By Michael Boroff, PsyD
Siloed care delivery by primary care providers and mental health specialists leaves vulnerable patients untreated. Mental health integration is essential to remedying the mental health crisis in the U.S.
Addressing access for the whole patient
It’s starting to sound cliche, but everyday it’s true. The numbers continue to climb and more people than ever are struggling with their mental health. As of 2020 in the U.S., 52.9 million people, or 1 in 5 adults, experienced mental illness. During the pandemic, 4 in 10 adults reported symptoms of anxiety or depressive disorder. Unfortunately, in our current paradigm that views mental and physical health separately, there’s a shortage of services that address mental health issues as part of a comprehensive care plan, which holds us back from making sustainable progress. More than one third of the U.S. population, about 130 million people, live in areas that have a dearth of mental health workers, and about 80% of rural counties lack access to a single psychiatrist.
We’ve swung the pendulum on stigma and people are raising their hand for care, but now what? Employers are still grappling with a sea of apps and the best path for integrating care delivery. While yes, society has embraced broader acceptance of digitally-enabled care models, are they really going to “solve” the mental health crisis? Particularly when they work in isolation?
More and more today the term “whole-person care” is used. While, yes, there is some debate about what that is, in mental health, it’s technology application that is supported with integrated care along a continuum; not an app in a silo. Certainly there are use cases for apps, but without an integrated primary care provider, there’s no single care partner to guide patients on their mental and physical wellness journey. Fragmented, siloed care actually restricts the visibility of caring providers and further contributes to the stigma associated with mental health challenges.
Providers who are on the front lines of care provision are speaking up about how the healthcare system can improve quality of care and expand access to services. Many solution providers (aka vendors) are talking about their ability to deliver new technology that achieves whole-person care, though some of that remains more promise than actuality.
The American Medical Association published a report earlier this year highlighting the severity of the mental health crisis and the vital need to reach people who require timely access to treatment. The organization asserts that the solution is found in behavioral health integration (BHI), which incorporates both mental and physical healthcare into delivery of services, in part, through digital enablement. In tandem with traditional interaction between providers and patients, technology that leverages digital tools for functions like screening and intake, telehealth services, and clinical decision support will help engage more people in mental health treatment and aid providers in its adoption and delivery. The report references ample evidence that BHI produces superior patient outcomes, improves patient experience and access, and can generate cost savings.
Further, the AMA and other leading medical associations established the BHI Collaborative, a group “dedicated to catalyzing effective and sustainable integration of behavioral and mental health care into physician practices.” The cohort’s objective is to empower physicians to expand access to mental health services through primary care settings and take a holistic, integrated approach that focuses on the well-being of the whole person.
The AMA has brought to light a very serious issue of which many employers and benefit designers are already aware: the current paradigm – which silos physical and mental health care – is not working. Companies are using employee assistance programs (EAPs) as a mental health front door, which has proven to be ineffective and simply not good enough to address the severity of these problems. Patients require care that incorporates visibility, collaboration, and integration among providers. So why do employers continue to settle for less? It’s about to change.
Turning the need and research into actionable care delivery
Member-centered primary health is a straightforward path for patients to see their primary care clinicians and mental health providers in a truly integrated fashion. More and more, employers are embracing an integrated model that engages patients and facilitates adoption by providers throughout the entire patient journey. It’s the journey from access to results. By incorporating technology to engage patients in mental health services such as screenings, diagnosis, and treatment, employers can see how proven integration models within primary care workflows are yielding positive results. Employers should both imagine and demand a world where success is being reported as improvement scores vs. visit volume.
Assuredly backed by data – supporting a new model of care
My experience-based assessment of the U.S. approach to mental health care does not stand alone; the numbers tell a troubling story about failings of mental health delivery and the impact of mental health disorders. The recent poll that found that two out of every five adults suffered from moderate to severe mental health issues during the pandemic also found adults reported difficulty sleeping (36%) or eating (32%), increases in alcohol consumption or substance use (12%), and worsening chronic conditions (12%). Isolation, job loss, health concerns, and excessive worry during this unprecedented time has had a major impact on well-being. Further, according to the National Alliance on Mental Illness, one in six U.S. youth experience mental illness each year, and suicide is the second leading cause of death among people aged 10-34; half of all lifetime mental illness begins by age 14. A lack of treatment for mental health conditions costs the U.S. more than $100 billion annually. Yes, this is a major problem, one that disrupts lives, livelihoods, relationships, and our basic human desire to find joy.
When desiring help, patients often turn to primary care providers who report that 70% of all visits include a behavioral health component. In fact, nearly two thirds of people experiencing depression and other common mental health conditions are treated exclusively in primary care settings. While these clinicians provide the majority of mental health care for these patients, only about 3% of the encounters are coded for primary diagnoses of depression and anxiety. These providers may not be trained on optimal treatment methods, underscoring the need for collaboration with and among mental health clinicians.
From a whole-patient view, mental health conditions are associated with significant morbidity and mortality, and these individuals have a higher likelihood of developing cardiovascular and metabolic diseases. Those experiencing both physical and mental health conditions also incur higher health care costs and experience worse overall health outcomes. The whole patient and how we treat them really does matter.
An integrated Primary Health team—in line with BHI strategies—enables partnered care toward holistic health, and the data shows it.
Crossover recently evaluated the effectiveness of its integrated approach in responding to the mental health crisis. When comparing the clinical outcomes of more than 3,000 Crossover members to patients in the community, study results showed Crossover to be significantly more effective than the community in improving overall mental health outcomes.
The data from our study and throughout this post reaffirms that an approach to interdisciplinary care works and the urgent call for inclusion of mental health within primary care models rings loudly. Mental wellness is a relational pursuit and cannot merely be managed by isolated transactions or singular care episodes. Instead, personalized care of each member, backed by healing relationships between doctors and patients, has the power to improve overall quality of life. Isn’t this the result every patient deserves?
About the Author
Michael Boroff, PsyD, is a clinical psychologist and the Mental Health Program Manager for Crossover Health. He oversees the mental health program across the country and works within Crossover’s integrated, team-based care model, to establish trusted relationships with his patients and their extended care teams to achieve optimal outcomes for his patients.