Fragmentation Hurts Everyone

By Benjamin F. Miller, PsyD

When did we think it was a good idea to design a healthcare system around parts and not wholes?  Did we think that we would enjoy having to have uncoordinated care with clinicians who didn’t talk to each other? Mental health and substance use, issues that impact nearly half of us at some point in our lives, often go untreated for a multitude of reasons. But one of those reasons is because of our fragmentation.

We pay for mental health and substance use differently.

We train our clinicians separately.

We policy these services differently.

So what happens when we do not adequately address mental health and substance use needs?

We spend more.

We get poorer outcomes.

People are unsatisfied.

Clinicians are frustrated.

The way that healthcare is set up is fractured, and this brokenness is seen more often with mental health and substance use than almost any other health condition.

Consider the 54-year-old woman who, for the first time in her life, is experiencing symptoms she thinks may be depression. Her type II diabetes has been managed for years, and she has actively been working on controlling her blood pressure through exercise and nutritional change. However, all this changes with the depression. She tells her primary care physician about this symptoms, and they prescribe a medication, which does not help her symptoms. She reports back and primary care makes a referral to a local mental health agency who the primary care clinician thinks can help.

And here the real problems begin.

Her first available appointment is not for three weeks.

She is not sure her insurance covers the services.

She is unclear about taking off another day of work, which could impact her paycheck.

And did she really want to talk about this again? She felt comfortable with her primary care clinician, but opening up again to a new person – a stranger, well that just did not sound appealing.

So her depressive symptoms worsen. Her medical conditions are negatively impacted. She changes her behavior – stops seeing her friends, eating right, and exercising. Everything gets worse.

She was a victim of fragmentation.

But this could have been avoided.

What happens when we integrate care rather than fragment care?

What would have happened if there was a mental health clinician onsite in the primary care practice to address her needs in that moment?

No waiting.

No fragmentation.

No frustration.

A team-based approach to delivering whole person care.

Many of the issues described above could have been avoided if this was the standard of care; sadly, it is not.

If the United States is serious about decreasing our total cost of care we need look no further than how we address mental health and substance use.

And the data support this.

Employers spend more on depression than any other health condition.

People with comorbid mental health and substance use with a chronic condition cost much more.

And consider one study that estimated that the healthcare system could save billions if we did a better job integrating mental health and substance use in primary care.

Yes, billions.

But what we do is continue to silo mental health and substance use. Our policies, payment, and delivery all reflects this.

But scientific evidence will not allow us to continue to treat the mind and body as separate.

We must integrate.

Separate will never be equal – it’s time to truly bring mental health and substance use into healthcare. It’s time for us to see comprehensive care as inclusive of mental health.

This is not about a benefit.

This is not about a talking point.

This is about total transformation.

Truly achiving better care at lower cost will be impossible if we do not aggressively pursue models of care that integrate mental health and substance use.

Now is the time.

People are waiting.


Benjamin F. Miller, PsyD is the Director, Farley Health Policy Center at University of Colorado School of Medicine and was a contestant in the 2016 Costs of Care Story Contest.

Read More From Our Blog

or subscribe to always stay informed.

Visit Blog

Read More From Our Blog

or subscribe to always stay informed.