Integrating people’s mental health with their primary care is increasingly seen as vital to better overall health. In fact, this issue received a lot of attention from President Joe Biden in his recent State of the Union address. The president outlined the national mental health crisis and steps needed to address it right away.
This is welcome news. As those of us on the front lines have experienced firsthand, addressing mental health has become especially acute during the pandemic. Of special concern is the significant shortage of mental health providers, a national challenge that we need to solve now.
In addition to President Biden, last summer, the top Democrat and Republican on the Senate Finance Committee, which oversees Medicare, released a bipartisan Request for Information to help develop legislation addressing barriers to mental health services. It is exciting to see two branches of government and leaders from both political parties giving these issues the attention they deserve. And health policy leaders are clearly engaged as more than 300 stakeholders submitted their views to the Finance Committee, including Oak Street Health, one of the country’s leading implementers of the behavioral health collaborative care model which integrates the work of primary care providers and mental health professionals to treat the whole patient.
The president’s focus and the efforts on Capitol Hill are not just timely but badly needed. Untreated mental illness reduces Americans’ ability to get the physical health care they need. People with depression often struggle to motivate themselves to go to doctors’ offices, even if treatment is available once they get there. Depression remains the world’s leading cause of disability.
Many Americans experience generalized anxiety disorder, post traumatic stress disorder, loneliness and grief—and the pandemic has certainly contributed to an increase in the prevalence of these diagnoses. According to the Centers for Disease Control and Prevention, 50% of the overall population will receive a mental health diagnosis during their lifetime and the Commonwealth Fund estimates that “about 1 in 4 Medicare beneficiaries have mental illness.”
One of the president’s proposals was to integrate mental health and substance abuse treatment into primary-care settings. Oak Street Health, where I lead behavioral health, is already doing this, with great results. By screening almost all our patients for behavioral health needs, we have found that about 60% may benefit from these services, which is about 10 percentage points above the CDC estimate. However, by integrating mental health with primary care via the collaborative care model, we have seen individuals respond to treatment within six weeks and demonstrate sustained improvement at six months.
This approach works because the team engages in measurement-based care with timely medical and behavioral health interventions. Our value-based, fully capitated model—in which quality outcomes matter more than volume of services—has allowed us to respond successfully to our patients’ needs.
The American psychology workforce is understaffed with demand for services set to increase by more than 40% over the next decade. Both underpaying licensed clinical social workers and limiting who can provide qualified services is unacceptable when there is an available workforce ready to step in. Licensed professional counselors are, surprisingly, not eligible for Medicare reimbursement. Bipartisan legislation pending in Congress would expand the expertise of these professionals to Americans over age 65. There is also bipartisan legislation to increase Medicare rates for clinical social workers. Congress should pass both of these important measures.
Congress should also authorize training grants and enhanced payments to organizations dedicated to implementing the Collaborative Care Model. Policymakers can provide additional incentive payments to providers serving a higher proportion of patients eligible for both Medicare and Medicaid, known as dual-eligibles. They should ensure Medicare pays for quality, not just the quantity, of mental health services rendered under the model.
It will not be sufficient, however, to focus only on treatment. A benefit of expanding a multidisciplinary workforce integrated in primary care is that we can equip teams to address a variety of challenges. The CDC uses the measure of healthy days to calculate when in the previous 30 days an individual experienced both good physical and mental health. Social risk factors can impact the number of healthy days. For instance, inadequate social or emotional support and food insecurity can result in fewer healthy days per month. Recent case studies demonstrate patients have more healthy days when interventions happen regularly. This is especially true with a holistic, team-based approach like Collaborative Care.
The bottom line is that government can expand access to quality care by focusing on outcomes over volume. The best way to do that is to reward teams incorporating social, mental and physical health interventions into their care methods. By implementing this model through value-based providers, we can heal our communities and create a health system that responds to a whole person and help begin solving the nation’s mental health crisis.