A major change in the financial incentives for care of Psychophysiologic Disorders (PPD) has just occurred in the United States (1). The case for integrating both medical and mental health care into primary care has always been compelling. Now, in 2017, the U.S. Medicare/Medicaid system has decided it will pay for a form of care that is strongly aligned with this concept (more on that below).
To understand why these changes are occurring, let us look at factors that contribute to premature death. The most important is a person’s behavior (accounting for 40% of premature deaths). The other broad categories, in descending order of importance, are Genetics, Social Determinants of Health (Housing, Workplace Safety & Health, access to nutritious food, several others), Professional Health Care and the Environment (particularly toxins).
The Behavioral category includes Depression, Anxiety, Post-Traumatic Stress, Adverse Childhood Experience (ACEs), Psychosocial Stress, Severe Mental Illness (SMI), Substance Abuse (Drugs, Alcohol, Nicotine), Diet, Exercise and Medication Adherence. Of these, the first five often are not recognized by the health care system because they present themselves in the form of pain or another physical symptom, i.e. a Psychophysiologic Disorder (PPD). Medical clinicians are trained to look for organ disease or structural abnormalities to explain these symptoms and, too often, fail to look for behavioral conditions.
This has been the case for thousands of years of medical history. What has changed as of January, 2017, at least in the U.S., is that the Center for Medicare and Medicaid Services (CMS) is now paying for a form of Integrated Care called the Collaborative Care Model (CCM) (1). In this model:
- A Behavioral Health Manager is part of the primary care team
- The BHM evaluates the patient and
- Collaborates with the MD to devise treatment
- Monitors patients closely via a registry
- Regularly reviews the patient’s status with a Mental Health Specialist
There are over 90 studies comprising 25000 subjects showing that this model results in:
- Improved mood disorder symptoms
- Better quality of life
- Lower health care cost
Other recent reforms known as Value Based Payment also provide an incentive to move away from traditional fee-for-service—which pays for volume, not outcomes—and toward pay-for-performance which rewards keeping people healthy. Because of these changes, when a patient presents with Medically Unexplained Symptoms or a Chronic Functional Syndrome, now there will be a financial reason to look for one or more of those five behavioral factors and uncover the cause of the patient’s illness.
Here is a list of some of the research findings that support Integrated Care because of significant overlap between Behavioral Health Conditions (BHC) and Medical Conditions (MC):
- Patients with BHCs cost two to three times as much to care for as those without them.
- In adults with 3+ chronic conditions, 56% have a BHC.
- In order of importance, the risk factors for cardiovascular death are: High Blood Pressure, Smoking, Depression, High Cholesterol, Obesity and Diabetes.
- People with mental illness are over 3x more likely to report substance abuse, 1.5x more likely to have a chronic medical condition, and 1.2x more likely to live in poverty.
- In the U.S. 15% of adults are treated for a BHC. More than 50% of them had 4 or more MCs.
- 70% of MD Office Visits have a BHC component.
- 1/3 of adults with a MC also have a BHC.
- 2/3 patients with a BHC do not get treatment.
- 9/10 patients with Depression do not get treatment at their Primary Care office.
Another rationale for Integrated Care is, as psychiatrist Roger Kathol MD put it: “Once you’ve effectively treated the mental health condition, then patients are better able to adhere to the treatments for their medical conditions.”
The Collaborative Care Model is ideal for diagnosing and treating PPD. Unfortunately, at the moment, most Behavioral Health Managers (BHMs) are not yet familiar with the idea that their training and experience in Behavioral Health Conditions is well suited to relieving PPD. Helping BHMs (and their physician partners) to recognize the potential benefits of applying their skills to PPD remains a significant task. But, as of 2017, the financial incentives have flipped from opposing this change to supporting it.
- Medicare Payment for Behavioral Health Integration. Matthew J. Press, M.D., Ryan Howe, Ph.D., Michael Schoenbaum, Ph.D., Sean Cavanaugh, M.P.H., Ann Marshall, M.S.P.H., Lindsey Baldwin, M.S., and Patrick H. Conway, M.D. N Engl J Med 2017; 376:405-407. February 2, 2017. DOI: 10.1056/NEJMp1614134