Analysis of the NEJM Catalyst Insights Council Survey on Care Redesign: Integrating Mental and Behavioral Health into Care Delivery. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
By Amy Compton-Phillips and Namita Seth Mohta
In the United States, we have historically separated diagnosis and treatment of mental illness from physical illness. What we are learning, at a high cost, is that having two separate and unequal systems of care results in suboptimal treatment of patients.
Our most recent NEJM Catalyst Insights Council survey, on mental and behavioral health integration into care delivery, reveals a stark corollary: 51% of Council members — a qualified group of U.S. executives, clinical leaders, and clinicians who are directly involved in health care delivery — consider their organizations’ mental and behavioral health services not very adequate or not at all adequate to meet the needs of their patient population.
By neglecting mental and behavioral health, our society has made it virtually impossible to succeed in holistic health, and thus to improve health outcomes.
(This survey defines mental and behavioral health broadly, encompassing clinical diagnoses such as anxiety and depression as well as behavioral issues. The survey also incorporates adverse social circumstances as a contributor to poor health.)
Consider the prescribing of psychiatric medication, which ranks second (behind basic screening) among the most prevalent mental/behavioral services provided at respondent organizations. Prescribing medications alone is rarely the right thing to do, even if it is the most expedient; medication usually works best when prescribed along with other forms of treatment, such as cognitive behavior therapy. Yet medication is what clinicians jump to when other services aren’t readily available.
Many survey respondents call out availability and access as the biggest changes they think would improve mental and behavioral health services across the United States. They want availability of a wider range of clinicians (beyond physicians) who can treat mental and behavioral health, and better availability of those services within the realm of primary care. They want access for patients without financial means to pay for services, and access to ongoing care without limits on length of time.
Insights Council members say the most pressing barriers to delivering mental and behavioral services are absent or inadequate insurance coverage (chosen by 34% of respondents), fragmentation of care (33%), and lack of access to specialty care (32%). Most respondents (79%) point to Medicaid or Medicare as the primary means of payment for their organizations’ mental and behavioral health services. Commercial insurers rank second as primary means of payment (52%).
If we try to fix these broken delivery systems merely by layering services on top of primary care in a cookie-cutter manner, we are doomed to fail. Instead, each health care system must conduct a community health needs assessment and create an integrated system that takes into account the characteristics of their specific patient population.
Take the example of Southcentral Foundation (SCF), an Alaska Native nonprofit health system, which just won its second Malcolm Baldrige National Quality Award for its “unique health care delivery system, the Nuka System of Care, [which] brings together organizational strategies and processes; medical, behavioral, dental, and traditional practices; and an infrastructure that supports wellness,” as described in the award summary from the National Institute for Standards and Technology. SCF provides a wide range of programs to address the physical, mental, emotional, and spiritual wellness for about 65,000 Alaska Native and American Indian people. SCF’s needs assessment revealed a population dealing with high rates of child abuse and neglect, intimate partner violence, and social isolation. SCF redesigned its care delivery around these needs, integrating specialty services into primary care and reducing the number of standalone specialty services. This reimagination of resources enables SCF to deliver high-quality care at a low cost and to make huge inroads with the health wellness of the population.
Effective care redesign must take into account different delivery needs. In rural Minnesota, for example, you likely would need a strategy of distributed services via telehealth to reach a remote patient population, whereas more densely populated urban areas would likely demand a higher concentration of face-to-face care.
Perhaps the most critical contribution to better integration of mental/behavioral services with traditional care delivery is breaking down cultural silos within provider organizations. Clinicians should be able to easily access and share information about patients, enabling different specialties to work together to create comprehensive treatment plans. Doing so would also more easily allow the integration of primary care services into psychiatric services, which 81% of survey respondents enthusiastically support.
The time has come for integration of mental and behavioral health with physical health. Our Insights Council makes clear that the current system is not working. We must lead the charge for change.
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
What single change would most improve mental and behavioral health services across the United States?
“Less stigma and therefore better insurance coverage for care.”
“Improved insurance, Medicaid, and Medicare coverage of psychological services.”
“An integrated system of community counseling, outpatient psychiatric care, and inpatient psychiatric units.”
“Acceptance that opioid dependence is a disease process and that access to care should not be a barrier for treatment.”
Download the full report for additional verbatim comments from Insights Council members.
Charts and Commentary
by NEJM Catalyst
We surveyed members of the NEJM Catalyst Insights Council, comprising health care executives, clinical leaders, and clinicians, about integrating mental and behavioral health into care delivery. The survey covers which mental and behavioral services Insights Council members’ organizations provide; the most pressing causes of mental and behavioral health issues; the biggest barriers to delivering mental and behavioral health services; the primary means of payment; the most effective means of integrating mental and behavioral health services with primary, specialty, and acute care; and the extent to which primary care should be integrated with psychiatric care. A total of 565 completed surveys are included in the analysis.
Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.
NEJM Catalyst wishes to thank Trina E. Chang, MD, MPH, Assistant Medical Director for Behavioral Health Integration at Partners HealthCare Center for Population Health and Director of Community-Based Studies, Depression Clinical and Research Program at Massachusetts General Hospital, for assistance in constructing this survey. Check NEJM Catalyst for monthly Insights Reports not only on Care Redesign, but also on Patient Engagement, the New Marketplace, and Leadership.
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.