Barriers for mental health in medical homes are key concern for Medicaid

Mental health services are not typically included in patient-centered medical homes, and lack of reimbursement is one reason. In most states and in most private insurance plans, mental health specialists cannot be reimbursed for care provided in primary care settings. In addition, if a primary care provider sees a patient solely for a mental health condition, there is no reimbursement for that care.

"That's just the way the rules are. It's the result of creation of mental health carve-outs that are designed to manage mental health care in specialty settings," says Thomas Croghan, MD, a senior fellow at Mathematica Policy Research and adjunct professor of medicine and psychiatry at Georgetown University School of Medicine, both in Washington, DC.

This ensures that care is not reimbursed outside the specialty sector. "They provide specialty care and have done very well at that, but they've also created artificial barriers as a way of controlling costs," says Dr. Croghan. "There is a whole set of insurance and reimbursement barriers to delivering care that need to be addressed."

The collaborative care model of delivering mental health care involves a set of standardized protocols for identifying and treating conditions. In many Medicaid programs, there are barriers to this sort of team-based care.

"These teams commonly include a primary care provider, a mental health specialist of some sort, and a care manager," says Dr. Croghan. "Most insurance plans are not set up right now to be able to reimburse providers for the things they do when providing team-based care."

Integrating Mental Health Treatment Into the Patient Centered Medical Home, a June 2010 white paper completed by Mathematica Policy Research for the Agency for Healthcare Research and Quality, compared current strategies used to deliver mental health treatment in primary care with those used in medical homes.

"There are a lot of good ideas to develop care plans for problems like depression and diabetes," says Wayne Katon, MD, professor, vice-chair and director of the Division of Health Services and Psychiatric Epidemiology at University of Washington Medical School in Seattle. "But most of the guidelines for developing practices for medical homes have not mentioned mental health as an integral part for developing health care, and I think that's a problem."

Viability of primary care

There are many more people with mental illness than can possibly be adequately treated in the specialty sector. In fact, though, this is often not necessary, according to Dr. Croghan.

"Many people have mental disorders that can be perfectly well treated by primary care physicians," says Dr. Croghan. "In fact, primary care providers are in a better position to diagnose them, because they come to the office with other medical illnesses. It would make sense to move in that direction."

However, primary care doctors may feel unprepared to care for common mental health problems. "The primary care offices tend to be very chaotic in terms of workload, with very short visits. If somebody has two or three health problems and one mental health disorder, very often providers prioritize the physical health problems. The mental health problems don't get addressed, because they take more time," says Dr. Croghan.

Historically, there has been a problem with the quality of care provided to people with mental health disorders by primary care physicians, notes Dr. Katon. There is also less rigorous training in medical school and residencies in treating mental health conditions.

In addition, those with severe mental health disorders often don't get good primary care for chronic medical problems. "There is a need to make sure that primary care doctors are available to patients in their usual treatment setting," says Dr. Croghan. "This is an area where we need to do some really constructive thinking for how to best provide this care for a very vulnerable group of patients."

Dr. Katon says that the medical home concept is, to some extent, a political and economic movement to make primary care more viable. "Primary care has been so difficult in the last 10 or 20 years, as payments for visits have decreased," he says. "Doctors were forced to see more and more patients each day. There has been a lack of continuity of good services for patients."

At the same time, there is a growing focus on improving the quality of care for people with chronic illnesses. "Obviously, you can't have more patients every day and better quality. Those two concepts are at loggerheads with each other," says Dr. Katon. Fewer medical students are going into primary care, due to the pressures of seeing more patients with less autonomy.

"Medical homes are a well-meaning concept that may indeed make primary care more viable, but the proof that it actually improves care is still very limited," says Dr. Katon. "My own view of it is that the medical health movement could help integrate evidence-proven models like collaborative care for depression into medical home. The question of how will it be paid for is a problem."

If one of the goals of the medical home movement is to provide more funding to make primary care more viable, and mental health is integrated into primary care, there is a question of how this would be reimbursed. "Where would that money come from? Would it come from medical home payments or some other way of providing care?" asks Dr. Katon.

Successful models

Some evidence-based models have been shown to significantly increase the quality and outcomes for common mental health disorders in primary care. One is collaborative care, in which an allied health professional provides extra visits to educate a patient about his or her condition, and tracks adherence and symptoms. If the patient is not doing well, return visits are arranged with the doctor or a mental health professional.

"There are 37 trials for collaborative care depression that have shown it to be a very effective model, but almost nothing in the medical home concept has mentioned anything about that as a way to integrate mental health care," says Dr. Katon. "Almost none of the state criteria or insurance criteria for medical homes say anything about integrating models like collaborative care into medical homes."

There is not clear evidence as to whether having a medical home alone will result in better care for any chronic conditions, whether physical or mental health disorders.

"There are some studies that suggest the medical home concept could improve those things, but we don't have that conclusive data," says Dr. Katon. "It's certainly not there in randomized trials."

Dr. Katon says that he doesn't believe that the medical home concept alone is enough to truly improve outcomes for diabetes or depression. He says that disease management models such as collaborative care must be integrated into primary care. "I think that could happen, but it isn't being spoken of overtly right now with the medical home concept. If I was a Medicaid director, I would be quite concerned about this," says Dr. Katon.

This is because the rates of mental illness in Medicaid patients are two- or threefold what they are in the general population. "And medical homes are not talking about mental health, or to provide clearer standards for what you would have to do to provide better outcomes," says Dr. Katon. "There are other movements afoot like the parity movement, where people are supposed to get equal reimbursement. But health reform has been strangely silent about mental health being an integral part of medical care."

Financial incentives

Dr. Katon says that in order to improve quality of care, whether for mental health or other chronic illnesses, financial incentives for primary care physicians must be tied to outcomes.

"Right now, there is a pay-for-performance movement in our country where insurers are paying for performance criteria for chronic illnesses. But there is not much proof that [this movement] has led to enhanced outcomes," says Dr. Katon. "Financial incentives need to be for enhanced outcomes and not just performance."

Dr. Katon explains that he believes the medical home concept is an effective approach to keep primary care more viable, including incentives to improve continuity of care for people with complex illness.

"We have to provide them with enough financial incentives so that [they] have the time to do this," says Dr. Katon. "You can't argue with that, but it will need to go a step further to improve quality of care for patients with chronic illnesses, particularly mental illnesses. And I think the talk about it and integration of it is still lagging behind."

Contact Mr. Croghan at (202) 554-7532 or and Dr. Katon at (206) 543-7177 or