Health Care Reform and Integrated Care: A Golden Opportunity for Preventive Psychiatry

Abstract

The Affordable Care Act (ACA) includes provisions to shift the U.S. health care system to address achieving wellness rather than just treating illness. In this Open Forum, the Prevention Committee of the Group for the Advancement of Psychiatry describes opportunities created by the ACA for improving prevention of mental illnesses and promotion of mental health. These include improved coverage of preventive services, models to integrate primary and behavioral health care, and establishment of the National Prevention, Health Promotion, and Public Health Council, which has developed a National Prevention Strategy. The authors describe the important role that psychiatrists can play in advancing prevention of mental illnesses, in particular by working to incorporate prevention strategies in integrated care initiatives and by collaborating with primary care providers to screen for risk factors and promote mental and emotional well-being.

The Affordable Care Act (ACA) allows for sweeping insurance and delivery reforms to the U.S. health care system. Many ACA components have not yet been implemented or are in the early stages of implementation, and political opposition may still threaten aspects of the ACA. However, exciting possibilities exist within the reforms outlined in the ACA to provide significant improvements to the nation’s current health care system.

The ACA emphasizes the importance of prevention in health care and includes provisions to shift the health care system to address achieving wellness rather than just treating illness. Two major areas of attention in health care reform are a greater reliance on the integrated treatment of illness in primary care settings, rather than in specialty care, and a renewed commitment to prevention. This convergence, and an increasing acknowledgment of the importance of preventive care more generally, presents a unique opportunity to bring prevention of behavioral disorders to the forefront of the health care system. Therefore, integration of primary care and behavioral health care is a propitious way to promote mental health and potentially even prevent mental illnesses. Expanding psychiatric services to incorporate prevention within a primary care setting will require a paradigm shift that challenges the way psychiatry has historically been practiced.

The ACA brings prevention to the forefront

Provisions in the ACA will enable the nation to begin focusing on wellness and prevention rather than on the traditional model of treating sickness and disease. The ACA builds on many recommendations of the Institute of Medicine report Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (1). Aspects of insurance reform require improved coverage of preventive health services, such as smoking cessation counseling and cancer screenings, without additional charges. As a modest first step, the ACA established the Prevention and Public Health Fund, investing $15 billion over ten years to assist states in their efforts to prevent illness and promote health (2).

In addition, the ACA created the National Prevention, Health Promotion, and Public Health Council, which has developed a National Prevention Strategy (NPS). The council consists of 17 heads of departments, agencies, and offices across the federal government and is committed to advancing prevention and wellness. Several of the priorities of the NPS pertain to prevention in the areas of mental health and substance abuse, including priorities such as preventing drug abuse and excessive alcohol use, preventing injury and promoting violence-free living, and promoting emotional and mental well-being (3). Within a broad partnership including local, state, community, and tribal organizations, the NPS identifies specific recommendations to address such priorities in order to improve the health of Americans. For example, some of the recommendations pertaining to emotional and mental well-being promote positive early childhood development, facilitate social connectedness and community engagement across the life span, provide families and individuals with the support to maintain well-being, and promote early identification of mental health needs and access to services (4). Thus the ACA represents a paradigm shift in the manner in which the United States approaches health care, high-lighting wellness instead of disease and supporting initiatives that center on prevention and promotion.

Integrated care is supported by the ACA

In addition to its attention to prevention, the ACA establishes clear guidelines for expanding the integrated care paradigm by creating incentives to coordinate primary care, mental health care, and addiction services. The ACA emphasizes use of integrated models to appropriately address complex and comorbid general medical conditions, including physical health promotion in behavioral health settings and mental health promotion in primary care settings. The ACA also promotes integration through federally qualified health centers, which will receive additional funding to expand primary care services to encompass a range of health issues that affect people throughout the life span, including colocation of primary and specialty care and inclusion of behavioral health services (5). In this way, the ACA supports a collaborative, population-based approach to managing a cohort of patients.

Another target of the ACA is a shift toward team-based care of patients, stressing the importance of patient-centered medical homes, accountable care organizations, and health teams as effective models for delivery of care. In fact, the ACA has allocated funding for demonstration projects for patient-centered medical homes. The projects are meant to elucidate the benefits and address potential pitfalls of medical home models in preparation for wide-spread implementation.

Psychiatrists’ prevention role in integrated settings

Given the increased focus on prevention in conjunction with a renewed emphasis on integrated care, the field of psychiatry is in a position to advance the goal of prevention of mental illnesses and promotion of emotional and mental well-being. In line with the ACA, this could best be accomplished in integrated care settings. Indeed, this appears to be the manner in which some states are choosing to allocate federal funding for integrated care. Although the ACA’s allocation of $15 billion for prevention of illness and health promotion is a modest step, it represents an opportunity for prevention of mental illnesses to figure more prominently in the distribution of funding. For example, $7.7 million of the ACA prevention funds has been allocated to the state of Georgia, and the only known mental health initiative to be funded is integration of primary and behavioral health care, which has received almost $1,000,000 (1).

To advance the promotion of mental health and prevention of mental illnesses, we must strive to incorporate behavioral health promotion and prevention into these integrated care initiatives. Examples include incorporation into primary care settings of behavioral health screening methods, such as the nine-item Patient Health Questionnaire for depression; screening, brief intervention, and referral to treatment (SBIRT) for substance abuse; and firearm safety discussions. As a further step toward advocating for primary prevention and wellness, mental wellness coaches and behavioral change experts must be part of the health team and patient-centered medical homes in these settings. As research further demonstrates the benefits of coached parenting, healthy living, and emotional management, these evidence-based models can be a key component of health promotion and primary and secondary prevention in integrated care settings.

Many psychiatrists have not worked in collaborative care settings or fulfilled a prevention role in mental health care delivery. However, the changing health care environment may well encourage this seemingly new role in novel settings. Many opportunities exist for psychiatrists to partner with primary care providers in this new role. Psychiatrists and primary care providers could collaborate on culturally and developmentally sensitive methods of screening for risk factors and adverse health behaviors, such as substance abuse, domestic violence, and firearm ownership. Using a developmental perspective, psychiatrists could provide primary care–based interventions focused on enhancing strengths and protective factors among young people and their parents (6).

Other countries are much further along in developing mental health care interventions that emphasize preventing mental illnesses and promoting mental health. For example, Canada has achieved provincewide success in Manitoba by focusing on childhood interventions and strengthening integrated care models (7,8). The American Psychiatric Association continues to emphasize the integrated care paradigm (9), and psychiatry should strongly consider placing an equal value on prevention and treatment of existing disease. Although expanding psychiatric services as described here may require a paradigm shift for many psychiatrists, such models have been successfully implemented (7). Psychiatrists in solo practice can establish relationships with local primary care providers. The time is right for individual psychiatrists to foster deeper collaborations to prevent mental illnesses and promote mental health.

Challenges and opportunities

Behavioral health care has been effectively integrated into some primary care settings. However, such integrated care models typically focus on the treatment and management of specific conditions, such as depression or anxiety disorders (10). Our new focus should be on managing whole-person wellness rather than disease states. Various challenges threaten these goals, but the design of health care reform presents a unique opportunity to overcome barriers and stimulate thought, collaboration, program development, training, and research in the area of preventive psychiatry—in addition to treatment—within integrated care settings.

Whatever the political fate of specific ACA provisions may be, it will soon become the responsibility of providers in the health care system to emphasize mental illness prevention and mental health promotion. Psychiatrists should serve as leaders in seizing opportunities to improve the provision of health care services— including preventive services—in the United States, lest we as a field be left behind.