Most mental and behavioral health patients first get help through their primary care doctor. In fact, more prescriptions for antidepressants drugs are written by primary care physicians than by mental health doctors.
But that can be problematic, said Highmark Medical Director for Behavioral Health Duke Ruktanonchai.
“For a lot of people they don’t understand they have a behavioral health issue. Many primary care docs don’t know exactly how to screen for it or diagnose it appropriately,” Ruktanonchai said.
Thanks to an 8-year-old federal law, insurance companies must offer benefits for mental health treatments that are substantially the same as the benefits for medical or surgical treatments. However, that does not always mean patients are actually getting the behavioral and mental health services they need, even when they get the right diagnoses.
Once a doctor makes the diagnosis, it becomes a “black box,” Ruktanonchai said.
“(The doctors) don’t know where to send patients,” he said. “And then the communication back also often doesn’t happen.”
One possible solution to that problem is employing a new technology. And Pittsburgh-based insurance company Highmark is pairing with a tech company called Quartet Health.
“(We’re) really just all about helping patients get the care they need to, you know, function,” Quartet Founder and CEO Arun Gupta said.
Quartet offers a program that can bring behavioral and physical health together in one streamlined process.
The problem
Here’s a common scenario: a patient visits a primary care physician for a specific ailment or illness, like diabetes. That patient may describe having low blood sugar and less energy, going as far as to say they don’t want to get out of bed. That could be a red flag for their primary care physician, that the patient should see a mental health specialist.
But often, the best a primary care physician can do is suggest a few mental health specialists they know and hope the patient follows up. And even if a patient does follow up and makes an appointment, it could be months before they’re able to see the mental health specialist. Frequently new patients have to wait months for an appointment because there aren’t enough providers to meet demand.
“When you have a patient sitting in front of you and they are engaged, time is of the essence,” said Bill Johnjulio, primary care physician and chair of the Allegheny Health Network Department of Family Medicine. “Right at that point in time they have made that decision and I think the longer you wait to then provide the next level of service, the mind fades, other things become important in our life and this issue of engagement might take a back seat to all the other life issues that are out there.”
In short, the patient walks away and never gets the help they need.
With Quartet, the doctor, or their staff, can enter the patient’s information into a cloud-based system, get a remote video consult with a mental health provider in two to three days and an in-office visit within two weeks.
The system is designed to send the patient to the mental health provider who can best serve their needs.
Kevin Caridad and his 20 clinicians at the Cognitive Behavioral Institute in Cranberry are on the receiving end of the remote consults and the face-to-face visits.
“What Quartet is allowing is, in tandem, primary care and behavioral health being a primary treatment rather than behavioral health, as it has been, as a secondary,” Caridad said. “Individuals that have, for example, stress management post having a heart attack are less likely to have a second heart attack with something like cognitive behavioral therapy.”
A better method
With a patient flowing from one system to the other, the focus can turn to another big issue that can lessen the quality of care for patients with both physical and behavioral health issues: the flow of their treatment records.
Commonly, the way a provider gathers information about a patient’s other care is simply through asking them during an appointment. But that’s not always a reliable method.
“Having an assumption that they are going to be able to tell you off the top of their heads is not accurate,” Caridad said. “They may not remember all their medications. They may not remember the dosage they’re on. They may not remember all the surgeries or their medical problems.”
Through the Quartet system, the patient’s medical records are passed from the primary care physician’s office to the mental and behavioral health provider, and vice versa.
Johnjulio said it’s important for him to know the diagnoses, the recommended course of treatment—including any prescriptions – and the mental health provider’s reasoning behind those choices.
“It’s just the more information we have about that visit, the better we can address those issues with the patient when they come back into our office so their mental health is getting addressed at each touch point,” Johnjulio said.
The primary care doctor can then make sure that the patient is following their treatment course and find out if there are there any changes that need to be made.
“Do we need to make a quicker referral sooner than your three month appointment?” Johnjulio said. “The more information we have, the better we can support the patient and then intervene when we see a need.”
But that means the insurance company working with Quartet, which in this case is Highmark, is covering more mental health visits and spending more money.
Patrick Kennedy, son of Ted Kennedy and former Rhode Island congressman serves on Quartet’s board of directors. Driven by his own history of mental illness and addiction, he pushed for legislation calling for parity in insurance coverage for physical and mental and behavioral health.
On the board, he spends time making the financial argument for more treatment, arguing that behavioral and mental health care need to be a part of treating physical ailments like heart disease, diabetes and cancer.
“All of which have an underlying behavioral health component, i.e. anxiety, depression, addiction,” Kennedy said. “If you can treat those, which often aren’t treated in the context of treating these other physical illnesses, you actually reduce the costs of treating those physical ailments.”
Kennedy called it a “value proposition” to spend more on mental health because the savings are seen in the treatment of physical health.
But those savings could be far off, Kennedy said. Insurance companies need to look beyond instant savings and at the bigger picture, he said.
Highmark rolled out Quartet in June, in six western Pennsylvania counties including Allegheny. The insurance provider is evaluating the outcomes of the first several months and will decide whether to expand use to other parts of its service area.
Quartet advertises that it could save as much as $10 per month per member. Ruktanonchai said the decision to expand needs to be based on more than dollars and cents.
“We’re living the result of a lot of fee-for-service models,” Ruktanonchai said. “So, when a doctor gets paid for just that one visit, they don’t necessarily think about what happens outside of the clinic or the hospital. And so as we think about the whole-person health and we think about behavioral health and emotional health, we’re thinking about community.”
Health care coverage on 90.5 WESA is made possible in part by a grant from the Jewish Healthcare Foundation.