Integrated care opens new doors to mental health, addiction care

In every American community — wealthy or poor, rural or urban, young or old — at least 1 in 5 people live with mental health disorders. And yet no American community has an adequate supply of mental health clinicians who can provide timely, affordable, high-quality care for the people who need it.

Untreated mental illness has a profound toll: poor health outcomes, missed work, high costs of care, and premature death. Only half of individuals referred for treatment are actually seen by a mental health care provider and, when they are, the average number of visits is just two. Only half of psychiatrists accept insurance, and less than half of U.S. counties have any psychiatrists at all.

Why is there such a mismatch between supply and demand for mental health care?

The main reason is that the U.S. health care system has for years driven a wedge between care for the mind and care for the body. With separate insurance, different methods and amounts of payment, and silos between clinicians, mental health care has been isolated from the rest of the health care system, making it hard for people to access.

But that divide is beginning to erode, thanks to a movement called integrated mental health care. Integrated care places mental health clinicians side by side with physical health clinicians in other specialties, like primary care and oncology. With mental health expertise and services integrated into these practices, patients can be quickly connected to well-coordinated whole-person care. Even for individuals without other health issues, accessing mental health care through their primary care provider is more convenient and less stigmatized.

We launched an integrated care program at Penn Medicine in January 2018. It is based on a model called Collaborative Care, originally pioneered at the University of Washington in the late 1990s. It embeds clinical social workers in primary care practices to proactively monitor and treat patients with mental health issues. We anticipated the program would see 500 patients in its first year. Instead, more than 13,000 have been referred into the program in the first two years, roughly 10% of whom reported having thoughts of suicide.

Here’s how the program works: When patients come to one of our primary care offices, they are screened for depression with two simple questions. If the screen is positive, or if a patient or primary care doctor identify other mental health concerns, a more detailed assessment is offered.

For common problems like depression, anxiety, and some substance abuse issues, patients are enrolled with social workers in our practice who do frequent check-ins over a three- to four-month period. Psychiatrists provide behind-the-scenes support and guidance to social workers and primary care doctors as they work directly with their patients. This team-based, protocol-driven approach allows us to spread psychiatrists — a scarce resource — over a much bigger population than they could see on their own.

Patients who do well “graduate” from the program and continue with regular primary care follow-up. For those who continue to struggle, the integrated team tries other strategies or connects them with mental health clinicians with additional expertise.

For more complex problems, like bipolar disorder or post-traumatic stress disorder, we help patients find mental health clinicians outside of our practice and follow up later to ensure they have been seen.

The Collaborative Care model has been proven effective in dozens of studies in various settings. Not only do measures of mental health improve, but medical conditions like diabetes also improve and use of the hospital and emergency room goes down. Integrated care also saves money. For every $1 spent on collaborative care, a seminal study found a $6 savings in overall medical costs.

Integrated care is gaining traction nationally. In 2017, Medicare created new payments to support integrated care. In August 2019, Illinois became the first state requiring all insurance companies to cover these payments. Democratic presidential candidate Pete Buttigieg’s mental health policy plan includes several integrated care initiatives. In September, Walmart opened its first store-based primary care clinic offering mental health services.

Still, more can be done to help spread integrated care. First, insurance companies and employers who provide insurance to their employees should end the practice of separating mental health insurance from medical insurance. Second, Medicare and insurance companies should cover payments for integrated care without any copays or deductibles for patients. Third, training programs for physicians, nurses, social workers, and others must begin teaching the skills these clinicians will need to deliver integrated care. Fourth, physicians, hospitals, and health systems should embrace integrated care as enthusiastically as they would a new wonder drug or innovative surgical procedure and immediately implement integrated care in their practices.

Mental health is a complex issue, and integrated care is no panacea. But it’s a practical, patient-centered solution with proven benefits, which is not easy to come by in American health care. By opening the doors of medical care to include mental health, we will help meet one of our communities’ most urgent needs.

Matthew Press, M.D., is interim chair of family medicine, associate medical director of the primary care service line, and associate professor of medicine in the Perelman School of Medicine at the University of Pennsylvania. He was previously employed by the Centers for Medicare and Medicaid Services and worked on payment for integrated mental health. Cecilia Livesey, M.D., is the chief of integrated mental health, associate residency training director, and clinical assistant professor in the department of psychiatry in the Perelman School of Medicine. The opinions expressed here are the authors’ and do not necessarily represent those of the University of Pennsylvania Health System or the Perelman School of Medicine.