Integrating Primary Care and Behavioral Health: The Next Frontier
Treatment for mental disorders and substance abuse, the so-called behavioral health field, has been historically separate from primary care. The development of behavioral health linkages to and integrated programs with primary healthcare appears to be the next frontier in the ever-changing world of behavioral healthcare.
The reasons given for the need to integrate care are: 70 to 80 percent of psychotropic medications are prescribed, and sometimes inappropriately prescribed, in the primary care setting; more than 50 percent of behavioral health services are provided in the primary care setting; 60 percent of medical visits have no confirmable medical or biological diagnosis; and patients with co-occurring medical, psychiatric and addictive disorders generate a disproportionate cost to health care systems.1
While integrating services under managed care can present problems, the lack of integrated behavioral health programs has resulted in inappropriate use of emergency rooms, increased medical costs and poor consumer service. Most people with severe and persistent psychiatric conditions or long standing substance abuse problems also have attendant medical conditions. These are frequently serious enough to require regular coordination with the primary care physician (PCP).
Medications may be in use which are dependency producing or may produce toxic reactions in the presence of certain psychotropics. Particular psychotropics require regular or extensive laboratory tests or medical screening to monitor potential detrimental effects on physical health. Aging consumers may be taking multiple medications which, in combination, produce symptoms mimicking psycho-logical impairment. Close coordination for all of these people is imperative.
One way of eliminating many coordination problems is for the payer to agree to a set of rules which delineate responsibility for authorization and payment in common situations which predictably will require use of both behavioral health and physical health resources.2
Several major organizations such as Digital Equipment Corp., General Motors and Delta Airlines have begun pilot projects to test the practicality of integrated programs for their employees. Digital and General Motors have developed standards for integrating primary care and behavioral health. Delta Airlines has begun working with MCC Behavioral Care Inc., a subsidiary of Cigna Corp., on a pilot study of a disease management program for depression. This program will look at total costs of treating this disease and loss of productivity to determine the extent to which those costs can be reduced through an integrated behavioral health and primary care program.
The National Committee for Quality Assurance (NCQA) is preparing to apply its accreditation standards for managed behavioral health care organizations to full-service managed care organizations. NCQA accreditation evaluates how well a health plan manages all parts of its delivery system — physicians, hospitals, other providers, and administrative services — in order to continuously improve health care for its members. The purpose is to bring about coordination between behavioral health and medical care.
Under the accreditation standards that went into effect in 1997, managed behavioral healthcare organizations must have mechanisms in place to collaborate with primary and specialty health care providers on diagnosis and treatment issues and on the use of psychotropic drugs. Full-service managed care organizations, on the other hand, have to include behavioral health in their quality-improvement studies but will not have to adhere to the same standards until 1999.
Oregon’s Primary Care/Behavioral Health Integration
Oregon’s statewide Medicaid plan uses county-run mental health carve-outs, while allowing fully capitated health plans to offer carve-in programs in counties that can support them without creating conflict in treatment protocols. The statewide implementation emphasizes county-run carve-outs while embracing the philosophy of integration.
In designing the process, state mental health officials were concerned that the program build on the strengths of the existing primary care delivery systems through county specific planning processes and county criteria that organizations had to meet in order to be selected. The process involved an analysis of each county’s needs and whether it could support both a carve-out program just for behavioral health and a program managed by the best rated health plan for that county.
Oregon’s mental health division’s long-term goal is to move toward full-service managed care organizations that can work within an integrated health care delivery system while preserving years of investment in community mental health systems.3
Pitfalls In Integration
Integration has been largely viewed within the behavioral health fields with skepticism because of its potential to drain dollars from behavioral health. According to participants of the third national Primary Care/Behavioral Healthcare Summit, which convened in November, 1997, the momentum is beginning to shift away from separate behavioral health carve-out programs to integrated services dominated by the managed behavioral health care companies.
There are many obstacles to integration: cultural differences between primary care and behavioral health, how reimbursement is going to work and how to get employers to support integrated programs as part of their health plans.
As in all forms of mergers and consolidations in healthcare, the integration of primary care and behavioral health services has the potential to further erode the quality of care and staffing components of behavioral healthcare organizations and managed care organizations. Under managed care arrangements, cost is a primary consideration to health care organizations. Multi-skilling (the act of increasing the number of employee responsibilities while decreasing the number of staff) and deskilling (assigning professional level responsibilities to lower level staff, e.g., LPNs doing the work formerly assigned to RNs) together with outsourcing support services will continue to be a major tool of for-profit organizations to control costs, regardless of implications to the care provided.
The next frontier may see a greater erosion of employment opportunities and quality healthcare services, as major healthcare organizations seek new ways to cut costs for treatment, while trying to increase profit margins through integration of services.
AFSCME Public Policy Department
August 1998
Notes
1. Mental Health Weekly, 11/17/97
2. PsychLink, On Managing Care: Coordination with Primary Care; 1997
3. Mental Health Weekly; 8/11/97.
