Mentally Ill People May Gain Benefits of Coordinated Care

One high-profile study found, for example, that people with mental illness treated in the public health system die 25 years younger than the national average, mainly due to a lack of appropriate primary care. The 2006 study by Colton and Mandersheid was published in the April 2006 Preventing Chronic Disease.

Research also has found that mental illness rates are significantly higher among patients with certain chronic conditions—such as diabetes, heart disease, and asthma—than they are in the general population.

The potential for coordinated care to improve overall patient health is particularly great when mental health treatment is provided in primary care, the setting in which patients often first report psychiatric symptoms to a clinician.

“There is no way there is enough system capacity to see all of the people with mental illness within the behavioral health care sector,” said Joseph Parks, M.D., director of the Division of Comprehensive Psychiatric Services in the Missouri Department of Mental Health. “It's a good thing that they are seen in primary care settings, because many of these people have other chronic health care problems.”

Parks called the coordination of primary care and mental health treatment “a marriage made in heaven” because many primary care physicians want help with patients who have substance abuse disorders, for example, while many substance abuse clinicians lack primary care medical support.

“It's a common problem,” said Ted Epperly, M.D., an Idaho family physician, about the inability to find mental health treatment for his primary care patients. “I can't tell you how often we see it.”

Despite the research supporting a coordinated approach to care, such programs for people with psychiatric illness have been largely limited to pilot programs and local efforts of small groups of clinicians because major health care payers have balked at paying for it.

Currently, only 10 percent of U.S. patients are treated using evidence-based, integrated-care models, said John Bartlett, M.D., M.P.H., a senior project advisor at the Carter Center Mental Health Program in Atlanta.

Parks said such care coordination will become widespread only when the major private insurers, as well as public ones such as Medicare and Medicaid, pay clinicians to provide such care.

“We need to demand better performance from our payer system, both public and private,” he said.

One incentive for congressional leaders to add care coordination to Medicaid is the potential for significant cost savings. Patients with nonpsychiatric chronic health conditions and mental illness incur significantly higher health care costs, on average, than chronically ill patients who do not have a mental illness, according to 2003 data from the federal Agency for Healthcare Research and Quality (AHRQ). The AHRQ study found that, on average, $1,913 is spent annually on care for adults with a chronic health condition and no mental illness, while $3,545 is spent on chronically ill adults with mental illness.

Coordinated care could help control such costs if it increases the use of evidence-based approaches in the treatment of psychiatric illnesses, said Bartlett. A growing body of evidence shows that the use of “effective approaches” to mental health care in primary care settings through care coordination can double the effectiveness of that care. Current widespread deviation from evidence-based mental health treatments leaves 70 percent of people treated for depression, for instance, without clinically significant improvement after two months, he noted.

“We don't have a lack of evidence [on effective treatments],” Bartlett said. “We have a lack of demand to implement that evidence.”

Information on efforts to include coordinated care for mental illness in health reform legislation is posted at <www.mhreform.org>.