The role of family physicians in mental health care delivery in the United States: implications for health reform.

The battle for connecting the mind and the body is seen every day in the largest platform of health care delivery: primary care. More care for mental health, behavioral health, and substance use is provided in primary care than any other health care setting. However, the historical fragmentation that has divided the mental health system from the physical health system has meant that collaboration between primary care and specialty mental health care is a challenge. This lack of integration remains a barrier to improving quality, outcomes, and efficiency of the delivery of care. Having 2 separate systems to take care of patients’ medical and behavioral health needs can result in high costs, low satisfaction, and poor outcomes, including premature mortality. Under the Patient Protection and Affordable Care Act, millions of Americans will now have insurance that will include mental health as an essential health benefit. In addition, the Mental Health Parity and Addiction Equity Act assures that mental health benefits will be covered on par with general health benefits. This new legislation holds the potential to address these longstanding problems with unmet need, but only if there are providers able and willing to provide treatment. Some authors have expressed concern that rural areas— and possibly urban areas as well—may experience an acute shortage of mental health providers. However, regardless of setting, all providers must continue to work to identify mental health conditions to better assess what they are doing or not doing for population health management. Increasing family physicians’ understanding of the importance of addressing mental health is a critical step toward better addressing this problem. As Xierali et al. highlight, there is great potential for family physicians to help fill the mental health gap in the United States. There are nearly twice as many family physicians as psychiatrists in the United States, and family physicians are more likely than psychiatrists to be situated in rural areas. The authors report that about 40% of family physicians report providing mental health services in urban areas, with up to 52% providing mental health services in more rural settings (rural-urban continuum codes 7–9). Psychiatrists, like other specialist groups, tend to cluster in urban regions, potentially reducing access to mental health care in rural areas. Xierali et al. suggests that family physicians can help fill this need. While this is indeed an ambitious goal and, as some might argue, one that medicine as a whole has been pursuing for decades, the assumption that one provider can adequately address all of a patient’s needs is being increasingly replaced by the necessity of teams and team-based care. As the article highlights, only 43% of family physicians nationwide provide mental health care, which begs the question, Why aren’t more family physicians providing mental health care? Lack of knowledge, competing work demands (too busy providing other types of services), and payment and reimbursement issues could all be Submitted 21 December 2012; revised 21 December 2012; accepted 21 December 2012. From the Department of Family Medicine and the Office of Integrated Healthcare Research and Policy, University of Colorado School of Medicine, Aurora (BFM); and the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta GA (BD). Funding: none. Conflict of interest: none declared. Corresponding author: Benjamin F. Miller, Department of Family Medicine, Office of Integrated Healthcare Research and Policy, University of Colorado School of Medicine, Mail Stop F496, Academic Office 1, 12631 East 17th Ave., Aurora, CO 80045 (E-mail: Benjamin.miller@ ucdenver.edu).