By Katie Kerwin McCrimmon
COLORADO SPRINGS – National leaders will be watching an ambitious experiment beginning at 11 sites across Colorado that aims to revolutionize and integrate long-separated primary care and mental health.
As the economy continues to falter while health costs climb, Colorado alone could save an estimated $3 billion a year by giving integrated behavioral and medical care to people with complex illnesses, according to Steve Melek, a Denver actuary from Milliman, an international actuarial and consulting firm.
The new program is called Advancing Care Together (ACT). It is bringing integrated care to adults and children in test sites from Cortez to Lamar and Fort Collins to Colorado Springs. Melek presented data at an ACT launch conference in Colorado Springs this month and will be assisting with the evaluation of the Colorado effort over the next three years.
Melek showed that Colorado patients with chronic medical conditions like diabetes — who also have untreated mental health challenges such as depression — cost insurance companies, employers or taxpayers an extra $625 per person per year. Depression may cause the patients to skip medication or allow their symptoms to worsen, which in turn can trigger costly hospital visits. Multiply those extra costs over millions of people who are already covered through commercial health insurance or government programs like Medicare and there are huge untapped opportunities to save.
“Roll that up and at a minimum, over one year, you’re spending $3 billion and maybe as much as $8 billion,” Melek said. “Depression is a big deal to employers.”
When health coaches or care managers use data to find and help these patients, care costs drop dramatically, sometimes by as much as 50 to 100 percent per patient, Melek said.
The numbers are not just theoretical. Melek presented data about a large health plan outside Colorado that hired Milliman to analyze what would happen if it gave patients behavioral health care. Melek studied two large pools of Medicare patients. Some got behavioral health and Melek’s firm compared them to “twins” who didn’t. The twins were other Medicare patients who were the same age with the same health challenges and even the same interests such as gardening, fly-fishing or watching NASCAR.
The program cost nearly $16 million in one year and provided mental health care to 13,000 patients. Some got telephone counseling. Others got longer-term therapy that extended three to four months.
The results were startling. The company saved $40 million, generating a return on investment of $2.50 for every dollar spent.
Dr. Kelly Lowther (lower left) a family practice doctor at Miramont Family Medicine in Fort Collins, maps out her company’s plan to use kiosks to help screen patients and help them receive mental health care. Assisting her is Dr. Bijal Balasubramanian, an epidemiologist and assistant professor at the University of Texas School of Public Health.
By the end of the year trial, the naysayers were demanding that more patients be included in the program.
“In 2012, they will more than double the program,” Melek said.
“People are looking for solutions to bend the cost curve,” he said. “There’s a lot of opportunity from these comorbid patients (people with two or more simultaneous health problems), complex for sure, but there’s a lot of opportunity.”
Along with the financial incentives, there’s also a powerful moral and medical imperative to bring immediate improvements now.
“There are simply tens of millions of people in the United States at this very moment who are not getting the health care they need to have longer and better lives,” said Larry Green, director of ACT, a national expert on integration and a faculty member at the University of Colorado’s Department of Family Medicine.
ACT organizers and the group’s high-powered steering committee, which includes national mental health experts and honorary member and former First Lady Rosalynn Carter, hope to find the “secret formula” for integration through results at the demonstration sites. Then they want to create a playbook that can then be duplicated around the country.
“What we’re doing (now) doesn’t work very well and it’s unsustainable,” Green said. “Our health system can’t be fixed without addressing the emotional and behavioral health of our patients.”
Green said Colorado has been a “hotspot for innovation” when it comes to blending primary health care with behavioral health. Even so, he said the current systems don’t work for most people.
“We’re in a mess. Our business models suck. We’ve got a lot of cultural problems. This is a big problem. The conditions are adverse. We can’t see our way all the way to the end,” he said.
Green and the ACT backers are convinced that within three years, the Colorado innovators who are each receiving $150,000 along with extensive coaching, technical assistance and evaluation will show dramatic improvements and offer key lessons for policymakers across the country. The Colorado Health Foundation is funding the four-year, $3.9 million ACT program.
“The people are waiting. We need to catch up and help them,” Green said. “This has been an intractable problem for decades.”
ACT aims to produce practical solutions now. Green said study after study has shown that integration of mental and physical care helps patients.
“As long as this care stays silent and separate and fragmented, the solutions will elude us,” he said.
The innovative aspect of ACT is turning knowledge into practice. Hence the acronym’s active tone: act.
“We aim to change practice across the country,” Green said. “It’s a reality-based approach to learning, not an idealized approach.
“We’re not interested in finding ways to do things that require being propped up by extra resources. We want to know how this can be done in real life for single mothers with three kids and two jobs.”
Dr. Patrice Whistler, a pediatrician with Primary Care Partners in Grand Junction, works with her partners to refine their plans for integrated physical and behavioral care.
Green said doctors and therapists have known for decades that people need integrated behavioral and medical care. The true innovators are on the ground.
“We have experts who have already figured a lot of this stuff out,” Green said. “The true game-changers are already out there in Colorado communities. They want to be better and could use a little help.”
A history of hiding the mentally ill
Dr. Mary Jane England is one of the top mental health experts in the country and is serving as chair of the ACT steering committee. England chaired a watershed 2005 report for the National Academies’ Institute of Medicine on improving care for people with mental health and substance abuse problems.
“We found that if you want to have quality in health care, you’re going to have to integrate mental health and substance use treatment,” England said. “On the other side, if people with mental illness don’t get good health care, they die two decades earlier.”
How did our country go so wrong in segregating mental health care from physical health care?
England says it’s because cultures dating back thousands of years had no good treatment for the mentally ill so they tried to hide them.
“The behaviors were difficult to manage, so they locked people up,” she said.
Attempts to hide the mentally ill continued well into the 20th century.
But then, scientific advancement produced a better understanding of mental illness along with drugs that could help tame symptoms. England calls the 1990s “the decade of the brain.”
“We understand the brain better now. We learned that brain cells regenerate. So, (mental illness) looks much more medical,” she said. “We found treatments that worked. Wow. You can do something about depression. You can do something about bi-polar disorder. Even schizophrenia. It’s difficult. But we have treatments.”
Today, primary care doctors can successfully treat many mental health problems. Access to care has in turn, reduced the stigma about mental illness.
“That’s what has made such a big difference,” England said. “The brain is part of the whole physical being. People are accepting that more. It’s the behaviors that frighten people.”
England is a visiting professor of health policy and management at the Boston University School of Public health. She earned her medical degree there in 1964 and became a child psychiatrist and is a former president of both the American Medical Women’s Association and the American Psychiatric Association.
England has worked extensively with Rosalynn Carter who is especially concerned with helping children and adolescents who are coping with behavioral health challenges. She said Carter is intrigued with ACT because she’s eager to see integration spread.
“We have the financial data. We know it’s right. Now, can we show that we can change clinical practice?” England said.
Another ACT steering committee member and advocate for change is former Colorado First Lady Jeannie Ritter. She became a vocal advocate for the treatment of mental illness during her husband’s term in office.
“This is a stigma buster,” Ritter said of ACT.
Giving people the ability to seek mental health care right where they get primary care is key.
But fusing the two worlds will be difficult. Many experts at the launch conference said that primary care providers spend too little time with patients while behavioral health experts spend too much. The doctors may need to slow down while the counselors need to speed up.
England said that mental health experts are quite accustomed to putting the patient first. When a patient is mentally ill, you simply can’t treat them without getting their buy-in, she said. Traditional doctors are just now learning to put patients at the center of the care and to ask them what they want.
She said it’s vital that everyone understand that the overall system is broken. We can’t look just at individual practitioners or clients and expect to generate system-wide results, England said.
“Change is tough. Some patients don’t ship easily from one system to the next,” England said. “But, I’m more hopeful today that ever before. I’m excited that there’s a movement toward wellness. People understand prevention and intervention. We have to talk about exercise and smoking cessation.”
England said national experts in the behavioral health community and in family medicine will be closely watching Colorado’s results.
“We can no longer just treat the medical problems.”
The 11 innovations sites for ACT are:
Axis Health System, Durango
Practice: Cortez Clinic
Project: Using a Personal Health Profile to Facilitate Integrated Care
Principal Investigator: Pamela Wise-Romero, PhD
Bender Medical Group, Inc., Fort Collins
Practice: Miramont Family Medicine
Project: AIMS: Automation of Mental Health Services
Principal Investigator: John Bender, MD
Denver Health and Hospital, Denver
Practice: Lowry Family Health Center
Project: Meeting Patient Preferences for Behavioral Health Screening and Treatment
Principal Investigator: Rob Keeley, MD
Jefferson Center for Mental Health, Wheat Ridge
Practices: Independence Outpatient Services, West Colfax Outpatient Services, Cedar Adult Intensive Services
Project: Healthcare Homes without Walls
Principal Investigator: Donald Bechtold, MD
Kaiser Permanente Colorado, Denver
Practice: TBN
Project: Practical Approaches to Integrating Mental and Physical Healthcare
Principal Investigator: Arne Beck, PhD
MidValley Family Practice, PC, Basalt
Practice: MidValley Family Practice, PC
Project: Optimizing Healthy Lifestyle Management
Principal Investigator: Glenn Kotz, MD
Plan de Salud del Valle, Inc.
Practice: Salud Family Health Center, Brighton
Project: Integrated Primary Care Workforce Development in the Medical Home
Principal Investigator: Andrea Auxier, PhD
Primary Care Partners, PC, Grand Junction
Practices: Western Colorado Pediatric Associates, Family Physicians of Colorado, Behavioral Health and Wellness
Project: Expanding the Patient Centered Medical Home
Principal Investigator: Patrice Whistler, MD
Southeast Mental Health Services , La Junta
Practice: High Plains Community Health Center
Project: Lamar REACT: Rural Excellence in Advancing Care Together
Principal Investigator: Jay Brooke, LCSW
University of Colorado Colorado Springs/CU Aging Center, Colorado Springs
Practice: Peak Vista Community Health Centers
Project: Cognitive and Psychological Screening to Enhance Integrated Care for Seniors
Principal Investigator: Michael Kenny, PsyD
Westminster Medical Clinic, Westminster
Practice: Westminster Medical Clinic
Project: Behavioral Health-A Shared Service Model
Principal Investigator: Scott Hammond, MD