Delivering health care has become too complicated.
We are screening for, discovering, and treating disease more frequently; people are living longer; and a greater proportion of the population is entering Medicare age – all leading to increasingly complex patients. It’s no surprise that health care costs have finally surpassed $3T. With increasing patient complexity and rising costs, the demands placed on physicians have increased in parallel.
Primary care physicians and specialists alike are being asked to coordinate more and more streams of information - whether from pharmaceutical companies, insurers, hospitals, or other providers. The administrative burden on those physicians has grown to rival the clinical burden. Yet even as more is asked of physicians, not enough has been done to create efficient systems to help accomplish those tasks.
Ripe for Clinical Transformation
One area of health care in need of clinical transformation is the integration of behavioral and physical health. More than 17% of American adults suffer from comorbid behavioral and physical health illnesses, translating to greater than 34 million people. Studies have shown that people with physical health issues (heart failure, for example) and an untreated or undertreated behavioral health issue (such as depression or anxiety) cost 2-3x more for treatment of their physical conditions. Per 2012 data, those patients accounted for almost $300B annually in excess and partially avoidable health care spend, mostly attributable to use of medical (as opposed to behavioral) services.
In any discussion of bending the health care cost curve, differences of that magnitude are impossible to ignore. Such cost variation occurs for multiple reasons, including patient non-compliance, increased utilization of high-cost and fragmented care (i.e. emergency room visits, inpatient admissions, repetitive/redundant treatments, etc.), and lack of improvement in a person’s health status, amongst others.
Growing Silos in Care
Over the last 30+ years, the silo between general medicine and behavioral health has only grown. Care in both realms is often provided independently of each other. Treatment regimens and access to resources have become increasingly separate with little to no overlap. Some medical practices have tried to place behavioral health providers (i.e. social workers, therapists, psychologists, and even psychiatrists) in primary care offices, though that’s an expensive proposition and difficult to scale. Mostly, primary care physicians and some specialists have been trying to manage behavioral health issues on their own with only 1 of 4 patients receiving effective care. When formal behavioral health services are required (for example, intensive outpatient treatment), many of those providers have little idea what resources are available or how to access them.
As an attending Internal Medicine physician, I’ve lived that predicament far too many times myself. I remember one recent case of a late-30s man with a history of alcohol and IV drug addiction that had left him with end-stage heart failure. Anytime he developed anxiety or stress, he’d have chest pain and usually come into the emergency room (ER). Since this man had severe heart failure, his cardiac lab results would always be abnormal, and he would invariably get admitted for further evaluation. In one year, this man had been admitted more than 10 different times from the ER for chest pain. Cardiologists and psychiatrists alike agreed his chest pain was largely related to worsening anxiety and depression. What this man needed most was regular access to outpatient behavioral health resources and a tangible care plan to help him cope with his poor prognosis. But despite my staff’s best efforts, we had so much difficulty getting him that access and were never able to break his cycle of hospitalizations.
How much better off would this man be if we could have found appropriate, timely behavioral health resources to support him outside the hospital? How many long-term health care dollars could we have saved? And what if we could have helped him with his addiction and behavioral health issues before he ever developed heart failure? I think about those types of questions almost every day – whether with this patient or others. Almost every physician can think of similar examples in their own practice.
Need for Change
Questions like those above have led to the necessary realization that current health care processes need to change - especially in ways that don’t add to physician workload or confuse patients. It’s naïve to think behavioral and physical health are entirely separate. Physical illness impacts a person’s psyche, and that person’s state of mind impacts his/her ability to manage chronic disease.
Collaborative care and value-based health care are common buzzwords and occasional punch lines in health care circles today. However, there is tremendous value in creating better, well-coordinated opportunities for partnership. Enhanced integration between physical and behavioral health is one logical target in improving the broader health care landscape. It is a very real gap in clinical care, makes complete economic sense, and is the right thing to do in promoting true patient wellness. But most importantly, patients and providers alike need and deserve it.
 I.e. traditional mental health conditions (i.e. anxiety, depression, etc.) and substance abuse
 I.e. medical conditions affecting the body
 In medicine, comorbidity is the co-occurrence of two or more disorders in the same person, regardless of the chronological order in which they occurred or any causal pathway linking them