The Mind-Body Disconnect: Realigning Behavioral and Medical Health Care

BY VICKI RITTERBAND
VITAL SIGNS STAFF WRITER

In 2010, Lisa Halpern had back-to-back emergency abdominal surgeries. Her hospital physicians took her off her medications for schizophrenia, which they believed would interfere with her post-operative recovery. They also ignored her eating disorder, she said, which resulted in dramatic weight loss during her hospitalization, landing her in a residential eating disorders program post-discharge.

“They did amazing work with the surgery — I can’t thank them enough for saving my life,” says Halpern, director of recovery services at Vinfen, a provider of community-based services to people with disabilities. “But they weren’t concerned about my being off my medications. They did not think it was their job to worry about my eating disorder or schizophrenia.” It was Halpern’s outpatient psychiatrist who put her on a different antipsychotic medication that would not exacerbate her stomach problems.

Despite a preponderance of evidence that illnesses of the mind and body are inextricably linked, behavioral and medical health care too often run on parallel tracks. Halpern’s experience was very typical in Massachusetts, according to a groundbreaking report on behavioral health released recently by Massachusetts Attorney General (AG) Maura Healey — the fourth in a series looking at health care cost trends and drivers in the state. The study examined the way behavioral health benefits are administered and reimbursed and how those processes meet the state’s goals of health care reform: delivering care that’s well coordinated, high quality, and cost-effective. The conclusion? Behavioral health care in Massachusetts is poorly coordinated with medical care, underfunded, opaque about issues of cost and capacity and unable to measure quality because of a paucity of “robust” metrics, Healey’s report found.

Separate and Not Equal

As a psychiatrist, Rohn Friedman, M.D., is all too familiar with the issues highlighted in the report. He, like the AG, believes that much of the blame lies with the fact that many Massachusetts health plans “carve out” behavioral health benefits and subcontract their management to managed behavioral health care organizations that have separate administrative and claims systems. While the original intent of the carve-outs was to rein in psychiatric costs, the unintended consequences have been numerous and harmful to patients, he says.

First, the majority of mental health services require prior authorization, forcing patients who may be in crisis to jump through hoops. Then the provider networks tend to be quite narrow and finding a provider who accepts new patients can be challenging. Finally, for the many patients with both psychiatric and medical problems, communication between the two sides of their care is virtually nil. “You can’t analyze data to understand the connection between a patient’s medical and psychiatric care because they’re in separate silos,” said Dr. Friedman, president of the Massachusetts Psychiatric Society. “That flies in face of the era we’re in now — where the focus is on coordinating and integrating health care overall.” The disconnect between the two is even more illogical considering that many psychiatric illnesses are managed by primary care providers.

The PCP Perspective

Every day in his Worcester office, internist George Abraham, M.D., appreciates how mental illness can profoundly affect physical health and vice versa. He estimates about one out of every five of his patients also suffers from a psychiatric illness; that number is even higher if he includes people who experience an episodic behavioral health issue, such as depression after a loved one dies. And the opposite is also true: on Tufts Medical Center’s inpatient psychiatric unit, between 30 and 40 percent of patients also have a significant medical illness, according to chairman of psychiatry Paul Summergrad, M.D.

“You don’t want to silo out each organ system and illness because they’re so intertwined,” said Dr. Abraham. “Depression affects how patients control their diabetes, how motivated they are to exercise and how compliant they are with medication. And conversely, one side effect of some behavioral health medications is weight gain.” While poor communication among different segments of the health care system is not unusual, it’s especially bad when dealing with the world of behavioral health, making it challenging to coordinate a patient’s care, says Dr. Abraham. “We get no notes, no records. We don’t know what medications our patients are on and we have to depend on our patients to tell us.”

Perverse Incentives

There is also a compelling financial argument for better integrating behavioral health and medical care, according to the AG’s report. Massachusetts commercial and public payers spend on average 2–2.5 times as much on patients who have a chronic disease plus a behavioral health condition than on those who have only a chronic medical condition. But because managed behavioral health care organizations are only on the hook for behavioral health care costs, they have little incentive to better coordinate care with the medical side, the study concluded.

Dr. Friedman sees this misalignment of financial incentives manifested in the long waits psychiatric patients often experience in the emergency room until an inpatient behavioral health bed opens up.

“From the standpoint of the mental health carve-outs, if the patient is staying in the ER for five days, they’re not paying for much of anything because the patient is in a ‘medical’ hospital,” explained Dr. Friedman.

If you invest more money in the mental health side, you’ll more than recover the costs on the medical side, but you can’t see that if the two columns are in completely different systems,” he said.

Integrated Care Models as Solution

Pilots of an approach called integrated medical-behavioral health care have shown to improve outcomes and save money and more of them should be launched, according to Dr. Summergrad. The approach plays out differently depending on the context, but it generally means bringing behavioral health care resources into a primary care office. For example, a care manager from the PCP’s practice would keep tabs on patients with depression, calling them to make sure they’re taking their medication and not suffering side effects. The PCP manages the depression treatment, supervised by a psychiatrist who is available for consults. If the patient’s depression is not responding, the patient would be referred to specialized treatment, but the PCP and the psychiatrist would be on a shared EMR system, so all providers know what’s going on.

Integrated medical-behavioral health care does exist in Massachusetts. For example, Boston Medical Center is piloting the use of social workers, psychiatric nurse practitioners and patient navigators in its family medicine practices. The Massachusetts Child Psychiatry Access Project, offers pediatricians and family practice physicians quick access to consultative services over the telephone with child psychiatrists. And meanwhile, MassHealth is beginning to promote integrated care through its Primary Care Payment Reform Initiative, which gives primary care providers risk adjusted capitated payments that encourage behavioral health integration.

As for Halpern, she has devised her own solution to the problem of fragmentation: she created her own multi-disciplinary care team, comprising an internist who specializes in eating disorders, a nutritionist, a psychiatrist and a therapist. “They communicate on email regularly and I’m the leader of the team,” she said.

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