Nearly 4,000 healthcare professionals from across the U.S. convened in Nashville last week for America's Health Insurance Plans annual Institute, and the conference theme of "Making Healthcare Work" resonates.
The industry is looking for innovative ways to deliver high quality care that consumers expect, and address older, sicker and more costly populations, amid regulatory challenges and a keen eye on how health plans use their dollars.
There's a huge opportunity to address the gray area, or gaps, that exist in order to make healthcare work. One important gap is understanding and addressing the interplay of behavioral, social and medical factors, especially for the most vulnerable plan members.
Physical, mental and social care must be married
Too often, patients with chronic health conditions are isolated into two camps--those with physical conditions and those with behavioral issues. The strong relationship between the two often goes unaddressed across the spectrum of care, from the physician level on up to insurers. Payers, in particular, tend to have an umbrella view of beneficiaries and their care, often believing that as long as physicians are addressing a patient's physical comorbidities, sufficient care is being provided.
This viewpoint is narrow as it fails to acknowledge the tie between physical health and mental health. Mental health issues can exacerbate physical health conditions and often create barriers to improvement. Treatment needs to be approached from a holistic standpoint, treating the whole person versus their individual conditions.
For example, though almost 90 percent of people with Type 2 diabetes are overweight or obese, and despite the strong link between obesity and depression, Type 2 diabetics may only see a primary care physician for counsel and treatment. A diabetic's PCP may not recognize a patient's depressive symptoms, perhaps due to lack of visibility, because of the stigma surrounding mental illness, masking of symptoms, denial and so forth. Obesity is also linked to other health conditions, such as sleep apnea, many of which go undetected. Sleep apnea is also associated with a higher rate of psychiatric conditions such as depression, and diagnosing it requires a specialist referral and a battery of tests. It's easy to see how a patient's secondary conditions can go untreated and unreported altogether.
And even more problematic, for many, the journey of care is halted before it even truly begins because of lack of access. Socioeconomic determinants may prevent patients from taking the necessary steps to obtain medical care or make changes. In other instances, patients may grow frustrated when faced with a narrow network of providers or the inability to schedule appointments.
Primary care physicians face mounting pressures in treating complex patients
Often the front line of the healthcare system, primary care physicians sometimes serve as patients' entryway and sometimes only point of care, especially for patients with mental health issues. And it's commonly accepted and supported by evidence that mental health issues go unrecognized and unreported for many reasons, despite their prevalence.
Forty percent of respondents in a survey of the incidence of mental health conditions in urban family medicine practices met criteria for a mental health disorder. Seventy-five percent of all antidepressant medication prescriptions filled are written by general practitioners. However, though they receive basic training in diagnosing uncomplicated behavioral health conditions, PCPs may feel burdened by the volume and needs associated with patient encounters involving mental illness. Are we asking too much of PCPs when we hold them accountable to quarterback physical and mental health?
The implementation of the Affordable Care Act and subsequent rise in the number of insured Americans, coupled with increasingly narrow networks, has led to an influx of patients seeking care from general practitioners. Stretched thin for time and lacking resources, it's not hard to see how even the most qualified and hardworking PCPs may not feel comfortable treating these conditions, particularly with Medicaid and Medicare populations.
Though intended to drive improvements in the delivery of care, the push for value-based care models and CMS' recent proposal for stricter regulations for Medicaid managed care places even more performance-related stress on PCPs. Yet most PCPs don't have the support and resources to the meet the challenge. If patient care were more evenly spread across a team of providers that included mental health specialists and social workers, quality of care and patient satisfaction would certainly rise.
We all know healthcare is personal, yet if we consider how siloed mental health and our social lives are from the rest of medicine, it's clear we have underestimated just how personal healthcare really is. Using precision empowered care management--marrying biological, psychological, and social factors to gain a more complete picture of individual health--is essential in filling in the blanks that will optimize outcomes and keep costs in check. There are simply too many variables to stick with the status quo.
Sam Toney, MD, is chief medical officer and EVP of clinical integrity for Health Integrated.