January 4, 2023 ‐ PSQH
By Matt Phillion
Behavioral health conditions have a documented impact on patients’ overall health: Annual spending for patients with behavioral health conditions such as anxiety, depression, or a substance use disorder is 3.5 times higher than those without. A recent study found that patients with behavioral health conditions face annual healthcare costs of $12,272 versus $3,552 for patients without. But it’s not just a matter of cost; over half of adults in the U.S. with mental illnesses, or roughly 27 million people, do not receive treatment for their condition.
With this in mind, physician organizations are increasingly calling for behavioral health integration in primary care to close the mental healthcare gap. So what opportunities are there to help deliver innovative, whole-person care?
“We’ve been talking about the value of this for decades,” says Nameeta Dookeran, MD, MSc, national medical director of behavioral health solutions at Emcara Health. “And the needle has moved significantly compared to what it was, but it needs to move a whole lot more. In general, there’s been growing literature showing the positive impact of integrating behavioral health into whole-person healthcare in terms of quality of care, patient outcomes, and system efficiency.”
Getting in the way of accelerating change in this arena, Dookeran says, is the industry’s continued tendency to silo behavioral health as a separate service line.
“We would not withhold insulin from someone with the physical health issue of diabetes because we cannot see the pancreas inside the body struggling to make insulin on its own. We also would not say, ‘I am not going to give insulin until I can see the return on the investment in helping the struggling pancreas out.’ And yet behavioral health is, on the business side of healthcare, often still looked at as an add-on as opposed to being something integral to be addressed, right alongside physical health, from the beginning. We’re having to make the case for something that we should not have to make the case for.”
Thinking of behavioral health as an integrated concept requires a paradigm shift with greater collaboration among healthcare teams focused on the biological, psychological, and social aspects of health, Dookeran says.
“If we prescribe medication for hypertension and the patient is dealing with untreated depression, they may have challenges achieving their physical health goals. Their hypertension medications, for example, may not work as intended if their depression is impacting their ability to manage life effectively, including their ability to manage the taking of their medications,” she says.
“In the last 10 years, there’s been a greater emphasis on what excellence in primary care looks like,” says Rhondee Baldi, MD, MSc, medical director at Emcara Health. “Patients often present behavioral health symptoms within primary care. And we’re moving primary care toward a more proactive, population-based approach, attempting to identify and get people the care and treatment they need before they’re severely ill.”
There is significant pressure on primary care to save money and gain efficiencies. “That aligns with integrating behavioral health,” says Baldi. “If we don’t integrate, total costs go up. As we move into value-based care payment arrangements, primary care and behavioral health providers can adjust workflows and the models of care we’re operating within, and be more flexible in how we deliver care and are reimbursed for it.”
“This is about much more than ‘integrating behavioral health.’ That terminology itself could be viewed as siloing,” says Dookeran. “Building a more robust, whole-person health focus within primary care in general is where the focus should be. This includes building healthcare systems and processes that facilitate more effective integration of the biological, psychological, and social aspects that contribute to whole-person health.”
What do these tools and integrations look like? “There needs to be more systematic and consistent use of validated behavioral health screening and assessment tools in primary care, for starters. And then there’s knowing what to do when those tools do pick up possible behavioral health needs; for example, creating collaborative systems so that primary care teams can engage in more patient-centered, tailored treatment planning to meet patients’ bio-psycho-social needs,” Dookeran explains.
“It’s not just about pressing a ‘behavioral health consult’ button in an electronic health record system,” she says. “When behavioral health needs are identified, there are a variety of factors to consider in tailoring behavioral health support to effectively meet individual patients’ needs.”
In an era when healthcare in general is witnessing shortages of and long wait times for both primary care providers and mental health professionals, the concept of whole-person, integrated healthcare provides an opportunity to increase access for patients.
“Emcara Health’s vision of integrated care does increase access,” Baldi says. “By identifying and treating people earlier within primary care, before they are severely ill, and getting them to an appropriate next level of care when they need it, we’re able to increase patient access even in the midst of a workforce shortage. But this takes capacity building.”
“The pandemic has made it apparent to us that we’ve got to think broadly about where we reach patients and where patients express a need for care,” says Baldi. “In typical models, the primary care physician will refer patients to a therapist or specialist, someone who can assist you, but patients get lost in the referral process. It’s one more thing they’ve got to coordinate.”
There’s also the stigma of mental health that must be overcome, Dookeran notes.
“While we need to identify behavioral health needs through more systematic screenings, we also need more thoughtful pathways for triaging patient needs so we’re better able to identify whether the patient would benefit from access not only to individual specialists, but to community resources, peer support groups, digital support tools, telehealth services, or even a higher level of care, such as an intensive outpatient program,” she says.
When the primary care physician just clicks through to a behavioral health referral, there’s a delay in getting patients to the appropriate care, and some patients might never even make it to that next step. The integration of behavioral and physical healthcare within primary care helps reduce such barriers to access.
Behavioral health issues can often disproportionately impact specific populations depending on social, economic, or even geographic issues. An integrated outlook can help alleviate this.
“Navigating the U.S. healthcare system requires a high degree of cognition and flexibility of time,” says Baldi. “Providing navigation to the right level of care is also what we’ve found to be beneficial for the most vulnerable of patients in order to access behavioral care: low education, lack of English as a first language, older people, those with low vision or impaired hearing, children, or patients who already have a behavioral health diagnosis.”
Even lack of tech literacy can have a huge impact on vulnerable populations for accessing and receiving care.
Emcara Health specifically looks to help patients who are using Medicare or Medicaid. These patients often are isolated, lack caregiver support, or have social stressors like lack of work and responsibilities caring for other family members.
“This kind of integration is helpful for people who face social and behavioral barriers as well as physical,” notes Baldi. And while integrated care might seem to most overtly help at-risk populations, it’s a concept that lifts all ships. “Integrated care is beneficial to everyone,” she says. “The problems we’re trying to solve in our healthcare system could plague any American at some point in their lives.”
Yes, Emcara Health focuses on especially vulnerable patients, but integrated care stands to help patch vulnerability in the overall healthcare system. “And while you risk-stratify and identify patients who would benefit the most, we’ve got to be careful even in this dialogue to not contribute to stigmas,” says Dookeran.
“We’ve been a very reactive healthcare system,” says Baldi. “People present with problems and we try to help them. At Emcara Health, we’re trying to create healthy environments focused on prevention and want to help patients maintain their health and improve it over time.”
To accelerate change toward integrated care, more bundled payments and value-based incentivization must happen, Dookeran says. We also need to think about facilitating access to appropriate, evidence-based, and affordable care.
“Over time, there will be the reward of less hospitalizations and more effective healthcare utilization as we shift healthcare funding to focus on whole-person health,” says Dookeran.
“At Emcara, we’re trying to build capacity in our teams to recognize behavioral health illness and to work with our patients to bring them treatment, care, and navigation support without having to refer them anywhere,” says Baldi.
Given healthcare’s evolving landscape, it’s difficult to verbalize a dream future for integrated care, but things are headed in the right direction. “We need a healthcare system that can do a lot of different things. There are lot of needs to meet,” says Baldi. “But we’ve come a long way in terms of making care patient-centered and continue to move in the system overall in that direction.”
“I think so much is put on the backs of primary care providers,” says Dookeran. “It may seem in some settings like it is the responsibility of the primary care provider to address everything but the kitchen sink on their own in order to take good care of the patient. But having a team wrapping around the patient, as we do in Emcara, to address healthcare needs with a patient-centered approach, there is more effective, collaborative treatment planning, and patient lives are truly positively impacted. That is a beautiful thing.”
“We recognize there’s a lot of suffering experienced by untreated behavioral health,” says Baldi. “From a patient perspective, a lot can be gained by creating a system where people can get the right care where and when they need it. It improves the quality of their lives and has a ripple effect all around them.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.