An Integrated Care Model

Roger Kathol

In their article titled “Fostering Sustainable, Integrated Medical and Behavioral Health Services in Medical Settings,” NIAC member, Roger Kathol, MD, CPE and Ron Manderscheid, PhD, propose an alternative approach to integrating behavioral health and primary care services. Unfortunately, “untreated behavioral health conditions in primary care settings are associated with treatment nonresponse, illness persistence, higher medical illness complication rates, disability, increased health care service use, higher health care costs, and premature death”. Moreover, “in 2012, the annual additional cost of medical care for the nearly 41 million Americans with behavioral health conditions was [about] $290 billion.”

The U.S. Department of Health and Human Services; national managed health care organizations; and state, county, and local governments have tried for nearly a decade to encourage the Integration of behavioral health into primary care. Unfortunately, three limiting factors affect them. First, it is perceived that a separate behavioral health care system is needed to care for those who have “difficulties with cognitions, emotions and behaviors.” In addition, it is believed that separate payment systems are required “to maximize value and ensure adequate control of and support for delivery of behavioral health services.” Last, due to stigma surrounding behavioral health conditions and treatments, it is “difficult for representatives of behavioral health and primary and specialty medical care to have the necessary dialogue that would facilitate service integration.”

Due to these limitations, current integrated care delivery models are “proceeding along several distinct and often uneven trajectories.” The “traditional and most commonly used” model for patients with comorbid physical and behavioral health conditions is cross-referral between behavioral health specialists and medical practitioners, both of whom typically work in 2 separate, noncommunicating service locations.” Although this model is simple, it is not very effective as most referred patients never make it to their referral sites. The bidirectional model was introduced to improve upon the cross-referral model. Under this approach, patients presumably “fall into one of two largely non-overlapping groups: patients with primary medical conditions but occasional behavioral health conditions and those with primary behavioral health conditions but occasional medical conditions.” However, patients with mild to severe behavioral health conditions “would be better served if behavioral health care services were available as a standard health benefit in patient-centered health homes.”

Drs. Manderscheid and Kathol offer an alternative model of integration that “should maximize health and function for patients with concurrent medical and behavioral conditions, regardless of service location.” Under their collaborative care approach, behavioral health is “viewed as a part of total health” in the patient-centered health home where “90% of patients with behavioral health conditions [are] seen in primary and specialty medical settings in which behavioral health is a core part of delivered services” and “the remaining 10% [is] seen in an embedded specialty behavioral sector that, like other medical specialty settings, has ready access to collaborative general medical services for its patients when needed.”

Including behavioral health professionals in patient-centered health homes will require considerable planning for best set up and delivery. Behavioral health specialists will need to leverage opportunities to “offer necessary evidence-based specialty services [that] could facilitate better outcomes” for people with untreated behavioral health conditions and comorbidities. From the standpoint of behavioral health specialty settings, every patient would have a lead behavioral health provider and should also have a collaborating primary care physician” that together would “function well as a team in providing preventive, acute, and long-term complex medical care along with BH care.” Additionally, an integrated care coordinator would be responsible for patients’ medical needs, social support (including housing, job support, and social network development), and health system logistics (for example, transportation or poor communication among providers).” They would “have good relations with the patient’s primary care physicians and clinical backup from a psychiatrist” and would thus “help patients overcome clinical and nonclinical barriers to improvement.”

Drs. Manderscheid and Kathol assert that their model of care cannot exist if there are separate payments for behavioral health and medical care. This separation is “the single most common factor that [prevents] integrated program initiation, development, and sustainability.” Thus, they recommend that medical and BH professionals demand that medical and behavioral benefits be combined in all provider contracts and that all health services be paid from a single budget by using common procedure.” If payment reform is not included in clinical reform, 60% of patients with untreated behavioral health conditions “will continue to add nearly $300 billion annually to the total health care budget.” Fortunately, the formation of Accountable Care Organizations (ACOs) offers current opportunities to transition to payment reform. Ultimately, the development of Manderschied and Kathol’s model will require that integrated financing reform be implemented over the next 3-5 years. Also essential to integration will be behavioral health and medical professionals’  “improved understanding of each other’s culture and practices,” as well as “ integrated care sites in primary, specialty medical, and specialty BH settings customized to meet the needs of the populations served.”

Access the related article: http://www.nhmh.org/news_items/nhmh-board-member-dr-roger-kathol-article-in-1-7-14-annals-of-internal-medicine-proposes-way-forward-for-true-behavioral-health-integration

Mon, 02/17/2014