Integrating Behavioral Health Care, Social Work and Primary Care

There is no question that there is an enormous push now for what is being called Value Based Purchasing of health care services.  In a sentence, payers would like to pay providers for achieving certain outcomes related to reducing the overall cost of care, while keeping people healthy by improving their care.  It is a worthy goal.

As primary care physicians have struggled to move in this direction they have encountered two major obstacles.  The first is that many patients with the poorest health and the highest health care costs have behavioral health and/or substance abuse problems.  The second is that social factors, long considered out of the purview of medical or mental health care, have emerged as major risk factors for ill health and extraordinarily high health care costs.  

So to prepare for the future, where payment will be based on cost and quality (together referred to as “value”), health systems must figure out a way to integrate care for behavioral health, social and substance use issues into their delivery models – either through providing those services on site, or through referral arrangements.

Many people now talk about integrating care and there are many organizations and providers trying to achieve this.  We often see this as the introduction of psychiatrists or other behavioral health providers into a primary care practice or the development of a referral relationship with good reporting back and forth between primary care and mental health. 

I have wondered what truly integrated care would look like.  You know, the kind where each specialist focuses on their own area of expertise but every person seeing the patient in the office is responsible for every aspect of their care and well being.  I believe an essential tool here is a fully integrated electronic health record – one which organizes progress notes chronologically irrespective of who the provider of care is that wrote the note or whether they are a primary care provider, behavioral health provider or a social worker trying to get housing for the patient.   Just as importantly however, is the requirement that every person touching the patient is working to help the whole patient and shares a common interest in all parts of the patient’s well being.

Let me cite an example of how I will know when we have achieved this level of integration. 

A 53-year-old patient with hypertension, diabetes and depression is seen bimonthly by her primary care physician and is being seen in every month by the Institute’s psychiatrist.  The psychiatrist reads his own prior note to recall the patient’s last visit to him and then proceeds to read the most recent primary care note as well.  He notes that the patient was started on a new hypertensive medication on the last visit.  He asks “I see Dr. Jones started you on a new medication for your blood pressure last visit.  How is it going?  Any problems with it?”

The patient answers, “As a matter of fact, I had to stop it after a few days because of a rash.  I guess I was allergic to it.”

“If you don’t mind, I’d like to check your blood pressure while you are here since it was a bit high on the last visit to Dr. Jones,” says the psychiatrist.

“Sure.  That would be great.”

As it turns out, the patient’s blood pressure is very high.

The psychiatrist then asks when the next appointment is scheduled with Dr. Jones.

“Not for another 6 weeks,” the patient replies.

“After our counseling session, I’d like you to see someone for your blood pressure before you leave.  Would that be OK?”

“I’d greatly appreciate that.”

At the end of her visit with Dr. Jones, he calls the nurse on the primary care team, explains the situation and the patient is put in with a physician on the team to adjust her medications.

Get it?

It’s not about people with different interests in the patient each sticking to their own domain.  It is about each member of the patient’s care system being concerned about the whole patient.   That’s the Holy Grail.  Now we just need to figure out how to get there.

Provider Accountability Meets Patient Choice

The health care system overall - and community health centers and family practices are no exception – have been constructed on a very paternalistic model.  We pretend we know what is best for our patients and make a system of comprehensive care that requires continuity, appointments to be kept, and patients to obey our orders for preventive care.  And we are increasing being evaluated and paid on our ability get our patients to comply with all of the preventive and chronic care imperatives that are determined to be today's best practices.

While we are evolving this system, patients are choosing to go to other models of care for urgent issues, camp physicals, immunizations, as well as for simple problems.  They seek problem focused, convenient, rapid throughput visits without being engaged in discussions driven by our advice about other issues and our response to EHR-driven reminders.  

We have to pay attention to what is happening now that new immediate care options are available more and more to our patients and we have to figure out where our comprehensive care model fits in.  I don’t have the answer to this yet but we have been talking about it a lot in our management team meetings.

Imagine that your life is in disorder and its three days before school starts, you forgot to get your child’s immunization updated and need a school physical form filled out.  Our health centers see this as a disruption in our appointment system and have difficulty  accommodating this type of visit in an efficient manner.  

Our patients, however,  can now go to any of a dozen local sources of immediate care and get this done.  I think we need to be able to figure out a way to keep our patients with us, while still allowing them to have a short visit if they need it, to accommodate their last-minute issues (haven’t we all had them at one time or another?) and still maintain them in our practice.   If we stick with our old model of requiring people to get care the way we think it should be done and remain oblivious to their chosen care model and the proliferation of places where they can get it respected, then we are truly in trouble.

The real issue now is that accountability for quality will still lie with their primary care provider team, yet our patients will have more and more choices for more convenient care in between their main chronic illness visits.  How we will adjust our practices to deal with that?

The Teaching Health Center: A Great Program Threatened by Republican Shortsightedness

After decades of concern for the deep and worsening crisis in our country due to a shortage of primary care physicians, the Obama administration proposed - and passed as part of the health reform bill, a program to directly fund health centers for the training of primary care physicians. Combining the longstanding committment to excellence in primary care with the social committment of the primary care providers that practice in community health centers, the idea of using this successful model to train a new generation of primary care providers was brilliant. Directly funding these programs was essential in that programs funded through hospitals often direct large portions of the training to the inpatient setting to extract more inpatient service from the residents in training. But the model, like other important parts of the health reform legislation is under attack.

H.R. 1216, authored by Congressman Brett Guthrie (R-KY), rescinds the unobligated portion of the $230 million in total mandatory funding available to support Teaching Health Centers (THCs) for FY2011-FY2015. This bill would make the program subject to the annual appropriations process rather than committing the $46 million per year for FY2012-FY2015 in the health reform legislation to fund Teaching Health Center activities.

This year HRSA announced 11 THC grantees, of which 9 are community health centers with our own Institute for Family Health's Kingston Family Practice among them. Funding this year through this program will support the expansion of our Kingston rural residency by 12 residents. The residents will train along side our dedicated primary care physicians - all practicing in medically underserved communities. 6 of these residents will be training in our remote rural center in Ellenville, New York, (pictured below) where they will learn what rural medicine is really like, and, upon graduation, will become part of a cadre of physicians trained to practice in parts of the country where there are few if any primary care services.

If enacted into law, H.R. 1216 will make it challenging for us and the other 10 programs that have already made the decision to participate in this program based on a promise of continuous funding. The new legislatiion being proposed means that the programs would have to fight for limited discretionary funding each year. The National Association of Community Health Centers has said "In this difficult budget climate and with House Republicans reluctant to support the implementation of health reform, despite clear statements by Energy and Commerce Members on both sides of the aisle that this legislation advances a worthy goal of training more primary care physicians, if H.R. 1216 were to become law it puts the new THC grantees future funding in jeopardy."


We need to do everything we can to support the continued funding of Teaching Health Centers. The primary care shortage is real and even in its first year, substantial increases in primary care training will be achieved through this program. Let's keep a good thing going!

ACOs and Federally Qualified Health Centers: A Lost Opportunity to Transform the Health Care of America’s Most Needy?

As our Nation struggles with the troublesome duet of embarrassingly poor health outcomes and seemingly unstoppable escalations in health care costs, a model has emerged with promise to blaze our way out of this quagmire. And unlike many other advancements in medicine, the first beneficiaries of this model are America’s most needy residents. The model, the Federally Qualified Community Health Center, incorporates almost every aspect of what health care experts believe are the fundamental characteristics of an advanced model of health care organization. Strangely, unless action is taken immediately, that model will be overrun by the implementation of Accountable Care Organizations – or ACOs – when ACOs have been developed to accomplish many of the same goals. Here’s what is happening…..

The Medicare regulations for ACOs were released on March 31, 2011 in draft for public comment. In brief, ACOs are meant to establish a financing system where payment enhancements are made to the ACO, and then to the providers, based on achieving specific health care outcomes and reducing (or in some cases stopping the escalation of) health care costs. This is achieved by assigning patients to ACOs based on their historical place of care and assigning cost predictions based on their historical utilization of health services and other health-related characteristics. So everyone – or almost everyone – wants to be an ACO so they can get the financial rewards from their efforts to improve care for their patients and reduce overall health care costs. In New York City, hospitals, medical groups and FQHCs have been planning their ACO strategy since the legislation outlining the goal of ACOs was passed last year in the health reform bill. Yet to the shock of the FQHC community, they were determined, along with Rural Health Centers (RHCs) and some others, to be ineligible to sponsor an ACO.

The implications of this will have enormous, negative impact on the future of FQHCs. To understand this, one needs to envision the advanced model that FQHCs have been developing over the past decade. To start with, they are governed – not just advised – by a board of directors that is made up of a majority of the health centers users. They are built in the community, governed by the community and therefore, serve as a model of how health care providers must be responsive to the needs of those they care for. They have been early adopters of electronic medical records, have been achieving certification as Medical Homes at a blinding rate (the highest recognition a primary care provider can achieve today). They have expanded hours to expand access, provide multilingual care where appropriate, and often integrate chronic disease management, mental health and dental services in one location. They engage networks of specialists to care for their patients – even though 1/3 of the patients they serve nationally lack health insurance. In short, they are the model for what everyone in the U.S. needs. So what is the issue?

ACOs will control the flow of funds for improved care and reduced costs and to insure that the benefits of these added payments accrue to those who have invested in the formation of advanced delivery systems, they must be in a position to control the distribution of these funds. We have always said that a rational system of care is built around a strong foundation of primary care – the FQHC. With hospitals and multispecialty groups in control, the same power relationships that exist now will exist in the future and what is worse – the same model of care and the same catastrophic economic results. We cannot afford to let this happen. The main question at stake here is whether we want hospital controlled ACOs sitting at the center of these new models, struggling to make up for the falling volumes of high-cost services they provide by fighting over market share with other hospitals, whether we want multispecialty group practices at the center of the ACO model with their frequent overrepresentation of specialists and underrepresentation of primary care or whether we want primary care as the ACO’s core – providing a rationally constructed system where the training of primary care practitioners in preventive care, care coordination and chronic disease management provides the foundation for improving quality and reducing cost. We all know what we need to do!

The elimination of FQHCs from the list of eligible ACO sponsors seems to result from a technical issue but it is hard to imagine that a technical work-around could not have been developed by CMS before the release of the draft regulations. The technical problem is that FQHCs are required by CMS to bill Medicare differently than practitioners in private practices bill. FQHCs do not use HCPCS codes to indicate the type and level of procedure done and they do not indicate the specific doctor who saw the patient as the claim form has only a place to indicate the clinic provider number. Because of this historical method, CMS claims the inability to collect baseline data back 3 years as they propose to do and the inability to attribute care to an individual provider. But for those FQHCs that choose to sponsor an ACO, this data is retrievable through a review of the medical records that contain this information. For those on electronic health records, this data could be extracted electronically. For those whose records are still on paper, a sampling methodology could be developed. Claims could be reprocessed for qualifying Medicare patients – those that CMS tells the center might be a candidate for an ACO by virtue of the FQHC providing a plurality of visits to the individual patient. The reprocessing would not effect payment but merely provide the needed baseline data for these patients. I am sure there are other solutions as well – and they need to be developed now.

The country needs FQHC’s as the sponsor and integrator of ACOs – especially as more uninsured patients achieve coverage through health reform in the ensuing years. ACOs sponsored by FQHCs would be based in a system with the most sophisticated primary care delivered in a fashion that by its very nature treats patients in order to improve their health outcomes and reduce their costs of care. We need to advocate quickly and powerfully that FQHCs be included as potential leaders of ACOs, in a position to insure that the distribution of funds through the proposed shared savings models is done in a manner that preferentially supports primary care.

For Medical Students: Primary Care, the Uninsured and Painful Lessons that Lie Ahead

On a rainy and blustery evening last week, I had the pleasure of speaking to an amazing group of first and second year medical students at Downstate Medical School in Brooklyn – part of the State University of New York. I am not sure whether they came for the Thai food or to hear me speak but I had the opportunity to tell stories of my medical school, residency and practice experiences – each highlighting some of the fundamental values underlying primary care. My message was that patients are increasingly demanding primary care as a trusted way of negotiating an otherwise incredibly confusing and fragmented health care system. I stressed that primary care physicians must stay focused on the needs of their patients above all else and that our loyalty and responsibility towards our patients must always remain first and foremost in our minds and actions – unfettered to the maximum extent possible – by advertising and loyalties to our hospitals or peers.

As I wrapped up my comments two questions came from the audience. The first, quite predictably, concerned my feelings about the “government controlling health care” and how I felt about that. I asked if the young woman asking the question from the very back of the room was asking about the much debated “public option” in the current health care plan passed by the House last week and she nodded affirmatively. I explained that the plan does not call for the government to control health care, rather that we would be adding another type of government subsidized and managed health care plan to the already existing government plans – namely Medicaid and Medicare.

A tougher question came from a young man in the front of the room who asked how our community health care system could survive financially taking care of the number of uninsured that we currently cared for. And that question truly cuts to the heart of the health reform debate, though I wasn’t fast enough on my feet to realize it at the time. Our 24 site community health care center network in Manhattan, Bronx and the Mid-Hudson Valley cares for over 10,000 uninsured individuals and provides them with over 35,000 visits a year. I explained that to pay for this we literally cobble together funding from dozens of sources. Our Federal 330 grant pays for some, New York State indigent care funding picks up another piece, and grants that support the care of the Homeless, the care of some uninsured patients affected by HIV and dozens of other grants for sub-groups of our uninsured patients – all go to support this work and keep us afloat. I stood there proud that our organization – the Institute for Family Health – had been able to accomplish this.

Yet I missed a real opportunity to underscore the fundamental reason we need health reform in this country. People need health insurance. Our country cannot depend solely upon health centers like ours as the safety net for everything patients who are uninsured need for their care. They must have coverage to pay for all the essential health care services they need. Primary care is the front end of an entire health care system which must provide access to people for diagnostic services, treatments, hospitalizations and medicines. With people of color 2 to 3 times more likely to be uninsured in New York City providing insurance for everyone is an absolutely essential step towards eliminating racial and ethnic disparities in health outcomes. And with primary care providers already struggling to create viable practice models in underserved areas, only full insurance coverage of the people who need these providers can sustain these practices and attract new doctors to these areas.

I am sorry I missed the opportunity to explain more to the students in Brooklyn last week about the failings of our current health care system. But I am not worried that their education will be lacking for very long. Soon the students will begin their clinical rotations in the hospital and there they will no doubt experience, first-hand, the failings of our current system to provide health care for all our people. They will see people suffering the effects of poorly treated chronic diseases – losing their legs and their kidneys to long-standing diabetes. They will see people with cancers that would have been curable if only they had been detected earlier. They will see people with advanced infections that have gone untreated for days or months and now require prolonged hospitalizations. These lessons will hit hard and perhaps some of them will understand and will choose to become the next generation of primary care physicians and the new champions for needed change in our health care system.

HIT and HIE for America’s Most Vulnerable Patients

Today I will testify before the U.S. Congress, House of Representatives, Committee on Oversight and Government Reform, Subcommittee on Government Management, Organization and Procurement. The hearing, entitled “Too Many Cooks? Coordinating Federal and State Health IT” could go on for weeks if the issue were to be thoroughly explored. I was asked by the Subcommittee Chair, Edolphus Towns to present our experience with health information technology in community health centers and make some recommendations.

The rollout of HIT/HIE must include special considerations for vulnerable, diverse populations or run the risk that it will increase disparities in health services delivery and health outcomes. I will make the following recommendations at the hearing.

Insure that all legislation that supports the implementation of electronic health records targets those patients at highest risk on our society. This requires that all developments have organized ways for community participation in their planning and execution and that providers in the health care safety net – community health centers and public hospitals – are included as primary targets for funding implementation of health information technology

Insure that all legislation that supports health information exchange (HIE) includes provisions that safety-net providers – specifically community health centers and public hospitals – must be included in HIE networks. This requires that they first be given the resources to implement electronic health records (because you need an electronic health record in order to participate in a health information exchange). This also requires specific funding for implementation and maintenance of connectivity to HIE networks for safety net providers who may otherwise be unable to pay for the needed interfaces of their systems with these networks

Fund the integration of all EHRs, but specifically those in safety net facilities, into local, regional and state health department systems that monitor the disease burden in the community and help people optimize their preventive health care measures. Medically vulnerable populations are often the first victims of infectious diseases as they also suffer from inadequate nutrition, housing, clothing, health education and access to medical care.

Mandate that all EHR systems capture data on race, ethnicity, gender and primary language so that providers can examine disparities that exist in treatment and in outcomes within their health care delivery systems and work to correct them through targeted efforts aimed at the highest risk populations

Encourage EHR vendors to provide a mechanism for alerting providers to clinical trials which may be relevant to their patients. People of color are underrepresented in many clinical trials in this country and EHRs provide an easy way to identify patients who meet clinical trial criteria so that they may be offered the opportunity to participate. This improves the relevance of clinical findings of these studies to ethnically diverse populations.

Create criteria for EHR certification that require that information produced for patient consumption such as health education materials, visit summaries, portals that allow patients internet access to their own health information – all be made available in multiple languages and at a 4^th grade literacy level when needed.

Insure that rural areas are funded to deploy broadband technology and that broadband access is provided in all public housing being built. A timetable should be set to retrofit all existing public housing facilities with broadband capability.

Require the input of communities of color in planning the privacy and security requirements for health information exchange and in developing consent procedures for participation in health information exchange. There are well documented, legitimate reasons that issues of privacy, security and consent procedures will play out differently in communities of color. Among other issues, it must be made clear that information provided by patients and entered in their electronic health records as well as information shared in health information exchange networks is not subject to government use for purposes of identifying undocumented immigrants.

Provide resources for health information technology adoption in prisons, in the foster care system, for homeless health care providers, for migrant health care providers and for other providers serving vulnerable populations so that these mobile and transient patients can have records that are available wherever they may go.

Create a national system for specifically monitoring the impact of health information technology and health information exchange efforts on vulnerable populations and tying future funding to successes in eliminating disparities in treatment by the participating health care providers and disparities in the outcomes of their patients.

Insure that any pay-for-performance systems include mechanisms for risk adjustment for outcome evaluations – not to reduce the goals that we must reach but to recognize the added difficulty that traditionally medically underserved people may have in achieving these goals.

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I look forward to suggestions and enhancements to the items cited above.