The Role of Health Care Providers

It is no longer possible for the health care system (including psychiatry) to ignore the vast number of patients with psychiatric disorders seen in the general medical setting, nor is it acceptable for patients with mental health and substance use disorders seen in the psychiatric sector to have less than optimal access to general medical services. While this should have its basis on ethical grounds, it is the economic impact of patients with concurrent physical and mental health needs that will drive change. It is well known that a small percentage of patients use the greater share of health resources.⁷ Interestingly, 50% to 80% of those in this complex group have general medical and psychiatric illness. At a projected cost in the trillions of dollars for excess general medical costs in patients with psychiatric disorders over the next 10 years, an increasingly informed health care system is taking steps to address the assessment and treatment of psychiatric disorders in the general medical setting. This is where psychiatry’s opportunity arises.

Nothing involving change is easy. The transition from segregated to integrated general medical and psychiatric services is no exception. The US health care system has become invested in a carved-out methodology. Moving from a carved-out to a unified health care system requires basic adjustments in the way that psychiatric disorders are handled. This can be achieved by following successful models of service integration of physical and mental health care seen in some inpatient or outpatient general medical or psychiatric settings. Furthermore, these models will ultimately mandate that psychiatric services be paid from medical benefits; thus, managed behavioral health organizations will be phased out. The challenge is to create the clinical and administrative synergy to allow this to happen.

At the core of recommendations for psychiatrists (Table 1) is the need for assessment and treatment of psychiatric disorders to become a basic part of health. By doing so, patients with psychiatric disorders, with or without physical comorbidities, will have access to the physical and mental health services that they require and deserve, regardless of service location. Ultimately, if value-added programs become a significant feature in the transition, reimbursement for mental health services will improve while total health care costs go down and patient health improves.⁸

Table 1	Suggestions for Psychiatrists
Administrative: transition to payment for health services from “behavioral” to “medical” health plans (over 2 to 3 years, but start now) Become a part of medical, not independent behavioral, provider networks Code and bill for clinical services, as physical health providers, from a single funding pool Sign provider contracts only if they allow: – Psychiatric intervention, regardless of setting – Same-day reimbursement for physical health and psychiatric services
Clinical: transition to practice capabilities for psychiatrists in the primary care setting and nonpsychiatric physicians in the psychiatric setting Organize value-added integrated clinical programs based on outcomes literature, eg, delirium prevention programs, proactive complex case finding collaborative primary care clinics, complexity intervention units (a new term for medical psychiatry units) Lead psychiatric collaborative care teams (eg, nurses, social workers, psychologists) with levels of involvement in service delivery based on value brought to patients Assure routine on-site primary care preventive and acute care services in psychiatric service locations (inpatient and outpatient)

Suggestions have been divided into administrative and clinical. However, one without the other is impractical and unlikely to occur. As part of the recommended transition, psychiatrists will need to become familiar with the literature that shows the impact that untreated psychiatric disorders have on outcomes and costs for patients treated in the primary care setting, and vice versa.⁸ Armed with this knowledge, cost and quality arguments directed to medical health plans and general medical hospitals and clinics will allow the transition to proceed.