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Comprehensive Primary Care Includes Mental Health


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Imagine this scenario. You go to see your longtime primary care provider. What you have to say you could only say to the person who has taken care of you and your family for years, has seen births and deaths. It’s still hard to say. In fact, you never thought you’d have to say it. But ever since you lost your mother, you’ve not been feeling your best. You’re eating foods you know aren’t good for you. You’re sleeping too much and not exercising at all. Your blood pressure is the highest it’s ever been, and your weight is becoming a problem. You feel down most of the time, and you’ve stopped doing the things you love. It was actually your neighbor that asked, “Are you depressed?”

So here you are, telling your doctor that you think you might be depressed. What happens next, as you will learn later, happens to millions of others in your same situation. Your provider hands you a questionnaire, known to health care professionals as a PHQ-9, and you learn together that you have symptoms of mild depression. Of the various treatment options she describes, you think that talking to someone about the loss of your mom would be most helpful. She refers you to the local network of mental health providers saying that this is the only way she knows to get you help.

Once you leave the office, the next steps for your care are entirely in your hands.

Maybe you go back to work. Or maybe you pick up the kids from school or run a few errands. Whatever you do, you don’t make the call right away. When you finally do, you hear of wait times of up to two months. And finding someone in your insurance network is equally daunting. You finally get an appointment. The first few visits go okay, but when you check in with your primary care provider to ask her if she has heard anything from the therapist as you are curious about the team “game plan,” the answer is no. You had assumed that all your providers would communicate. You are somewhat surprised but attribute it to providers being busy. You think to yourself, “If only my providers were able to collaborate better…”

While it appears that the patient was getting the care they needed, fragmentation complicated things at several points along the way. And most of the time these cracks in the system prevent the patient from ever getting care. The depression goes unchecked, which impacts the diabetes, which impacts the blood pressure and so on.

For decades we have known that more mental health issues are seen and treated in primary care than in any other health care setting. Some of this prevalence is due to primary care being the largest platform of health care delivery in the country. Despite this well-known fact, consider the following statistics:

  • 80% with a mental health disorder will visit primary care at least one time in a calendar year
  • 50% of all mental health disorders are treated in primary care
  • 67% with a mental health disorder do not get behavioral health treatment
  • 30-50% of referrals from primary care to an outpatient mental health clinic don’t make the first appointment

The numbers associated with mental health conditions comorbid with chronic disease aren’t any rosier. The AHRQ Medical Expenditure Panel Survey found that patients with mental health conditions on top of their chronic disease cost about 50% more than those with chronic disease alone. This would all be fine if we did a good job treating the whole person, but the health care system excels at treating parts, not wholes.

As the authors of the AHRQ study pointed out, “Carve-outs of mental health benefits (i.e., only paying for mental health care delivered by mental health professionals, high copayments for mental health treatment, and inadequate reimbursement are barriers to effective collaboration and disincentives for primary care physicians to screen for and adequately treat mental health. Fixing disparities, removing mental health carve-outs, and creating blended payment systems could improve mental health treatment in primary care. This would support integrated, patient-centered mental health care that is consistent with the principles of the medical home.”

It’s no wonder that in a recent Senate hearing on mental health, experts from around the country called on the federal government to better integrate care. It seems that though we know the areas in health care that could better meld mind and body, a chasm lives between the system that we have and the system that we want.

To begin to close this chasm, we must:

Maybe when we do, we can start to better understand what must be done to meet all of a person’s health care needs. After all, health is health is health.

This article was provided through our partnership with Primary Care Progress. Dr. Miller is also a judge in the 2014 Primary Care Challenge.

Benjamin Miller

Benjamin Miller

    Benjamin Miller is an assistant professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine, where he is the Director of the Office of Integrated Healthcare Research and Policy.

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