Collaborating With Our Medical Colleagues

August 2, 2008
Roger G. Kathol, MD

,
Sarah Rivelli, MD

Volume 25, Issue 9

Ninety percent of patients with psychiatric disorders are seen in the general medical sector. Two-thirds of these patients receive no treatment for their psychiatric illness. Of the one-third that does, only one-tenth is provided minimally adequate treatment.1 Furthermore, nontreatment or nonevidence-based treatment of psychiatric disorders in the primary care setting is associated with at least double the total health care costs for patients, mainly from increased general medical care and nonpsychiatric prescriptions.2,3

CHECK POINTS

  • Each area of medicine has unique features but none to the extent that mandate independent service locations and independent reimbursement.

  • Moving from a carved-out to a unified health system requires basic adjustments in the way that psychiatric disorders are handled.

  • If value-added programs become a significant feature, reimbursement for mental health services will improve while total health care costs go down.

  • A central focus is quality of care and health improvement in association with lower total health-related cost and less impairment.

Ninety percent of patients with psychiatric disorders are seen in the general medical sector. Two-thirds of these patients receive no treatment for their psychiatric illness. Of the one-third that does, only one-tenth is provided minimally adequate treatment.1 Furthermore, nontreatment or nonevidence-based treatment of psychiatric disorders in the primary care setting is associated with at least double the total health care costs for patients, mainly from increased general medical care and nonpsychiatric prescriptions.2,3

The plight of patients seen in the psychiatric setting with concurrent physical health problems, who need general medical services, is no better. There is substantial evidence that these patients have difficulty accessing services in the general medical sector. This is associated with quicker progression of physical disease and, ultimately, premature death.4,5

Case Vignette

Karen, 34 years old, has been treated by her primary care physician for the past few months. She came in for diffuse muscle aches, frequent throbbing headaches, crampy abdominal pain, and dizziness. She was given a muscle relaxant, butalbital combined with caffeine and aspirin for headaches, and a hypnotic for sleep.

Noticing the number of prescription refills 4 months later, her physician became concerned and asked Karen about the number of pills. Karen reported tension and anxiety. She confided that she had been molested as a teen and sometimes had nightmares that made it hard to sleep and explained that clonazepam improved her sleep, decreased nightmares, and helped with muscle aches. Her physician renewed the prescription and usage escalated. At 6 months, her doctor again expressed concern about medication overuse.

Karen revealed that she had been hospitalized 9 months earlier for suicidal ideation and that she struggled with depression. With no access to psychiatric records, Karen’s physician knew nothing of this history and suggested that Karen return to her mental health practitioner. Karen explained that she had discontinued seeing her psychiatrist because his care was not covered by her insurance. She had tried to get a new psychiatrist through her insurance provider directory but after 7 calls, the best she could do was to get an appointment in 8 weeks with a nurse clinician at a clinic 15 miles away. At that point, she decided to stick with her primary care provider for mental health care. She did not ask her physician for depression medication because her family already thought she was taking too many pills.

Her primary care physician requested Karen’s psychiatry records, but they could not be released without special permission. While processing the paperwork to get the records, Karen continued to use large amounts of clonazepam. She also started consuming alcohol heavily. One afternoon, she became suicidal and was taken under duress to the local emergency department (ED) for psychiatric evaluation.

Case Vignette

Michael, 46 years old, has been hospitalized in the psychiatry unit for hyperactivity, heavy spending, sexual indiscretion, lack of sleep, and pressured speech. His symptoms were controlled with lithium and other medications. At discharge, Michael’s lithium level was 1.2 mEq/L. A 10-day postdischarge follow-up was arranged with a psychiatrist on Michael’s insurance provider list.

Six weeks after discharge, Michael visited his primary care physician (Dr S) for potential treatment of hypertension. Dr S prescribed hydrochlorothiazide
25 mg/d and recommended a low-salt diet. He encouraged Michael to continue seeing a psychiatrist for mental health issues and psychotropic prescriptions. A week later, Michael called Dr S to report nausea, fatigue, and loose stools and was treated for mild gastroenteritis with hydration and rest.

Within 3 days, Michael became confused, had difficulty in walking, and had slurred speech. He was taken to the ED. Informed of Michael’s recent inpatient mental health admission, the ED physician thought symptoms were related to psychosis and called a psychiatrist who suggested that Michael’s lithium level be measured: it was found to be 3.7 mEq/L. Michael was admitted to the ICU for acute lithium intoxication.

A Disconnect in Today’s Health Care

There are 2 primary reasons why patients with comorbid general medical and psychiatric illness find it difficult to obtain coordinated physical and psychiatric services. The first and most obvious is that the health system pays for mental health and chemical dependency care from segregated budgets.6 This is based on the erroneous assumption that mental health and substance use disorders are somehow sufficiently different from other health problems that they require completely separate clinical delivery areas and payment mechanisms. In fact, psychiatry is the only area of allopathic medicine in which this occurs.

As jointly trained physicians in internal medicine and psychiatry, we argue from our experience in day-to-day clinical care that patients with psychiatric disorders are as similar to patients with physical illness as patients with surgical conditions are to those with chronic medical illnesses treated with medication only. Each area of medicine has unique features but none to the extent that mandate independent service locations and independent reimbursement. The artificial separation of psychiatric care from physical health care is a disservice to the physical health of patients in whom emotional and behavioral factors contribute to poor illness outcomes. It is also a disservice to patients with psychiatric disorders in whom coexisting general medical illness causes or exacerbates psychiatric symptoms and/or leads to premature death.

The second reason for “disintegrated” physical and psychiatric services is tradition. Nonpsychiatric physicians and psychiatrists have lived in separate worlds for so long that they can no longer visualize a medical environment in which coordinated care could occur. Few physical health physicians have much more than passing knowledge of advances that have been made in psychiatric diagnosis and treatment during the past 30 years, thus few use evidence-based approaches to care or see a need to request assistance from psychiatric specialists. Moreover, primary and specialty medical physicians find it convenient that “psych” patients are cared for in different locations. That way they can inconspicuously avoid involvement in those patients’ medical care since clinical service locations make it inconvenient to do so.

Psychiatrists harbor their own biases. Many continue to argue that psychiatric disorders require special privacy laws-as if erectile dysfunction and treatment for spousal abuse are not equally in need of privacy. Privacy is necessary for all personal health information, whether general medical or psychiatric, but information should not be withheld between clinicians. Psychiatrists have also made themselves largely unavailable to nonpsychiatric physicians. While this originated with payment disparities, it has grown to a “we” versus “they” mentality, with hostile overtones in some settings. Wait times of 3 weeks to 3 months for adult psychiatric appointments and 3 to 6 months for child psychiatry are the rule rather than the exception.

Many psychiatrists feel uncomfortable treating patients in whom comorbid medical illness must be factored, just as their medical counterparts feel out of their element when emotions or aberrant behaviors interfere with medical/surgical interventions. Separate assessment and treatment of physical and mental illnesses has allowed practitioners to focus on treatment in their primary discipline while their comfort with cross-disciplinary disorders deteriorates. However, patients with comorbid physical and mental illness are the norm, and practitioners have yet to adequately address this disease complexity.

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 1Suggestions for Psychiatrists


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.

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 2Suggestions for Medical Physicians


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 3Suggestions for Health Care–Related Administrators


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)

References:

References


1.

Wang PS, Berglund P, Olfson M, et al. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication.

Arch Gen Psychiatry.

2005;62:603-613.

2.

Kathol RG, McAlpine D, Kishi Y, et al. General medical and pharmacy claims expenditures in users of behavioral health services.

J Gen Intern Med.

2005;20: 160-167.

3.

Thomas MR, Waxmonsky JA, Gabow PA, et al. Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO.

Psychiatr Serv.

2005;56:1394-1401.

4.

Druss BG, von Esenwein SA. Improving general medical care for persons with mental and addictive disorders: systematic review.

Gen Hosp Psychiatry.

2006;28:145-153.

5.

Miller BJ, Paschall CB 3rd, Svendsen DP. Mortality and medical comorbidity among patients with serious mental illness.

Psychiatr Serv.

2006;57:1482-1487.

6.

Rosenheck RA, Druss B, Stolar M, et al. Effect of declining mental health service use on employees of a large corporation.

Health Aff (Millwood).

1999;18:193-203.

7.

Zuvekas SH, Cohen JW. Prescription drugs and the changing concentration of health care expenditures.

Health Aff (Millwood).

2007;26:249-257.

8.

Kathol R, Saravay S, Lobo A, Ormel J. Epidemiologic trends and costs of fragmentation. In: Huyse F, Stiefel F, eds.

Medical Clinics of North America.

Vol 90. Philadelphia: Elsevier Saunders; 2006:549-572.

9.

Kathol RG, Melek S, Bair B, Sargent S. Financing mental health and substance use disorder care within physical health: a look to the future.

Psychiatr Clin North Am.

2008;31:11-25.

Evidence-Based References


Kathol R, Saravay S, Lobo A, Ormel J. Epidemiologic trends and costs of fragmentation. In: Huyse F, Stiefel F, eds.

Medical Clinics of North America.

Vol 90. Philadelphia: Elsevier Saunders; 2006:549-572.
Thomas MR, Waxmonsky JA, Gabow PA, et al. Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO.

Psychiatr Serv.

2005;56:1394-1401.