With the nation facing a mental health crisis marked by a shortage of providers and the increased incidence of depression, anxiety, substance use disorder, and suicidal ideation, the direct impact of behavioral health on physical well-being is increasingly known. Primary care providers (PCPs) are often best positioned to address behavioral health issues before they escalate into the more severe mental health issues that dramatically impact patient outcomes. However, most PCPs lack specialized behavioral health expertise, referral resources, and the time needed to effectively assess, treat and manage such conditions. 

To address this reality and the singular impact that mental health has on overall patient health outcomes, Magellan Health created a solution based on the evidence-based Collaborative Care model. Our solution integrates behavioral healthcare in the primary care setting, supporting providers through both high touch and high-tech care. Already proven in use, the solution provides PCPs with the technology-enabled access to behavioral health experts to support them in screening and evidence-based treatments founded in measurement informed care. Patients are supported with an app-based solution that delivers digital cognitive behavioral therapy and other targeted solutions based on their needs.

In this Q&A, Caroline Carney, M.D., President of Behavioral Health and Chief Medical Officer, Magellan Health, will provide readers with a primer on the need not just for an integrated approach, but also how it works, how it impacts patient outcomes and value-based approaches, and how it will help to alleviate the shortage of mental health professionals.

Despite the documented and direct correlation between behavioral health and physical health outcomes, only 27% percent of mental health treatment needs are being met, according to an analysis by the U.S. Department of Health and Human Services. Why are primary care providers well positioned to effectively address and alleviate this gap through a collaborative care model?  

Primary care physicians (PCPs) are the foundation of our healthcare system, serving as the primary point of care for a myriad of conditions ranging from well-child visits to complex chronic illness. They also prescribe more behavioral health drugs than other providers, indicating the need for accurate screening, diagnosis and treatment of mental health and substance use disorders. Because they deliver whole person care, they are uniquely positioned to be the frontline providers for persons who need behavioral health services. Why? Data show that nearly half, 44%, of patients did not receive behavioral healthcare in the six months prior to being admitted for inpatient behavioral healthcare, but more than half – 56% – visited their PCP in the six months prior to being admitted. Further, PCPs are present throughout patients’ mental health journeys – Magellan’s own data shows that 64% of those who died by suicide saw their PCP within the last four weeks of their lives. 

Primary care providers are simply too overwhelmed to do everything well, to keep up on the changes with everything they are responsible for, and under the time pressures they have to deliver care for acute and chronic needs. The schedules, the training, and the pressures don’t allow for adequately addressing mental health and substance use needs, especially across the population.  

‍Why is a collaborative approach to care needed to empower primary care physicians to address low and moderate behavioral health issues before they escalate into serious mental health issues that significantly impact patients’ physical and overall health?

I am a board-certified physician of internal medicine and psychiatry and I have cared for patients in integrated settings the whole of my career. I currently support a team of nurse practitioners and therapists who provide behavioral health care in a rural Federally Qualified Health Center (FQHC). I am often exposed to the predicament PCPs face today: 

• The specialized behavioral healthcare most patients need is not accessible or is challenging to navigate; and
• PCPs lack the specialized expertise and resources needed to confidently, effectively and efficiently address patients’ mental health needs even though they dramatically impact physical health outcomes. 

In the U.S., there continues to be a rising need for mental health services, a demand that far outpaces provider availability. In order to address the access to care need, models such as collaborative care provide an excellent solution for the delivery of holistic primary and behavioral healthcare in an integrated setting.

Our own data, and data from sources like Milliman and other companies, shows the impact of behavioral health conditions on overall health, and the costs associated with the care of persons with co-morbid or co-occurring conditions. In addressing both physical and behavioral health, we can provide individuals with needed care, deliver evidence-based mental health treatment, and lower overall total cost of healthcare costs. For instance, if I address and treat a patient’s anxiety or depression, tend to their psychosocial needs, and ensure they make medical visits and engage in medical care, it follows that lower use of emergency services and inpatient health services occurs.

Can you elaborate on key components that should be included in collaborative care models and how they empower PCPs to effectively and efficiently address patients’ behavioral health conditions issues at scale? 

Collaborative care models are all based on an integrated care model developed at the University of Washington that has been validated in more than 90 randomized and controlled trials. They have been hard to scale because of challenges in managing patients over time, having the right teams of support, and lacking reimbursement from payers like Medicare. However, in recent years, Centers for Medicare & Medicaid Services (CMS) approved paying for collaborative care codes and many states have followed. Collaborating with NeuroFlow as Magellan’s technology platform, we’ve built a scalable model based on the key components of collaborative care:

• The team is composed of the primary care provider, a Magellan dedicated care manager, and a psychiatrist.  
• Screening and referral is done in the primary care setting, and managed by the care manager, thus alleviating the PCP from screening. The care manager notifies the PCPs which patients need further assessment.
• The psychiatrist reviews cases and makes treatment recommendations according to evidence-based algorithms.
• Patient screening data are collected over time which provides the foundation for measurement-based care and helps providers log time for billing purposes.
• The platform makes it easy to integrate behavioral health protocols into the practice’s existing workflows and creates a closed loop of communication between Magellan’s dedicated care management team, psychiatrists, the PCP and patients. The platform also streamlines the routing and management of interventions and referrals to in-network providers. 
• Patients can download an application that delivers digital cognitive therapy and other needed supports and assists the providers in monitoring for deterioration and even suicidality.
• Magellan can also provide a model of delivering telehealth psychotherapy services for individuals needing that type of care.

What impact are you seeing among practices that have embraced a collaborative care model approach?

Our experiences are still early, but have been very positive. Our initial pilot was in a rural FQHC that provides primary care services in a behavioral health underserved area.  In the first year, we’ve grown from supporting one PCP to three and found:

• 23% more patients were screened for behavioral and mental health issues; and
• 38% of patients were identified with low to moderate behavioral health concerns. 

In another use case in a large health system’s pediatric clinic, we have enrolled a high number of children who otherwise would have waited weeks to months for behavioral health concerns to be addressed.  ‍

Are you optimistic that this approach will make a significant difference in patient outcomes?

In the behavioral health arena, we are seeing more demand for services than ever before. I consider this one of the best upsides of the COVID pandemic—people are seeking services and stigma against mental health has declined. It’s been incredible to talk openly with people about the need for care. Unfortunately, we do not have enough behavioral health professionals – a reality that will not change materially for several years. This collaborative care model ensures that primary care providers can be reimbursed for identifying and managing conditions that might have gone unrecognized or untreated. The model supports providers and patients in a time of limited resources. 

I am highly confident that Magellan Health’s Collaborative Care Management solution addresses this by enabling PCPs to address low and moderate level behavioral health concerns while routing more serious cases to in-network psychiatrists for diagnosis and treatment plans. Because our solution is scalable and creates the perfect triangle of care supporting the patient through the primary care, care management, and psychiatry consultation, we will be able to implement in many settings across the country, especially primary care clinics, Accountable Care Organizations (ACOs) and specialty settings with a high burden of mental healthcare needs. The more people who receive the right care early in the course of their mental health need will ultimately relieve pressure on the specialty mental health providers, and ultimately reduce expensive and preventable utilization.  

As a longtime provider of integrated care, the ability to scale collaborative care means one primary thing: people of all ages will get the right care at the right time and the downstream morbidity of mental illness will decrease. PCP burden will decrease. Stress on the behavioral health system will decrease. It’s a no-brainer. Let’s get the best care out there!