Dr. Alison Lynch, MD gave a very accessible talk at the Iowa Public Library, “Integrating Physical and Mental Health to Treat the Whole Person,” on 10/8/2014, sponsored by the Community Mental Health Center for Mid-Eastern Iowa. See the link or the tweet below:
Dr. Lynch was trained in our combined Psychiatry-Family Medicine Residency Program and has joint appointments in The University of Iowa Hospitals and Clinics (UIHC) Departments of Psychiatry and Family Medicine. She’s also on staff at the Community Mental Health Center for Mid-Eastern Iowa (CMHC). You may recall she’s involved in a variety of integrated health care initiatives, CoMeBeh among them.
The presentation is excellent for a general audience as well as physicians and other providers who care for the medical and mental health care needs of patients.
The first 20 minutes gives you a good general overview of how important it is to think about the ways in which mental and physical health issues interact in the whole person. About 23 minutes into the talk, Dr. Lynch gives an overview on the general principles of integrated care.
She mentions one example of how medical providers can help patients access mental and substance abuse care, SBIRT, which stands for Screening, Brief Intervention and Referral to Treatment for alcoholism.
About 38 minutes into the video, she talks about unified physical and mental health systems which is difficult to achieve because of the split American payer system. “Split American payer system?” What’s that about?
So this is probably a good time for a brief historical look at the integrated care initiative beginning with the designer of the UIHC Medical-Psychiatry Unit, Dr. Roger Kathol, MD, who is the mover and shaker in the world of integrated care and has had a lot to say about the approach for many years. This 1998 article in Psychiatric Times gives us a perspective on how far we’ve come–which in the opinion of many is probably not that far.
Fast forward to the December 2014 “Moving to an Integrated Medical and Psychiatric Payment Platform” article in Psychiatric News. The authors give an excellent overview of the evolving payer approach:
Independent medical payors (managed care organizations—MCOs) and behavioral health (BH) payors (managed BH organizations—MBHOs), whether carved-in or carved-out, reimburse nonpsychiatrists and psychiatrists for services to the same patient from separate funding pools. To assure that funds from MCOs and MBHOs are used for intended services, that is, medical funds for medical treatment or BH funds for BH treatment, MBHOs require BH service delivery in separate BH clinical locations.
Sixty percent to 80 percent of BH patients, including the majority with serious mental illness and substance use disorders, choose to access services primarily in the medical sector. Most of these patients are untreated or ineffectively treated because BH services are nonexistent or provided by nonpsychiatrist practitioners with assessment and intervention limitations. Lack of treatment for comorbid medical patients is associated with medical and psychiatric symptom persistence, medical treatment resistance, increased medical complication rates, impairment, and substantially higher annual health care expenditures.
The future demands that psychiatrists provide services in the medical setting, where the majority of patients with psychiatric illness are seen. Unfortunately, segregated MBHO reimbursement prevents this, since competing medical and BH business practices are designed to protect resources from cross-disciplinary use. A logical solution in the new world of parity would be for BH benefits to roll into medical benefits such that medical and BH services could be coordinated and supported by a single integrated budget.
The MBHO industry resists an integrated budget since it makes its money by segregating BH payments. A growing number of health care stakeholders, however, understand the negative health and cost impact of segregated reimbursement. For instance, several state Medicaid agencies have combined medical and BH Medicaid budgets. There are also commercial insurer demonstration projects attempting to consolidate payment procedures.
Advocate Health Care (AHC), the largest health system in Illinois, provides an interesting example of a delivery-level system introducing financially sustainable value-added BH care in the medical setting. Based on an assessment of health and cost outcomes of AHC’s own medical/surgical patients with concurrent BH issues, AHC is piloting a hub-and-spoke model in the South Chicago market with a full systemwide launch by late 2015. This model places psychiatrists, psychologists, social workers, therapists, and nurse practitioners on site, either physically or via telehealth, for 24/7 proactive screening, treatment planning, and treatment initiation in systemwide medical emergency departments (EDs), inpatient general hospital settings, and outpatient primary care and specialty medical clinics.
Change moves at a glacial pace–but change occurs nevertheless.
About 40 minutes into the program, Dr. Lynch discusses the new Integrated Health Home project in Iowa supported by Magellan, Iowa’s leading insurance carrier for last two years. The catch? If you don’t have medicaid or are not medicaid eligible, you can’t get into the Integrated Health Home.
Moving on about 48 minutes into the presentation, Dr. Lynch opens it up for questions from the audience. Questions arose about how “super-specialization,” or “hyperspecialization” as some would call it, hurts rural communities. The gist is that lifestyle goals and the current American payer/business model doesn’t support training more integrated health care specialists. The more hyperspecialized you are as a physician, the bigger population you need to serve in order to cover practice costs.
The trend is not toward producing more combined medicine/psychiatry residency training programs partly because of the siloed billing practices. The multidisciplinary team-based model will be the wave of the future, not one doctor for both mental and physical issues.
At times the basic message at a systems level seems to be that unless integrated care systems and interventions get paid for by insurance companies, integrated care won’t happen. Some think moving to a Single Payer System would fix the problem, although some might claim that Canadians would probably argue the point (maybe not).
Access to physicians in general is difficult, especially in rural areas so it would make sense to adjust expectations down when the question arises whether there will ever be “enough” integrated care doctors. Although Radio Iowa reporter and News Director O. Kay Henderson seems to counter the suggestion that the shortage of doctors in Iowa will worsen because of expected retirements (“According to the Iowa Board of Medicine, over 6800 doctors worked in Iowa last year. That’s two percent more than the year before and the number of doctors working in Iowa has been growing faster than the state’s overall population.”), it would still be prudent to remove all disincentives to recruiting and retaining Iowa physicians.
Did you think I wasn’t going to mention that? Welcome 2015!