There is limited access to quality mental healthcare in the United States. Only 20% of adults with common mental health disorder see a specialist in any given year. Only 40% receive any form of treatment for their condition. Of those that do receive treatment, one-third receive treatment that could be considered minimally adequate based on practice guidelines. Patients do not receive sufficient dose, duration, or type of medication—often due to lack of regular clinical monitoring. As a result, as few as 20% of patients started on an antidepressant in the primary care setting will show substantial improvement. When given a referral to see a mental health specialist, only half will use it. There are substantial financial costs to the healthcare system by undertreating mental health conditions. For example, depression increases healthcare costs by 100% in Medicaid beneficiaries with another chronic medical condition versus those without depression [1]. One mechanism of this may be that depressed patients are less likely to engage in the activities necessary to manage their comorbidities, leading to increased downstream healthcare utilization.
The psychiatric collaborative care model is one option to provide better psychiatric care within the context of primary care. It consists of three team members. First, the primary care physician (PCP) who, in addition to managing a patient’s medical conditions, also prescribes psychiatric medications. Second, a behavioral health care manager that holds a masters or doctoral degree-level education or specialized training in behavioral health. Often these are clinical social workers, physician assistants, and nurse practitioners with training in behavioral health techniques. This member’s role is to provide care coordination, brief behavioral health interventions, and support the treatment initiatives begun by the PCP. The third member is the psychiatrist. Their role is to consult on cases that are diagnostically challenging or difficult to treat. The three individuals work as a team to understand the patients psychiatric needs and treat appropriately. The psychiatrist’s time commitment may be minimal as the behavioral healthcare manager can do a significant amount of the work assessing patients and following up with them. Typically the interaction with the psychiatrist will be over telephone or video conference. Each patient’s progress is tracked over time with validated tools (i.e. PHQ-9 for depression) and changes are made to the treatment plan accordingly.
One of the greatest benefits of collaborative care to patients is the reduced wait time for psychiatric consultation. In many areas, accessing a psychiatrist may take 1-3 months. Collaborative care uses the efficiencies of team-based clinical workflow to increase the efficiency of a psychiatrist, allowing them to treat multiple patients in a short time frame, thus making them available to treat a greater number of patients. Kristine McVea, MD, is an internist at OneWorld Community Health Centers Inc. in Omaha, Nebraska who uses collaborative care in her clinic. Using this model, she has been able to reduce the wait list for psychiatric care from 300 patients to zero [2]. Secondary benefits to patients are that many simply do not want to see a mental health specialist and would prefer their treatment to be integrated within primary care.
There have been over 70 randomized controlled trials that have consistently shown the efficacy of collaborative care in treating mental health conditions. These studies have been performed in diverse healthcare settings such as network and staff model health systems, as well as private and public providers. Collaborative care has been studied with different finance structures, including fee-for-service and capitation. The studies have included diverse patient populations, including both the insured and uninsured, with different ethnic backgrounds, and with different psychiatric conditions. The literature supports the clinical effectiveness of collaborative care versus traditional care [1].
The IMPACT study is the largest to date on collaborative care. It included 1,801 adults over 60 years of age with depression across 5 states. Subjects were randomly assigned to either a collaborative care program or to usual care. The study found that the collaborative care group was more than twice as likely to report a substantial improvement in their depression over 12 months. They also reported less physical pain, better social and physical functioning, and overall better quality of life [1]. Further studies have corroborated these findings in depressed adolescents, cancer patients, and diabetics. The IMPACT study found that an initial $1 investment on collaborative care saves $6.50 in long-term healthcare costs [1]. Thus not only is it financially feasible, it is a method to drastically reduce healthcare costs. There is no indication that such a model is only possible in the context of psychiatry—other specialists could very likely provide similar care with plausibly similar improvements in treatment and cost.
As of January 1, 2018, there are financial incentives for physicians to use the collaborative care model. In the 2018 Medicare Physician Fee Schedule, there is a provision which allows the PCP to bill Medicare for each case seen in this model. The PCP collects the revenue directly, then uses it to pay the behavioral healthcare manager (usually a member of their clinic) and the psychiatrist (usually consulted at an hourly rate). Another option is for the PCP and psychiatrist to split the revenue.
Today, we often speak of team-based care in healthcare. Collaborative care may be the epitome of that approach.
- Unutzer J. The Collaborative Care Model: An Approach for Integrating Physical and Mental Healthcare in Medicaid Health Homes. Center for Health Care Strategies. https://www.chcs.org/media/HH_IRC_Collaborative_Care_Model__052113_2.pdf. Accessed September 1, 2019.
- Eramo L. Psychiatric Collaborative Care Management May Improve Outcomes, Boost Revenue. Medical Economics. https://www.medicaleconomics.com/medical-economics-blog/psychiatric-collaborative-care-management-may-improve-outcomes-boost-revenue. Accessed September 1, 2019.
Jason Paul Singh is a student at The University of Arizona College of Medicine – Phoenix, class of 2020. He graduated summa cum laude from the University of Michigan – Ann Arbor with a BS in economics. His academic interests include alternative healthcare models and methods to improve efficiency in medicine. In his spare time, Jason enjoys traveling, reading and running. Please feel free to contact him at jpsingh[at]email.arizona.edu with any questions or comments.