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Integrated care: a beloved platitude

November 28, 2017
by Ed Jones, PhD
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The phrase, “motherhood and apple pie,” has long been used as an everyday critique of proposals with vaguely positive ideas that no one could generally oppose, but that don’t carry enough content or substance to know how constructive they really might be in practice. I nominate the idea of integrated care to that tradition.

Integrated care is a slogan. It seems like a high principle, but it is really a ruse or gross exaggeration in most cases, especially when behavioral health is on the table.

Prominent thought leaders from many specialty healthcare disciplines have encouraged us to integrate behavioral healthcare solutions into primary care. Many are increasingly recognizing that behavioral health problems are so prevalent as to be considered epidemic. Depression is the number one source of disability, and an escalating opioid crisis in the United States is resulting in overdose deaths unlike anything we have seen before. More people are now overdosing from opioids each year than died annually from AIDS at the peak of that crisis.

Utilization and quality oversight: communication among care managers

It is important to narrow the field of discussion since integrated care is a slogan in many areas of healthcare, from payer levels of quality oversight (health plans and managed behavioral healthcare organizations) to the trenches of healthcare delivery (primary care providers, accountable care organizations, etc.) to newly integrated digital tools (e.g., Health Cloud and myStrength).

Health plans with behavioral health units managing behavioral healthcare (e.g., Anthem, Aetna) and independent managed behavioral healthcare organizations (e.g., organizations like Magellan, Beacon, New Directions) insist that they foster integrated care since they encourage communication between physical health and behavioral healthcare managers. Shall we address the results that validate the existence and the importance of this integration? We can’t. We simply don’t have a body of evidence for integration by any of these entities.

There is no established evidence that health plans effectively integrate their medical and behavioral health services, nor that managed behavioral healthcare organizations do this. Since no payers or quality oversight entities are really asking for serious evidence in this regard, health plans and managed behavioral healthcare organizations can just proclaim their excellence in this area. We really have no idea how well they integrate medical and behavioral health services, and we have no idea whether superior integration at this level would lead to better clinical results.

Clinical delivery integration: communication among specialty clinicians

It would seem reasonable to presume that it is important to get our primary care providers and psychotherapists talking with one another, but again we have no body of evidence that integration of front line clinical providers makes a difference. This sort of communication between clinicians was accepted as essential long ago, even though the lack of such communication was also accepted as the norm. My experience is that this matters little for the vast majority of people (mild to moderate problems), and yet it could make a difference in clinical outcomes for the most severely impaired. Therefore, we should discuss some version of the collaborative care model.

The prevailing idea for collaboration today is to have specialty healthcare providers, like behavioral healthcare clinicians, find an effective way to integrate into the dominant primary care model. I would argue for a different model: Let’s make the specialty of behavioral healthcare first-rate, and then, let the benefits from that transformation flow to primary care and other healthcare specialties. This is not the space for a detailed argument about how we structure our healthcare system, and so I will just articulate one of the main healthcare priorities that I embrace. Our emotional health is primary for our overall health status, and all care should be grounded in an understanding of emotional health.

SUD and mental health integration: perhaps the most desperate case

Integration in this domain may seem like a tangential topic given that only a little more than 10% of those needing substance use disorder treatment in any given year get it. However, we should still address the question of integration since comorbid substance use disorder and mental health conditions are the norm. The reality is that most substance use disorder programs focus exclusively on sobriety, while others provide limited resources for mental conditions. This is a major problem that must be addressed, and the reality is that evidence-based digital tools for depression, anxiety, and the like could be incorporated into substance use disorder programs at low cost. More professional help is needed, but digital tools are a good place to start for people desperate to manage their co-occurring mental health conditions.

Video, phone, digital and text-based integration into care: a new model