Nonpsychiatric physicians should have a vested interest in helping psychiatrists take a more active role in the treatment of mental health and substance use disorders in primary and specialty medical settings since concurrent mental health and substance use disorders predictably reduce physical health improvement and create challenges for general medical staff. It is only through collaborative effort that improved mental health and substance use disorder specialty services will become available for patients.

Helping psychiatrists will not be a priority because each discipline has its own issues to foster. However, few general medical physicians will refuse to support or participate in psychiatrists’ efforts as long as psychiatrists take the lead. Table 2 suggests how primary and specialty medical physicians can cooperate to enhance psychiatrists’ successful transition. These are approaches that psychiatrists should help medical physicians adopt.

Table 2 Suggestions for Medical Physicians
Administrative: collaborate with psychiatrists as equal partners in medical health plan provider contract negotiations
  • Support psychiatrists for inclusion as a part of medical provider networks
  • Support alteration in coding and billing for psychiatric services as a part of physical health benefits of the medical health plans
  • Sign medical health plan provider contracts only if:
    – Psychiatrists (and eventually other mental health providers) are paid through medical benefits of the medical health plans
    – There is same-day reimbursement for physical health and psychiatric services
Clinical: incorporate psychiatric practice capabilities for psychiatrists in the primary care setting and physical health practice capabilities for nonpsychiatrists in the mental health setting
  • Participate in the development of value-added integrated clinical programs based on outcomes literature, eg, delirium prevention programs, proactive complex case finding collaborative primary care clinics, complexity intervention units
  • Support psychiatric collaborative care teams (eg, nurses, social workers, psychologists) in the primary care setting
  • Provide routine on-site primary care preventive and acute care services in psychiatric service locations (inpatient and outpatient)

Nonpsychiatric physicians who live in rural areas should be particularly interested. These efforts can increase the potential for access to psychiatric support in underserved settings, either through easier recruitment into more desirable practice settings or with the development of clinical arrangements not possible in today’s reimbursement environment, such as the creation of telepsychiatric capabilities.

 

It is impossible to talk about improving services for patients with mental health and substance use disorders without discussing the role that nonclinical decision makers have in the change process. Table 3 outlines suggestions for health care–related administrators representing purchasers, fund distributors, and care delivery systems. Without their buy-in and involvement, no change can be expected.

Table 3 Suggestions for Health Care–Related Administrators
Health care purchasers (employers/government agencies): purchase health packages in which
  • Employees/enrollees can be treated in clinical settings in which active communication and coordination of physical health and psychiatric services and providers occurs without difficulties
  • Psychiatric services are a part of physical health benefits
  • Health management activities for physical and mental health do not require handoffs
  • Performance is measured based on total health costs of the population served, not discrete physical and mental health subsets
  • Quality improvement projects recognize the relationship between physical and mental health
Fund distributors (general medical health plans/government programs/third party administrators): create internal work processes and fund distribution business practices in which
  • Psychiatric services become a part of physical health benefits
  • Health management integrates physical and mental health services through a manager-patient relationship
  • Claims are paid using one set of coding and billing procedures, regardless of service or setting; no separate reimbursement for mental health (inpatient and outpatient)
  • Performance programs measure total health and health cost as a primary focus
  • Value-added programs become financially competitive with other clinical programs
Care delivery (hospitals, clinics, practitioners, care facilities): support and encourage the development of programs that facilitate the integration of physical and mental health care
  • Outpatient integrated value-added programs (eg, screening and brief intervention for alcoholism, substance use disorder treatment in the medical setting, primary care buprenorphine clinics, reattribution training for primary care physicians)
  • Inpatient integrated value-added programs (eg, delirium prevention programs, proactive complexity-based consultation services, complexity intervention units)

Each of these stakeholders has different constituencies and thus different objectives. Nonetheless, a central focus for all would be support for programs in which quality of care and health improvement would be associated with lower total health-related cost and less impairment. Existing data suggest that by improving mental health care through care coordination for complex untreated or poorly treated patients with psychiatric disorders seen in the physical health setting, such a result can be achieved.9 Thus, health administrators need to consider what policies they want to support in order to promote optimal health and ensure cost containment.

The End Game

Two patients who were caught in the crosshairs of a noncommunicating physical health and mental health and substance use disorders system are profiled in the case vignettes. For the past 20 years, physical health and psychiatric disorders have grown progressively further apart despite mounting evidence that addressing the needs of both, and their interaction, is critical for patients like Karen and Michael to keep from being harmed by our health system. The suggestions found in the Tables are based on the recognition that psychiatric disorders dramatically affect outcomes in illnesses of the body and vice versa. Fast-forwarding 10 years, our goal as psychiatrists should be that psychiatric disorders become one with physical health as issues related to a person’s health and be addressed comprehensively—clinically, administratively, financially. To achieve this, all of the major stakeholders must be involved.



Drugs Mentioned in This Article
Buprenorphine/naloxone (Suboxone)
Butalbital/aspirin/caffeine (Fiorinal, others)
Clonazepam (Klonopin, Rivotril)
Hydrochlorothiazide/spironolactone (Aldactazide, others)
Lithium (Eskalith, Lithane, Lithobid)
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