The doctor will analyze you now
As a child growing up in rural Alaska, Vera Starbard was diagnosed with major depression. She’d been sexually abused by her uncle and was plagued by thoughts of suicide. By the age of 10, she’d already spent time as an inpatient in a psychiatric hospital. “It was a really dark time,” she says. “And I didn’t feel like it was ever going to get better.”

As a child growing up in rural Alaska, Vera Starbard was diagnosed with major depression. She’d been sexually abused by her uncle and was plagued by thoughts of suicide. By the age of 10, she’d already spent time as an inpatient in a psychiatric hospital. “It was a really dark time,” she says. “And I didn’t feel like it was ever going to get better.”

But when she was 11, things changed. Her family moved to Anchorage, and they joined the Southcentral Foundation, a health care provider for native Alaskans. The foundation was launching a new approach to health care—one that wove mental health into the rest of its primary care.

For Vera, that meant every checkup included a mental health evaluation. Her primary care team included a psychologist or social worker who offered care on-site. There were a variety of group counseling programs to choose from. Every person she saw had her health record, there were no outside charges, and there was never a wait to make an appointment.

Perhaps most important, accessing mental health treatment was as easy as going to her regular doctor, and there was no stigma attached: Her mental health services were provided at the same time and in the same place as other medical care, just like heading down the hall for an X-ray or blood test.

In Anchorage, she still had a lot to work through, and difficult times ahead. But today, at age 35, she says that Southcentral’s approach to mental health care saved her life. “There’s a higher than not probability that I would have committed suicide without the resources at my disposal,” she says.

Vera Starbard at home in Anchorage, Alaska. A victim of sexual abuse as a child, she credits the easy access to behavioral health care at Southcentral Foundation with helping her overcome profound depression. | Ash Adams for POLITICO

It's a truism that the mind and the body are connected, but the U.S. health care system has long treated them as separate—with separate doctors, separate hospitals, separate payment systems. That’s a major reason people with acute mental illnesses don’t get help. Ditto for chronic conditions like depression and anxiety. People may not seek help because of stigma. They may not find it because there are too few providers and they are too hard to locate. Or people don’t have health insurance, or can’t afford the co-pays, or lose interest when faced with a long wait.

The result is that many people who need mental health care aren’t getting it. According to a recent article published in the Journal of the American Medical Association, nearly 18 percent of adults surveyed in 2015 reported having a mental, behavioral or emotional disorder. And 20 percent of respondents said either they or a family member had needed mental health care but didn’t get it, either because they couldn’t afford it, their insurance wouldn’t cover it, they were afraid or embarrassed, or they had no idea where to go.

At the patient level, this means people with mental health issues suffer when they don’t need to. And at the policy level, there are huge reasons to fix this, primarily the high long-term cost of untreated mental illness. Mental health plays a big role in chronic conditions like hypertension, obesity and diabetes. “You can go ahead and give all the insulin you want,” says Donald Berwick, former head of the Centers for Medicare and Medicaid Services, founder of the Institute for Healthcare Improvement and a big proponent of behavioral health integration. “If you’re not addressing the attendant behavioral health issues, you’re not just missing the chance to reduce suffering, you’re reducing the chance to save a lot of money.”

In part because of their Alaska Native heritage, which puts a high value on spiritual health, the leaders of Southcentral recognized decades ago that behavioral health is tightly linked with bodily health. So they became one of the early adopters of integrated care. They embedded treatment for mental and emotional ills in their primary care practices, and found that patient satisfaction rates skyrocketed and usage of medical care went down, saving millions of dollars while improving patient outcomes.

In the nearly 30 years since Southcentral hired its first psychologist, pretty much every study has shown that integrating mental health care into medical care results in better patient outcomes and lower costs. A few years ago, analysts at actuarial firm Milliman estimated that integrating medical and behavior heath care could shave $26 billion to $48 billion each year from the nation’s health care costs.

But adoption has been slow, in part because of the way much health insurance is structured. Mental health is often a separate benefit, if insurance pays anything at all. Doctors are paid more for procedures on sick people. They get less if they keep their patients healthy and out of the hospital.

Of all the structural problems in the U.S. health care system, the segregation of mental health care from the rest of medical care is arguably the most costly, both financially and in terms of patient health. With new pressure to find ways to bend the curve of health care costs, and the growing burden of chronic disease and worker disability, perhaps no policy could have as much bang for the buck as finally integrating mental and physical health care.

IN THE MIDDLE of the 20th century, mental illnesses weren’t considered illnesses per se; fully debilitating illnesses were seen as “insanities” and their sufferers often confined against their will in special mental hospitals. Illnesses that were less debilitating—milder depressions, say, or anxiety or substance abuse—were viewed as weaknesses of will, often ignored by medical professionals. Payment followed suit; for mental health providers it was low, for primary care providers it was essentially nonexistent.

People had to either figure out a way to live with their conditions, or suffer as their illnesses got more acute. The arrival of more effective medications for mental illnesses opened things up a bit—doctors could write a prescription, and patients could feel better without months or years of talk therapy. Still, several studies in the 1980s showed that many patients didn’t get treatment, with as many as one-half of patients saying no when their doctors suggested they get mental health care.

The search was on for something better. In the early 1990s, private foundations and the federal government, through the Substance Abuse and Mental Health Services Administration, began funding clinical studies around the country. Could primary care providers be trained to recognize depression, and get their patients treated? Would that make a difference? The studies showed the answers were yes and yes. In 1996, the Institute of Medicine published a suggestion—integrate primary and behavioral health care so that patients would get diagnosed and treated by their doctors or via direct referral to a behavioral health specialist as part of their routine medical care. Big health care systems like Kaiser Permanente and the Veterans Administration began experimenting with integrating behavioral health care in some locations.

Physician's assistant Ingrid Carlson examines 6-month-old Milo Rebne. Southcentral Foundation's exam rooms have comfortable chairs and minimal equipment – the idea is to encourage conversation between health providers and patients, or in this case Milo's mom, Heather Lee Rebne. | Ash Adams for POLITICO

Southcentral Foundation was ahead of the trend, having started thinking about integrating its care in 1985. CEO Katherine Gottlieb, an Alaska Native who won a MacArthur “genius” grant award for her work at Southcentral, says there was a simple reason: “We did a survey of our community.’’

Southcentral asked community members to rank their health care priorities among choices like cancer care, diabetes, obesity and behavioral health. The top five priorities, says Gottlieb, were all related to behavioral health—child sexual abuse, child neglect, domestic violence, behavioral health counseling and addictions.

So Southcentral forged forward with its goal of making patients with behavioral health issues feel welcome. It built an airy new primary care center that looks as much like a mountain lodge as it does a place to get medical care. Huge windows frame the snowcapped peaks of the nearby Chugach Mountains, and the halls are filled with Alaska Native art—beadwork, blankets, dolls, carvings and paintings of totem animals such as ravens, orcas and eagles. There’s an expansive lobby designed to host community gatherings. Foundation planners say the setting sends the message that the health of the community directly relates to the health of each of its members.

Today, a patient with a history of mental illness, like Vera, gets evaluated by her doctor whenever she comes in for a medical appointment. If Vera seems anxious or depressed, the doctor might talk to her about it, or call in the behavioral health consultant. But the same goes for patients without a history of behavioral problems. A diabetes patient who has stopped taking his pills, for instance, might find himself in a 20- or 30-minute discussion with his primary care doctor about ways to deal with anxiety or depression. The primary care doctor or the behaviorist on the team might suggest more formal counseling, or the request might come from the patient. When hospital care is needed, patients are sent by their care team, and they return to that care team when they get out.

The system puts mental illnesses into the realm of routine health care. “We know that for tons and tons of people, stigma is a really big deal in behavioral health,” says Douglas Eby, vice president of medical services at Southcentral and one of the many staffers who’ve been there since the beginning. “But getting behavioral health during your visit with your primary care provider, or by the guy down the hall, at the same place and maybe during the same visit—then it’s nothing different, and not likely to be stigmatized.” Your employer won’t find out, and your buddies won’t see your truck parked outside a mental health office. Integrating behavioral health care into a medical setting normalizes it, he says.

Southcentral takes things a step further, with several innovative group therapy programs, some of them building on Native American culture—“learning circles” where people talk about how they dealt with internal conflict and about how to resolve their feelings. Vera attended an intensive one-week group therapy session where people shared memories of domestic violence, abuse and neglect. “That was the week I figured out I could be happy,” she says. Family, faith and friends also helped, but what she learned at Southcentral was instrumental. “That was the start of not being a victim anymore, of seeing that there was light at the end of the tunnel and I wouldn’t always be depressed.”

Southcentral’s administrators credit integration for lowering hospital admissions and visits to the emergency room by more than a third between 2000 and 2015. In a recent survey, 97 percent of patients said they were satisfied with the care. In 2011, the foundation was awarded a Malcolm Baldrige National Quality Award for delivering top-quality care for less cost than the vast majority of U.S. providers.

THE BIGGEST CHALLENGE all along, says CEO Gottlieb, has been money.

Southcentral gets by on a combination of private insurers and government programs including Medicare, Medicaid and the Indian Health Service. But most of them don’t pay much for mental health care, and they don’t pay anything at all for some of the counseling and group sessions the foundation offers. So Southcentral subsidizes behavioral health care with savings from the medical side, and it gets grants as well.

TOP: A mask in the lobby of the primary care building at the Alaska Native Medical Center. Beadwork, sculpture, and paintings are intended to make the foundation’s 65,000 patients feel connected to their native Alaskan heritage. BOTTOM: Behavioral health consultant Emily Degroot speaks with patient Elizabeth Pawluk. | Ash Adams for POLITICO

Payment is a challenge across the country.

A landmark study of 113,452 patients in 102 group practices within the Intermountain Healthcare system in Utah and Idaho showed how much can be saved by integrating mental health care. Some practices included mental health care in a “medical home.” In other practices, patients were referred to outside therapists. Annual medical costs were $515 higher per year for patients who did not get mental health services through their primary providers.

While the benefit to patients was clear, the study had a second conclusion—that providers lost money by integrating mental health. As physician Thomas Schwenk noted in an accompanying editorial, during the 2010-13 study period the integrated practices received $115 less per patient per year than the traditional practices, because payment was based on procedures and office visits. Since patients in the integrated practices needed less medical care, the doctors made less money.

Such payment practices are common, and Schwenk wrote that it’s going to take “a profound change in the fundamental structure of the U.S. health care delivery system” to integrate behavioral health care into the primary care environment. That would take heavier reliance of payments going to groups of doctors caring for groups of patients, not piecemeal payments for individual services.

There’s broad support for behavioral health integration within the health care community and in Congress; there are few critics on record, and no one is lobbying against it. The trade association for companies that provide health care services to people in insurance plans, the Association for Behavioral Health and Wellness, is a big booster. Patient groups love it for the access it gives, and for the destigmatization. Supporting health care reform that favors behavioral health care is a major legislative priority for the National Alliance for Mental Illness, which represents people with mental illnesses and their family members.

Andrew Sperling, a lobbyist for NAMI, echoes the conclusion that the chief challenge is money. According to a SAMHSA estimate, Medicare spent $29 billion on mental health care in 2016, and the Medicaid bill was $67 billion. Sperling would like to see more for various demonstration programs. And if funds for Medicaid are cut, “a lot of the innovation we’ve seen with primary behavioral health integration would be stifled,” he says.

Still, some doctors and other providers are not totally on board. Many psychiatrists today don’t accept Medicare or other insurance, making access still a problem. And primary care practitioners and behavioral health workers may need training in how to work in an integrated system. “People who become cardiologists and rheumatologists and all the other ‘–ologists’ get minimal instruction in behavioral health,” says Berwick.

Psychologists and social workers may also have to be retrained, says Berwick’s IHI colleague Mara Laderman. Mental health consultants in integrated care systems work differently. “They’re focused on action-oriented problem solving over one session or a couple of 20-minute sessions, as opposed to having a more longitudinal therapeutic relationship,” she says. “You know, that 50-minute, hour appointment.” Southcentral’s Eby confirms that—he says they have to look long and hard for people willing to give care outside of those 50-minute boxes.

LEFT: A garden with Alaska Native traditional healing plants outside Southcentral Foundation’s primary care facility. Patients, including those with behavioral health issues, can ask for a referral to one of the traditional healers employed by the foundation. RIGHT: Health care providers use a bulletin board to send the message that patients are in charge. | Ash Adams for POLITICO

SOLVING THESE PROBLEMS will take more than money; it will require changing the culture of medicine. Many groups are moving in that direction; the American Medical Association, the American College of Physicians, the American Psychiatric Association, the American Psychological Association and other groups have policies promoting integrated care and offer information to their members on how to adopt it.

The federal government supports a multitude of initiatives designed to promote behavioral health care integration. The Affordable Care Act set aside money for model projects. Close to a billion dollars has been granted for programs that will promote behavioral health care, like setting up patient-centered medical homes within Medicaid. And starting last January, Medicare has been paying physicians for behavioral health care management and consultation. There are new billing codes that allow physicians to charge for helping their patients get behavioral health treatment, managing their patients’ care, and working with psychiatrists.

Authors of an article in the New England Journal of Medicine say it’s a “major step forward” and predict millions of beneficiaries will benefit and that there will be millions of dollars in savings. There could be a ripple effect: Medicare often serves as an example to other insurers.

Southcentral Foundation leaders are often invited to speak at conferences or to health care organizations in the Washington, D.C., area, and when they do, they usually stop by Capitol Hill or federal agencies to talk about the benefits of providing mental health care in a primary care setting. Douglas Eby’s trips have led him to believe that there will be more support in the future for fully integrated systems.

“We are popular with the whole political spectrum,” he says. “We cut costs like crazy and emphasize self, and family, so Republicans love us. Democrats love us because we’re all about community and social factors and reforming the pillars of society so that everyone has improved access to care. When we walk into different political offices, we emphasize different parts of the system so that they can hear our story in their words and values, but it is all very true and the truth is the same truth.”

Conversations are a key part of the relationship between providers and patients -- called "customer-owners" -- at Southcentral Foundation. Physician’s Assistant Ingrid Carlson speaks with customer-owner Taylir Kueter, 20. | Ash Adams for POLITICO

Berwick, with plenty of experience on Capitol Hill when he was head of CMS, is concerned about protecting funding for some of the demonstration projects in the current chaos of health care funding. But in the long run, he says, integrating behavioral health into primary health care is inevitable. “Look, we’ve got to solve the health care cost problem,” he says.

In Anchorage, Vera Starbard is watching with interest. Until recently, she figured that all health systems offered mental health care right along with primary care. “That’s literally what I had grown up knowing as health care.”

But recently, she’s seen several friends who are not part of Southcentral struggle to get mental health services. One friend, who, like Starbard, had been sexually abused, struggled for months to get approval from her health insurance company. Then her friend’s intended counselor stopped taking new patients. “I’m only now seeing how good integrated care is,” says Starbard. “We definitely took it for granted.”

Joanne Silberner is a freelance health writer based in Seattle.

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