How Integrated Care Is Bridging the Gap Between Physical and Mental Health Services

There is a strong association between drug use disorders and mental illnesses. What's behind this?

• Behavioral health patients often struggle with the subjective nature of pain. In response, their providers and plans may support the use of powerful and addictive analgesics, including opioids. A study published in the Journal of the American Board of Family Medicine revealed that the mentally ill receive half of all annual opioid prescriptions in the U.S.
• The long-term ingestion of some substances may contribute to worsening mental health. At the World Psychiatric Association's World Congress in Berlin in 2015, a presentation from the Max Planck Institute of Experimental Medicine suggested that adolescent consumption of marijuana accelerated the development of schizophrenia, according to Scientific American.
• Some drug use disorders and mental illnesses have similar underlying causes, such as genetic vulnerabilities and abnormalities in specific regions of the brain. The National Institute of Drug Abuse noted that the same dopamine receptors are the targets of addictive drugs and many antidepressants and antipsychotics.

The ongoing drive to better understand the link between mental health and drug use has prompted examination of behaviors like the higher-than- normal smoking rates in patients with schizophrenia. One theory is that smoking may be a form of self-medication for the symptoms of schizophrenia. Another is that it could be the result of overlapping brain circuitry vulnerable to addiction and mental illness. It is necessary to continue to study the causal relationships between mental health issues and drug use to ultimately determine the best ways to care for patients.

Healthcare insurers and providers, along with the justice system and government agencies, have responded to changing perceptions of drug use disorders by endorsing integrated care. This approach ideally bridges the traditional chasm between physical health (widely covered by insurance) and mental health (more limited coverage). Combining the two is essential for effective treatment, but how much progress has been achieved to date?

Integrated Care Report Card: The Struggles to Broaden Mental Health Access

The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) is a leading proponent of integrated care. The organization has flagged limited access to primary care among vulnerable populations and the general complexity of the healthcare system as obstacles to life-changing treatments for patients with mental illnesses and/or substance use disorders. It has formulated guidance for pursuing integrated care within many different settings, including primary care clinics and patient-centered medical homes.

It remains an uphill struggle for many behavioral health patients to find accessible treatment. The challenge is multifaceted, with aspects related to limited insurance coverage along with insufficient numbers of suitable facilities and mental health professionals.

Insurance Coverage

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) mandated that insurance claims for mental health and substance abuse have equal footing with traditional medical and surgical procedures. In reality, mental health claims are still not accepted at near the rate of physical health claims. A 2015 study by National Alliance on Mental Illness revealed a 30-percent denial rate for mental health treatments among privately insured Affordable Care Act (ACA) enrollees. That's double the rate of refusals for all care among ACA patients.

Some mental health patients face limited insurance coverage.

One major underlying issue is varying definitions of whether a given mental health condition is "medically necessary" and, as such, eligible for the same extent of coverage as a physical one. For example, a health plan might impose strict limits on the number of annual visits for a behavioral health condition (e.g., an eating disorder), and, in contrast, have much fewer limits for treatment addressing physical ailments (e.g., heart disease).

Facilities and practitioners

Many Americans do not have easy access to inpatient psychiatric hospitals, particularly in rural communities. For example, there are fewer than 10 such facilities in Maine, according to VICE. In addition, mental health professionals are in short supply. The Health Resources and Services Administration has estimated that 89.3 million Americans live in Mental Health Professional Shortage Areas, far more than the 55.3 million in areas with primary care shortages.

The shortage is related to another facet of the broader insurance issue we discussed earlier: reimbursement rates for mental healthcare providers. A 2015 article in the Journal of the American Medical Association revealed that only 55 percent of office-based psychiatrists accepted insurance, compared to 88.7 percent of specialist physicians. Their participation in health insurance networks has also declined more precipitously.

Evidence-based Medicine and the Way Forward for Integrated Care

To improve access to services for mental health care and substance abuse, consistent treatment protocols and documentation of these conditions are necessary. Evidence-based medicine (EBM) has already revolutionized how providers and payers approach both chronic and acute illnesses; EBM practices could likewise be extended further into the realm of behavioral health to strengthen the care for patients, from testing to diagnosis to treatment. The SAMHSA resources also provide a good starting point for setting up integrated care in offices and clinics.

The justice system has a vital role to play in supporting integrated care, too. State attorneys-general are especially important players here, as they can help negotiate settlements that establish precedents for out-of- pocket costs and affordable access to services, such as counseling.

Finally, partnering with an independent medical review provider like Advanced Medical Reviews (AMR) can contribute to a behavioral health system that works for everyone. Physician-level peer reviews, as provided by AMR, ensure that an extra level of attention is given to these claims to ensure best practices, based on current evidence and guidelines, are being heeded by payers and providers. By following evidence-based guidelines with input from all health stakeholders, we can ensure high-quality and sustainable services that bridge the gap between physical and mental health to deliver relief to behavioral health patients affected by mental illnesses and/or drug use disorders.