Lee Badger, PhD Howard Robinson, DSW Tillman Farley, MD New York, and Fort Lupton, Colorado Submitted, revised, June 21, 1999. From the Graduate School of Social Service, Fordham University, New York (L.B., H.R.), and Salud Family Health Centers, Fort Lupton (T.F.). Reprint requests should be addressed to Lee Badger, PhD, Graduate School of Social Service, Fordham University, Suite 704, 113 West 60th Street, New York, NY 10023. E-mail: LBadger@hotmail.com.
References
Financing a Mental Health Partner
How can a rural physician pay for the mental health professional? There are several possible options that could be used alone or, more likely, in combination. The particular approach will depend on the community, its support for a mental health professional, and the patient demographics of the primary care setting. One possibility is direct billing, but this option is not likely to be sufficient by itself because rural per capita income tends to be very low, many patients are not insured, and carve-outs have reached into rural areas. If the physician could convince the community that it has a stake in a mental health professional, supplemental community funding could be created through a line in the county or city budget. This approach has been attempted with preliminary success in at least one rural community. The paradoxical outcome was that the mental health professional’s extensive involvement in the community, in the schools, in family violence prevention projects, and so forth, resulted in her being less available to the clinic itself. A third option might be to establish a collaborative partnership in which the mental health purveyors with the state carve-out agree to place mental health providers in the primary care clinic. Some physicians might value the contributions of a mental health provider so highly that they would designate a portion of their own salaries to provide a direct subsidy. Finally, the primary care physician could hire an intern. Although the limited duration of placement (generally 1 year) might interfere with the desired continuity of services, interns are inexpensive (or free), and their supervision can be provided by the academic sponsor. This option would be very attractive to many social work graduate schools, especially those that place an emphasis on training for rural practice.
Conclusions
We agree with deGruy18 that “most rural mental health care will be rendered in the primary care setting or it will not be rendered at all.” The model of integrated services that we propose conforms to the recent Institute of Medicine definition of primary care as the provision of integrated, comprehensive, and coordinated services by an individual or a team of professionals.58 The integration of psychosocial services within rural primary care is readily available, economically feasible, and urgently needed, but physicians must take the lead to implement this collaborative treatment partnership, if it is to become a reality for the millions of Americans who, undetected and untreated, continue to suffer mental distress.
