PCPs as Default Mental Health Providers
It is estimated that nationally 70% of Mental Health services are provided by Primary Care. However, most PCPs do not consider providing Mental Health services to be one of their primary functions. Unfortunately a typical online view of Primary Care prevalence distributions looks like the following:

While the prevalence distributions vary from practice to practice, the degree of the behavioral health disorders is universally under-estimated. Examining prevalence for disorders beyond depression; PTSD, Substance Abuse, and other disorders lock in depression such that treating depression alone will not help the patient. Similarly, prescribing anti-depressants to a Bipolar patient can be dangerous. Automated in-depth information is extremely useful for a PCP to appropriately treat or refer.

Why Integrated Behavioral Health
Acknowledging that Primary Care is the frontline for Mental Health, integrating Behavioral Health reduces costs - to a point. Specifically, depending on the prevalence levels within the target population (typically a function of practice type - FQHC/CHC rural/urban, private practice small office/large system, academic or government) and the level of integration/PCP support (automated screening, Behavioral Health Care Coordinator, Triage Therapist, Behavioral Health Consultant or Mental Health on staff), costs are driven down to some optimal point, after which higher levels of integration push overall costs higher again.

Costs are driven down by effectiveness of detection/treatment (reduced utilization at the practice/ER, reduced medication usage, reduced co-morbid complications [cardiac, diabetes, obesity, etc], higher productivity for employers, etc) and offset by the increased cost to fund the integrated activities (screening program, additional staff, facilities, etc). While the cost benefits are obvious for healthcare in general, bluntly, practices are expected to bear the cost of integration, but do not share directly in the cost savings from effectiveness.

As Employers/Payors, who are benefiting from effectiveness, come around to compensating practices for integration, cost justification for integration by the practice is a moving target. Grants are often obtained by FQHCs, CHCs and academic settings. Associations are advocating, and larger healthcare organizations are negotiating new CPT billing codes with payors. Payors are marketing lower healthcare costs and high productivity to employers. Pay-for-Performance is including depression as one of its measures. The VA is mandating Behavior Health Consultants. At a minimum, automated screening can be shown to be at least cost neutral (see below) and is a great place to start.

Take the first step
Due to the different types of practices, uncertainty about the prevalence levels within their patient population and their specific funding situations, it is not always clear what level of integration is optimal. Rather than trying to plan, justify and fund an Integrated Behavioral Health program in a single step, it is better to define a migration path, demonstrate need and increase the level of integration appropriately. The first step in this migration path is to start an automated screening program (screening is needed for all levels of integration anyway). Within a relatively short period of time (100 - 200 cases) and small cost, a prevalence graph like the one shown above, may be automatically generated that will break down your practice's population with a reasonable degree of certainty and you will have the data to show the initial level of need for Behavioral Health services.

The natural reaction to taking this first step is that it will open the flood gates. This does not happen in practice. Adoption of the screening program is a slow process and automated electronic screening is at least time neutral. Specifically, the time required to process screening results are offset by the time saved getting to the root causes of presented problems that are masked by psycho-social issues (estimated nationally at partially up to 70% of the time and exclusively 20% of the time). The PCP is better able to treat (medications or counseling) or refer appropriately and their job has not really changed, they just have better information to do it.

Once your practice gets a handle on the prevalence distribution for its population, you can take the next step, looking at whether it would be cost-effective to support the PCPs with a Behavioral Health Care Coordinator/program or possibly move to a Triage Therapist or Behavioral Health Consultant on staff. Move to the higher levels of integration, only when it makes sense.

Please Contact Us to learn more or discuss how Integrated Behavioral Health might work in your setting.