The Value Of Behavioral Health Integration For Patients With Chronic Pain

Despite the historical division of the 2 care models, mental health (including substance use disorder) and physical health are not separate issues—they are inextricably linked.

Consider the case of chronic pain: Research reveals that people with chronic pain are 4 times more likely to have depression or anxiety than those who are pain-free. And when patients do not receive effective treatment for their mental health issues, they often become high utilizers of physical health services.

Of course, given the ongoing impact of the COVID-19 pandemic, the prevalence of both chronic pain and mental health issues in the United States is sky-high. More than 20% of US adults live with mental illness, around 20% have chronic pain, and 8% experience high-impact chronic pain where the pain significantly limits activities of daily living. Women, veterans, adults living in poverty, adults on Medicaid, and adults in rural areas have higher rates of chronic pain conditions.

The majority of these chronic pain conditions are treated within a primary care setting. In fact, around 76% of back pain, 75% of neck pain, and 68% of headaches are treated in primary care.

These statistics underscore the value of integrating behavioral health within primary care where patients with chronic pain are already seeking treatment. An integrated approach to care can improve outcomes for those who experience both mental health issues and chronic pain.

The connection between behavioral health and chronic pain

Pain is a highly individualized experience which, according to the biopsychosocial model of pain, is determined by the interplay and interconnectedness of physiological, psychological, cognitive, social, and environmental factors. Highlighting the significance of the psychological aspect of pain, the International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."

It is therefore not surprising that chronic pain from conditions like arthritis, back problems, fibromyalgia, and migraines commonly occur at the same time as mood disorders like anxiety and depression. After all, chronic pain can decrease sleep quality and increase stress, both of which take a toll on mental health. And depression can make a person more sensitive to pain.

The relationship between mental health and chronic pain represents an unfortunate chicken-and-egg scenario. For example, people with migraines are 2 to 3 times more likely to be diagnosed with generalized anxiety disorder, panic disorder, agoraphobia, or post-traumatic stress disorder than those without migraines. And people with anxiety disorders are twice as likely to develop migraines as those without anxiety disorders. Research indicates that pain and mental health conditions, such as anxiety and depression, involve the same neurotransmitters and neural pathways in the brain, further illustrating their interconnectedness.

Given this bidirectional relationship between chronic pain and mental health disorders, it's critical to treat both issues to pursue positive patient outcomes—particularly increased daily functioning and improved quality of life.

Challenges to widespread mental–physical healthcare integration

While the symbiotic relationship between mental and physical health is generally understood by the medical community, several challenges exist that minimize widespread, comprehensive behavioral health integration. These challenges include:

• Lack of behavioral health practitioners. More than 150 million people live in federally designated mental health professional shortage areas and those who are able to access care are likely to encounter providers who are suffering themselves—more than 50% of behavioral health providers report experiencing symptoms of burnout, which can lead to professional inefficacy.
• Primary care providers' lack of behavioral health experience. Patients who pursue mental health treatment from primary care providers in a collaborative care setting may find that providers lack the experience and/or comfort level to distinguish physical symptoms from issues related to mood. This incomplete understanding of patients' behavioral health concerns can contribute to a lower quality of care and substandard treatment outcomes.
• Financial hurdles. Not only is it costly to hire and integrate behavioral health providers into a primary care practice, but billing issues (e.g., restrictions for a medical and a mental health visit on the same day) and reimbursement issues (e.g., primary care providers being reimbursed at a lower rate for mental health treatment compared to medical evaluation) also create barriers to behavioral health delivered in primary care.
• Siloed electronic health records (EHRs). Patient records are not often shared between nonbehavioral and behavioral healthcare providers, creating a barrier to the flow of information between clinicians. This can happen when patient records are only accessible with special permission, or when the records (and thus the care management software behind them) are not designed for behavioral health integration. In addition, patient information may not be shared due to fears of privacy violation that stem from a long-standing stigma of behavioral health conditions.
• Cultural conflict between medical and mental health practitioners. While mental health providers typically engage patients in long-term therapy, many medical professionals model short and efficient interventions. Case in point: some medical providers report seeing up to 4 patients an hour, whereas behavioral health providers commonly see 1 patient during that time. Such divergent practice styles and models of care can make integration complex.

Risks when behavioral health integration does not exist

In a fragmented care landscape, patients are burdened with the complex and time-consuming task of coordinating care themselves. Risks of nonintegrated systems include:

• Gaps in medication management. Without a clear flow of information between medical and behavioral healthcare providers, patients may be at risk for drug interactions and having medication side effects mistaken for symptoms of other conditions, leading to suboptimal care.
• Untreated conditions. When physical and behavioral healthcare operate in silos, patients with mild or moderate mental health symptoms often fall through the cracks, leading to untreated conditions. Without integrated care, patients with mental health conditions are also less likely to get the treatment they need for their physical health conditions.
• Considerable financial burden. There's also a financial burden associated with untreated behavioral health conditions, largely from the complications and associated treatment of physical health conditions like chronic pain. In a study of patients with physical health conditions, those who also had behavioral health conditions—27% of the study population—accounted for 56.5% of total annual healthcare costs for the entire study population. Only 4.4% (less than $68) of those costs were for behavioral health treatment.
• Chronic opioid therapy. Without an interdisciplinary care team, people with chronic pain may rely more heavily on opioids for pain management, increasing the risk of opioid use disorder and overdose. In fact, the current opioid crisis has been sparked in large part by an increased focus on adequate pain treatment, the prescribing of opioids like OxyContin for pain, and the disreputable practices of certain drug makers. Given the potential safety issues with prescribing addictive medications like opioids—and the fact that opioids are not always indicated for chronic pain—the treatment of pain has become more complicated.
• Lack of affordable care. One chronic pain specialist found that when his practice referred patients to other providers for behavioral health concerns, 90% of the patients never went to see the mental health provider. Most of the psychologists and psychiatrists were out of network or fee-for-service cash practices, so patients couldn't afford the care.

Measurable benefits of integrated behavioral care

Here's some good news: The integration of behavioral health and general medical healthcare can be instrumental in improving patient outcomes and promoting cost savings.

For example, the Integrated Pain Team (IPT) clinic at the San Francisco VA Medical Center integrates and colocates pain-trained primary care providers with a psychologist and a pharmacist to provide interdisciplinary care. In a study of patients with chronic pain, twice as many patients in the IPT clinic as in a control group reduced their daily opioid dose by 50% or more after 90 days. After 180 days, the daily opioid dose of the IPT group was 103% lower than that of the control group.

Since Pain and Spine Specialists (PASS) began integrating behavioral health providers into their practice (with offices in Maryland, Pennsylvania, and Virginia), 71% of collaborative care patients have reached a treatment response, and 37% have reached depression remission within 4 to 8 months of usage (vs. 20% in treatment as usual).

As for the cost-effectiveness of integrated care, at the Mayo Clinic in Florida, a comprehensive outpatient rehab program for chronic pain reduced medical costs by 90% over 18 months. The program included biofeedback, cognitive-behavioral therapy, occupational therapy, physical therapy, and seminars on stress minimization and sleep.

Strategies for successful behavioral health integration

Behavioral health integration has the potential to make a difference in the lives of patients with co-occurring conditions like chronic pain. And even in a historically fragmented care landscape, payers can take steps to promote integrated care. Consider these strategies:

• Invest in appropriate digital tools. Payers can build partnerships with leaders in healthcare technology to develop digital solutions for physical and behavioral health. For example, PASS uses a platform called NeuroFlow to coordinate patient care between pain management and behavioral specialists. These types of tech platforms link patients with both sets of providers, allowing practices to seamlessly integrate pain management and mental healthcare.
• Empower primary care services. For private payers, empowering primary care services can mean building more robust networks that include behavioral health professionals and connecting these professionals with primary care providers. For example, Capital District Physicians' Health Plan (CDPHP) encouraged partners to create telehealth “micro-networks" that include both therapists and prescribers. These networks collaborate through an EHR, allowing the health plan to exchange data and push essential information to providers.
• Promote value-based care. Payers can also work toward integrating behavioral health into a value-based care system rather than a fee-for-service model. Using a pay-for-performance model, payers can incentivize different provider types to work together for patients' best interests. For example, CDPHP pays providers to prioritize behavioral health issues by conducting screenings and discussing treatment options with patients with the ultimate goal of improving patient outcomes.
• Build trust with culturally competent care. Creating behavioral health integration in any form includes the capability to deliver or connect patients to culturally informed and humble care. This is a way to ensure that all patients—including those in the Black community who have experienced a lack of trust in providers due to historical discrimination—have their voices heard and their care needs met.

RTI Health Advance is a strategic partner for behavioral health integration

As Turk et al. concluded, “Living with chronic pain requires considerable emotional resilience and tends to deplete emotional reserve." Fortunately, patients' quality of life can be greatly improved through the integration of physical and mental health services.

Do your company's policies and services reflect an integrated approach to care? RTI Health Advance can help you understand the needs of your member populations—and design (and measure) integrated care programs accordingly. Contact us.