Dr. Ellen Hight knows how much healthier many of her patients could be if only they changed their behavior: if they quit smoking, ate better, exercised, got more rest – even if they took their medications more dutifully.
When she has the time, she tries to discuss it at least briefly with the patients. But she often doesn’t have the time, and even when she does, it’s not really her area of expertise.
Now, however, she has another option. When someone in her practice, University Family Medicine in East Greenwich, needs advice on the importance of changing daily habits, and on how to change them, she can walk out for a minute and return with an expert.
She can introduce the patient to a psychologist who specializes in this kind of work, have a quick three-way conversation, and then let the psychologist take it from there. The same is true when she has a patient with depression, anxiety or a substance-abuse problem.
Hight is participating in a pilot project sponsored by Blue Cross & Blue Shield of Rhode Island to demonstrate the effectiveness of putting mental health, substance-abuse treatment and behavioral-medicine providers right in primary-care doctors’ offices.
The concept, known as co-location, is not new – it’s been done for decades in some practices across the country, and documented in major research studies.
In Rhode Island, the Allied Advocacy Group, a collaboration between health professionals, major healthcare payers, policymakers, educators and consumers, has been working on this issue since 2000, and a few medical practices and some community health centers, most notably Thundermist Health Center, have embraced the model for years.
But it’s still far from the norm, and Blue Cross wants to help change that. So the insurer is investing $300,000 to give grants of $75,000 apiece to University Family Medicine, Hillside Avenue Family and Community Medicine in Pawtucket and Scituate, OB-GYN Associates in Providence and Pediatric Associates in East Providence to help them implement co-location and show how it can improve their patients’ health.
“We believe behavior change is really critical to improving health,” said William A. Hancur, associate director for behavioral health at Blue Cross. “These initiatives put emphasis on the health care delivery system to focus on behavior change rather than symptom reduction, usually through medication, which is the way healthcare has pretty much evolved.”
Sure, primary-care doctors do some of this, Hancur said, but medicine has in recent years “overloaded on biochemistry,” and drug companies exacerbate the problem by marketing directly to consumers. “The reality, of course,” he added, “is that most of our problems are the result of our behavior, and if we changed our behavior, we wouldn’t need all that medication.”
So a big part of this project involves proving that point, showing the impact that good advice on exercise, weight loss, healthier eating, stress reduction, etc. could make.
That’s the area in which co-location could yield the biggest cost savings, said Paul Block, co-director of Psychological Centers Inc. in Providence, whose professionals are working at the four pilot sites as well as at nine others in the state. And it’s also, Block said, the area in which doctors seem least likely to make referrals if the provider isn’t right on site.
But there’s another side to this as well. Very large numbers of people struggling with depression, anxiety, substance abuse and other problems never set foot in a mental health provider’s office, but they do go to the doctor.
“Only 2 to 5 percent of those folks ever go to a behavioral health provider,” said Hancur. “That’s why we see that at least 60 if not 80 percent of the psychotropics – the antidepressants and the anti-anxiety drugs and the sleep aids – are prescribed by PCPs, because that’s where people are going. The problem is that the PCP for any number of reasons… is limited in their ability to identify and treat these problems effectively. Having the behavioral health expert there in the practice makes that a slam-dunk.”
Plus co-location makes it likelier that a patient will actually get treatment, said Dr. Michael Fine, physician operating officer at Hillside. If the mental-health provider isn’t on site, Fine said, “somewhere between half and two-thirds never get there.”
“It’s very different when I walk out of an exam room, walk in with a psychologist or a social worker and say, ‘Here’s my expert on stress. I want you to work together on stress.’ ”
Hight, at University Family Medicine, said it’s “amazing how open patients are” to talking with a psychologist if the person is right there.
Still, there are challenges. Providers have to work with patients to strike a balance between privacy and effective treatment (the oft-cited example, Block said, is the patient who has cheated on a spouse and may want to keep it secret, but may also have an STD).
And finding space for mental-health providers is a major challenge. Medical practices can generate $200 or $300 per hour, per room, Block said, whereas a psychologist or social worker might produce $75 or $100. So giving up prime space for something that doesn’t generate a lot of income is difficult. Conversely, if it’s done as a sublease situation (as many of Block’s setups are), the rent may be too steep for mental-health providers to afford.
Compensation is also a factor. Most insurers won’t pay for those 15-minute consultations without a mental-health diagnosis, though in this, Blue Cross is very progressive, Block said, because it has reimbursement codes for “health and behavior assessments” that allow a mental-health professional to consult on a medical case. (Medicare also pays for this.)
The pilot project only began Oct. 1, but Hight and many of her colleagues are enthusiastic. She’s making the connection to behavioral health more than ever, she said, “and it’s really good for the patients.” •
