By Katie Kerwin McCrimmon
Integration is a hot buzzword to describe efforts to blend physical and behavioral health care.
But the sad truth from experts who have been doing integration for decades is that most efforts won’t work, either because managers don’t know how to fully integrate their health systems or because they can’t pay for it.
Colorado health policy leaders are trying to strengthen and expand integration pilot programs with a jolt of federal cash. Much like “Race for the Top” funds in education, states are competing for a new pot of $700 million in federal cash to fuel innovations in health. Colorado officials are applying for $87 million and could get an answer by the end of October.
Known as the “State Innovation Model,” or SIM,the Colorado effort would harness both private insurance companies and public payers like Medicaid to speed integration. Currently, most mental health systems are totally separate from physical health care. In general, the two worlds operate differently, don’t share health records and providers get paid separately, making splintered systems extremely hard for patients who desperately need unified care.
The innovation cash aims to jumpstart payment and system reforms that already may be percolating in the states. Each state is taking a different approach. Colorado leaders decided to focus on integration, and all the major payers are on board to try shifting from traditional “fee-for-service” payments and instead pay providers global fees so they can treat interrelated physical and behavioral problems.
As Colorado health leaders wait to see if they’ll win a share of the federal cash, Parinda Khatri, an expert from one of the nation’s leaders in health integration, Cherokee Health Systems, came to Colorado last week to share insights on how to blend care and how to pay for it. Khatri spent a day working with providers at the Anschutz Medical Campus. She was a Levitt lecturer for the University of Colorado’s Department of Family Medicine.
For psychiatric patients, ‘visit’ can happen under a bridge
Khatri emphasized that adding a counselor at a doctor’s office doesn’t guarantee integrated care. Nor does staffing mental health centers with primary care providers.
She said most integration efforts will fail because leaders “underestimate the practice transformation required.”
As she visits sites trying to do integration around the country, she often sees what she calls “geography changes.” Primary care providers will add “mini mental health centers,” or she’ll see the reverse.
Instead, providers with expertise in both physical and mental health need to be available in one location all the time.
“If someone walks in the door and they need to see you, you see them,” Khatri said. “The next day is not good enough. They need to see someone at that moment.”
True integration requires a total overhaul, from the first point of contact with a patient to simultaneous visits with both behavioral and medical experts and follow-up care.
“Providing first-line care differently means changing everything from check-in, to scheduling. Everything has to change,” said Khatri, director of integrated care at the Cherokee.
That means that when a patient calls for an appointment, trained staffers ask them what they need, then try to determine who should see them first. Almost always, patients see behavioral health providers first and medical providers second.
“We’ll schedule them back to back,” Khatri said.
Providers can take time to confer about how best to help a patient. And even the schedulers are trained to make sure ongoing care works best for the patient.
“We have some people with so many chronic problems that we’ll arrange to see them every three months,” Khatri said.
In other cases, providers have to get creative. Recently, Cherokee managers have been trying to boost the percentage of psychiatric patients who come in for follow-up care within seven days after a hospitalization. Providers know these patients have a poor track record for making appointments and showing up. So health workers decided to take iPads and track down the patients where they are — even if it means doing a “visit” under a bridge.
Going where ‘the grass is browner’
Based in eastern Tennessee, Cherokee began as a small mental health system in rural Appalachia in 1959, then morphed into a blended provider of primary care, dental and behavioral health simply because patients needed help.
“Integration is not a separate program at Cherokee. It is the underscoring framework for everything we do,” Khatri said.
Cherokee providers now care for about 63,000 patients a year, one-third of whom are uninsured and 40 percent of whom have Medicaid. That means paying for the care is a perpetual struggle.
The system has 57 clinics located in communities and schools throughout 14 counties. Some are located in stable suburban areas. Others serve homeless people and the urban poor, while a telehealth network and clinics in rural areas reach people in remote areas where there is no cell phone service.
“We’re very committed to the underserved,” Khatri said. “Cherokee goes where the grass is browner.”
Cherokee workers began providing integrated care because the patients needed it. In some small towns, people didn’t want their cars seen at a mental health center, but they were willing to show up for primary care.
“We expended into primary care operations to go where we needed to go. Primary care is where the action is. And that’s where behavioral problems get treated anyway.
“If we wanted to have an impact on the population, that was the way to do it.”
Khatri said mental health system managers were furious when Cherokee expanded into primary care.
“They didn’t want one nickel going to primary care. We had to set up a different corporation and jump through a lot of hoops to make that happen,” Khatri said.
In other parts of Cherokee’s territory, non-Cherokee providers didn’t want to care for Cherokee patients because they were seen as “tough patients” who had a myriad of behavioral and physical problems. So, the system kept expanding.
“We did it because the patients needed help,” Khatri said. “Integration isn’t the goal. It’s the way to meet a goal. It’s the means to an end.”
Providers need to open their eyes to the full spectrum of problems a patient could have. She cited an extreme example. If a patient comes in with a knife in his back, he clearly needs help with the physical wound. But health care workers must also address how and why the knife got there in the first place.
“If he’s got a knife in his back, there’s a deeper problem there,” she said. “Behavioral health is a routine part of medical care.”
Payoff in savings
The big challenge, of course, is paying for integrated care.
Khatri said that’s an eternal struggle that must change.
“What we’ve had to do is cobble things together. This is a pain. The energy that goes into this really needs to go into our clinical care. But, it can’t because we’re always having to cobble this together.”
She said global payments that cover a patient’s care — whether it’s for physical or behavioral health problems — are critical now.
“We are sick and tired of this piecemeal approach,” Khatri said. “If we can get the outcomes, shouldn’t we just get paid to do whatever we need to do for the patients?”
She said data on Cherokee patients show they have higher usage of primary care clinics, but lower usage of specialty care and at hospitals.
“Eastern Tennessee has high rates of hospitalizations: 35.2 percent for regular folks compared to 18.6 percent for our patients. This is powerful.”
Khatri said providers used to see health insurance companies and public payers as “the evil empire,” but have now learned to partner with them and analyze data together on patient usage patterns and how to cut costs.
The bottom line is that everyone must band together to change reimbursement systems.
“Please fight for a different way of funding what you do,” Khatri told Denver providers. “It’s not OK. People don’t come to us in little pieces. They come to us as whole people. We shouldn’t be caring for them (in pieces) and we shouldn’t be funding (the care) in that way.”