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Professional News
 DOI: 10.1176/appi.pn.2013.7b24
Collaborative Care Well Suited to New Medicaid Health Home Option
Psychiatric News
Volume 48 Number 14 page 1-1

Abstract

Implementation of collaborative care for the 20 percent of Medicaid beneficiaries with depression could save the program approximately $15 billion a year. This is the first in a series of articles on integrated care.

Abstract Teaser

A model of collaborative care is well suited to the new Medicaid “health home” state option, authorized by the Affordable Care Act (ACA).

So say five national leaders in integrated care in a policy brief developed for the Centers for Medicare and Medicaid Services by the Center for Health Care Strategies and by Mathematica Policy Research.

The policy brief, published in May, is one more sign that integrated care has surpassed the “tipping point” and is quickly becoming a dominant feature of health system reform. (“Collaborative Care” and “integrated care” are often used interchangeably, but collaborative care is a specific model backed by evidence that includes a psychiatric consultant as a core member of the care team; integrated care is a more general concept that simply means the integration of mental health care and primary care and may or may not include the involvement of a psychiatrist.)

Integrated-care models have evolved from the traditional consultative role that consultation-liaison psychiatrists have practiced, to a “co-located” model in which psychiatrists see individual patients in a primary care clinic, to a fully collaborative care model in which a psychiatrist takes responsibility for a caseload of primary care patients and works closely with primary care clinicians and other primary care–based mental health care providers.

Anchor for JumpAnchor for Jump

Jürgen Unützer, M.D., says psychiatric consultants in a collaboartive care network provide mental health specialty support for the primary care treatment team, particularly regarding patients who are not improving as expected.

Mark Moran

In their policy brief, Jürgen Unützer, M.D., and colleagues described in detail how a psychiatrist would operate within a collaborative care system (see sidebar).

Though models may differ, the core principles of collaborative care are constant: patient-centered care teams providing evidence-based treatments to a defined population of patients using a measurement based “treat-to-target” approach. (The latter refers to the use of tested instruments so that symptoms can be measured with numerical targets established for clinical treatment goals.) The concept is a feature of the delivery-system reforms in the new health care reform law, and policymakers and many clinicians have converged on the idea that the full range of medical services should be brought together in one patient-centered location.

APA’s Council on Healthcare Systems and Financing has established the Work Group on Integrated Care, and a growing and dedicated cadre of psychiatrists is advancing the cause of integrated care and the participation of psychiatrists in integrated-care models. In coming editions, Psychiatric News will profile some of these psychiatrists and focus on the opportunities and challenges associated with this emerging model of care.

Among those will be Wayne Katon, M.D., who was the subject of a “Q and A” column about psychiatry, mental health, and integrated care in the June 19 JAMA. In that issue Katon said health reform has provided a tremendous stimulus for positive change in terms of integrating of mental health care into primary care.

“We’ve seen more interest in the last five years than the last 20,” he said. “There are a number of dissemination centers around the country that are helping to train clinicians in this model. There is also an overrepresentation of people with mental illness among the currently uninsured individuals who may gain access to insurance through health reform. That’s another incentive to adopt collaborative-care models to help provide mental health care more efficiently.”

But if integrated or collaborative care really is the wave of the future, it is one that may take different shapes as it rolls in depending on regional variations, state laws, payment systems, and other factors. The policy brief by Unützer and colleagues focused on collaborative care as it may fit into the Medicaid Health Home State Plan Option.

Under that option as delineated by the ACA, states can link Medicaid beneficiaries who have at least two chronic conditions, have one chronic condition and are at risk for another, or have a serious mental illness to a health home to coordinate that person’s health care. Regardless of the conditions targeted by the health home, the associated providers must meet all federal and state qualifications to serve as health homes and must deliver a defined set of services. Across these services, a key desired outcome of the health home model is improved integration of primary and behavioral health care delivery.

In their brief, Unützer and colleagues outlined the clinical and cost-savings benefits of collaborative care. More than 70 randomized, controlled trials have shown collaborative-care models for common mental disorders such as depression to be more effective and cost-effective than usual care, across diverse practice settings and patient populations, they noted.

One of the largest randomized, controlled trials of this model is the IMPACT study conducted by Unützer and colleagues at the University of Washington from 1998 to 2003. That study randomized 1,801 depressed adults in 18 primary care clinics to usual care—defined as primary care or referral to specialty mental health as available—or a 12-month collaborative-care intervention. The study involved 450 primary care providers in eight health care organizations operating in five states; in the original IMPACT study and numerous replications, patients receiving collaborative care were found to have less depression, less physical pain, better functioning, and a higher quality of life. There was also greater patient and provider satisfaction.

“Importantly, from a public-policy standpoint, IMPACT has been found to lower overall costs substantially for patients receiving the intervention through more efficient mental health treatment and lower use of inpatient care, pharmacy, and other outpatient services associated with comorbid medical conditions,” Unützer and colleagues wrote. “Long-term (four-year) cost analyses from the IMPACT study found that patients receiving the collaborative care intervention had substantially lower overall health care costs than those receiving usual care. An initial investment in collaborative care of $522 during Year 1 resulted in net cost savings of $3,363 over Years 1-4. This corresponds to a return on investment of $6.50 per dollar spent, with average annual savings of $841. The collaborative care intervention yielded net savings in every category of health care costs examined, including pharmacy, inpatient and outpatient medical, and mental health specialty care.”

Using those data, they estimated that implementation of collaborative care for the 20 percent of Medicaid members with diagnosed depression could save the Medicaid program approximately $15 billion a year.

“The research evidence for collaborative care for common mental disorders such as depression and anxiety disorders, along with robust experiencing such programs in diverse health care systems around the country, suggest that states should consider using this model as a building block for health homes and other initiatives that aim to better integrate care for Medicaid beneficiaries with chronic physical and behavioral health needs,” they wrote. ■

The policy brief, “The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes,” is posted at http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Guide-to-Health-Homes-Design-and-Implementation.html. The interview with Wayne Katon, M.D., in JAMA is available to subscribers at https://jama.jamanetwork.com/article.aspx?articleid=1697958.

Psychiatrists’ Role in Integrated Care 

So what exactly would a psychiatrist do in an integrated care system?

Jürgen Unützer and colleagues, in a policy brief for the Centers for Medicare and Medicaid Services, noted that psychiatric consultants provide mental health specialty support for the primary care treatment team, particularly regarding patients who are not improving as expected. Consultant responsibilities include regular (usually weekly) reviews of a caseload of patients treated for common mental disorders such as depression in a primary care practice by a consulting psychiatrist, with a focus on patients who are not improving as expected and treatment recommendations for those patients to the treating primary care physician.

“In most cases, recommendations are summarized in brief, focused written or electronic notes to the primary care physician [PCP],” they wrote.

Review and recommendations are typically provided through a care manager supporting the PCP in primary care, but in some cases the communication is directly between the PCP and the consulting psychiatrist. “The consulting psychiatrist is also available to the PCP during the week by pager to answer questions about recommendations made,” they wrote. “The level of effort for consultants is typically three hours per week for each care manager’s primary care caseload (typically 50-100 patients).”

The AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington has posted a sample job description for a consultant psychiatrist working within an integrated care system at http://uwaims.org/files/team-building/ConsultingPsychiatristJobDescription.pdf.

As APA President-elect Paul Summergrad, M.D., noted in an interview with Psychiatric News, it is unlikely that traditional forms of psychiatric practice will all change, let alone disappear. But in the meantime, psychiatrists should educate themselves about evolving systems of integrated care in their area and may want to begin experimenting with a consultative role to existing collaborative care networks.

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Jürgen Unützer, M.D., says psychiatric consultants in a collaboartive care network provide mental health specialty support for the primary care treatment team, particularly regarding patients who are not improving as expected.

Mark Moran

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