• Integrated Health Care (MH+PH)

• “Integrated care” means treating both physical health conditions and mental health conditions in a comprehensive, coordinated way, where both the patient’s physical and mental health practitioners work together, and are in active, regular communication, over all the patient’s conditions.

• What will integrated care mean for future health care delivery? 1) physical health services provided in the mental health setting, and mental health services provided in the physical health setting, 2) common and consistent mental and physical health condition reimbursement (to practitioners) from one payment pool, 3) single health record and documentation system, 4) communication among, and co-location of, unified network of mental and physical health specialists, and 5) co-management as the means to deal with complex clinical problems (Cartesian Solutions, 2010).

• Most of the primary care practices in the U.S. today do not provide integrated health care; but many are moving in this direction — called “patient centered medical home.”

• In the past, many believed the way to reduce healthcare costs was to segregate, and tightly restrict access and use of, behavioral health services. But what happened was that by doing so, healthcare service use shifted from the behavioral sector to the medical sector and led to an increase in total health care expenditures. (Rosenheck et al, Health Affairs 18: 193-203, 1999).

• The improved health outcomes of integrated care have been demonstrated in numerous programs and pilots. In medical patients who also suffered from depression, a 31% differential improvement of integrated care over usual care was demonstrated after 12 months (Gilbody S, et al, Arch Intern Med, 166: 2314-2321, 2006).

• Integrated care is associated with greater depression care satisfaction (Unutzer et al, JAMA 288: 2836-2845, 2002).

• Integrated care increases general medical doctors’ satisfaction, and depression treatment skills (Levine et al, GHP 27: 383-391, 2005).

• “Complex health” patients are defined as those with co-existing medical and psychiatric conditions.

• Mental health disorders are more commonly seen in general medical outpatient settings, and this is particularly true in patients who have chronic illnesses such as diabetes mellitus, asthma, congestive heart failure, end state renal disease, etc. This group is particularly at risk for general medical and psychiatric treatment resistance, increased complications of disease, high health care service use, and disability since few get treatment. Only 10% of all patients with mental health disorders are seen in the mental health care sector, the other 90% are seen (not necessarily treated) in the general medical sector, and have little access to mental health specialist services (Kathol, Cartesian Solutions, 2008).

• While there are many more patients with medical illness who also show mental health issues, patients with serious mental illness also have a high prevalence of co-existing physical illness. This is so pronounced that a recent study of Medicaid patients hospitalized in a state mental health system had more than 25 years reduction in life span, compared to age matched controls. (Jones et al, Psychiatric Services 55: 1250-1257, 2004).

• In nearly all health plans, 5% of patients are “complex” and they utilize 50% of health resources, (Zuvekas & Cohen, Health Affairs 26: 249-257, 2007). Over 2/3 of this small group have concurrent physical and mental disorders yet are cared for in a clinical system in which mental health practitioners and medical practitioners rarely converse with each other about their clinical assessment and treatment (Kathol, Cartesian Solutions, 2008).

• Interaction is limited between mental health professionals and medical physicians because they work in segregated segments of the health system, and are paid from competing funding pools. This dis-integrated care leads to poor clinical outcomes, high total health care costs, and reduced productivity. A compelling literature now demonstrates that by integrating mental and physical care, it is possible to reverse these negative outcomes (Kathol, Cartesian Solution, 2008).

• In today’s healthcare market, less than 4% of the health care dollar is used to support clinical mental health treatment – 2% less than 17 years ago. (Kathol et al, JGIM 20: 160-167, 2005).

• While mental health benefit expenditures constitute a small component of the health care budget, health plan members who use mental health care services utilize twice the number of medical and medical-pharmacy services as those without (Ibid).

• Only 10% of patients with mental disorders receive evidence-based mental health care treatment from mental health professionals. (Kathol et al, JGIM 20, 160-167, 2005).

• The other 90%, of patients with mental disorders, go to primary care doctors to be seen. Of that group, 70% currently do not received evidence-based mental health treatment by non-mental halth practitioners. (Ibid).

• 70% of patients with psychiatric conditions are seen in the primary care setting, but few psychiatrists can practice there due to payment issues. (Kathol, ibid).

• Of mental health conditions ineffectively treated, 45% persist over time, and 22% worsen (Kathol, ibid).

• 78% of high emergency room utilizers had a psychiatric condition (Cartesian Solutions, 2007).

• 66% of patients, with total annual health plan claims over $100,000, have had a mental health condition. (Cartesian Solutions, 2007).

• The net annual cost of ineffectively treated, and separately seen, chronic medical conditions and co-existing psychological disorders, is $132 – $351 billion. (Melek & Norris, Milliman Research Report, July 2008).

• $2 trillion is the U.S. health system excess spending projected for patients with mental health disorders during the next 10 years if mental health management is not integrated with physical health management (Cartesian Solutions, 2008).

• Employers rank mental illness as the health issue they believe has the most effect on their indirect health costs — ahead of high blood pressure, heart disease, asthma/allergies, diabetes, cancer, smoking, substance abuse, and back problems. (Employer Benefit News, 21 (6), May 2007).

• Medical costs account for only 25% of employers’ total health costs; the other 75% is attributed to absenteeism and presenteeism (Goetzel et al, JOEM, 46: 398-412, 2004).

• When mental health treatment was separated out from medical care treatment 30 years ago, it created a separate reimbursement structure for practitioners and indepdndent mental health care managed care companies (MBHOs) came into existence. With MBHOs, healing the mind became progressively more and more separated from that of the body (Kathol, Cartesian Solutions, 2008).

• Stigma, for those with mental health problems, was assured and perpetuated, not because of the nature of the mental disorders themselves, but because they were placed in an autonomous reimbursement system. For example, erectile dysfunction and genital herpes are as sensitive health topics as are mental disorders, yet they are now a part of mainstream medicine, included among information available to all the patient’s clinicians. Mental disorders, on the other hand, have remained segregated and stigmatized. (Ibid).