January 2006 | Back to Table of Contents

Pulse

Big Push

Minnesota doctors are slowly moving toward making mental health care an integral part of primary care.

Faris Keeling, M.D., is trying to move a mountain. Not one of the rocky cliffs overhanging Lake Superior near Duluth, where he works as medical director of integrated behavioral health care for the Duluth Clinic system. He’s up against a wall of a different sort.

For two years, Keeling has been trying to push mental health care into the realm of primary care at three of the 20 clinics under his watch. With a limited budget, he’s trying to make three major changes at the clinics: apply a chronic-disease-management model to depression, have visiting psychiatrists do consultations right at the clinics with the primary care providers, and locate psychotherapists and case managers at the clinics to work in teams. Making these changes has been slow going, “frustratingly slow going,” says the family physician and psychiatrist. “But it always is when you’re changing big systems.”

Keeling’s effort is part of a Minnesota Psychiatric Society initiative to integrate mental health care and primary care. The Duluth Clinic and nine other clinics around the state are trying to demonstrate to third-party payers (and anyone else paying attention) that mental health care ought to be—and can be—part of primary care.

“Doctors love it. Patients love it. Staff at clinics love it. Everybody loves it,” Keeling says. “Just finding the money to make it happen is what’s slow going.”

So Keeling and others are making do with internal resources and ingenuity instead. At Ely Clinic, for example, they’ve brought in a psychotherapist to work onsite with doctors and other staff. The therapist will remain an employee of a local behavioral health organization. They’ve designated staff to follow-up with depressed patients. They’d like to hire a social worker but know that the clinic can’t bill for the social worker’s services unless that person is actually doing psychotherapy. “The problem in primary care is that if you can’t bill for it, you can’t have it,” Keeling says.

Roger Kathol, M.D., a co-chair of the Minnesota Psychiatric Society Integrated Care Task Force and president-elect of the society who is leading the integration initiative, says the society has asked the Minnesota Council of Health Plans (MCHP) to collaborate with the network of clinical programs. Kathol explains that unless insurers make changes, integration can’t happen in any significant way. “We’re asking health plans to think out of the box and pay out of the box,” he says. In early December, the MCHP Board adopted a resolution endorsing the integration of medical and behavioral care and requesting that the task force work with individual health plans to move the initiative forward.

Systemic Disincentives
Currently, most third-party payers reimburse behavioral health providers from a budget that’s separate from the one used to reimburse medical providers. This, he explains, gives physicians no incentive to provide treatment beyond making the initial diagnosis and writing a prescription but does provide an incentive to quickly shift the patient to a behavioral health provider. Under the current system, psychotherapists are often in payer networks separate from the physician and reimbursed at low rates.

The payment systems were designed as cost-saving strategies, according to Kathol, who says they stem from a belief that behavioral health care is ineffective. “We’ve been brainwashed into thinking that treatment for behavioral health is ineffective and nobody gets better,” he says. “Some plans still sell their [behavioral] health product to purchasers by saying that you want to pay as little as you can and give as little service as you can, and that’s the way you’ll save money.”

But the proponents of integrated care say such an approach does the opposite. Keeling explains it this way: “Here’s what usually happens. A patient with depression or anxiety goes in to see a primary care doctor. They get put on medicine but don’t get a lot of education about it. There isn’t time. … At least 40 percent of the time, the studies show, the patient stops taking the medication within two weeks. Of course, six months or a year later, he is back in the office still depressed, still anxious, but worse now with headaches, stomach aches, more somatic symptoms, which then get chased with MRIs, GI consultations, endoscopy, and neurology consults.”

Keeling and others argue that it would be less expensive for payers to have a system in which psychotherapists and case managers work alongside doctors and nurses in primary care clinics to make sure the patient is well-treated for common mental health problems such as depression and anxiety. Physicians could refer patients to a familiar face down the hall rather than to an unknown therapist across town, making it more likely than not that the patient would follow through with psychotherapy.

Cheaper and Better
Its advocates say the integration movement is more than a pragmatic response to a dysfunctional payer system. Primary care, they say, is the best place to treat many patients with mental health problems. “Primary care is the place in our health care system where you are most likely as a patient to get an integrated, holistic, mind-body approach [to care],” Keeling says. “Mind-body dualism is trained into all of us. You go over there for your mental health care, and you come over here for you body. The payer system only reflects the split in the larger culture.”

And they argue that many physical problems are intertwined with psychological issues. Kathol gives the example of the diabetic patient who is also depressed. “We know from numerous studies that depressed diabetics have worse hemoglobin A1Cs, higher service utilization, more diabetic complications, and worse outcomes,” he says. “Unless the depression is addressed, those outcomes will continue to be the same. You get the depression better, and then they start being able to comply better with their diet, their exercise, and oral hypoglycemics.”

When they receive more funding from the health plans, Kathol says that the Duluth Clinic and other demonstration sites plan to document that putting behavioral health specialists and case managers in primary care settings improves physical health outcomes as well as behavioral health care outcomes.

If they do, physicians like Keeling may discover that it is possible to at least get the mountain to budge.—C. Peota