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Full Integration With Primary Health Care?

Ron Manderscheid, PhD, has been heavily involved in two decades of efforts to get mental health care and primary care integrated into a single service.

In landmark work on the subject in 1998 and 2000, the U.S. Surgeon General reported "a startling majority of adults and children with mental illness" receive no treatment, and that "more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services."

The nation's top public health office devoted the entire 2000 portion of its report to what it identified as one of the major reasons for the mental health system's failure: its lack of integration with the primary health care system.

Sixteen years later, a key member of that original Surgeon General policy research team, Ron Manderscheid, PhD, is still hammering on the need to move beyond a traditional philosophy and business model that has long walled off mental health from the rest of the nation's health care system.

Manderscheid, currently the Executive Director of the National Association of County Behavioral Health and Development Disability Directors, spoke at the University of Pennsylvania about his just-published article in the Annals of Internal
mental health reports
The Surgeon General's Office called for the integration of mental health and primary care services in the 1990s. Now, the Affordable Care Act's 'ACO' and 'medical homes' models provide a potential structure for doing that.
Medicine, "Fostering Sustainable, Integrated Medical and Behavioral Health Services in Medical Settings."

Early death rates
That paper notes the "prevalence of chronic health problems and correspondingly high rates of early death" among persons with behavioral health problems and attributes this to a "lack of access to primary health care services."

In a seminar co-hosted by Penn's Center for Mental Policy and Services Research (CMHPSR) and the Leonard Davis Institute of Health Economics, Manderscheid pointed out that the Affordable Care Act provides new sources of funding and new structures that have the potential to significantly improve the overall mental health system that has been in disarray since the early 1960s. Then, the country's long-time use of large-scale state hospitals to house mentally ill individuals gave way to a new approach that closed those institutions and hoped to somehow integrate mentally ill individuals into various modes of local community care. Ultimately that effort failed and turned hundreds of thousands of mentally ill people out on the streets with no place to go and no care at all.

Steam grates, park benches
Today, large numbers of the mentally ill are incarcerated in jails and prisons, inappropriately consigned to nursing homes or left homeless to sleep on steam grates and park benches. Others with family social support networks do have places to live, but because health insurance policies have rarely covered mental health services, they've been unable to get needed care.

Although the ACA theoretically changes that by requiring policies sold on the exchanges to include mental health coverage, reports from across the country document a shortage of public and private mental health professionals available to actually provide such treatment.

Massive funding cuts
A recent Department of Health and Human Services report to Congress said 55% of the country's 3,100 counties have no practicing psychiatrists, psychologists or social workers. In counties that do have them, it is common for doctors to decline new patients. Meanwhile, the National Alliance of Mental Illness' (NAMI) state-by-state budget reviews show that from 2009 to early 2013, the states collectively cut $4.45 billion in funding from their mental health services programs. The NAMI report concludes "after years of attempting to meet rising demand with diminishing resources, public mental health systems are stretched to the breaking point."

Manderscheid noted, "A huge part of what integrated delivery systems and the Affordable Care Act are about is social justice."

Millions of children
"Fifty-five million or 25% of the adult U.S. population has a diagnosable mental disorder every year," he said. "Thirteen million U.S. adults or 5.8% of the population have mental health problems that seriously impact their life in the community, the family and in their employment. For children, the data's much worse. About 16 million, or 20% of the child population, have a mental disorder every year. About eight million of those qualify as serious emotional disturbances."

"About one third of adults and two thirds of children who have the more serious disorders receive no care at all," Manderscheid continued. "We're dealing with phenomena that are very large and very robust. That fact that these percentages haven't changed over 30 years is very telling."

Manderscheid, also an adjunct professor and researcher at Johns Hopkins' Department of Mental Health, has held a number of high-level positions within the U.S. Department of Health and Human Services over the last three decades, including Senior Policy Advisor on National Health Care Reform.

'Treat and refer' strategy
To date, he said, the closest providers have gotten to implementing the 16-year-old integration suggestions of the Surgeon General's office is a "treat and refer" basis. This is when separate primary care and mental health providers agree to refer some cases to each other. Studies have determined that this informal strategy has not been effective.

Other providers are experimenting with "bidirectional integration" -- placing a behavioral health practice in the same physical quarters as a primary care practice. But both practices operate as separate entities with uncoordinated and incompatible billing and payment systems. These experiments are funded by grants and have not shown themselves sustainable without them.

Manderscheid said neither of these approaches addresses the "huge population" of patients who come to primary care with behavioral health issues that ARE the aggravating condition.

'Full service' integration
What's needed, he said, is "full service" integration in which primary care and behavioral health professionals are part of the same organization, working together as a team with a unified billing and payment system.

Manderscheid pointed out the ACA's little-known section 2703 that allows states to amend their Medicaid plans to create health homes for specifically defined populations. "For example," he said, "In Pennsylvania, I could go and create a health home for adults with serious mental illness in Philadelphia. It wouldn't have to be statewide. It can be focused on a local population."

He said another potentially powerful ACA change is that while Medicare accountable care organizations (ACOs) can only be created and run by hospitals, primary care practices, federally qualified health centers and rural health centers, Medicaid's rules are more open. In Medicaid, behavioral health entities can create ACOs that operate health homes potentially focused on "full service" integration of primary care and mental health services for their patient panels.

'Grand challenge'
"The grand challenge," Manderscheid said, "is how can we foster the development of health homes and ACOs without losing many of our behavioral health providers along the way? The 'mom and pop' operations are going to be gone. I expect a lot of behavioral health entities to disappear during the next five to ten years. But we need to be very careful and attentive to what we want to keep and what we can afford to lose."

Another more fundamental challenge that many don't understand, he said, is simply getting the most needy mental health patients to sign up for the insurance that could avail them to life-changing care.

"The ACA is designed to provide approximately 39 million uninsured people with insurance coverage and about 11 million of those have a behavioral condition that involves mental health and/or substance abuse," he said. "The challenge is how do we enroll those 11 million? Many of the people who are eligible and need this insurance don't have a clue about insurance or enrollment procedures or how to operate something like We need to help them. Otherwise, they are a population that will be left behind. And the proof of that is in Massachusetts where, eight years after their program started, there's still about 3.5 to 4.5% of the adult population not enrolled -- and the bulk of that group are people with behavioral conditions."

Manderscheid said he routinely dogs county behavioral health directors across the country to get involved in the process of getting people insured. "I'm very serious about this," he said. "I want every director to be out there enrolling people."

"Everyone," Manderscheid continued, "has a tendency to think that the Affordable Care Act takes care of the medically needy and washes that issue off the table. But that's not true, particularly in the case of mental health."

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Hoag Levins is a journalist and managing editor of digital publications at the Leonard Davis Institute of Health Economics.

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