Setting a new standard for care

Why the latest HHS announcement on mental health and primary care matters

In 1996, the National Academies of Sciences, Engineering, and Medicine (NASEM), at the time known as the Institute of Medicine, released a powerful report on primary care. While primary care has always been the backbone of our health care system, this rich report lifted up several areas which we could improve on this foundation. There was one chapter in particular, written by my friend and mentor, Dr. Frank deGruy that stands out even today.

In his writing, Dr. deGruy lays out a rock solid case as to why mental health and primary care should be seen as one - as integrated. Inseparable. Even 20 plus years ago, the evidence was clear that the separation of the two led to more problems for the patient and their family. He wrote:

“Mental health care cannot be divorced from primary medical care, and all attempts to do so are doomed to failure. Primary care cannot be practiced without addressing mental health concerns, and all attempts to do so result in inferior care.”

Inferior care. Let that sink in for a second.

This very loud call to action was new to a lot of people. Frontline clinicians likely knew of the challenges getting access to mental health for their patients, but most people simply didn’t know that there was even an option to bring mental health clinicians into primary care as a part of the primary care team. We, as a community, had become used to fragmented, siloed care. We were trained in it, we were paid to provide it, and policy only supported it being separate.

Just two years later, Dr. Alexander Blount published what became the go to handbook for those looking to know more about mental health and primary care. Integrated Primary Care: The Future of Medical and Mental Health Collaboration was the must read “how to” book for those wanting to integrate. It had case studies and wonderful examples from the field so that we didn’t just have to imagine anymore what this work could look like - we could actually see it up close through the eyes of those on the ground doing the work.

A lot happened over the years to give this integrated approach more traction. There was the science, which only got stronger thanks to leaders like Drs. Wayne Katon and Jurgen Unutzer. There was the increase in dissatisfaction from our communities who were being told to wait longer for help or even worse, just getting lost in the transition between primary care and specialty mental health. There was the beginning of new payment models that broke the fee for service stranglehold on primary care allowing more innovation like bringing mental health into the clinic to occur.

For those who want a deeper history into mental health, primary care, and integration, there is a book chapter that I wrote years ago that goes into a lot of detail on the separate histories of mental health and primary care.

For years, people kept advocating for more integration to occur. Papers were published, talks given, and yet it felt like scaling up this successful model was still an aspirational dream. Sure, there had been progress, but this model had not become a new standard of care delivery for primary care. And even more frustrating, it wasn’t getting the attention of policy makers.

Almost 10 years ago, I published a paper that spoke to the challenge of practices being ahead of the policy community. I wrote:

“Innovation in health care delivery often far outpaces the speed at which health policy changes to accommodate this innovation. Integrating mental health and primary care is a promising approach to defragment health care and help health care achieve the triple aim of decreasing costs, improving outcomes, and enhancing patients' experiences. However, the problem remains that health policy does not frequently support the integration of care.”

I couldn’t understand why there was not more policy action on the topic.

Fast forward until this past week when the Secretary of Health and Human Services (HHS) Xavier Becerra and team put out a press release highlighting a roadmap for advancing mental health and primary care integration. They focus on several key opportunities that could strengthen and scale integration:

• Expanding access to mental health by integrating mental health into primary care settings

• Recruit, train, and support a diverse mental health workforce

• Strengthen the implementation and enforcement of mental health parity

• Engage several of the highest-risk populations

• Integrate promotion and prevention programs in community-based settings from early childhood to young adulthood, inclusive of schools

• Test models of care integration facilitated through value-based payment arrangements and emerging technologies as well as an opportunity to reduce the technology gap

• Drive resources into integrated care through pay-for-reporting and pay-for performance mechanisms based on integration-related quality measures

While there’s a lot here to unpack, there are three things that stand out to me:

1. Mental health and primary care integration has gotten some much deserved and needed attention. Just last year, a report published by the Bipartisan Policy Center put forward several actionable recommendations for the Congress to consider. This report pushed more on all branches of government to do more for integration. It got the attention of key leadership who began holding committee hearings. In the Senate, this was a big deal as the Finance Committee gave out assignments based on five key areas in which integration was a dominant theme. You couldn’t turn on a hearing and not hear of people talk of mental health and primary care integration. It’s time had come.

2. Without going deeper on how we pay for care, a lot of attempts to integrate will fall short. Thankfully there appears to be interest in looking at new ways to pay for this team-based approach to care. In 2019, our team published a paper lifting up a promising payment model for integration. The data were there that paying for primary care differently to include the cost of mental health was a difference maker for sustainability as well as outcomes. This model continues to this day in Western Colorado, and has been written about extensively elsewhere. The HHS roadmap as well as pending legislation in Congress pushes this payment issue much more, which is critical!

3. There must be a way to increase community awareness of integrated models. People still expect fragmented care - we need to give them exposure to models of integration and have them become part of our advocacy efforts to push for more policy change that supports integration. This roadmap could be strengthened by greatly enhancing the communication arm helping our community better understand the peril of fragmentation and the promise of integration. Information on what’s available, where, and for whom will be vital to help our friends and family know where mental health may be available in primary care practices.

Overall, for people like me who have been working on this issue for over 20 years, it’s a very positive step forward for our field to see this roadmap from HHS. But even more importantly, these policy steps begin to move us in a new direction where we are bringing mental health to where people are - and primary care is one of the best places to do this!