Let’s integrate primary care and mental health care
Often, if a patient tells their primary care doctor they are depressed, the doctor sends them away with a list of therapists who may or may not be taking new patients or accepting insurance. The doctor might prescribe medication but not set up time to regularly follow up.
behavioral health care and primary care are among the most important medical specialties to keep patients healthy and avoid exacerbating illnesses. Yet both are in crisis. It is difficult to find a primary care doctor. According to data from massachusetts health Quality partners and the center for health Information and Analysis’s primary care survey, in 2021 more than one-third of residents reported difficulty obtaining necessary health care in the prior 12 months.
The ability to find a behavioral health clinician — particularly one who can address a patient’s particular needs and accepts insurance — has long been a challenge, one worsened by the cOvID-19 pandemic. because of stigma and practical barriers, many people don’t bother trying. According to the blue cross blue shield Foundation in massachusetts, in a survey fielded from December 2020 through march 2021, 57 percent of massachusetts adults who reported needing behavioral health care either had difficulties getting appointments for care when needed or did not obtain any behavioral health care.
The collaborative care model involves teambased care, combining primary care providers and behavioral health clinicians in a primary care office. In years of studies, the model has proven effective in treating depression and anxiety. It is also cost-effective, since it fosters early intervention. Officials in north carolina are so enamored with the model that the state offers doctors technical assistance to implement it, in addition to providing high medicaid reimbursement rates.
In 2017, the centers for medicare and medicaid services approved billing codes that let practices bill insurance for collaborative care. masshealth began using the codes in 2018, and in 2022, massachusetts legislation required reimbursement from private insurers.
Transforming the practice of medicine is never simple, but there are resources available to help doctors implement collaborative care. more physician practices should take that leap.
Wayne Altman, an Arlington doctor who founded an alliance of physicians dedicated to improving primary care, started using collaborative care in January. he said it feels “luxurious and indulgent” to easily refer patients to mental health care and work with clinicians in his practice. “but it feels that way because we’re so used to scarcity in mental health resources,” Altman said. “people are used to mental health care being inaccessible and expensive.”
When a patient enters Altman’s office with a mental health concern, he can refer them to an in-house care manager and therapist. While the therapist provides short-term clinical therapy, the care manager does everything else: talking to patients to understand their concern, coordinating with community-based resources, following up with patients, and providing nonclinical advice. The care team consults with a psychiatrist, who can recommend or adjust medication, which is prescribed by the primary care doctor. Outcomes are tracked in a database.
In Altman’s practice, the behavioral health clinicians are employed by the brookline center for community mental health’s Innovation Institute, with funding from philanthropic foundation Accelerate the Future. but the model is expected to become self-sustaining through insurance reimbursement. (because the change healthcare data breach delayed insurance reimbursements, financial data is not yet available.)
collaborative care opens new financial opportunities. Traditionally, a therapy session or primary care appointment is reimbursable but the time doctors spend making follow-up phone calls or coordinating with another medical provider is not. The new codes reimburse for that time. At the same time, studies have shown that health care costs overall are lower with collaborative care because early treatment avoids more serious medical problems.
collaborative care can also address workforce burnout because a care manager, a position that requires only a bachelor’s degree, can conduct nonclinical activities that would otherwise fall to a primary care physician or master’s-level therapist. A consulting psychiatrist who meets with the care team can advise on treatment for a group of patients more efficiently than if they were to treat each patient individually. most importantly, myriad studies show the model works to improve symptoms, particularly in patients with moderate to mild depression and anxiety, although it has been used for other illnesses. “This is probably one of the most evidence-based approaches to delivering mental health services in medical settings, especially primary care,” said Anna Ratzliff, codirector of the AIms center at the university of Washington school of medicine, which focuses on integrating mental and physical health care.
One example is Aloft Integrated Wellness in exeter, n.h., which pioneered using collaborative care for pediatrics in 2020. It hired two master’s-level therapists, a bachelor’s-level care manager, and a colorado-based consulting child psychiatrist. In 2.5 years, coinciding with the cOvID-19 pandemic, 550 patients were treated and only one went to the emergency department for behavioral health needs, according to Aloft’s data. According to Aloft, patients are able to schedule appointments within two weeks and can receive short-term therapy. screening tools ensure treatments are working.
Aloft cofounder Jessica lyons said the care manager performs tasks as diverse as meeting with school counselors, helping families address food insecurity, and instructing patients on sleep hygiene. While the practice opened with grant money, lyons said it has become financially sustainable.
Implementing collaborative care takes effort. providers need to bill differently, and there are up-front costs for hiring clinicians and creating a patient database.
Different practices are experimenting with different models. While the federal billing codes require a case manager, physician, and psychiatric consultant, some practices add other staff, like master’s-level therapists. mass general brigham is trying a model where primary care doctors refer patients to remote clinical social workers employed by concert health for psychotherapy. Ratzliff said collaborative care has been tried in specialties including obstetrics and cancer care.
It will take trial and error to figure out how the model works best. but evidence suggests that when done well, collaborative care improves health care quality while lowering costs and letting clinicians focus on what they are trained to do. These are goals worth pursuing.