Lawmakers and physicians met during the first Tennessee Senate Health and Welfare Committee of the year on Wednesday, where they discussed integrating behavioral health with physical health to improve the state’s national health rank.
Committee Chair Sen. Rusty Crowe (R-Johnson City) began the discussion by noting that Tennessee ranked 44th in overall health in America’s Health Rankings’ 2023 report.
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“This committee has been thinking for years, ‘How do we start chipping down at these numbers that we’re seeing relative to our national rankings?’” Crowe said. “My thought was, [integrated behavioral health] may be one way we could do it.”
Integrated behavioral healthcare combines primary care and behavioral healthcare in the same setting, where providers of both disciplines work together to achieve the best outcomes for their patients.
Randy Wykoff, MD, dean of the College of Public Health at East Tennessee State University (ETSU), presented more detailed data to the committee from the AHR report. For 12 of the measures, Tennessee is ranked among the top half of states, but for 20 of the measures, the state is among the bottom 10. He also noted that Tennessee had no metrics in the top 10.
“If you look at the ones where we’re in the bottom 10, these are the ones that really strike you,” Wykoff said. “Drug deaths, smoking, obesity, physical inactivity, adverse childhood experiences, and so on.”
Wykoff said there are three possibilities as to why Tennessee is stuck in some of these metrics: the measures are inaccurate, the health challenges cannot be solved, or the state is not doing what it needs to in order to solve the problems. He concluded that the state needs to be doing more to change its ranking.
“Our understanding of what it takes to be healthy has changed a lot in the past couple of decades. And today, we need to focus on three things. We need to make sure we provide healthcare, we need to change behavior, and we need to reduce poverty, which is jobs and education. Those to me are three pillars of what we need to do in Tennessee or in the United States in general, to improve health.”— Wykoff
Wykoff said in order to improve the provision of healthcare, the state should encourage young people to go into healthcare professions, increase the workforce in rural and underserved areas through incentivization, and look at ways to make healthcare more affordable.
To lessen poverty, Wykoff wants to focus on not only high school education, but also promote secondary education among young people. He said there is almost an eight-year difference between the life expectancy of men who did not get a bachelor’s degree and men who did. For women, the difference is five years.
Wykoff emphasized that people living in poverty have trouble affording healthcare and therefore have significantly worse health outcomes. He said a poor American, in this case making less than $10,000 per year, is three times more likely to die before the age of 65 than a person making $100,000 or more per year.
Tennessee has seen a significant improvement in one of its education metrics—graduation. In 2005, Tennessee had the second worst graduation rate in the nation. In 2023, Tennessee had the seventh highest graduation rate.
“That’s a real accomplishment, and I think the take-home message here is that there’s really nothing we’re talking about today that can’t be improved or changed over time,” Wykoff said.
To change the behavior of Tennesseans so they lead healthier lifestyles, he said the state should focus on reducing tobacco and nicotine use among young people, increasing opportunities for drug treatment, increasing the availability of mental health services, and promoting lifelong physical activity in K-12 students.
Jodi Polaha, PhD, director of the Institute for Integrated Behavioral Health at ETSU, presented more information to the committee on why they should focus on integrated behavioral healthcare, echoing Crowe’s remarks.
“We think a strengthened primary care health system through integrated behavioral health is already transforming health in (parts of) Tennessee,” Polaha said. “But we really need your help in making it stick and stay and spread.”
Polaha discussed why primary care is so important. It is accessible, preventative care with a physician that has a closer relationship with their patients. She said stronger primary care means better healthcare overall.
A majority of patients who go to their primary care provider are there for a psychological concern. Implementing integrated behavioral health would be able to better address these patients’ concerns.
“Put the services where people are seeking them.”— Polaha
The impact of integrated behavioral healthcare, Polaha said, includes better access to more coordinated care, an increase of patients taking part in and control of their health, improved physical and mental health outcomes, and lower costs. The lower costs are due to monitoring, prevention and early intervention, and because patients are more invested in their own health.
“At least one study showed a lower cost, about 11 percent savings, when integrated behavioral health was part of the practice,” Polaha said.
Gayatri Jaishankar, MD, medical director of the Department of Pediatrics at ETSU, spoke about her own experience working as a pediatrician in an integrated behavioral health clinic.
“I feel like I have formed these long eternal relationships with all these families to where [they say], ‘If Dr. J. says that this is what I should do, then yes, I’m going to do it.’ Often they’ll call and ask my nurse, ‘Can you ask Dr. J. what she thinks? Here’s what I want to do. Can you ask her if she thinks this is something I should do?’ So I really, truly feel like I’m able to advocate for those families and help them and really provide compassionate care to our greatest assets, which are our children.”— Jaishankar
Jaishankar teaches pediatric residents, so her students are learning under the integrated behavioral health model.
Laura Shultz, PsyD, senior director of behavioral health at Methodist Le Bonheur Health, was asked to start behavioral health services at a clinic that had primary care, dental care, pediatrics, and obstetrics. Initially, she said many of the physicians were skeptical about the model.
“The same physicians who initially were a little bit nervous: ‘How do we do depression screening? We don’t know where to send them,’” Shultz said. “By the end, they were full believers, begging us to do more trauma screenings because they saw the transformative power in their practices.”
She said 98% of the physicians said they won’t practice at non-integrated behavioral health clinics. However, she also recognized that getting funding to implement this model can be difficult.