FIG1 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
Roger Kathol, M.D.
Photo courtesy of Roger Kathol, M.D.
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
"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.
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
"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
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."
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
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>.▪