With the recent spate of mass shootings in the U.S., I thought it would make sense to explore the connection between mental health and something I talk about a lot on this blog, population health management (PHM). Mass shootings are the result of more than just mental illness — the ease of availability of automatic weapons in the U.S. being another obvious one — but for our purposes I’ll focus on the mental health aspect of our ongoing national nightmare, and how PHM may someday soon play a role in stopping it.
The problem is formidable. Mental disorders are, as the website for Harvard’s T.H. Chan School of Public Health describes them, “the major overlooked challenge to population health both in the United States and globally” with major depression “projected to be the leading cause of burden of disease globally by 2030.” And with care for mental illness being unevenly distributed throughout the country both geographically and along ethnic lines, there is no ready-made solution.
Complicating matters is the structure of the U.S. healthcare system itself. Counter to the widely-accepted view that mental and physical wellbeing are inextricably linked, care for mental and physical conditions is often not coordinated between healthcare providers. Consequently, matching people up with appropriate mental healthcare is a complex issue.
Without going into the particular situations that led to the atrocities in Buffalo, New York and Uvalde, Texas, among others, there are some trends in the delivery of mental healthcare in the U.S. that can shed light on why these things keep happening here. Once the problem is identified in all its intricacies, I firmly believe it will become possible to mitigate the mental illness dimension of the problem. And PHM has been put forward by some as a good starting place.
A Convergence of Ideas
At this point I should note that for the purposes of this blog post, I’ll use the CDC’s definition of the term “behavioral health,” which they consider to cover “mental health and substance use conditions.” Although I haven’t seen substance abuse linked to the recent mass shootings, it’s entirely possible that I missed something. For that reason, I feel that using this more comprehensive term is appropriate in this context.
At the beginning of this post I mentioned that there’s been a steady convergence of the notions of mental and physical wellbeing for the past several decades. This idea had its origin in a 1951 article called “Outline for a study group on World Health and the survival of the human race: material drawn from articles and speeches.” In it, Dr. Brock Chisholm, the first Director-General of the World Health Organization (WHO), said, “without mental health there can be no true physical health.” Evidently this sentiment was revolutionary for its time, and in the ensuing decades, many healthcare systems across the world have taken his words to heart, supported by scientific studies that bear out the deep link between physical activity and mental wellbeing.
This connection between environmental, physical, and mental health was put to the test recently during the COVID-19 pandemic. In a 2020 CDC article titled “The Critical Need for a Population Health Approach: Addressing the Nation’s Behavioral Health During the COVID-19 Pandemic and Beyond,” the authors speculate that if a population health model of behavioral and clinical care delivery had predominated in the U.S. during the opening stages of the pandemic, the harmful mental effects of COVID would have been more muted.
It should be noted here that I haven’t seen any research done on correlations between gun violence and COVID lockdowns, so any talk of COVID in this context is purely speculative on my part. I think it’s safe to assume that the stresses attending COVID haven’t exactly dampened people’s desire to act out in violent ways. But since the scourge of gun violence has been with us since well before COVID-19 arrived on the scene, it’s hard to know for sure.
With that said, although the CDC article doesn’t put forward many concrete solutions to moving the U.S. healthcare system toward a population health footing, its authors quite rightly note that “Adopting a population health approach helps to address the needs of the total population, including at-risk subgroups, through multiple levels of intervention and to promote the public’s behavioral health and psychological well-being.”
Barriers to Behavioral Healthcare
This “multiple levels of intervention” is the tricky part, of course, since, with some notable exceptions (two of which I’ll discuss a little further on), behavioral healthcare specialists aren’t often co-located with primary care physicians (PCPs). Under evolving guidelines, PCPs are encouraged “to perform basic screenings for depression, substance abuse, and interpersonal violence,” but this is not enough to identify everyone who needs help. Indeed, according to a recent article in the Harvard Medical School Primary Care Review, the author notes that “while many patients depend on referrals from primary care for mental health services, nearly two-thirds of primary care providers struggle to find community-based clinicians to refer to.”
Two-thirds of PCPs! And then there’s the matter of affordability, which is arguably the biggest barrier when it comes to people seeking care for mental illness. The author of the above Harvard Medical School article points to a survey run by the California Health Care Foundation, which found that “over half of respondents were concerned about out-of-pocket costs for services and postponed care accordingly.”
For those fortunate people who can find appropriate mental healthcare, study after study has document how, even after passage of legislation such as the Mental Health Parity and Addiction Equity Act of 2008, the Affordable Care Act, and developments such as Medicaid expansion, it’s still very challenging to afford these services in most places given that relatively few mental health practitioners accept insurance.
Leaving insurance aside, one study found that 18% of people who sought mental health care “reported at least 1 contact with an out-of-network mental health provider, compared to 6.8% who used a general health provider.” This means that nearly triple the number of people seeking mental healthcare pay higher costs when compared to those seeking physical healthcare.
Behavioral Care Integration
OK, that may seem like a lot of bad news. But believe it or not, I still feel optimistic about all of this! Why? Because to my mind, any instance where people are trying to implement PHM and haven’t completely given up is a win. And increasingly, that’s just what’s happening in behavioral care sites across the country. Looked at from this perspective, two examples of integrating behavioral and physical healthcare give us ample reason for hope: the behavioral health home (BHH) model of care delivery in Maryland, and Cherokee Health Systems in Tennessee.
In a 2019 Medical Care article, the authors examine healthcare leader and staff perceptions of the BHH system in Maryland. (To learn more about Maryland’s BHH program, check out this separate study). According to the article, “Behavioral health home (BHH) models have been developed to integrate physical and mental health care and address medical comorbidities for individuals with serious mental illnesses (SMIs).” And beyond that, achieving population health management is a stated goal of the program.
The BHH initiative is an example of “co-locating” mental and physical healthcare services in a single physical location to better facilitate care coordination. Although this approach isn’t specific to Maryland (Iowa, New York, and Missouri have implemented similar programs), the experience of the Maryland BHH program highlights not only the advantages of this approach, but also its challenges.
As a starting place, since PHM is such a nebulous term, I always think it’s important to contextualize the term. In the case of the article about Maryland BHHs, the authors consider PHM to be an approach that “addresses needs along a continuum of health states for a specified population using continuous health monitoring and targeted interventions…Care coordination strategies organize patient care activities across multiple providers.”
Before we delve into the BHH program, let’s be clear: this initiative has encountered a lot of challenges. When asked to identify the biggest barriers to effectively implementing PHM, survey respondents pointed to a number of factors including lack of experience, inability to acquire health information technology, and state regulations. But it’s important to remind ourselves that embodying PHM is an uphill battle. Most providers are nowhere near working within this framework, so please don’t misread my exploration of the challenges facing Maryland’s BHHs as a criticism.
Moving on, I found it interesting that the state regulations piece — an approach meant to spur PHM — has come to be seen by some as detrimental to instituting PHM in the Maryland program. Since many providers in these frameworks lacked experience with PHM, the article states that “there were beliefs among some that direct clinical care for consumers with SMI was more important than population health management tasks.” It seems that one version of BHH in Maryland in particular, called the “Medicaid BHH,” has stuck in some people’s craw as a counterproductive approach to mental healthcare.
Medicaid BHHs are based in psychiatric rehabilitation programs and (according to a previous study run by the same group) received “a $102.86 per-member per-month payment contingent on the delivery of two health home services to each consumer per month.” Because the state requires providers in this type of setup to deliver two services per month to each participant to receive the per-member-per-month reimbursement “regardless of health needs,” this seems to have led some survey respondents to perceive this PHM approach as a distraction from focusing on delivering services to the highest-need patients.
A few possible solutions are put forward in the paper, including a suggestion to take a page from a BHH program in Vermont that runs on a hub-and-spoke model where reimbursement is split between specialty substance use treatment programs and PCPs. Such an approach actually spurs external provider participation in the BHH and encourages tighter coordination. And since financial reimbursement isn’t tied to quality metrics in the Maryland BHH program, the authors suggest that participating in alternative payment models that prioritize high-value care might help improve patient outcomes.
Another institution that integrates mental and physical healthcare is the Cherokee Health Systems in Tennessee. According to the Agency for Healthcare Research and Quality (AHRQ), “Cherokee Health Systems is a Federally Qualified Health Center (FQHC) and a Community Mental Health Center, and is a national leader in integrating primary and behavioral/mental health care.”
The current CEO of Cherokee Health, Dr. Dennis Freeman, is a psychologist who has been providing care at that institution since 1978. Early on, Freeman recognized that most people in need of behavioral health services were seeking out care at primary care clinics. In a “go where the people are” moment of insight, he recruited PCPs and “paired them” with behavioral healthcare providers. In time, Cherokee evolved into a Community Mental Health Center with primary care services, essentially becoming a hybrid of a FQHC that offers both primary care and behavioral healthcare services at 22 clinical locations.
While it’s not clear if the practitioners at Cherokee consider the care they deliver to fit into a PHM framework, as the paper makes clear, the system has “adapted to the needs of the population” with special attention paid to marginalized patients. The fact that the health system reaches out to underserved populations like migrant workers and refugees underlines this PHM approach. I encourage you to read this paper to see how, albeit with a lot of effort, behavioral healthcare can be assimilated into the physical care structure of the U.S. healthcare system.
Although behavioral and physical healthcare are deeply intertwined, this discussion goes to show how challenging it is for even the most adept healthcare consumers to pursue affordable, effective behavioral healthcare in the United States. But oftentimes, the people who most need this care are the least equipped to seek it out. If they’re lucky, they have a loved one or friend who can help them navigate this intimidating process. But for those who lack the resources or social support to get the care they need, the U.S. healthcare system can prove an insurmountable series of obstacles.
Let me finish by saying that I don’t mean to pick on the U.S. approach to behavioral healthcare, because other comparable countries like Canada and the United Kingdom have their own share of issues in this regard. But the U.S. is unique in terms of the sheer number of mass shootings and gun deaths when compared to just about every other comparable country, and mental illness undoubtedly plays a role. With this country’s substantial financial resources, coupled with a population health approach that can enhance efficiencies, we can and should do right by each other.