After the birth of her youngest son nearly 20 years ago, Elay Nantz of Colorado developed carpal tunnel syndrome in her right hand, sank into post-partum depression, and attempted suicide. After a three-month stay at a Colorado psychiatric hospital, she endured a carousel of specialists who only wanted to know “What do you want?” or “What do you need?” and then wrote countless prescriptions. If she stood her ground and said the pills weren’t working, they would refer her to another doctor. Two of her four psychiatrists even fell asleep during her counseling sessions. Eventually, she stopped seeking treatment.
Nantz has struggled with depression for most of her life and has bounced in and out of doctors’ offices. She felt that the mental health system just saw her as a wallet to rifle through. “None of them gave a crap about me,” she says.
After she had surgery on her hand in 2009 and began physical therapy, her health improved. But after Nantz got divorced in 2010, she lost her private insurance and went on Medicaid—which her physical therapist did not accept. Her hand grew weak and shook so much that she could not hold a fork. It would tumble to the ground and stay there until one of her three children picked it up. A bad day would lead to deeper depression. She felt worthless.
The combination of depression and carpal tunnel meant she could not work and provide for her children. Her thoughts turned to suicide again: “I felt like the only exit I could see was me dying—my head was a mess—like I was in a cave and I couldn’t get out,” she told The American Prospect. “I was getting ready to kill myself.”
Nantz believed that the health-care system simply viewed her as a depressed woman with shaky hands rather than a 45-year-old mother of three who wanted to work and care for her family. But after running out of other options, she decided to try counseling one more time. In 2015, she met Dr. Yaira Oquendo-Figueroa, a staff psychologist at a Salud Family Health Center in Denver.
Oquendo-Figueroa took an “integrated care” approach to Nantz’s problems that focused on breaking through the institutional barriers that separate mental and physical health care. In integrated care settings, behavioral health specialists work together with primary-care doctors to treat individual patients. An ongoing relationship between physicians and a patient is the basis of primary care, and it provides a pathway for coordinating mental health treatment.
Oquendo-Figueroa listened carefully to Nantz’s problems and helped her develop the mental “tools” to steer her thoughts in a positive direction. She also connected her with an acupuncturist to treat her carpal tunnel. “She changed my life and the perception of everything,” Nantz says of Oquendo-Figueroa. “I think she’s a magician.”
Mental and physical care have long occupied distinct silos in the American health-care system. However, if Congress has its way, the treatment gulf between these two areas could become even wider, particularly for poor and low-income people who rely Medicaid, the largest health insurer in the United States.
Medical professionals like Oquendo-Figueroa have redoubled their efforts to offer a program of treatment that addresses psychological issues and physical ailments in tandem—which can go a long way to helping patients like Nantz. “You can’t separate the head from the body,” the doctor says.
Primary-care physicians see the majority of patients with mental health problems in the United States, but they are not trained to provide specialized treatment for mental illnesses. According to Benjamin Miller, a University of Colorado’s School of Medicine psychologist who specializes in linking mental and physical care, fewer than 4 percent of primary-care physicians accurately screen for depression. There has been little change in the percentage of adults who use mental health services, or who report an unmet need for mental health services. Two-thirds of doctors say that they can’t get their patients access to outpatient mental treatment because of a shortage of workers, lack of coverage, or inadequate coverage.
Meanwhile, suicide rates in America have risen by nearly 25 percent over the past 15 years and, of the 20 percent of Americans who suffer from mental illness, only about one-fifth get treatment. “The U.S. health-care system [has] two cultures of care that isolate the mind from the body, and mental health has fallen victim to that,” says Miller.
In the 1970s, Salud Family Health Center opened in northeast Colorado to serve patients who were historically underserved or completely uninsured, like the state’s migrant farm workers. In 2013, the Center for Medicare and Medicaid Services (CMS) recognized Salud as a “patient-centered medical home,” a health-care delivery model that promotes strategies like integrated care. This model upends the traditional health-care system by providing mental health care in primary-care settings, where it is most accessible.
For many people, primary-care clinics and doctors’ offices are a safe haven. “People want an [ongoing] relationship with someone, they want to feel connected [and] to know you’re they’re for them,” Miller says. He believes that nurturing these relationships provides patients with an avenue to discuss and manage mental health issues before they become serious.
The Colorado health center includes a mobile legal team that advocates for patients, especially undocumented immigrants or Medicaid recipients who live paycheck to paycheck. The center also sends behavioral health professionals around the clinic to meet patients in other departments. “Let’s say that a patient is coming for a dental cleaning, and the hygienist concludes that the patient may be anxious or depressed,” says Oquendo-Figueroa. “I go there and do a consult right there in the dental area.”
While that practice may seem invasive to people who have health-care plans that cover behavioral therapy, a dental clinic might be the only time that some Medicaid or Medicare recipients can talk to a mental health professional.
Washington State’s Mental Health Integration Project features telepsychiatry to help treat low-income patients on Medicaid and Medicare. Encouraging patients to stay in touch with care managers and consulting psychiatrists over the phone allows those health centers to reach more people, and not just during regular visits.
Anne Shields, the associate director of the University of Washington’s Advancing Integrated Mental Health Solutions program sees e-medicine as one possible solution to a shrinking, aging workforce of psychiatrists, especially in rural areas of the country where there were never many specialists to begin with. From 1995 to 2014, while the total number of physicians in the United States grew by 45 percent, the number of psychiatrists only increased by 12 percent. In 2010, 59 percent of psychiatrists in the United States were 54 years old or older. “Primary-care settings are very diverse, small practices,” Shields says. “Rural health centers have no more than three people working and they’re not going to be able to hire a behavioral health-care manager.”
While health-care staffing often determines the number and types of services a hospital provides, integrated care relies on coordination between doctors to identify the specific treatments that will work for an individual patient. Using this approach, a small rural health center can strive to provide the same high-quality integrated care that an urban hospital system does.
Yet despite the health benefits that integrated care provides, the American health-care system continues to rely on traditional strategies. Treating mental and physical conditions separately has not only prevented vulnerable populations from accessing treatment, but it has also driven up those costs. Miller has calculated that, on average, physical conditions cost twice as much per person per month to treat when there is a mental illness present as well.
Moreover, mental health crises often play out in emergency rooms, which are the least efficient and most expensive care locations. Integrated care has reduced the patients’ reliance on emergency room treatment by focusing on preventative services, and targeting mild or moderate symptoms before they become severe.
The Cherokee Health System in Tennessee found that integrated care patients used emergency services 68 percent less than the regional average; specialty care 42 percent less; and hospital care 37 percent less. These savings amounted to a 22 percent discrepancy between CHS’s total cost and the regional average.
Most health-care networks prioritize people with serious mental illnesses over patients with mild or moderate symptoms, which prevents people from getting the help they need earlier. “The bulk of mental health services are in the public system, but people can’t get those services until they have had many crises,” says Debbie Plotnick, a vice president of Mental Health America, one the nation’s leading mental health advocacy groups.
Meanwhile, Republicans in Congress could tear wide open the existing gap between having insurance that covers mental health treatment and having access to that treatment with their plans to undo the Affordable Care Act. The ACA repeal proposals fail the two-step process Miller of the University of Colorado uses to evaluate potential reforms: “Does this continue to further fragment our experience with health?” he says. “And does this limit my patient’s ability to get access to mental health treatment where they want it?”
Moreover, transforming Medicaid into a block grant program means that mental health programs would take a significant hit as state officials search for savings to offset the federal cuts. Miller believes that integrated care programs would be the first to go, forcing medical professionals to make difficult decisions about whether they can marshal the resources to help people like Nantz. Repealing the ACA would simply take programs designed to bridge the gap between mental and physical illnesses backward—states, Miller says, “can’t take a chance on this right now.”