WASHINGTON – The American Psychiatric Association is putting out a call for much tighter integration of primary care and mental health care, saying that it will lead to better services for patients and a reduction in costs to the health system.
"Studies have shown that concurrently treating behavioral and physical conditions leads to better control of the illness itself, but also better patient satisfaction, quality of life, and reduced costs," Dr. Jeffrey Lieberman, president of the APA, said at a briefing, sponsored by the American Psychiatric Association.
The APA released a report that shows that effective integration could save $26 billion to $48 billion a year in general medical care. The report was written by the consulting firm Milliman, which the APA commissioned to take a look at integrated care models and the potential to improve care.
Dr. Jeffrey Lieberman
Dr. Lieberman, who is also chairman of the psychiatry department at Columbia University Medical Center, New York, said the Milliman report was only the latest in a series of studies that have shown that addressing medical conditions and behavioral issues simultaneously is more effective and more cost-effective than creating silos to address each. A recent review by the Cochrane Collaboration of 79 randomized controlled trials, including more than 24,000 patients worldwide, compared collaborative care with routine care for depression and anxiety (Cochrane Database Syst. Rev. 2012;10:CD006525). The review found that collaborative care is more effective, increasing patient satisfaction and quality of life.
"The jury is now in, that integrated care is effective," said Michael F. Hogan, Ph.D., the former commissioner of the New York State Office of Mental Health, at the briefing. He said the specialty mental health system is not the solution to helping people with mental illness and comorbid conditions improve.
Almost half of people with a mental disorder first consult with a primary care physician. On average, it takes 9 years after the first symptoms for a patient to receive a diagnosis, Dr. Hogan said. Given that the average age at which those symptoms appear is age 14 years, that means a lot of individuals are struggling without a diagnosis during adolescence, he said, calling that a "bad approach."
And, about 50% of the 38,000 people who commit suicide each year have seen a primary care physician within a month of the completed attempt, he added. Dr. Hogan said that not only do primary care physicians need the tools and education to help them do a better job in diagnosing and treating patients with mental disorders, but that they also need a team that includes a psychiatrist or behavioral health specialist.
Dr. Frank V. deGruy III, the Woodward-Chisholm Professor and chair of the department of family medicine at the University of Colorado Denver, agreed that primary care physicians needed a psychiatrist as a team member for the roughly 20% of patients seen in primary care practices who have mental disorders co-occurring with chronic health problems.
The "relative neglect of behavioral care" has been a major reason for the lack of comprehensiveness in collaborative care, said Dr. deGruy, who is also a past president of the North American Primary Care Research Group. He added that the Milliman report helps provide a missing piece and made him feel that "comprehensive, effective, coordinated care is right at our threshold."
The Milliman report – which drew on claims data for 20 million people enrolled in commercial insurance, Medicare, or Medicaid – found that only 14% of those who had a mental disorder were receiving treatment but that they accounted for 30% of the spending by those insurers. That totaled about $525 billion for 1 year, according to the report.
Even though they are insured and are being treated for their mental illnesses, the lack of coordinated care represents lost opportunities, said Dr. Paul Summergrad, president-elect of the APA. The Milliman report found that general health care costs were two to three times higher for people with a mental disorder and a chronic condition, compared with those without a mental condition.
The higher costs were mostly attributable to patients falling through the cracks or not getting proper care – which showed up in more emergency room visits, more hospitalizations, and hospital readmissions, said Dr. Summergard, who is also chair of the psychiatry department of Tufts University and psychiatrist in chief at Tufts Medical Center, Boston.
"There’s no way we’re really going to deal with the total issues around health care and health care costs unless we reach out to everyone," he said, adding that "we need to make sure we’re all working together to provide that care."