies, 15 years ago, would say, ‘We do not pay for two visits on the same day,’” she says. But leaders at Cherokee Health believed that if they treated a diabetic patient with high blood glucose levels and depression out of sync, they would jeopardize the patient’s health. “Sure, we might get the claim denied,” Khatri says, but the price of the patient not returning for a separate appointment was too high. Eventually, the payers relented and Cherokee Health was able to change that same-day rule for its system. She credits “significant advocacy to go against the grain.”

In the NEJM Catalyst Insights Council Care Redesign Survey, “It’s Time to Treat Physical and Mental Health with Equal Intent,” coordinated and co-located care is chosen as the most effective means of integrating mental and behavioral health services with primary, specialty, and acute care (by 57% of respondents). A fully integrated outpatient practice is next (54%). Four-fifths of survey respondents (81%) think primary care should be integrated into psychiatric care for mental/behavioral health.

Marc D. Graff, MD, Physician Reviewer for the Treatment Authorization Unit, Managed Care Division of the Office of the Medical Director for the Los Angeles County Department of Mental Health in California, says he doesn’t understand why payers and providers are reluctant to integrate mental-behavioral health services with primary care. The benefits of doing so far outweigh the costs.

Graff is concerned that value-based care will make it difficult to assess the success of mental and behavioral services. “It’s hard to measure what percentage of what you do actually helps,” he says. But integration could bring about transparency and help eliminate waste, such as understanding a patient’s medical history and avoiding ordering of duplicate lab tests. “There is nothing worse than finding out you’re ordering the same labs as the patient’s primary care physician,” he says.

Using telemedicine, Graff is able to reach out to his geriatric patients who might otherwise go unaided. “While not all my patients are housebound, some can’t get out of bed because of their mental health conditions such as depression,” he says.

Depression ranks second among the most pressing causes of mental and behavioral health issues, according to our survey, with addiction and substance dependence scoring first place. Khatri says health systems have to be agile to address these concerns. For instance, Cherokee Health opened a prenatal addiction clinic after observing a heightened number of pregnant women addicted to opioids, their children being taken to foster care, and then the children coming to the health system with severe developmental delays. “The problem was right in our faces and, in a year and a half, we quintupled our substance abuse treatment services,” she says.

Even at integrated care delivery systems, such as the U.S. Department of Veterans Affairs, getting services fully aligned is challenging due to staffing concerns in the mental and behavioral health fields, says Kevin J. Smith, PhD, Clinical Psychologist for the Veterans Addiction Recovery Center at the Louis Stokes Cleveland VA Medical Center in Ohio. Every clinic at the Cleveland VA, even the smallest ones, offer integrated care with a psychologist or mental health social worker available on-site for a brief assessment. Smith says this encourages a “warm handoff” of patients from primary care providers to mental health staff. However, if patients seek care outside of the health system, because of geographic convenience or lack of benefits (e.g., due to dishonorable discharge), syncing up care can become difficult.

In his opinion, one solution might be to have primary care staff better trained in substance abuse and mental health issues. But he finds that some primary care providers have been unwilling to take the necessary training to learn more in these areas.

Khatri and Graff also have observed significant barriers to integration of services, such as bringing on double-boarded physicians who could address internal medicine and substance abuse and addiction issues. “In most systems, if you have a second board, that’s nice, but it doesn’t get you any more money or anything special,” says Graff, stressing that there is no incentive on the employee side.

At Cherokee Health, a payer denied credentials to a primary care physician who also was board-certified in addiction medicine to provide both behavioral health and primary care services. “Rather than have one clinician provide comprehensive primary care, psychiatric, and addiction medicine care, they were willing to pay for the patient to see three different people,” Khatri says. “That’s the kind of thing that is very challenging when you are trying to be transformative. Insurance companies are not able to change quickly and be as nimble. It’s like turning the Titanic.”