Why behavioral health should be part of a holistic healthcare approach

• Patients with a combination of medical and behavioral issues have medical costs that are two times higher than the general patient population.
• Including comorbidities with behavioral health in health plan contracting discussions may make a difference in demonstrating return on investment for these services.
• Trends including a greater awareness of mental health impacts and an increase in telehealth for treating behavioral health may increase patient access to such services. 

When behavioral health issues go untreated, high medical expenditures may follow for not only behavioral health, but also any physical health comorbidities. This dual risk often compounds the cost of care. In fact, people with a combination of medical and behavioral issues have medical costs that are two times higher than the general population (Druss, B.G., Reisinger Walker, E., Mental disorders and medical comorbidity, Robert Wood Johnson Foundation).

When health systems must reduce the total cost of care for a patient population, they typically begin by addressing the cost of chronic health issues. However, because medical conditions, mental health conditions and substance use disorders are connected and often occur at the same time, it’s critical that health systems recognize and address the complex interdependencies between them. This can have the greatest impact on outcomes and costs.

For example, how often do anxiety or depression interact with a patient’s ability to manage chronic obstructive pulmonary disease (COPD), or how often does the stress of managing COPD worsen a patient’s mental health issues?

Innovation

Health systems are embarking on progressive strategies to manage risk and the total cost of care, while taking holistic views of patient care that include treating behavioral health comorbidities alongside other chronic conditions.

For example, a Colorado demonstration project for an alternative payment model called Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) delivered positive results. The six primary care practices receiving SHAPE payments saw $1.08 million in net cost savings for their public payer populations over 18 months, principally through reductions in downstream care utilization.
The alternative payments supported behavioral health services in primary care practices where at least one onsite behavioral health clinician provided integrated behavioral health services.

Medicare strategies

Medicare presents another opportunity for healthcare providers to incorporate behavioral health into their risk mangement strategies. For example, an increasing number of health systems are taking on risk through Medicare programs such as MSSP (Medicare Shared Savings Program) and MACRA (Medicare Access and Children’s Health Insurance Program Reauthorization Act). These programs from the Centers for Medicare & Medicaid Services (CMS) aim to shift how health systems provide care for Medicare patients, encouraging providers to see their mission as population health management, which includes addressing behavioral health.

Commercial payer engagement

It is challenging for health systems to move to population-health-management Medicare payment models while providing care only under fee-for-service models for employers and commercial payers. From facility planning to physician network alignment, it is difficult for health systems to create coherent strategies to serve such divergent care models.

When health systems have tried to engage employers and other commercial payers on population health management, most providers have struggled to make a compelling business case. Commercial payers have pushed back on whether there is a clear ROI for behavioral health.

Including comorbidities with behavioral health in contracting discussions may demonstrate the value of access to such services. If a patient with a behavioral health issue can receive treatment before a comorbidity episode occurs, then the patient has a better outcome and the payer sees the managed cost drop for the physical health comorbidities. Keeping these patients from preventable and high-cost trips to the emergency department (ED) is an obvious win for patients, payers and providers.

Emerging models

Forecasting behavioral health services likely to be utilized and the downstream avoidance of other hospital services can be difficult for payers and providers. However, there are emerging factors that contribute to understanding the impact of behavioral health access on improved patient care and financial projections for health systems.

For example, consider how the social stigma surrounding behavioral health has been lifting, increasing public conversations about personal battles with mental health issues. This type of awareness may encourage health systems to provide access to more behavioral healthcare providers. As a result, more health plans may include behavioral health benefits.

Rural health systems may also contribute to a rise in behavioral health service availability by offering access through telehealth. For example, a mobile app could provide access to transportation or address isolation issues, both social determinants of health. What’s more, patients’ comfort in interacting with their cell phones can reduce some of the stigma of seeking and receiving behavioral health services.

More data needed

How can health systems know how much care is going to be utilized and what will be the downstream effects of meeting the unmet demand? Unfortunately, conclusive data has yet to emerge showing whether these changes will avoid costly medical conditions with chronic care and increase or decrease the total cost of care for patient populations. However, a few studies provide data on behavioral health utilization and cost, such as “The Impact of Psychological Interventions of Medical Cost Offset: A Meta-Analytic Review,” Clinical Psychology: Study and Practice.

Some health systems seek to use historical data to understand differences in care utilization and costs when a patient population that had an unmet need for behavioral health services later gains access to these services. But specific markets vary by many factors including demographics, existing alternatives and present rates of comorbidities among potential behavioral health patients, so strong comparisons can be elusive.

Without more apples-to-apples data available in the early stages of these efforts, health systems typically find that showing payers the “art of the possible” is the best result of rigorous projection work.

See related sidebar: Keeping an eye on Massachusetts

Shifting attribution

Progressive health systems are also considering the role of attribution — identifying a patient-provider relationship that addresses the full continuum of care — in managing care for patients with behavioral health issues and comorbidities. This should be the starting point for provider organizations seeking to take on financial risk in contracts. Traditionally, primary care physicians have been assigned responsibility for managing patients’ health with a holistic view, but it might make more sense to assign this role to a specialist.

For example, if cardiologists, endocrinologists or nephrologists are managing patients’ chronic conditions, the higher number of interactions those physicians have had with patients may put them in better positions than primary care physicians to lead holistic care for those patients.

Similarly, health systems might consider assigning behavioral health specialists to manage patients’ entire care regimens and costs. In some situations, behavioral health specialists will be better suited to manage the underlying behavioral health conditions that often compound the impacts of other physical health conditions. Health systems might consider designating a cohort of patients with behavioral health conditions and other chronic conditions for this approach. With the high number of patient touches in behavioral healthcare, these specialists might be well positioned to also talk with patients about their medical conditions and refer patients to chronic care specialists. This could be a bridge between the patient and chronic care resources.

Look beyond the inpatient future

Finally, as health system leaders develop behavioral health strategies, they should avoid focusing solely on inpatient care and instead focus on a continuum of care that provides mental health resources in their communities.

     There is no doubt as to the benefit that inpatient psychiatric facilities provide. Yet system executives should ask themselves two questions when considering building a new inpatient facility:

• Is building a facility the most important need in the community to treat patients with these conditions?
• Will the facility be cost effective?

In certain situations, avoiding the high cost of inpatient care by moving to an ambulatory setting might better serve patients and enhance cost management by allowing for flexibile care coordination that includes behavioral health. However, it is important to ensure that shifting the site of service did not send downstream costs higher. Understanding the downstream services and costs avoided is fundamental to building the business case for inpatient facility investment as well as demonstrating value to the community.

Accountability on the rise

In this era of rising accountability, the economic incentives are increasing for providing high-quality, well-coordinated and low-cost care. Health systems can mitigate risk by including behavioral health in a holistic healthcare approach.