Ending the Segregation of Mental Health

Don't blame carve-outs

Joe Burns
Contributing Editor

Brian Wheelan, executive vice president and chief strategy officer for Beacon Health Options, a managed behavioral health company in Boston, contends that the definition of integrated care and what it takes to achieve it is being oversimplified. “There’s a narrative that says, ‘Just put all your money for behavioral health and primary care in one place and you’ll magically integrate care.’” He argues that the realities of integrating care are actually more complex and vary substantially based on the population characteristics and types of behavioral health services that are being delivered.

Brian Wheelan

The myth of integration breaks down when it comes to serious mental illness, says Brian Wheelan of Beacon Health Options. Very few primary care practices are equipped to handle the challenges presented by these complex conditions.

“No one is arguing that individuals should not be screened and treated for all their medical and behavioral health needs, but to place the blame for fragmented care squarely at the feet of so-called carve-outs is a false premise,” says Wheelan. He supports payment reform and its role in promoting more integrated care, but he believes that specialization should not be lost in the process. His perspective stems largely from Beacon’s work in the public sector, where managing the safety net mental health and substance use care systems has revealed the clinical and administrative complexity of managing and reimbursing community-based behavioral health services. He acknowledges that many individuals with mild-to-moderate behavioral health conditions are better served and more likely to engage in services offered within the primary care physician’s office. But Wheelan rejects the notion that the doctors or managed care plans without specialized expertise can make that a reality.

Instead, he argues that patients who have substance use problems and those with serious mental health conditions are actually better served in managed care programs that specialize in building and managing provider networks that include a variety of evidence-based behavioral health care services. Most primary care physicians (PCPs) will tell you, says Wheelan, that there are limits on whom they can effectively treat in their offices without dramatically disrupting their practices.

His analysis is useful even if you disagree with certain parts of it. Wheelan organizes people with behavioral health problems into different groups, and the relevance of integration varies with the group. One group, which typically includes about 4% of all members of a health plan, will have serious mental illness like schizophrenia, bipolar disorder, or a debilitating personality disorder. “For these individuals, the myth of integration breaks down because very few primary care practices are equipped to handle the challenges presented by their complex conditions. It’s a small group of people, but their care is costly,” Wheelan says.

Most primary care physicians will tell you that there are limits on whom they can effectively treat in their offices without dramatically disrupting their practices.

A second group includes patients with substance use problems, such as addiction and alcoholism. Health plans struggle to care for this group because they may require detox and residential treatment. Often treating these patients requires a separate license, according to Wheelan, and determining the medical necessity of treatment is challenging. “What do you do if this is a patient’s 11th referral to detox?” he asks. “You need specialty care for this group.”

A third group includes patients with mild to moderate depression, and it’s for these individuals that treatment in primary care is definitely the most effective and appropriate, if done well, he says. One problem, in his view, is that many PCPs often fail when attempting to co-locate behavioral health clinicians. Another is that health plans must guard against a tendency by PCPs to overprescribe psychotropic medications rather than access traditional outpatient therapies that evidence shows to be highly effective.

A fourth group includes patients being treated by specialists, such as cancer patients. “If you organize a practice around caring for patients with a high-cost condition and pay with bundled payment, much of the time, mental health care belongs in that payment,” says Wheelan. “You see this model in medical homes for oncology and diabetes and in headache or pain clinics.”

Lastly, there is a group of people with conditions like heart disease and obesity that have comorbid depression. In Wheelan’s opinion, PCPs in large group practices may have the staff and resources to care for these patients but perhaps not PCPs in more constrained circumstances. Even PCPs in large groups need to refer serious cases to full-time mental health professionals, he notes.

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