Many areas of the U.S. lack integrated behavioral health in primary care

A Graham Center Policy One-Pager in the June issue of American Family Physician overlaid the geographic locations of integrated behavioral health clinics in primary care over a color-coded map of U.S. counties’ percentages of residents reporting poor mental health. In an ideal world, these clinics, which are associated with better health outcomes, higher patient satisfaction, and lower costs, would cluster in regions with greater mental health distress. Unfortunately, the Graham Center analysis found that the opposite was frequently the case, with such clinics “notably lacking in … rural Kentucky, Louisiana, Tennessee, and West Virginia.”

What factors could account for this apparent mismatch between integrated behavioral health supply and demand? A recent Health Affairs Forefront article noted that obstacles to widespread adoption include an ongoing debate about the need for high fidelity to the evidence-based Collaborative Care Model, which can be difficult to implement, and inadequate fee-for-service payment relative to costs of practice re-design and ongoing services. Successful efforts to improve behavioral health integration in Rocky Mountain Health Plans, Blue Cross Blue Shield of Michigan, Rhode Island, and Minnesota have relied on multiple approaches customized to primary care structures and community needs.

A 2022 study in the Journal of General Internal Medicine examined characteristics of integrated behavioral health associated with primary care clinician confidence in managing depression in a network of community health centers (CHCs) in 10 mid-western states. Primary care clinicians reported more confidence when their CHCs had depression tracking systems; when they were satisfied with the accuracy of depression screening; when they had access to behavioral health treatment plans; and when they cared for more patients with depression. In contrast, clinicians working at CHCs with more patients living below the poverty line had lower confidence in prescribing antidepressants, while those at CHCs with more Black patients had lower confidence in diagnosing depression.

Integrated behavioral health clinics may or may not provide treatment for persons with opioid use disorder or other substance use disorders, even though these commonly co-occur with mental health problems. In a Substack post, Ben Miller explained that shared vulnerability, dual diagnosis, and bidirectional influence support pairing mental health and addiction treatment. Obstacles to concurrent treatment in primary and specialty care settings include societal stigma, diagnostic classification systems, health system fragmentation, and different treatment philosophies.

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This post first appeared on the AFP Community Blog.

Housing matters for good health

What does a "renter's utopia" in Vienna have to do with optimal treatment of asthma?

Francesca Mari's recent New York Times Magazine article about public housing in the capital city of Austria features images of beautiful, well-maintained apartment buildings with rooftop swimming pools, lots of green foliage and attractive playgrounds. 80 percent of the city's residents qualify for public housing, a staggeringly high percentage that might imply to an American that the vast majority of people living there are poor. Actually, Vienna makes its plentiful supply of municipal housing (which they call "social housing") available to a large portion of the middle class, and tenants cannot be turned out no matter how much their incomes increase after signing the initial rental contract.

To American eyes, the whole Viennese setup can appear fancifully socialistic. But set that aside, and what’s mind-boggling is how social housing gives the economic lives of Viennese an entirely different shape. ... Imagine having to think about [housing expenses] to the same degree that you think about your restaurant choices or streaming-service subscriptions. Imagine, too, where the rest of your income might go, if you spent much less of it on housing. Vienna invites us to envision a world in which homeownership isn’t the only way to secure a certain future — and what our lives might look like as a result.

In contrast, wrote Mari, one of several "fatal" compromises to the real estate industry in the Housing Act of 1937, restricted eligibility for public housing in the U.S. to "those so poor that they could never secure decent housing in the private market." These units were deliberately underfunded and poorly constructed. As millions of past and current residents of American urban housing projects could testify, "America's public housing was designed to fail: to be unappealing to anyone who could afford to rent."

Which brings me to patients with asthma who live in American public housing projects or neighborhoods in similar states of disrepair. In West Philadelphia, the Children's Hospital of Philadelphia (CHOP) partnered with community organizations to implement Community Asthma Prevention Program Plus, a program that performed home inspections of CHOP patients with asthma and completed repairs to 97 homes that were deemed likely to benefit these patients, including carpet removal, roof and plumbing repairs, improving ventilation, and eradicating mold.

That's great, but what if the home is located next to an interstate highway, factory, or power plant emitting pollutants that can't be easily remediated by a contractor? Or if these patients' asthma exacerbations are triggered by the stress of living in a violent neighborhood? The logical next step is to move to a different home. The case settlement for a 1995 lawsuit against the U.S. Department of Housing and Urban Development for discriminatory public housing practices created the Baltimore Regional Housing Partnership (BRHP), which as of October 2020 had provided housing vouchers to more than 5,200 households to move to privately-owned housing in low-poverty neighborhoods. A research team followed 123 children with persistent asthma whose families moved with BRHP's assistance from 2016 to 2020. Compared to a control group, these children experienced fewer exacerbations, fewer days with symptoms, and lower measures of stress.

Hospitals and health systems are now investing in affordable housing to improve health in many areas of the country, reasoning that being homeless or housing insecure presents a huge obstacle to attaining control of asthma, diabetes, and other chronic diseases. Health care payers are also taking notice. In an ambitious experiment, California's Medicaid program is spending $12 billion over the next 5 years on "a new kind of safety net that provides housing and other services for [145,000] people who are homeless or at risk of becoming homeless and have complicating conditions like mental illness or chronic disease." Whether the experiment will achieve its aim of moderating the program's soaring health care costs remains to be seen, but even if it doesn't, giving people access to decent housing is a worthy end in itself. Kudos to Philadelphia, Baltimore, and California for thinking outside of the health care box, but I'd rather be in Vienna: a city where grinding poverty and housing vouchers aren't necessary for persons of modest means to afford a clean and safe apartment for as long as they want to live there.

Patient portals and electronic health record transparency: pros and cons

After completing my fellowship, I considered taking a job filling in for a family physician on sabbatical who had been in solo practice for thirty-plus years. Even for these pre-electronic health record (EHR) days, his written notes were telegraphic. A typical example: "Patient doing fine. Labs normal. Continue current meds and follow up in 6 months." That was it. What he recorded in the chart was for his eyes only. No need to write an essay, or even a paragraph, when the only purpose was to jog his memory for the next time he saw the patient.

A few years later, the federal government handed tens of billions of dollars to physicians and health care organizations to convert their paper charts to digital form in exchange for requirements to use these records to measure quality of care and increase transparency of health information to patients through so-called “patient portals.” Notes became longer and more detailed. The negative effects of EHRs on physician burnout and health care team communication have been well-documented. Aside from initiatives such as OpenNotes, however, transparency was not fully implemented until last year, when the Office of the National Coordinator for Health Information Technology re-interpreted a previous rule against “information blocking” as an expectation that patients would have real-time online access to their office notes and test results rather than having to request them. With little fanfare, the floodgates opened.

In an insightful article in The New Yorker, Dr. Danielle Ofri, a general internist, admitted her newfound reluctance to list an extensive differential diagnosis for anemia in the EHR because she worried that mentioning colon cancer or a duodenal ulcer could scare the patient. After all, she observed, “my inbox was already jammed with panicked messages from people convinced that they had catastrophic illnesses, based on minuscule lab discrepancies and panic-inducing Google searches.” Comparing EHR transparency to the “C-SPAN effect,” in which live, nonfiltered television coverage of Congress made lawmakers more likely to grandstand to the camera, Ofri noted that granting patients instant access to test results has also had unintended consequences:

In one devastating stretch of twenty-four hours, two of my patients learned of their cancers’ metastatic reappearance by way of the portal. Their inboxes pinged with new test results; they read them before either their oncologist or I had even seen the scans, let alone called. … In the past, I’d do the legwork [for the evaluation] before I called the patient. Now that buffer is gone, and I am pressured to act immediately: the patient has seen the result, and further delay would be unconscionable. This timbre of rush imperils thoughtful analysis, and I worry incessantly about missteps.

In contrast to the mixed feelings of primary care clinicians and staff about patients having online access to their health records, research suggests that patients overwhelmingly prefer to see test results immediately, even though those marked as abnormal increased worry prior to discussions with health professionals. Sometimes, portals save time. Rounding on my practice’s adult inpatient service last month, I was pleasantly surprised that in several cases I could skip through the text of a recently resulted blood or imaging test finding – which the patient or their designated decision-maker had already seen on a smartphone app – and jump straight into the implications for their condition and care plan. Finally, portals allow patients to proactively correct or update medications, allergies, and problem lists outside of office visits, rather than taking up precious minutes with medical assistants or physicians in the examination room.

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This post first appeared on the AFP Community Blog.

Counseling parents about the leading cause of death in U.S. children: guns

A former colleague of mine maintained throughout his career that the most logical way for family physicians to provide preventive services for adults was to focus on the most common causes of death. Although the top diagnoses leading to death recorded by the Centers for Disease Control and Prevention in 2021 were heart disease, cancer, and COVID-19, that’s not what he meant. Instead, he was speaking of the “actual causes of death,” or the behavioral causes of the causes, which from 1990 to 2017 were tobacco use, poor diets, and physical inactivity. Clinicians can have the largest effect on preventing death in adults by counseling patients to stop smoking, eat healthier foods, and exercise.

What about children and adolescents? All-cause mortality in Americans aged 1 to 19 years has been increasing since 2019, partially due to COVID-19 but mostly from a rise in fatal injuries that began prior to the pandemic. Motor vehicle accidents, which have long been the top cause of death in this age group, were surpassed for the first time in 2020 by homicides and suicides from firearms. Mass shootings in schools and public places attract media attention, but data from the Gun Violence Archive show that these account for a tiny fraction of firearm-related deaths.

In comparison, a 2022 American Academy of Pediatrics policy statement reported that 28 children and young adults through age 24 die from gun violence in the U.S. every day – the equivalent of a typical classroom. A recent Commonwealth Fund report comparing the U.S. to 13 other high-income countries found that Americans are five times more likely to die from being shot than residents of Canada, Switzerland, or France. The report also noted that nonfatal and fatal firearm injuries generate more than $1 billion in initial medical costs each year.

A cross-sectional study of four major cities (New York City, Los Angeles, Chicago, and Philadelphia) found that firearm assaults in children increased substantially during the pandemic, with Black, Hispanic, and Asian children being significantly more likely to experience violence. In March, a nationally representative poll found that 21% of adults have been personally threatened with a gun, 19% have had a family member killed by a gun (including suicide), and 17% have personally witnessed someone being shot. However, only 26% of parents of children under age 18 said that their child’s physician had ever asked them about having guns in the home, and only 5% said that their doctor had discussed gun safety.

A 2020 American Family Physician article on prevention of childhood injury recommended that physicians “ask patients whether there are guns in the home and counsel them about the risk of gun-related injury and about safe storage practices … [and] consider contacting legislators if local gun laws are not in the best interest of children's safety.” A previous editorial that I co-authored with other AFP editors noted that “child-access prevention laws (e.g., safe gun storage) reduce self-inflicted and unintentional firearm deaths and nonfatal injuries among youth, and may reduce unintentional firearm injuries among adults.” By counseling patients in our offices and advocating for legislation to promote firearm safety, family physicians can complement community health initiatives that reduce the risk of gun violence in children. For example, Communities That Care, a prevention program that addresses risk and protective factors for behavioral problems early in life, was recently shown in a randomized trial to reduce the prevalence of handgun carrying in 4400 adolescents living in 24 small towns in 7 states.

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This post first appeared on the AFP Community Blog.

What's the matter with corporate primary care?

I've been meaning to write about this topic for a while, but Dr. Josh Freeman at Medicine and Social Justice beat me to it last week. Josh is a fellow blogger, retired family physician, and Chair emeritus of the Department of Family Medicine at the University of Kansas. His latest post, "Private equity, private profit, Medicare and your health: They are incompatible," explored in depth the negative effects of private equity and for-profit corporations buying up subspecialty and primary care practices, also discussed in a KFF Health News article and in the New York Times. Put simply, the goal of those purchases is to turn a quick profit - often by "upcoding" to charge more for visits and procedures and slashing critical support staff - rather than to serve the best interests of patients and clinicians. Part of the corporate rush to invest aggressively in primary care is the unintended consequence of privatizing Medicare and moving away from the fee-for-service payment model; private health insurers now receive a lump sum "value based care" payment for every enrolled Medicare beneficiary based on their medical complexity and health risks, a process that Paul Branstad and Claude Maechling observed can easily be gamed:

Value-based contracts with full-risk capitation payments, mostly Medicare Advantage (MA), but also variants of accountable care organization (ACO) models, have grown rapidly to become the majority payment model for Medicare beneficiaries. However, there is no demonstrated proof that these payment arrangements improve the health of beneficiaries more than fee-for-service arrangements. We also fear that, in their current forms, such contracts reward ever-increasing scale and will evolve into a competition that only the very largest consumer companies can win. Once these winners emerge, their vested interests will focus on preserving their oligopoly at an additional cost to US taxpayers of $75 billion a year. Too late will we realize we have lost our last best chance to reinvent a health care system centered around the large-scale provision of high-quality primary care—even though this is what value-based contracts started out trying to do.

Another reason that retail giants such as Amazon and CVS Health have recently invested billions of dollars in primary care companies (One Medical and Oak Street Health) is that they anticipate steering thousands of patients to their pharmacy and disease management products. CVS Health's CEO is confidently projecting that investors will realize "double-digit returns on invested capital over time as clinics mature and synergies are realized."

Although private investment has infiltrated nearly every sector of health care, including oncology clinics, neonatology practices, and the gastroenterology practice where I refer most of my patients for procedures or challenging gastrointestinal problems, the profit motive may do the most damage in primary care, which improves population health when it is treated as a common good rather than as a loss leader for more profitable procedural subspecialties and hospital-based services. As Soleil Shah and colleagues wrote in the New England Journal of Medicine: "Though potentially beneficial for certain well-insured patients, the trend of corporate investment in primary care could threaten equitable access to care, raise health care costs, and reduce physicians’ clinical autonomy."

Sounding the alarm about the "existential threat of greed" in a JAMA Viewpoint and his Institute for Healthcare Improvement 2022 National Forum keynote address, Don Berwick made these stark observations about the wrong direction that the excessive pursuit of financial profit has been taking the U.S. health care system, and now corporate primary care:

Profit may have its place in motivating innovation and higher quality in health care, as in any industry. But kleptocapitalist behaviors that raise prices, salaries, market power, and government payment to extreme levels hurt patients and families, vulnerable institutions, governmental programs, small and large businesses, and workforce morale. Those behaviors, mostly legal but nonetheless wrong, have now accumulated to a level that poses an existential threat to a sustainable, equitable, and compassionate health care system. ... US health care costs nearly twice as much as care in any other developed nation, whereas US health status, equity, and longevity lag far behind. Unchecked greed is not the only driver of that failure, but it is a major one. Few, if any, other developed nations tolerate the levels of avarice, manipulation, and profiteering in health care that the US does. Salve lucrum [Hail, Profit!] is the wrong answer.

Photo courtesy of Pompeii in Pictures https://www.pompeiiinpictures.com/pompeiiinpictures/R7/7%2001%2047.htm

Updated immunization and screening recommendations aim to eradicate hepatitis B

In November 2021, the Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices (ACIP) replaced risk factor-based eligibility in adults with a recommendation for universal hepatitis B vaccination in persons aged 19 to 59 years. The ACIP noted that despite routine administration of hepatitis B vaccine in infancy, as of 2018 only 30% of U.S. adults had received the full vaccine series, and one half of acute hepatitis B cases occurred in persons aged 30 to 49 years. A national survey of family physicians in February 2022 found that more than half of respondents were not aware of the updated guidelines, and only 8% had fully implemented them.

Gaps in screening and treatment also put patients at greater risk of developing chronic hepatitis B and its complications. An analysis of insurance claims data from 2015 to 2020 found that even though all pregnant patients should be screened for hepatitis B at their first prenatal visit to prevent perinatal transmission, 14.6% did not have hepatitis B surface antigen (HBsAg) testing, representing as many as half a million births each year. Another study found that between 2016 and 2019, less than 30% of persons with chronic hepatitis B and cirrhosis started antiviral therapy within 12 months of diagnosis.

Since access to hepatologists is a barrier to patients with hepatitis B receiving appropriate management, a previous AFP Community Blog post described a practice model for family doctors to evaluate and treat these patients “in-house.” However, the complexity of screening and management guidelines has led to calls for a simplified approach to hepatitis B. In response, the CDC recently recommended that adults aged 18 years and older be tested for hepatitis B at least once during their lifetimes, regardless of prior immunizations or risk factors, mirroring the universal screening approach to hepatitis C and HIV. (Notably, the U.S. Preventive Services Task Force currently recommends a risk-based screening strategy in adolescents and adults.) To facilitate interpretation, screening should include HBsAg, antibody to HBsAg, and antibody to hepatitis B core antigen.

In a JAMA Viewpoint, Dr. Samuel So and colleagues asserted that as two-thirds of non-institutionalized persons with chronic hepatitis B are unaware of their infection, universal screening and vaccination of adults “are a major step forward to reducing chronic hepatitis B-related morbidity and mortality in the U.S.” Another commentary emphasized focusing on health equity in the national push to eradicate hepatitis B and hepatitis C, which is the target of a recently proposed national initiative. A white paper that I co-authored for the Hepatitis B Foundation presented challenges to implementing the updated CDC recommendations, best practices in primary care and hospital settings, and priority action items involving education, multi-stakeholder collaborations and technology innovations, and addressing vaccine hesitancy.

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This post first appeared on the AFP Community Blog.