Executives focused on population health, clinicians want better mental health integration

Population health management, a hard-to-define concept that loosely means (or seems to mean) strategies employed in a cost-effective manner to improve the health outcomes of a community as a whole, may not be a primary concern for clinicians. The New England Journal of Medicine (NEJM) Catalyst Insights Council surveyed clinicians, clinician leaders, and executives on their health care delivery priorities and found that many believed that better integration of mental health care with physical care was the most important way they could improve community health. Clinician comments, however, indicated that they were less enamored with the idea of population health management than proponents may have hoped.

Survey and comments

Out of the 297 responses, 24 percent stated that if they were given $100,000 to spend on changing their clinical practice to improve community health this year, they would invest in mental and behavioral health services. The next highest responses were building interdisciplinary teams and creating community partnerships with other organizations, both at 13 percent. When the same question was imposed with a long-term view ($1 million over the next ten years), behavioral and mental health stayed at the top, at 19 percent.

 The survey also asked respondents about how important they believed population health to be: a fad, essential, or a middle ground. The average score was a 77 out of 100. While in the top quartile, the survey analysis found it to be a “tepid endorsement” in light of how focused organizations are on implementing population health.

The comments received from administrators and executives showed that they hold a more positive view of population health than clinicians. Leaders are focused on the inevitability of transitioning away from fee-for-service, and while they hold some anxiety about the future, population health seems to be a popular option. Clinicians, however, want to maintain a focus on patients themselves rather than an entire population. Those providing the care want their focus to remain individualized.

While one executive of a nonprofit community hospital said that, “Population health management is key to enabling people to take control of their health care needs,” another at a for-profit payer said that precision medicine was as “equally important” as population health, even though the organization focused on the latter. A clinician at a post-acute care provider stated that he has “not been impressed with the vision nor the outcomes of current population health research and programs,” and a leader at a medical school stated that population health is “important but not sufficient.”

Behavioral health integration

Integration studies and discussions rarely mention population health, even though providers and leaders feel that population heath success depends on better provision of mental health services. The idea of behavioral health integration with physical care is not a new one, but has been gaining traction in recent years. Care collaboration has been pushed by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), but a winning model for mental health care integration has not yet emerged. A Journal of General Internal Medicine article reviewed integration in primary care practices and noted that models requiring significant reorganization were too complex for ready adoption, when compared with “co-location” options. However, when patients show signs of depression when screened in a primary care setting, integrated practices offered treatment faster than other settings.

When behavioral health care is not integrated or co-located, as many as 60 to 70 percent of patients presenting in emergency departments and primary care locations leave without receiving proper treatment. Although some enter the area of health care where mental health problems are exclusively treated, many fail to follow up. Two models have shown particular promise: one where psychiatrists consult on cases where patients have more complicated mental illnesses or fail to respond properly, and another where teams of behavioral health and primary care providers treat mental conditions and other medical conditions simultaneously in order to prevent one improperly managed chronic condition from worsening another.