Why have we been slow to integrate physical/behavioral health?

By Jennifer Caspari, Ph.D., specialist master, and Mike Van Den Eynde, managing director, Deloitte Consulting, LLP

Despite a strong connection between physical health and behavioral health (i.e., mental health, substance use disorders, and social well-being), the medical community has historically treated the two as distinct models of care. However, people who have behavioral health issues tend to have worse medical outcomes than peers without these challenges.¹ Fortunately, there has been a push to break down these silos and integrate physical and behavioral health, shifting the focus to the whole person.²

The relationship between physical, psychological, and social health has long been understood. In the 1970s, Dr. George Engel, a psychiatrist and internist, developed the biopsychosocial model of care. This model is based on the interconnection between biological, psychological, and socio-environmental factors and the role they play in health, disease, and human development. This whole-person approach to health underscores potential flaws in the existing biomedically-focused structure.³

Based on our experiences, health care systems were not designed to deal with the ambiguity of psychosocial factors and their impact on disease and health. But, the traditional approach to health care can sometimes impede assessment, diagnosis, and treatment. Consider this: People who have diabetes are two-to-three times more likely to suffer from depression than people who do not have the disease. However, only 25% to 50% of people who have both diabetes and depression are diagnosed and treated for depression. Without treatment, both can get worse.⁴

Jennifer’s experience: When I was a practicing behavioral health clinician, I worked with a patient who had been showing up to the emergency room every couple of months complaining of chest pains. During triage, she would say she couldn’t breathe and was convinced she was dying. This patient, who was in her late 60s, also had diabetes. I first met her during a scheduled post-discharge appointment with her primary care doctor. The clinic’s protocol required a brief behavioral health assessment during every transition-of-care visit. It was clear to me that she was experiencing anxious symptoms. Over a period of six months, I met with her every two weeks (sometimes in-person and sometimes virtually) and we discussed some of the underlying stressors that were exacerbating her anxiety. I helped her understand the connection between her anxious symptoms, stress, and her breathing issues. We talked about strategies that could help improve her overall wellbeing, and discussed coping skills she could use whenever she felt anxiety creeping in. I also collaborated with her primary care physician on a treatment strategy for her diabetes. For example, we helped her uncover the facilitators in her life that could help her create a healthy eating and exercise routine. During and for years after six months of this treatment course, she visited the emergency department (ED) only once or twice.

There is strong evidence that primary care teams, which include a behavioral health provider (e.g., psychiatrist, psychologist, social worker, family therapist), tend to see better patient outcomes. Financial metrics also tend to be better when care is holistic.⁵ We are whole beings beyond our physical bodies.

COVID helped to normalize behavioral health issues

Mental health, social issues, and substance use disorders have long been stigmatized in our society. This might be one of the biggest challenges in integrating physical health with behavioral health.

The COVID-19 pandemic, which caused many people to experience anxiety and depression, helped to highlight the connection between physical and behavioral health. Mental health, substance abuse, and stress rates have doubled since the pandemic began.⁶ The pandemic helped to destigmatize the need for mental health support and subsequently has accelerated the focus on integrated, whole-person care. Some high-profile athletes have recently publicly acknowledged a need for mental health support, which has further helped to destigmatize it.⁷

Four key benefits of integrated care

The integrated care movement has been around for several decades. Even before the pandemic, the idea of integrated health had been gaining traction. A growing number of employers, for example, understand that poor mental health can have a negative effect on productivity and staff retention.⁸ Depression among employees results in an estimated 200 million lost workdays each year, costing employers between $17 billion and $44 billion, according to the Centers for Disease Control and Prevention.⁹ The benefits of integrated care span the quadruple aim and lead to better patient outcomes, lower health care costs, and an overall better patient and provider experience. Consider the following benefits:

• Better patient outcomes: Integrated care models have demonstrated an ability to decrease rates of hospitalization and readmissions. They can also improve disease-specific health outcomes and improve quality of life while decreasing depressive symptoms and length of hospital stays. Recent studies indicate integrated care models reduce hospitalizations by an average of 18.6%, and cut emergency department visits by 25%.¹⁰
• Lower costs: Annual cost savings for an integrated care model is estimated at up to 17%. Reducing avoidable health care issues can translate to lower costs and more efficient and effective care.¹¹
• Improved clinical experience: Clinicians tend to have a better experience when working in an integrated care environment. This can help to reduce burnout rates among clinicians and staff and improve diagnostic capabilities as communication bonds are strengthened across care teams.¹²
• Improved patient experience: Nearly all surveyed clinicians (96%) agree that integration improves quality of care. It can also provide enhanced patient access to services, including behavioral health care, reduced provider mismatch, improved health behaviors, and higher patient satisfaction.¹³

Integrated care is whole-person, team-based care that provides access to affordable, evidence-based care at a population level, across the care continuum. Even partially integrated care can produce better patient outcomes and lower health care costs than non-integrated care. Results typically improve as the level of integration increases, particularly for at-risk populations.

Maintaining forward momentum in moving toward integrated care, however, could be impacted by the health care provider’s reimbursement structure. Under a traditional fee-for-service model, clinicians typically have less of a financial incentive to integrate care or to keep patients healthy and out of the hospital. A value-based care model, by contrast, could give health systems a financial incentive to move to a whole-person care strategy. However, even under a fee-for-service model, the benefits of an integrated care model are clear. We can no longer ignore this connection.

Endnotes:

^{1. Strategies for integrating behavioral health and primary care, Agency for Healthcare Research and Quality, March 17, 2022}

^{2. Integrating behavioral health into primary care, American Academy of Family Physicians, 2021}

^{3. The biopsychosocial model 25 years later, Annals of Family Medicine, November 2004}

^{4. Diabetes and mental health, Centers for Disease Control and Prevention, May 7, 2021}

^{5. Integrating behavioral health into primary care, American Academy of Family Physicians, 2021}

^{6. Mental health and substance use disorders in the era of COVID-19, March 31, 2021}

^{7. Athletes and mental health: Breaking the stigma, Cleveland Clinic, August 10, 2021}

^{8. Workplace mental health benefits can reduce sick days, increase productivity, FORTUNE, June 9, 2022}

^{9. Depression Evaluation Measures/Workplace Health Promotion, Centers for Disease Control and Prevention}

^{10. Association of team-based primary care with health care utilization and costs among chronically ill patients.” JAMA Internal Medicine. November 26, 2018}

^{11. Potential economic impact of integrated medical-behavioral healthcare, Milliman Research Report, January 2018}

^{12. Primary care behavioral health integration, North Carolina Medical Journal, July 2018}

^{13. Physician satisfaction with integrated behavioral health in pediatric primary care, Journal of Primary Care & Community Health, September 15, 2016}

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