Primary Care Clinicians Evaluate Integrated and Referral Models of Behavioral Health Care For Older Adults: Results From a Multisite Effectiveness Trial (PRISM-E)

Gallo, et al. has demonstrated that not only is integrated behavioral health care beneficial clinically, but that primary care physicians generally prefer this model of care. Despite the demonstrated efficacy, however, there has been only modest adoption of this collaborative model nationwide. An important question concerns the willingness of the players to resolve a considerable number of complex and practical problems that arise when such programs are implemented in community practice. Three groups of problems are important.

The first centers on practice culture and addresses whether behavioral health care is viewed as an integral part of primary care that is reflected in the practice’s mission statement, or it is viewed as an ‘add-on’ advanced by one or two champions. This issue reflects the view of the practice as a whole and, as such, it is tied to how long these services will be sustained by the practice over time. We have a spotted record when it comes to the uptake of behavioral health care efficacy trials in real world practice.

A second set of problems concerns practice logistics. Issues of confidentiality are paramount. Are there shadow charts for confidential notes and who has access to them? Are office staff educated and respectful about issues of scheduling and confidentiality, especially since it is often the case that family members and other members of the patient’s community receive care at the practice? How much information is communicated between the behavioral health practitioner and the primary care physician, and how are releases of information forms handled?

A third set of problems involves practice finances. What position does the behavioral health practitioner hold in the practice: employee, partner, self—supporting outsider? Who manages and pays for billing of behavioral health care services? Most practices serve patients insured by different third party payers. These include carve-outs, PPOs, and other managed care insurers, each with different rates of reimbursement, different procedures and different forms. Is billing assumed by the practice, as it would be for all other clinical services? Importantly, can behavioral health care generate sufficient reimbursement to support overhead and the salary of a behavioral health specialist? Can behavioral health care be self-supporting and not viewed as a ‘cost-center’ in the practice budget, especially given the relatively low reimbursement rate?

All of these are real-world issues that reflect how behavioral health care is considered by the practice – as an ‘add-on’ or as part of ‘what we do’ in the care of the whole person.

Competing interests:   None declared

Gallo et al.’s well-conducted survey validates and extends the findings of prior naturalistic work (e.g., Valenstein et al.1) namely, that primary care providers (PCPs) prefer onsite mental health care. It thus makes intuitive sense that this preference is most pronounced among family physicians, and among respondents who tend to provide mental health care themselves and who find specialty care inaccessible. However, the likely overlap between these three provider variables begs the question of which factor is primary. For example, family physicians are more likely to provide mental health care than other providers are.2 They are also more likely to practice rurally, which probably complicates referrals. Providers who cannot refer will naturally provide more mental health care themselves, and so on.

Second, I wonder whether preferences have different determinants at different stages of specialty treatment. If preferences were assessed early in the trial, then they may be driven by ease of referral. If assessed late in the trial, then overall clinical outcomes probably rule the day. Repeated measurements may be needed to disentangle these two issues.

Finally, translatability and sustainability are major issues. Access (related to PCP preference) usually varies by payor; a given onsite specialist may or may not be paneled by a given patient’s insurer. While the older patient sample is study strength, it may have restricted variation in mental health coverage, giving co-located services an advantage. For example, I practice psychology within two family practice clinic sites. I’m amazed at the immense clerical time spent negotiating the "carve-out du jour," arranging for pre- certification, determining out-of-network co-pays, etc. In lieu of mental health parity or some other access-enhancing mechanism, access to onsite services can sometimes raise daunting administrative issues.

James E. Aikens, Ph.D. Departments of Family Medicine and Psychiatry University of Michigan Medical School Ann Arbor, MI, USA

References: 1. Valenstein M, Klinkman M, Becker S, et al. Concurrent treatment of patients with depression in the community: provider practices, attitudes, and barriers to collaboration, J Fam Pract, 1999;48:180-7.

2. Gallo JJ, Meredith L, Gonzales J, et al. Do family physicians and internists differ in knowledge, beliefs, and self-reported approaches for depression? Int J Psych Medicine. 2002;32:1–20

Competing interests:   None declared