A career on the way to full service integration

I was exceptionally honored earlier this year to receive the Carl A. Taube Award for Lifetime Contributions to Mental Health. This award is made annually by the American Public Health Association (APHA) Mental Health Section at its national meeting. The award is especially meaningful to me because Carl Taube was my very good friend, colleague, and mentor at the National Institute of Mental Health (NIMH). This year marks the 25th anniversary of his untimely death at age 49.     

First, I would like to say a few words about Carl Taube.

As a young man, he developed and led the NIMH National Reporting Program for Mental Health Statistics, which I subsequently managed. Carl then went on to found the first NIMH national program in mental health economics, and he oversaw the rapid growth of a mental health services research field. He concluded his NIMH career as the Director of the Division of Biometry and Applied Sciences.

Carl was very intuitive, and he was very adept at negotiating bureaucratic hurtles. After retiring from the Institute, he went on to a second career at the Department of Mental Health in the Bloomberg School of Public Health at Johns Hopkins University. That second career was cut short by his death. The direction of my own career and research owe very much to Carl and his influence.

For my APHA award lecture, I chose to focus on the integration of behavioral health and primary care. Integration is a foundational issue confronting behavioral healthcare today, and it is one that we must undertake successfully as part of implementing the Affordable Care Act (ACA). This issue has been a primary focus of my own work for more than a quarter century.

As early as the mid 1980s, we came to recognize that the prevalence of chronic diseases, such as heart disease and diabetes, was disproportionately high in persons with serious mental illness. These diseases not only were more prevalent in this population, but they also occurred at an earlier age than in the general population. As a result, we even explored the potential of training primary care physicians to serve as case managers for adults with serious mental illness. However, during the late 1980s, circumstances were not welcoming for broad mental health service innovations, and these practices were not implemented in the service delivery world.

Early in the 1990s, we spent considerable time and effort thinking through the proposed Clinton Health Security Act. Like the much later ACA, the Clinton Act would have centered our health care system in primary care. Within the Clinton framework, mental health and substance use care would have become specialties affiliated with primary care, much as cardiac care is today. Subsequently, after almost two years of acrimonious debate, the Clinton Act was not passed by the Congress; however, many concepts generated by this work have continued to live on in other contexts.

In 1999, the then Surgeon General, Dr. David Satcher, published the first-ever Surgeon General’s "Report on Mental Health" in the 200 year history of the U.S. Public Health Service. This report was notable in two respects: First, it documented that treatment does work: mental health care does have a sound scientific base. Second, it called for the integration of mental health and primary care during the following decade.

One year later, in 2000, Dr. Satcher organized a meeting on mental health-primary care integration at the Carter Presidential Center. This was a landmark meeting not only because it produced a second Surgeon General’s report on service integration, but also because it outlined major tasks that would be necessary for the US Department of Health and Human Services (HHS) to accomplish if service integration were to become successful. Work on those tasks, such as program coordination between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA), began immediately and continues to the present day.

In 2003, the George W. Bush Administration published the report of the President’s New Freedom Commission on Mental Health. The very first principle elucidated in that report focused on service integration: There can be no good health without good mental health, and vice versa. As an outcome of that report, SAMHSA commissioned a study by the Institute of Medicine on the key dimensions of service integration. The final report of that project, "Improving the Quality of Health Care for Persons with Mental and Substance Use Conditions," published in 2006, actually provided very practical information on how care could be integrated. I was honored to serve as the Government Project Officer for this important IOM study.

Also in 2006, Craig Colton and I published the first-ever state-level mortality data on persons with serious mental illness who were served in public mental health systems. The findings were both devastating and discouraging: Public mental health clients were dying 25 years prematurely, on average, in part because they lacked access to any primary care services. In large measure, these findings shaped and focused the subsequent national political debate about service integration.

Facilitated by the 2008 Mental Health Parity and Addiction Equity Act, the 2010 ACA clearly moves toward full service integration within a primary care framework. This landmark legislation calls for the creation of medical homes operated by primary care providers and health homes operated by behavioral health providers that offer fully-integrated services. In this new context, an urgent need exists to replicate the original mortality work to determine whether the years of life currently being lost actually are increasing or decreasing.

A very important benchmark is our national healthcare spending. In 2012, what is shocking to note is that more than 27.5 percent or $444 billion of our national spending is for persons with behavioral health conditions. It also is very important to note that only 6.8 percent or $91.8 billion is spent on specialty behavioral health care. Clearly, good integrated care has great potential to reduce the total cost of care for behavioral health clients whether they are served inside or outside of the specialty sector.

Just a few months ago, Roger Kathol and I have published an analysis of the phases of service integration. The three phases are treat-refer; bidirectional co-location, and full integration. In the past, the first phase, treat-refer, did not work well because clients hardly ever arrived at the referral site.  The second phase being implemented now, bidirectional co-location, is problematical because treatment teams are not fully integrated, even though behavioral health and primary care providers frequently are co-located in adjacent offices. The third phase which we advocate, full integration, currently is being developed. It requires fully integrated treatment teams and fully integrated financing of services, both of which are designed to overcome previous difficulties in service provision.

Today, more than 75 percent of all behavioral health care services occur in primary care settings. This percentage is likely to grow to 90 percent over the next decade. However, as a result of the ACA, the entire behavioral health system also is likely to double in size during the next 10 years. By that time, both of these settings are is likely to be fully integrated.

To conclude, in the short-term future, behavioral healthcare is on the cusp of major, foundational changes. As we move toward fully-integrated treatment teams and fully-integrated financing, I foresee much better care for our behavioral health clients. The problems we identified in the mid 1980s now are being addressed, and the solutions we foresaw actually are beginning to be implemented.

Were he here today, Carl Taube would be quite pleased with the progress that we are making!