DB Strives To Heal Rift Separating Mind, Body

Mind and body may be one, but when it comes to treatment, it seems they often need to be in two places. But the Minnesota Psychiatric Society (MPS) is embarking on an ambitious effort to mend this split and establish sustainable, real-world models of integrated care.

Roger Kathol, M.D., task force chair of the MPS's Integrated General Medical and Behavioral Health Program Development Initiative, told Psychiatric News that fragmentation of care—a feature of many aspects of American medicine—has been especially acute in the treatment of mental illness and substance abuse, where the traditional “mind-body split” is reflected in the way that mental health services are organized and financed. The growth of behavioral health carveouts has supported this fragmentation—to the detriment of patients and at substantial cost, he said.

“The clinical and financial interaction between medical and psychiatric illness is huge,” Kathol told Psychiatric News.“ For instance, a third of diabetic patients suffer from depression, yet treatment of the diabetes and the depression is administered as though it were occurring in separate individuals.

“It is critical to link psychiatric symptoms and functional impairment to the patient's medical illness and to integrate the care provided—not to just coordinate the services of the people giving it,” he said.

Kathol is also MPS president-elect and an adjunct professor of internal medicine and psychiatry at the University of Minnesota.

The project's task force members include psychiatrists, pediatricians, family practice physicians, and representatives from state government, health plans, employers, patient advocacy groups, and the Minnesota Medical Association. Insurers involved in the effort include the state's five major companies—Blue Cross/Blue Shield of Minnesota, Medica, Health Partners, Preferred One, and First Plan.

Eight outpatient clinics throughout the state are participating, as is the inpatient clinic at Bethesda Hospital, which has two inpatient programs.

Negotiations Still Under Way

The initiative is still in the early stages, with negotiations ongoing between MPS and health plans in the state. But the vision behind the initiative promises a sea change in the way psychiatric conditions are treated.

“The Minnesota Psychiatric Society has been advocating for a shift in public policy toward psychiatric disorders, reframing psychiatric issues in a public health rather than a social services framework,” said MPS President William Dikel, M.D. “We recognized that most mental health treatment in the state was being provided by primary care physicians, who had insufficient training in screening, diagnosis, and treatment and who generally did not have close working relationships with psychiatrists. We have successfully advanced legislation that will reimburse psychiatric consultation to primary care physicians. We believe that, through integrating psychiatric and primary care services, we will succeed in early intervention efforts, reduce health care expenditures, eliminate mental health carveouts, and build a defense against psychologist prescription privileges.”

And Kathol said the integrated-care initiative has generated statewide enthusiasm. “There are a lot of general practitioners who are dying to have behavioral health support, because they can't get it now,” he said.“ They want someone there who can be available to help them and their patients.”

According to the MPS, the initiative is designed to encourage participating clinics to “create state-of-the-art, integrated care programs” with the hope that “health plans will collaborate by supporting `out-of-the-box' reimbursement approaches that fairly compensate for and encourage coordinated general medical and behavioral health care.”

Crucial to the program's success, according to the MPS, is “the development of a reimbursement environment for general medical and behavioral health specialists and participant general medical hospitals and clinics conducive to coordinated assessment and treatment of medical and psychiatric health care concerns or illness in the nonpsychiatric setting. This will be done through collaboration between providers, care delivery organizations, government agencies, health plans, and employers.”

Customization Will Be Crucial

Kathol said clinics will need to possess certain core components in order to participate, but the ability to “customize” their integrated service model to the population the clinic serves will be essential.

“We want to allow them to use their clinical setting as a model based on the strengths of their personnel and the targeted population they serve,” he said. “They can create a clinical setting that meets the needs they have rather than trying to meet outside service requests.”

According to the MPS, core components of participating outpatient clinics include the following:

Participating clinics will also be encouraged to use mental health teams, with active psychiatrist involvement, proactive screening for high-risk cases, a mechanism for patient follow-up to ensure adherence, and clinical and economic outcome measurement.

Kathol told Psychiatric News that critical to the success of the initiative is a common source of reimbursement for general medical physicians, psychiatrists, and behavioral health specialists working in general medical settings. And he said that carveouts have been a severe impediment to the integration of care.

“A critical component is that behavioral specialists working in the general medical setting are paid for clinical services they provide rather than being subsidized from outside,” Kathol said. “Integration is anathema to carveouts since they have a financial disincentive to support behavioral health care outside the psychiatric setting.

“A lot of psychiatrists feel that we have to learn to live with behavioral carveouts. But I would encourage people to consider working with medical, not behavioral, managed care companies, because it's the carveout system that prevents the coordination of care for their patients.”

A description of the Minnesota initiative is posted online at<www.mnpsychsoc.org/DESC.doc>.▪