This commentary is by Dr. Ashley Miller, a pediatrician and owner of the South Royalton Health Center. She has practiced in the Upper Valley for about 15 years.
I am writing to implore Vermont’s policymakers to invest in primary care now, as the mental health crisis that is crushing Vermont’s young people is also putting immeasurable strain on our beleaguered primary care health system.
Much like mental health, primary care is in crisis. The primary care physician is the backbone of our health care system; patients trust their primary care office. But without adequate support, primary care clinicians cannot meet the increasing mental health needs of their patients, young and old.
We need to change the way we incentivize health care spending and increase what we spend on primary care to both save health care dollars and mitigate the impact these acute mental health outcomes are having on Vermont’s entire health care system.
We need to integrate mental health services into primary care through collaborative care models that use our existing workforce and allow primary care to provide appropriate care now.
In my clinic in South Royalton, I’ve treated five patients between the ages of 13 and 18 years old with fairly lethal suicide attempts in the last 10 weeks.
I am lucky to have co-located mental health; I have a counselor, as well as a care manager. I also have a psychiatrist who comes in two hours every month to consult with me about medication management.
Overall, I am fortunate compared to a lot of my colleagues, but since the pandemic the mental health crisis for our youth has come to a boiling point. Previous to the pandemic, I used to provide mental health care in roughly 25 percent of my clinic visits. Since the pandemic, this has increased to 50 to 60% of my daily practice.
We have a wonderful system in Vermont. We have the infrastructure to provide excellent mental health care. But we do not have the staff, and the staff that we do have is often underqualified and currently overwhelmed, at two times the capacity.
The local community mental health centers, also known as designated agencies, are there to provide the wraparound intensive services, but currently one of my local community mental health centers is running a six-month waiting period for counseling and the other has not had a psychiatrist for almost a year. Which means the current escalating volume of patients with significant mental health concerns will end up back in care of the primary care practice.
We do the best we can, but we worry for our patients every day. One of the five suicidal patients I mentioned above was admitted to the Brattleboro Retreat, but the psychiatric floor had very little capacity and after the patient spent about 48 hours there, they were sent home with little more than medication recommendations.
The Retreat is overtaxed, the designated agencies are struggling to find adequate staff, the hospital emergency departments do not have the space and we in primary care are trying to meet all of the increased mental health demands of our patients with very little resources.
I don’t say any of this to begrudge my colleagues who are working so hard in mental health to try to see all of these children and who are supporting us in every way possible, but I really think Vermont can do better.
We have an amazing infrastructure, as I said, but we need to invest in recruitment and adequately train mental health professionals and primary care clinicians. With minimal investment, we can integrate mental health services into primary care through programs that utilize the existing workforce like the Collaborative Care Model. The Collaborative Care team is led by the patient’s existing primary care provider (PCP) and gives the PCP and patient access to support from behavioral health care managers, counselors, psychiatrists, allowing patients to receive high quality psychiatric care in their medical home/primary care office.
We also need to provide accurate and reasonable payment for these services. I talked to a psychiatric nurse practitioner who has been practicing in pediatrics for 10 years on the West Coast, who is looking to move back to the East Coast. I thought, “finally I can have a psychiatrist in my office, full time. This is amazing!” She took one look at what our insurers are paying for her time and efforts and said she couldn’t work in Vermont.
This is where we need to do better so we can be set up for success. The Vermont legislature is considering a bill that would require Vermont’s commercial health insurers to spend 12% of their total health care spending on primary care. This would follow states like Rhode Island, who ten years ago required their commercial health insurers to increase their investment in primary care to at least 10.7% of their total health care spending, and this year is adopting new policies to support and promote behavioral health care integration into primary care practices.
It is time for Vermont to invest in support for primary care, to help mitigate our current mental health crises and prevent future suffering.
