October 27, 2010

Nearly 1.4 million people in New York State simultaneously suffer from mental health and substance use disorders, but less than 6% of this population receives treatment for both conditions. The Commissioners estimate that 70% of people with co-occurring mental health and substance use disorders also have one or more chronic health care conditions, but often lack access to primary care services.

Commissioner Hogan noted that Federal health reform includes three major elements related to expanding and integrating mental health and substance use services: (1) health care coverage for many more people; (2) parity for mental health services; and (3) myriad opportunities for demonstrations and pilots, some of which may support integrated care.

Patient-centered medical homes, for example, may advance efforts to ensure that mental health specialists are part of the health care team on the hospital floor and in primary care practices. Too often today, even if a primary care provider screens for and diagnoses a patient’s mental health condition, the patient must then follow up on a referral to an offsite specialist. This disconnected system allows too many people to fall through the cracks and not get the care they need.

In a reformed system, mental health and substance use treatment clinics would also provide primary health care services, and primary care sites would also provide mental health and substance use treatment. The Commissioners believe that, within 20 years, those co-located services could be the standard of care in New York.

New York is in many ways ahead of the curve. We are only the second state to pay for integrated care through Medicaid. Employers are increasingly focused on wellness and prevention, including screening for mental health and substance use issues. The State already has been shifting resources to focus more on outpatient care and community-based services, and will take advantage of Federal health reform dollars to expand access to care through community health centers. We also have made great strides in screening and brief interventions for mental health and substance use disorders, but the actual delivery of evidence-based treatment has been slower; the Commissioners estimate that patients only receive the integrated care they need 20% of the time.

What will it take to improve? We can learn from other states, like Pennsylvania, Rhode Island, and Michigan, that have been leaders in managing and coordinating care effectively, saving health care dollars as a result, and reinvesting those savings to continue to improve.

It will also take practice redesign, bringing together clinical and administrative leaders within health care organizations to change the way care is delivered, to ensure coordinated and continuous care from a diverse team of providers. Chronic illness care demonstrations in the health reform law will help to advance this work for the highest-need patients who often receive episodic, high-intensity care rather than regular services and treatment. Finally, the payment system must be realigned to support more integrated care, perhaps through Medicaid carve-outs.

There will be no one-size-fits-all solution in a state as diverse as New York, but Federal health reform offers some potential models and opportunities to integrate care more effectively, to realign incentives, and to support health care teams that provide a full range of coordinated services.

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