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Getting Mental-Health Care at the Doctor's Office
Providers Take Integrated Approach, With Patient Numbers Set to Jump Under New Law and Psychiatrists in Short Supply
Seattle psychiatrist Anna Ratzliff oversees mental-health care for nearly 500 patients—most of whom she will never meet.
As the consulting psychiatrist for four primary-care practices, Dr. Ratzliff confers weekly with 10 care managers who follow the patients closely, provide counseling and chart their progress in electronic registries. She helps devise treatment plans and suggests changes for those who aren't improving.
"I get to touch so many more lives than I would if I were seeing these patients in person," she said.
The Health Law Rollout
Dr. Ratzliff's practice is part of a burgeoning effort to integrate psychiatric care into primary-care practices, in a bid to make more efficient use of a limited number of mental-health professionals. Providers are bracing for a surge of new patients seeking mental-health care under the federal health law, and some are using new ways to deliver more care to more patients at less cost.
Starting next week, plans sold on the new insurance exchanges must provide at least some mental-health coverage; existing plans must do so when they come up for renewal. And a 2008 federal "parity" law bars insurers from putting more restrictions on mental-health benefits than on medical services. As a result, as many as 62 million more Americans will have access to mental-health coverage, by White House estimates.
But using those benefits may be difficult in some areas. Some 90 million Americans live in communities with fewer than one psychiatrist per 30,000 residents, according to government surveys.
The idea of having primary-care providers treat mental-health issues with psychiatrists' oversight isn't new, but it is catching on in community health centers, large health systems including Kaiser Permanente and the Veterans Health Administration, and pilot Medicaid and Medicare projects.
"We're seeing more interest in this in the last five years than the last 20," said University of Washington psychiatrist Wayne Katon, who pioneered the concept in the early 1990s.
Also spurring interest is the growing awareness that medical and mental-health problems are often linked. Patients with diabetes and heart disease have twice the rate of anxiety and depression as the general population, which in turn makes it harder to make healthful changes like losing weight, studies have shown. Approximately 25% of primary-care patients have one or more psychiatric disorders—mostly anxiety, depression or substance abuse, according to a JAMA study.
Time-pressed Primary-care doctors typically hand such patients a referral to a mental-health specialist, but only 60% of patients followed through, according to a 2002 study in Seattle conducted by the University of Washington.
In an integrated-care practice, doctors can do a "warm handoff" instead, personally introducing patients to a counselor on site.
"It's so important to capture that moment," said internist Thomas Goforth, medical director of the Family Health Center of Harlem, an integrated-care center in New York City. "If a patient gets comfortable with a counselor before ever leaving the building, he's much more likely to return."
In some practices, psychiatrists and psychologists work alongside primary-care providers on cases. In others, primary-care doctors prescribe antidepressants or other medications, and care managers—typically licensed clinical social workers—confer weekly with patients to monitor progress, often using a standardized nine-question depression quiz.
Many care managers also provide cognitive behavioral therapy and other counseling. "The goal is to give patients the skills to approach problems differently," said Jürgen Unützer, a University of Washington psychiatrist, who has helped more than 1,000 clinics nationwide adopt the model.
Many studies have shown that integrated care can reduce patients' depression and cut costs. One University of Washington study of 1,800 patients found that providing a year of integrated care cost $600 a patient but saved an average of $4,000 in lower medical bills over the next four years.
Still, integrated care is a big adjustment for psychiatrists, whose training typically focuses on one-on-one relationships.
Moreover, some critics say it provides superficial, cookie-cutter care and relies too heavily on medication. In cities where psychiatrists are plentiful and patients can pay for traditional therapy, "this is a really hard sell," Dr. Unützer said.
Traditional fee-for-service reimbursement does pose problems for integrated practices. Psychiatrists usually can't bill for patients they don't see in person. Many insurers won't pay for telephone consultations, and some Medicaid plans will pay for only one service a day, even if a patient sees multiple providers at the same clinic.
Health plans that pay capitated fees, or flat fees per patient, have been faster to adopt the integrated-care plans. The American Psychiatric Association, the American Psychological Association and the American Academy of Family Physicians have all endorsed the concept.
And many patients like the approach. Magali King, 54 years old, gets treated for schizophrenia, bipolar disorder and diabetes at Dr. Goforth's clinic in Harlem, and joins in his monthly fitness sessions. "They are helping me keep everything in balance," she said.
Body and Mind
Who needs, gets, gives care
25% of U.S. adults experience a mental-health issue in a given year
60% of them receive no treatment
68% of adults with a mental-health disorder have at least one medical condition
29% of those with a medical condition have a mental-health issue
50% of care for mental-health disorders is delivered by primary-care providers
66% of visits to family physicians involve stress-related symptoms
Sources: National Alliance on Mental Illness; National Comorbidity Survey
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