(Courtesy of Healthcare Advocacy News)
Dr. Ben Miller is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. He is a co-principal investigator and co-creator of the National Research Network’s Collaborative Care Research Network, and has been the principal investigator on several federal grants examining mental health and primary care integration.
In an interview with Catherine Strode, Coordinator of the Health Care Advocacy Program, he discussed how we are currently working with a fragmented system that has many competing interests. He went on to describe a vision of health care reform that is centered on primary care and a coordinated team of providers.
“The vision is to create a seamlessly integrated, comprehensive, whole person health care system. The end game here is that you, as an individual, can have all of your needs met in one setting, services surrounding you. In order to do that, we have to go back and reexamine everything that we’ve built up to this point in health care. If we do that, what we find is that we have multiple systems to take care of the whole person.
From a policy perspective, and even from an administrative systems perspective, it’s inefficient. We have a mental health system which is supposedly there to take care of your mind, correct? But what we find is that most people don’t take advantage of that system when they have a mental health condition. They go to another health care environment. Most of the time, that’s primary care. One in five are going to present with a mental health condition and 70% of psychotropics are prescribed solely by primary care providers. If the primary care physician tries to refer these patients out, we know that on average 40 to 60% don’t go.
Data that came out of a Health Affairs article a few years back, when they interviewed 6600 primary care physicians, showed two-thirds couldn’t even access specialty mental health.So even if they wanted to refer the patients, they couldn’t. That’s why the problem has to be fixed at the primary care level. A more robust primary care system must have mental health or else it’s going to fail.”
How do we achieve that system you are describing?
“There are two directions we can take this. At the bottom, I think the community is going to have to demand this. One of my frustrations in my job is that we have decades of research showing the inseparability of mental health and primary care. Yet we don’t have a community that’s standing out there on the street corner saying, ‘This is what I want.’ Most folks haven’t experienced that. So what they come to expect is this fragmented care. That’s a problem. I want everyone to know that when you have truly integrated care it will benefit you. Not only clinically, for your outcomes, but some folks actually like it better.
From the top down, I think the policy folks need to start to recognize that the way health care is currently set up, that could be administratively, that could be clinically, that could be the way we train and educate our providers, is to support and perpetuate fragmentation.”
How would an integrated system tangibly look?
“We know that primary care is the largest platform for health care delivery in the country. We also know that high performing countries, anywhere in the world, that have the best outcomes clinically have the highest performing primary care. We don’t do too well when compared to other countries because of the lack of importance we have yet to put on primary care. What it would look like is that we could take care of all aspects of that individual. This is your team: You’ve got your primary care provider, you’ve got your medical staff, i.e., your nurses, your MA.s.
Then you’ve got your behavioral health team. So let’s say you’ve got complex diabetes. You have an expert in health behavior that can work with you on developing an action plan towards you losing five pounds and being able to manage more recommendations around lifestyle management. What happens if you come in the door, and it’s not so much the mental health piece, but you’ve got all these psychosocial issues going on in your life. If you can’t pay for the medication, what if that money went toward keeping your lights on? It’s a psychosocial issue that your behavioral health provider can help you work with.
I think psychosocial issues predominantly will trump a lot of these areas that we are talking about in mental health.It’s hierarchy of needs. If you have no roof over your head, you have no transportation, you’ve got no food, what does it matter if you’ve got a psychologist there to talk about your depression. There’s certain things you’ve got to take care of first and I think that oftentimes is one of the areas that we miss out on.”
It sounds like a big leap. What are the baby steps?
“I’m not the baby step kind of guy. And I’ll tell you why. Because I think we’ve been baby stepping for almost 30 years, trying to fix health care. And if you look at the mess we’re in right now, it is the fact that health care is a morass of competing interests. You’ve got cultures that are vying for the same territory.
A good example of this is when we talk about how we pay for providers. We talk about fee-for-service; we talk about I will pay you for what you do. But that doesn’t necessarily promote high quality care that facilitates collaboration with multiple providers. So health care is flawed on the onset. So when we talk about what are the baby steps, I see that we’ve been trying to do baby steps for years.
The Affordable Care Act is a baby step. What we need is true second order change; where we change the rules of the game. It is not about benefiting the provider and their bottom line. It’s about reintegrating health care back into the community, building services around that patient. This is not policy talk. This is aspirational. But I have to tell you, I don’t think we can keep doing work-arounds and see us bend the cost curve. I don’t think we can keep doing work-arounds and see the community be satisfied and really have all their needs met. What I think we need to do is rethink what we’re talking about when it comes to health care.”