When Dr. Albert J. Puerini Jr. needs to refer a patient to a cardiologist, or an endocrinologist, he doesn’t have to give it much thought. He’s worked for years with a handful of specialists, and he knows they will provide timely and expert care and keep him well-informed, too.
But when a patient is seriously depressed or anxious, or has an alcohol problem, Puerini has a tougher time. He knows some good providers, but nowhere near enough to meet his patients’ needs, and he doesn’t have close collaborative relationships with them.
Cost is also a concern; a lot of providers don’t accept all the insurance plans his patients are covered by, so even a handful of therapy sessions can prove expensive.
Plus some plans require special referral procedures, or else they won’t cover mental-health services. And even if he does everything right for his patient, getting an appointment may prove impossible – because unlike, say, cardiologists, therapists can’t see hundreds of people per month – not with hour-long appointments and repeat visits.
Altogether, Puerini said, it can be “very, very hard to make even the first contact.”
Puerini, a family doctor in Cranston and president and CEO of the Rhode Island Primary Care Physicians Corp., which represents small primary care practices across the state, said the problem is widespread, and a recent study in the journal Health Affairs confirms that.
Two-thirds of primary care doctors surveyed in the 2004-05 Community Tracking Study, which covered 6,600 physicians, said they couldn’t get outpatient mental-health services for at least some patients who needed them – a rate twice as high as for other specialty services.
The data used in the study, by Peter Cunningham, a senior fellow at the Center for Studying Health System Change in Washington, D.C., predates the passage last year of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which required that group health plans cover physical and mental-health equally. But even doctors in states that already had parity laws – as Rhode Island does – reported serious access issues.
In Rhode Island, industry leaders, individual providers and insurers – especially Blue Cross & Blue Shield of Rhode Island – have been aware of the issue and have been trying to address it for years.
One key strategy has been the “colocation” of mental-health services within primary care practices, which aims to address not just systemic barriers, but also patients’ own misgivings about seeing a therapist and difficulties following through with referrals.
“Most primary care physicians will readily say that a lot of what they see in their practices has significant behavioral medicine and mental-health implications,” said James Campbell, president of the Rhode Island Psychological Association. “It can be difficult at times to get patients to acknowledge that and make the referral, and that’s where having colocated services makes it a lot easier. Instead of, ‘Go call Dr. Soandso, and make an appointment across town,’ it’s ‘Let me walk you down the hall and introduce you.’ ”
On-site therapists can help not just patients with mental-health problems, Campbell added, but also those with medical problems “that have behavioral elements,” such as asthma, hypertension and cardiac problems – and those overwhelmed by a major new diagnosis.
Thundermist Health Center, one of the pioneers in colocation, does so much mental-health work that it employs its own therapists and clinical nurse specialists. They not only consult on cases that involve behavioral issues, said Dr. David Bourassa, senior vice president and chief medical officer, but they also do same-day acute assessments.
But the need is huge: About half the patients at the center are affected by mental-health issues, said Dr. Jeffrey Borkan, physician-in-chief of family medicine at Memorial and chair of family medicine at The Warren Alpert Medical School of Brown University, and cost and insurance limitations can be big barriers.
In the face of those challenges, Borkan said, doctors do the best they can. They make referrals to Gateway, Butler Hospital and elsewhere, and those whose lives are “too chaotic” to pursue therapy – quite a few – they treat themselves, often with medication.
Asked whether colocation can work for everyone – since, as Puerini noted, most PCPs are in small practices, with no extra rooms to spare – Campbell said it can be done, but insurers have to provide the funds to make it affordable, and it has to be made very easy.
Borkan says insurers still make it harder to get mental-health care than other services; there are waiting lists; and as with primary care, there are shortages of providers, aggravated by a skewed payment system.
“If you have certain surgical issues, you’ll find a place. Even if you need cosmetic surgery, you can find 50 places and no waiting lines,” he said. “But if you have primary care or mental-health issues … you may not be able to find care.” •
