Integrating Physical and Mental Health Care, in Need of Pragmatic Incentives

It is as impossible to move your body without taking your mind along as it is to split physical from mental health. Problems in physical functioning may trigger a range of emotional coping mechanisms which can become pathological. Likewise, problems in mental health affect the rest of the body. Indeed, people with depression have a 1.5 to three times higher risk of dying from cardiac disease [1]. The medical world is aware of this and has tried to integrate physical and mental healthcare for at least a decade [2].Integration efforts have included universal screenings for behavioral health disorders within primary care and the co-location of physical and behavioral healthcare providers.

Two recent developments have further increased the importance of combining mental and physical health. First, the COVID-19 pandemic exacerbated the rates and severity of mental health problems in the U.S. and globally. Prior to the pandemic, 8.5% of U.S. adults experienced elevated depressive symptoms. In 2020 and 2021, that percentage was27.8% and 32.8% respectively [3]. During the pandemic, children and teenagers visited the Emergency Department (ED) with mental health problems with a 25%-30% increased frequency[4]and such COVID-19 related increases in ED visits were also seen in young adults and racial minority groups [5].The second development is the persistent policy shift towards value-based care, reinforcing the notion that the patient’s mental health should be considered in (almost) every visit. After all, the patient who does not adhere to antihypertensive drugs because of undiagnosed anxiety or the patient with obesity because of depression will have received lower quality care at greater cost if mental health problems are not addressed. Furthermore, mental health conditions are an important factor in value-based risk scores, a scoring system that assumes physicians are aware of mental health problems and ask their patients relevant questions accordingly.

Physicians, especially those in primary care who function as the gatekeepers in our healthcare system, should be incentivized to talk with patients about their mental health, screen for mental health conditions, and diagnose and organize treatment for these conditions without fear of not being able to handle those themselves: if screening leads to diagnosis, the primary care physician must have an approach at hand to ensure the patient is treated. Therefore, in 2017CMS launched procedure codes for Collaborative Care (CoCM) as a model to stimulate the delivery of behavioral health within primary care. In the CoCM, the treating provider forms a team with a behavioral health (BH)care manager and a psychiatric consultant. The BH care manager tracks depression symptoms and can offer brief psychotherapy and medication management. The psychiatric consultant is in close contact with the care manager about the patients whom both providers are tracking within a registry, but normally does not see the patient. The BH care manager, in turn, is in frequent communication with the physician. The CoCM has been shown to improve outcomes for depression and anxiety, also in co-occurrence with chronic physical illness, and potentially for substance use disorders[6, 7].Additionally, the CoCM can lower healthcare costs by 5%-10% [8].

Although many health systems use the CoCM for integrating behavioral health in their primary care sites, others have been reluctant or have chosen not to for several reasons. First, implementing and sustaining the CoCM requires substantial financial resources and time, and the administrative burden can be perceived to be prohibitive [9]. Total planning and implementation costs of the CoCM to treat depression in elderly patients at seven sites in California ranged from $39.3K to $60.5K per site, with the highest costs for workflow development. In this California CoCM model, the primary care sites partnered with community-based organizations. Cost calculations included both salaries and non-personnel costs, planning and implementation costs (including costs associated with the community partnership),and costs of care delivery. Once implemented, the cost per patient to sustain the program ranged from $154-$544 per month. [10].Second, the clinical guidance of patients with depression and anxiety within the CoCM are highly dependent on staff for whom credentialing is not required. Medicare does not specify a minimum education, although according to the AIMS website these are typically nurses and social workers [7, 11]. Whereas less-highly-trained clinicians and staff allows each to work at the top of their skillset, it also carries risk of lower-quality care for patients with psychologic and psychiatric pathology who are inherently difficult to manage. The treating (and billing) CoCM provider may still need to weigh in heavily in the patient’s disease management, lowering the physician’s incentive to raise mental issues in the first place. It may exacerbate a two-tiered system of care in which only those who can afford mental health care without going through insurance can see a psychiatrist quickly and frequently. Lastly, the spectrum of mental health issues is wider than anxiety and depression alone and includes many conditions for which CoCM is not validated.

In our opinion, although proven highly valuable, we should be cautious not to see CoCM as the panacea for solving the mental health problems which are ubiquitous in our society. The CoCM model is a response to a systemic failure to provide adequate mental health services, but its administrative burden has not made it easy for primary care providers to meet the identified needs of their patients. Health policies to integrate physical and mental care, aside from psychiatry training of PCPs, should continue to provide more patients access to more licensed and trained providers, to increase reimbursement for mental health providers, and to nudge more providers to accept health insurance [12].The need for collaboration between the PCP and those providers, whether in a CoCM or not, is of course beyond dispute.

References

1. Penninx BWJH, Beekman ATF, Honig A., et al. Depression and cardiac mortality. Arch Gen Psychiatry 2001; 58:221-7.Doi:10.1001/archpsyc.58.3.221
2. The Kaiser Commission on Medicaid and the Uninsured. Integrating physical and behavioral health care. Issue brief, February 2014. https://www.kff.org/wp-content/uploads/2014/02/8553-integrating-physical-and-behavioral-health-care-promising-medicaid-models.pdf, accessed August 1^st 2022
3. Ettman CK, Cohen GH, Abdalla SM, et al. Persistent depressive symptoms during COVID-19: a national, population representative, longitudinal study of U.S. adults. The Lancet Regional Health Americas. 2021L October 4^th. Doi: 10.1016/j.Lana.2021.100091
4. Leeb RT, Bitsko RH, Radhakrishnan L, et al. Mental Health- related Emergency Department visits among children aged < 18 years during the COVID-19 pandemic – US, Jan 1- Oct 17 2020 MMWR, CDC, Nov 13^th, 2020; 69(45):1675-80
5. Anderson KN, Radhakrishnan L, Lane RI, et al. Changes and inequities in adult mental health-related emergency department visits during the COVID-19 pandemic in the U.S. JAMA psychiatry. 2022;79(5):475-485. doi:10.1001/jamapsychiatry.2022.0164
6. Archer J, Brower P, Gilbody S. et al. Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews. 2012.Doi: 10.1002/14651858.CD006525.pub2.
7. https://aims.uw.edu/collaborative-care/, accessed Aug 2^nd, 2022
8. Davenport S, Matthews K, Melek SP, et al. Potential economic impact of integrated medical-behavioral healthcare: Updated projections for 2017. Milliman Research Report. Feb 2018.
9. Carlo AD, Corage Baden A, McCarty RL, Ratzliff ADH. Early Health System Experiences with Collaborative Care (CoCM) Billing Codes: a Qualitative Study of Leadership and Support Staff. J Gen Intern Med 2019;34(10):2150-2158. Doi: 10.1007/s11606-019-05195-0
10. Hoeft TJ, Wilcox H, Hinton L, et al. Costs of implementing and sustaining enhanced collaborative care programs involving community partners. Implementation Science 2019: 14:37. Doi: 1186/s13012-019-0882-6
11. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-FAQs.pdf. Accessed 8/4/2022
12. https://www.nami.org/Support-Education/Publications-Reports/Public-Policy-Reports/The-Doctor-is-Out/DoctorIsOut. Accessed 8/1/2022