Here’s How an Early Career Experience Stirred My Passion for Whole-person Care

When it comes to health care, I’m passionate about many things. But for many years, one core belief has influenced a great deal of what I do on a day-to-day basis: The patient is best served when we can treat the whole person. I could turn to plenty of data points to validate this idea, but in my case, it was a personal experience that shaped my perspective … in a profound way.?

Early in my practice as a family physician, I began working with a female high school student who had Type 1 diabetes. On multiple occasions, she experienced serious complications, including diabetic ketoacidosis, because she had stopped taking her insulin. Each time, she wound up admitted to the intensive care unit. Eventually she would recover; inevitably, the cycle would repeat itself. ?

Her decision to skip insulin doses had nothing to do with the cost of the prescription. Psychological factors drove her behavior. Like practically every teenager (and every adult, for that matter), she hated being different. She lived in denial of her disease. Depression and associated behavioral health issues prevented her from managing her diabetes effectively. Her primary care physicians, including myself, did what we could to treat her depression, but she needed more expert behavioral health support, and her options were limited. It’s challenging enough for an adult to find a mental health provider. It was considerably more difficult to find a good match for a 16-year-old young woman with diabetes. She tried a few counselors and at least one psychiatrist, but she never found the right specialist she could relate to for her unique needs. Finally, after multiple cycles of ICU admissions and subsequent recoveries, her fortune ran out. She again experienced diabetic ketoacidosis, but her family only discovered her, unconscious, the following morning. She survived, but never awoke after experiencing significant brain damage. At the age of 16, she was permanently institutionalized. ?

This young woman’s story underscores the fact that there’s no treating the body without addressing the needs of the mind.??

The Benefits of Integrating Mental Health into Primary Care Yields Are Quantifiable … and Incalculable??

COVID-19 has contributed to the dramatic rise in mental health challenges Americans have confronted in recent years. Studies suggest that young people are feeling particularly vulnerable to psychological distress as a result of the pandemic. If there is a bright side, it’s that the crisis has also provoked national dialogue around well-being.??

Unfortunately, acknowledging our national mental health crisis doesn’t necessarily make it easier for individuals to access care when they need it. Nationally, more than 60% of youth who experience major depression do not receive the treatment that can help. More than half of adults with mental illness do not receive treatment. Many factors can get in the way of mental health care, including the stigma around treatment, a lack of self-awareness related to one’s own mental health needs, time and cost constraints, and the scarcity of mental health professionals??

Integrating behavioral health into primary care can help knock down these and other barriers to mental health resources. According to CDC (Centers for Disease Control) data, just over 10% of adults over the age of 18 received counselling from a mental health professional in 2020. By comparison, nearly 80% of adults over the age of 18 had a “wellness visit, physical or general purpose check-up” in 2020. These numbers highlight why the most strategic approach to identifying and addressing mental health needs is to screen members when they receive primary care.?

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has made it a priority to invest in ways to reward primary care providers who are attuned, and ready to respond, to their patients’ mental health needs. We believe that treating the whole person through an integrated approach to mental and primary care can identify potential mental health risks before they escalate into a crisis and address the needs of those individuals who experience co-occurring physical and mental health conditions. Primary care providers with the right preparation and resources at hand are ideally situated to coordinate timely, responsive care and steer patients to the appropriate level of quality care. This helps optimize the availability of mental health resources and improve patient access to care.?

This doesn’t mean physicians need to shoulder the extra burden of psychological care alone. Under the Collaborative Care Model, for example, a practice identifies patients with persistent mental health needs. A team behavioral health care manager facilitates screenings, evaluations, and follow-up calls for each of these patients. The manager also meets on a regular basis with a consulting psychiatrist to track patient progress. In the cases when a treatment plan proves ineffective, the consulting psychiatrist and the case manager readjust their strategy. The consulting psychiatrist rarely works directly with the patient. Instead, they make recommendations to the primary care provider through these regular consultations with case manager.??

Cultivating and rewarding behavioral health expertise in primary care practices will help minimize one of the most significant barriers to care: stigma. It delivers care to those patients who might otherwise avoid mental health support because they fear professional or social repercussions. Furthermore, making mental health care routine for everyone will help reshape cultural perception in the long run. As more patients and primary care providers engage in productive discussions about well-being as a matter of course, patients will come to recognize that mental health exists on a continuum and that everyone experiences mental health needs at some level.??

An integrated approach to primary care doesn’t just improve health outcomes for the patient. It also lowers costs. One recent report estimates that patients experiencing mental health and substance use challenges generate roughly $752 billion in health care expenditures. Addressing mental health care into medical care could save an estimated 5% to 10% of these costs. According to the North Carolina Psychiatric Association, the Collaborative Care Model (CoCM) offers a 6:1 return on investment: “In a world where 50% of patients who receive referrals for specialty mental health care never follow through, improved treatment in a primary care practice under the care of the CoCM team is a big win.”?

The dollar savings are significant … but not nearly as significant of the lives that could be saved, or the quality of life experiences that could be enhanced.???

Making It Easier to Access High-quality, Stigma-free Mental Health Care?

When I look back at my former patient’s complicated health trajectory from all those years ago, I understand that diabetes didn’t destroy her life – the lack of access to timely and appropriate mental health resources to address her depression did.??

Her story still makes me sad 20 years later. More importantly, it also encourages me to do more. That’s why I’m so proud of Blue Cross NC’s efforts make it easier for North Carolinians to access high quality, stigma-free mental health care. Integrating behavioral health into primary care is one way we are making that happen.?