With the implementation of the Affordable Care Act in 2014, states have an unprecedented opportunity to improve the health of millions of Americans by integrating physical care with mental health care.
The challenge is creating systems of care in which doctors and specialists collaborate effectively to realize this goal. How do we achieve, as the Institute for Health Care Improvement recommends, the triple aim of more satisfied patients, better health outcomes and lower costs?
The state of Washington is a leader in this regard and has the potential to serve as a model for the rest of the country. From more than 20 years of research, much of it done in Washington state, we have found that integrating mental health and medical care works.
The federal passage of the Affordable Care Act, which took effect on Jan. 1, triggered the final implementation of the 2008 Mental Health Parity Act, which requires insurers to cover treatment of, say, depression just as they would cover a splint for a broken leg. The expansion of Medicaid eligibility in Washington state could further extend access to 328,000 new people. Many more may now have access to mental-health care.
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If we act now, we could help millions of people with mental illness get the care they deserve. Twenty-five percent of Americans will experience a mental health problem over a lifetime. The problem often goes untreated, and may lead to hardships with employment, family and social relationships, and physical health. Most people have had a friend or family member experience these problems, and know of the suffering and difficulty of obtaining effective treatment.
Currently only one in five adults living with a mental-health or substance-use problem sees a mental health specialist. Only half of all mental-health problems are accurately diagnosed in primary care, and only half of those referred will actually see a specialist. Many of the 39 counties in Washington state don’t have a single licensed mental-health professional.
This shortage is particularly acute in rural areas. But even in our cities, too many people who desperately need help for mental health problems are not receiving the treatment they need. They wind up boarded in hospital emergency rooms awaiting placement for treatment.
Evidence shows that collaborative-care programs work and would help avert some of these crises. In this approach, a mental health-care manager and a designated psychiatric consultant work at a primary-care doctor’s practice to care for patients with common problems such as depression and anxiety. These programs cannot solve all mental-health needs, but increasing access before patient problems escalate is an important step in the right direction.
More than 80 studies have demonstrated the effectiveness of collaborative care programs. Millions of individuals have both mental and physical health problems. People afflicted with serious depression, anxiety or other mental health problems usually take better care of themselves under the collaborative-care model. They are more likely to follow medical and mental health treatment advice. This often results in improved overall health.
People with one or more chronic illnesses, such as diabetes and heart disease, have twofold higher rates of common mental illness such as major depression. Individuals with more severe mental illnesses, such as bipolar disorder or schizophrenia, die 10 to 25 years earlier than those without mental disorders — and not from their mental illness. These individuals often succumb to poorly treated medical conditions. Programs providing both physical and mental health care in the same setting can help both of these populations live longer, more rewarding lives.
Washington state has offered a collaborative care program for behavioral health problems to low-income and safety-net populations for the past five years through the Mental Health Integration Program.
The program was originally supported in 2008 in King and Pierce counties to serve unemployed patients receiving short-term disability and expanded to more than 140 community health clinics statewide in 2010, reaching vulnerable populations in even the most remote parts of the state.
Tax-levy dollars in King County fund care for other high-risk populations, including the uninsured, military veterans and their family members, mothers of infants and young children and older adults.
Since its inception, the Mental Health Integration Program has served more than 35,000 patients and has improved care while reducing costs. The service is also associated with lower rates of police arrest and homelessness.
A pay-for-performance component was introduced in 2010 to reward clinics that achieve high quality indicators, such as reducing the time it takes for a patient with depression to improve. This innovation has substantially improved health outcomes.
Integration has obvious benefits, and Washington state’s Mental Health Integration Program is a great example. The program has achieved the triple aim of better access to care and better health outcomes at a lower cost. Still, there is no denying that reaching these goals will require a major change in practice.
Health-care organizations as well as medical and mental-health providers need to see the value in integrated services and continue to learn how to collaborate effectively.
Regulators need to remove barriers that make it difficult to provide integrated services. Government agencies and insurance companies have to create payment mechanisms and financial incentives for providers.
Washington Gov. Jay Inslee recently released a vision statement calling for integration that can help move us in this direction. Our state sent an ambitious State Innovation Plan to the federal government. This plan further challenges us to move toward this goal.
Much work remains to be done. It’s imperative that we grasp opportunities to innovate and implement integrated care programs that meet our patients where they are.
Wayne Katon and Jürgen Unützer are professors of psychiatry at the University of Washington School of Medicine.