Barriers

In the September 24, 2008 issue of the Journal of the American Medical Association (JAMA), Kuehn (2008) raises the highly important need to address mental health services and their funding in the context of primary care. The author drew several main points discussed in  a Substance Abuse and Mental Health Services Administration (SAMHSA)/Health Resources Services Administration (HRSA) document  (Kautz, Mauch, & Smith, 2008) that outlines barriers for financially sustaining integrated primary care. The SAMHSA/HRSA article entitled Reimbursement of Mental Health Services in Primary Care Settings (PDF - 1.64MB) highlights how physicians need access to mental health services in the primary care setting and the various barriers that can support and enhance integration.

The SAMHSA/HRSA report indicates that if primary care behavioral health clinicians were to be placed side by side with their primary care physician counterparts, this would address close to the 40% of individuals who sought treatment for their mental health issues in primary care (Kautz, Mauch, & Smith, 2008). Consider that the service penetration of a typical mental health carve out is 6% or less than usual care (Barry, 2004). This percentage means there are elevated numbers of patients with mental health complaints not seeking specialty mental health agencies and outpatient mental health providers, but seeking treatment elsewhere ergo primary care.

As noted, primary care is often the first stop for patients with mental health issues leading some to label primary care as the de facto mental health service system (Regier et al., 1993). If trained primary care behavioral health clinicians and primary care physicians could treat 40% of patients at the same time, there would be an immediate impact on the overall health of the public. This integrated approach not only meets the need that obviously exists; it also frees increases the availability of primary care physicians for other patients.

The SAMHSA/HRSA document identified seven priority policy and financial barriers associated with having non-physician providers working in primary care. Examples of a few barriers highlighted were the inability for same day billing of separate providers (e.g., physician and psychologist); lack of payment for collaborative care; absence of funding for non-physicians in primary care; and lack of reimbursement for screening and providing preventive mental health services. By addressing these barriers, not only would the integration of primary care behavioral health clinicians into primary care become more of a reality, it would provide a more comprehensive and seamless approach to addressing the health of the American public (Blount, 1998).

As Katon and Unutzer (2006) have noted, evidence to support the collaboration that occurs between a primary care physician and a mental health provider when they operate in the same setting is effective beyond conventional levels of statistical significance. Katon and Unutzer challenged researchers, policymakers, and health care organizations to move past measuring the effectiveness of integrated and collaborative care and put the research into practice. The SAMHSA/HRSA document is an important step in moving our health care system forward. By recognizing how addressing mental health needs in primary care by skillfully trained non-physician clinicians presents barriers, the report describes how overcoming these obstacles will prove to have beneficial results. This approach has recently been echoed by the Robert Graham Center in their call for the inclusion of mental health in the medical home (Petterson et al., 2008).