It’s true that the Mental Health Parity and Addiction Equity Act (MHPAEA, or “Parity” as it is often referred to) and the Patient Protection and Affordable Care Act (PPACA) create many opportunities for integration between mental health, substance use disorder and primary care providers. However, some of that integration will feel like a draconian imposition or a missed golden opportunity unless providers recognize the importance and urgency of stepping forward to play a leadership role. Waiting for federal measures, initiatives and grants, or remaining passive while managed care organizations develop care and disease management programs without your involvement will prove to be unsatisfactory.

This author believes it’s time for an entrepreneurial approach to integration and that the opportunity has never been so good. Not only are there a number of reforms that enable an unprecedented level of integration (discussed below), there are a number of very good medical and epidemiological reasons to integrate care. Diabetes and obesity are two very good examples. The problem, however, is that the three fields we wish to integrate share too little in the way of norms and standards so the act of integration itself is more difficult than most imagine. In particular, the mental health and substance use disorder treatment fields need to normalize and standardize across disciplines and — very importantly — public and private sector boundaries. Having attended and presented at a number of industry conferences in the first few months of the year, it is evident that overwhelming cultural, social, clinical, scientific, technological, programmatic, financial and professional boundaries exist between professions and sectors. These must be negotiated and overcome in order for the fields to advance their agendas and achieve access, quality and financial goals related to integration. Some providers have demonstrated keen business acumen and a willingness to innovate and invest in their future, some have already done so and others are frightened. Normalizing and standardizing will help everyone.

Case in point: Prevention at the point-of-care

The PPACA provides specifically for the coverage of prevention in the commercial health plan market, Medicare and Medicaid. In 2010, the law stipulates that all new health plans and plans in the individual market provide first-dollar coverage for preventive services. Also in 2010 is a call to create a Patient-Centered Outcomes Institute to identify national priorities and compare the effectiveness of treatments and strategies. 2011 will see increased training support for primary care physicians and the establishment of a new CMS innovation and healthcare quality entity. It will also usher in vastly improved prevention coverage in health plans, and 2012 will finally enable the creation of truly integrated and accountable care organizations by virtue of intelligent reforms to the rules concerning physician reimbursement. By 2013, a national pilot program will enable payment bundling in order to encourage greater collaboration than ever before.

The American College of Preventive Medicine (ACPM) supports the recommendations of the US Preventive Services Task Force (USPSTF) that primary care providers should screen all adults for depression. What’s more, the USPSTF recommends that all primary care providers should have systems in place to ensure accurate diagnosis and treatment. There’s no question that primary care providers are the first line of defense when it comes to behavioral health, encountering the vast majority of people suffering from depression, addictions and other disorders. The resurgence of patient-centered medical/healthcare homes (long ago recommended by pediatricians) and reimbursement reforms will enable — once and for all — the proper and effective integration of efforts. Primary care should have such systems of care in place and behavioral healthcare professionals should lead their development and dissemination.

I believe that while depression is a good point of departure, primary care physicians can just as readily screen for other disorders. We’re missing an opportunity to build a comprehensive solution if we focus only on depression.

The possibilities

Our infrastructure and mechanisms can and should soon address all of the following behavioral health capabilities in primary care settings:

• The early identification of serious mental illnesses in adolescents and young adults as well as serious emotional disturbance in children.
• The early identification of mental illness in older people and post-partum depression in women.
• The identification of co-morbid conditions that will benefit from integrated treatment such as depression and heart disease.
• The identification of mental health conditions like anxiety that can masquerade as medical conditions like a racing heart, headaches and back pain.
• Conversely, the identification of medical problems that masquerade as mental health disorders.
• The co-location of primary care physicians and nurse practitioners with behavioral healthcare professionals in both primary care and behavioral healthcare settings.

The problems to overcome

However, all of these exciting developments are dependent upon several absolutely essential prerequisites (all of which stymie the field presently):

• Mental health, substance use disorder and primary care screening tools must be standardized. There are too many tools and a general lack of consensus around what is truly effective. Until healthcare professionals agree to standardize their favorite tools, payers will be reluctant to invest in their use and efficacy. Standardizing tools invariably involves trade-offs. Standardizing should not, however, suggest that any tool be used that hasn’t first been scientifically-validated.
• Assessment tools must also be standardized. A high degree of variation in assessment methods and tools necessarily calls into question the validity of diagnosis and treatment plans.
• Treatment planning tools must be standardized. They must also be aligned with medical necessity standards and protocols in order for treatment to be eligible for coverage. The future for behavioral healthcare will necessarily involve some degree of managed care, case management, disease management and population management and standardized tools will make that possible and less onerous.
• Having standardized screening, assessment and treatment planning tools, the behavioral health and primary care fields can then begin to normalize and standardize records. The future for health IT and meaningful use among electronic health records will be much brighter as a result.
• Terminology must be normalized. There is no greater and more glaring example of the need for normalization than the manner in which people are referred to. Providers refer to individuals as “consumers,” “patients” and “clients.” Health plans refer to individuals as “customers”, “members,, “participants”, and “subscribers.” Medicare and Medicaid refer to individuals as “enrollees” and “eligibles.” What a breakthrough it would be if we could agree on one or two terms instead of more than ten. Add to this cacophony terms like “disorders,” “conditions” and “disease” and you get my drift.

Applying ourselves to the solution and taking a leadership position now will benefit the behavioral health and primary care fields enormously. I can think of several visionaries and entrepreneurs I’ve met lately who will certainly step into that opportunity and make the most of it. All of us can. Real value creation awaits us when we do.