American Hospital association January 2012 TrendWatch Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes O ne in four Americans experiences a mental illness or substance abuse disorder each year, and the majority also intense alterations in thinking, mood and/or behavior over time. Substance abuse disorders are conditions resulting increased provider accountability will spur efforts to coordinate care across currently fragmented settings to improve has a comorbid physical health condi- from the inappropriate use of alcohol, the efficiency and effectiveness of care tion.1 In 2009, more than 2 million prescription drugs and/or illegal drugs.4 delivered to individuals with behavioral discharges from community hospitals Behavioral health disorders may also health conditions. were for a primary diagnosis of mental include a range of addictive behaviors, Many providers already are work- illness or substance abuse disorder.2,3 such as gambling or eating disorders, ing with private payers to meet these The range of effective treatment characterized by an inability to abstain same goals. Initiatives span value-based options for behavioral health disor- from the behavior and a lack of aware- purchasing, accountable care organiza- ders—which encompass both mental ness of the problem.5 tions, patient-centered medical homes, illness and substance abuse disorders— Health reform creates new impetus and efforts to reduce readmissions. is expanding. Research indicates that and opportunity for better managing These initiatives will have important better integration of behavioral health the care delivered to individuals with implications for the delivery of behav- care services into the broader health these conditions. Expansion of health ioral health care. And as the demand care continuum can have a positive insurance generally, along with improved for behavioral health services is likely to impact on quality, costs and outcomes. coverage of behavioral health treatment continue to outstrip capacity, improv- Mental illnesses are specific, diagnos- under parity laws, will broaden access ing care integration can help to better able disorders. Each is characterized by to needed services. At the same time, manage this need. Highly Prevalent, Behavioral Health Disorders Have a Significant Economic and Social Impact Behavioral health disorders affect a sub- der during their lifetimes.8 While behav- used behavioral health services in a year.11 stantial portion of the U.S. population. ioral health disorders primarily affect The economic and social costs associ- Nearly half of all Americans will develop adults, they also are prevalent among ated with behavioral health are significant, a mental illness during their lifetime.6 An children. Among children, mental health underscoring the importance of treating estimated 22.5 million Americans suf- conditions were the fourth most common these conditions.12 In the majority of fered with substance abuse or dependence reason for admission to the hospital in cases, behavioral health conditions are in 2009,7 and 27 percent of Americans 2009.9 Studies reveal that approximately serious enough to cause limitations in will suffer from a substance abuse disor- 17 percent of Medicare beneficiaries have daily living and social activities.13 For a mental illness.10 An analysis of Medicaid example, behavioral health conditions beneficiaries across 13 states found that hinder worker productivity and raise more than 11 percent of beneficiaries absenteeism, resulting in reduced income bringing behavioral health into the care continuum or unemployment.14 In 2007, persons Behavioral health conditions are prevalent among adults in the U.S. diagnosed with serious mental illness had annual earnings averaging $16,000 less Chart 1: Percent of U.S. Adults Meeting Diagnostic Behavioral Health Criteria, 2007 than the general population.15 Each year, approximately 217 million days of work 57% are lost or partially lost due to productiv- Within Past 12 Months ity decline related to mental disorders, Ever in Lifetime costing United States employers $21.7 billion annually.16, 17 35% Behavioral health disorders also 32% 31% can have a profound social impact. Individuals with behavioral health con- 25% 21% ditions are more likely to live in poverty, 19% 13% have a lower socioeconomic status, and 10% 11% lower educational attainment.18 Lack of treatment amplifies these outcomes and Anxiety Disorder Mood Disorder Impulse-control Substance Any Disorder increases the likelihood that individuals Disorder Disorder will end up homeless or incarcerated.19 Note: Anxiety disorder includes panic disorder, agoraphobia, specific phobia, social phobia, generalized anxiety disorder, post-traumatic These social impacts, in conjunction stress disorder, obsessive compulsive disorder, and adult separation anxiety disorder. Impulse-control disorder includes oppositional with treatment costs, present a signifi- defiant disorder, conduct disorder, attention deficit/hyperactivity disorder, and intermittent explosive disorder. Substance disorder includes alcohol abuse, drug abuse, and nicotine dependence. cant and growing economic burden that Source: Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC. has made mental illness one of the five most costly conditions nationwide.20 In 2008, the U.S. spent nearly $60 billion and private payers account for roughly and state and local governments on mental health services, up from $35 equal shares of spending, public payers accounted for 61 percent of behavioral billion in 1996.21 In contrast to general account for the majority of behavioral health care expenditures, compared with health care services, in which public health expenditures. In 2005, Medicaid 46 percent for all health services.22 Behavioral Health Disorders and Medical Conditions Often Co-occur, Raising the Risk of Suboptimal Outcomes Individuals with behavioral health dis- had a history of mental illness and dying from a future heart attack or other orders often have co-occurring physical 54 percent had a history of both mental heart condition.27 Depressed patients health conditions. In the past year, 34 illness and alcohol and substance use.25 also are three times more likely than million adults—17 percent of American Individuals with co-occurring physical non-depressed patients to be noncompli- adults—had comorbid mental health and mental health conditions present ant with treatment recommendations.28 and medical conditions.23 Mental health many treatment challenges. A physical Moreover, individuals with mental illness and medical conditions are risk factors condition may exacerbate a mental health more frequently have risk factors, such as for each other and the presence of one condition, while a mental health condi- smoking and obesity, which contribute to can complicate the treatment of the tion may hinder treatment for a physical increased likelihood of chronic conditions other. For example, a recent study found ailment. Medical conditions with a signif- such as stroke and diabetes.29 that individuals with bipolar disorder, on icant symptom burden, such as migraine Patients with comorbid mental health average, have a greater number of medi- headaches, chronic bronchitis, and and medical conditions experience higher cal conditions than individuals without back pain are associated with increased health care costs, with much of the claims for mental illness.24 And a study incidence of major depression.26 About difference attributable to higher medi- of Medicaid beneficiaries in New York one fifth of patients hospitalized for a cal, not mental health, expenditures. State determined that, among patients at heart attack suffer from major depres- One analysis found that although the high risk of hospitalization, 69 percent sion, which roughly triples their risk of presence of comorbid depression or 2 TRENDWATCH anxiety boosts medical and mental health Individuals with behavioral health conditions frequently have care costs, more than 80 percent of the co-ocurring physical health conditions. increase stems from medical spending. Monthly costs for a patient with a Chart 2: Percentage of Adults with Mental Health Conditions and/or Medical Conditions, chronic disease and depression are $560 2001-2003 more than for a person with a chronic disease without depression.30 The presence of comorbid conditions Adults with Mental also can lead to suboptimal patient out- Health Conditions comes. Research indicates that individu- Adults with als with mental illness die younger than Medical Conditions people without such diagnoses, but from 29% of Adults with Medical the same leading causes of death as occur Conditions Also Have Mental Health Conditions nationwide, such as heart disease and 68% of Adults with Mental cancer.31 Individuals with serious mental Health Conditions Also Have illness die, on average, 25 years earlier Medical Conditions than the general population.32 Such poor outcomes may be linked to lack of appro- Source: Druss, B.G., and Walker, E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation. priate care. One study found that almost one third of patients with schizophrenia did not receive appropriate medical treat- The presence of a mental health disorder raises treatment costs for ment for their diabetes, and 62 percent chronic medical conditions. and 88 percent, respectively, did not receive appropriate treatment for high Chart 3: Monthly Health Care Expenditures for Chronic Conditions, with and without blood pressure and high cholesterol.33 Comorbid Depression, 2005 Individuals with comorbid conditions $1,420 are at heightened risk of returning to Without Depression $1,290 the hospital after discharge. A Canadian With Depression study found that 37 percent of patients with mental illness discharged from acute $840 $860 care hospitals were readmitted within a period of one year, compared with only 27 percent of patients discharged without a mental illness.34 In addition, individuals with substance use disorders are among the highest-risk populations for medical $130 and psychiatric rehospitalizations.35 $20 Patients with comorbid mental and Mental Health Medical Total physical health conditions are readmitted Expenditures Expenditures Expenditures for a broad range of reasons. Specifically, these patients have multiple health condi- Source: Melek, S., and Norris, D. (2008). Chronic Conditions and Comorbid Psychological Disorders. Cited in: Druss, B.G., and Walker, E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood tions, may lack a strong support system, Johnson Foundation. and may not adhere to treatment regi- mens. These factors can impede recovery and increase the likelihood that patients anxiety had a threefold risk of cardiac- and remained elevated until about 90 days will return to the hospital. One study related readmission, compared to those post-discharge.38 This finding underscores found that heart attack patients who were without anxiety.37 the vulnerability of patients during the depressed were more likely to be readmit- Among children, the risk of rehospital- immediate post-discharge period and high- ted in the year after discharge.36 Another ization was highest during the first 30 days lights the importance of integrated care study concluded that patients with severe following a first psychiatric hospitalization and post-discharge support services. 3 bringing behavioral health into the care continuum Fragmented Care Delivery and Provider Shortages Impede Effective Treatment for Behavioral Health Conditions Behavioral health care is fragmented. and other funding constraints.43 Many Washington, DC reduced their mental Individuals who seek behavioral health states have slashed their mental health health funding by a total of $1.6 billion care often receive treatment in both the budgets.44 Twenty-eight states and between fiscal years 2009 and 2012.45 inpatient and outpatient settings from generalists and specialists, and rely on Cost is a common barrier to receiving mental health care services. a myriad of community resources.39 Patients with physical health conditions Chart 4: Reasons for Not Receiving Mental Health Services, Among Adults can receive care from yet another group Reporting Unmet Need, 2009 of providers who do not have linkages to those delivering behavioral health Could Not Afford Cost 45.7% care. Even more troubling, the majority Could Handle Problem Without of adults with a diagnosable behavioral 26.6% Treatment at Time health disorder do not get any treatment Did Not Have Time 16.3% for their behavioral health conditions.40 Did Not Know Where to Go For Services 15.3% One of the biggest barriers to Health Insurance Did Not 11.7% accessing behavioral health services is a Cover Enough Treatment critical shortage of treatment capacity. Treatment Would Not Help 10.6% Currently, 55 percent of U.S. coun- Concerned About Confidentiality 9.3% ties have no practicing psychiatrists, psychologists or social workers.41 There Did Not Feel Need for Treatment 9.1% also is a shortage of facilities formally Might Cause Others to Have 9.0% Negative Opinion providing behavioral health care. Only Might Have Negative Effect on Job 7.9% 27 percent of community hospitals have an organized, inpatient psychiatric Note: Excludes those who reported unmet need but received some services. unit,42 while state and county psychiatric Source: Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: hospitals are closing due to state budget A Primer. Washington, DC. The health care system’s capacity to deliver mental health services has been shrinking. Chart 5: Total Number of Psychiatric Units(1) in U.S. Hospitals and Total Number of Freestanding Psychiatric Hospitals(2) in U.S., 1995-2010 1,550 700 650 1,500 600 Psychiatric Hospitals 1,450 550 Psychiatric Units 1,400 500 Psychiatric Hospitals 1,350 450 400 1,300 Psychiatric Units 350 1,250 300 1,200 250 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Note: Includes all registered and non-registered hospitals in the U.S. (1) Hospitals with a psychiatric unit are registered community hospitals that reported having a hospital-based inpatient psychiatric care unit for that year. (2) Freestanding psychiatric hospitals also include children‘s psychiatric hospitals and alcoholism/chemical dependency hospitals. Source: Health Forum, AHA Annual Survey of Hospitals, 1995-2010. 4 TRENDWATCH To achieve these cuts, states have increasing. Emergency department (ED) behavioral health care needs at hospitals eliminated or downsized emergency and visits involving a primary diagnosis of nationwide. In 2008, 80 percent of ED long-term hospital treatment, and com- mental illness or substance abuse disorder medical directors surveyed reported that munity mental health treatment pro- increased from about 4.2 million in 2006 their hospitals board psychiatric patients grams, among other services. Colorado, to more than 5 million visits in 2009.47, 48 and 42 percent reported a rising trend.49 for example, has reduced payment rates Due to this increased utilization and a Boarding can adversely affect psychiatric for mental health providers and cut shortage of beds, ED boarding—the prac- patients by exacerbating their conditions, funding for residential treatment.46 States tice in which admitted patients are held as patients are held in typically loud, are making decisions to reduce services in the ED until inpatient beds become hectic environments not conducive to as demand for behavioral services is available—is growing for patients with their recovery. Treatment Settings for Behavioral Health Care The first point of contact for individu- Treatment for behavioral health problems is most frequently als seeking mental health care is typi- delivered on an outpatient basis. cally a primary care provider.50 In fact, primary care is the sole form of health C  hart 6: Types of Mental Health Services Used in Past Year, Among Adults care used by more than one third of Receiving Treatment, 2009 patients receiving care for a mental health condition.51 Patients also may 4% 2% access mental health care through Combination of Inpatient, Inpatient Only, Rx specialists (e.g., psychiatrists), social Outpatient, and/or Rx service providers (e.g., counselors) 13% and informal volunteers (e.g., sup- Outpatient Only port groups).52 Mental health services 49% are delivered at a range of locations, Rx Only including hospitals, outpatient clinics 32% and community settings. Of the 30 Outpatient and Rx million adults receiving mental health services in 2009, the most common services were outpatient therapy, outpatient prescription drugs or a combination of the two.53 Note: Excludes treatment for substance abuse disorders. Prevention and Detection Although mental health care is Source: Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC. most frequently delivered on an outpatient basis, community and psy- chiatric hospitals remain a vital source anxiety disorders and schizophre- inpatient care provided by community of care for behavioral health patients.54 nia.56 Hospitals treat these and other and psychiatric hospitals.57 Psychiatric Nearly all hospitals report that they conditions by stabilizing patients, hospitals offer inpatient psychiatric provide care to patients with mental establishing treatment regimens and and nursing services, conduct proce- health and substance abuse disor- transitioning patients to outpatient dures and observe patients so that they ders.55 The most common behavioral and community-based services. do not harm themselves. Notably, the health conditions treated in hospitals Overall, about 27 percent of behav- vast majority of inpatient behavioral include mood disorders, substance- ioral health care expenditures in 2005 health services are provided in com- related disorders, delirium/dementia, went toward hospital-based services— munity hospitals. 5 bringing behavioral health into the care continuum Treatment Works Despite the challenges of delivering and Increased utilization of prescription drugs and decreased reliance coordinating behavioral health care within on inpatient services has shifted spending over time. the broader health care system, effective treatment for behavioral health conditions Chart 7: Distribution of Mental Health Expenditures by Type of Service, 1986 and 2005 does exist. For instance, pharmacotherapy has become an increasingly important $32B $113B 7% part of behavioral health treatment. A Prescription Drugs 27% wave of new, effective drug treatments for 22% Prescription Drugs depression, anxiety and schizophrenia has Residential* 14% boosted medication as a share of mental 24% Residential Outpatient health expenditures from 7 percent in 33% 1986 to 27 percent in 2005. Effective Outpatient 42% drug treatments also have allowed more Inpatient 19% patients to receive care in the outpatient Inpatient setting, which accounted for 33 percent 1986 2005 of mental health expenditures in 2005, up Note: Excludes spending on insurance administration. Data not adjusted for inflation. from 24 percent in 1986.58 * Residential treatment includes spending in nursing home units of hospitals or in nursing homes affiliated with hospitals. Pharmacologic treatments, such as Source: Substance Abuse and Mental Health Services Administration. (2011). National Expenditures for Mental Health Services & Substance Abuse Treatment 1986-2005. Washington, DC. As cited in Kaiser Commission on Medicaid and the Uninsured. antidepressants have been shown to (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC. improve quality of life for mental health patients.59 Medications also are often treatment for depression in 2006 than have been shown to reduce medical, enhanced with psychosocial treatments. did in 1996.61 disability, and workers’ compensation Cognitive behavior therapy, in combina- Treatment has been shown to have claims, improve worker productivity and tion with psychotropic medication, has a positive economic impact by reduc- decrease absenteeism.63 decreased symptoms of principal general- ing employer costs and boosting worker Treatment also has evolved to meet ized anxiety disorder, panic disorder and productivity. In one study, work impair- patient needs. Technological advances, social anxiety disorder.60 ment of employees with mental illness such as telepsychiatry, have improved care The relative ease of seeking treat- (defined as when emotional distress has for patients in rural and other under- ment in ambulatory settings, along with an impact on day-to-day functioning) served areas. Telepsychiatry—a form of shifting perceptions of behavioral health, was cut nearly in half after three weeks video conferencing that can be used to may encourage more individuals to seek of outpatient treatment, from 31 percent provide psychiatric services—has been treatment. A survey comparing percep- to 18 percent.62 Employer-based initia- shown to be as effective as face-to-face tions of major depression found that tives to increase access to mental health communication,64 as well as to increase more individuals attribute the condition treatment have also proven beneficial. For access and diagnosis and enhance care to neurobiological causes and endorse example, Employee Assistance Programs coordination.65 South Carolina Telepsychiatry Network The South Carolina Department telephone and video conferencing, of stay for patients experiencing a of Mental Health and the South giving patients in 27 participating behavioral crisis across participat- Carolina Hospital Association hospital EDs greater access to mental ing hospitals declined from six days received funds to develop a statewide health specialists.66 The program has to three days. One hospital, Springs telepsychiatry network. The program produced measurable results, both in Memorial, reported a savings of allows mental health providers to terms of patient outcomes and cost $150,000 in the first eight months conduct psychiatric consultations via savings. The statewide average length of its participation in the service.67 6 TRENDWATCH Aleda E. Lutz VA Medical Center, Saginaw, MI The Aleda E. Lutz Veterans ments. The telepsychiatry technicians three hours each way. Patient concerns Administration (VA) Medical Center (THTs), who are onsite with the about confidentiality of information in Saginaw, MI has been using tele- patients, and the health care provider being shared over the lines are allayed psychiatry for the past five years to at the remote site have protocols for by the T3 encryption system as well as provide individual therapy and how to handle specific situations or the very solid firewalls that are in place counseling as well as ongoing evalu- emergencies. For example, if a patient to protect their privacy. ation and assessment for behavioral with post-traumatic stress disorder The VA’s 1,100 sites of care in the health patients.68 needs direct intervention during a ses- U.S., South Pacific and Puerto Rico Before initiating telepsychiatry, sion, the provider, who may be up to are connected by an electronic medical one onsite visit with the mental 150 miles away, may immediately call record that allows health care provid- health professional is recommended the THT (usually a nurse) on his/her ers to share information and coor- to complete a psychosocial exam and cell phone and tell him/her to provide dinate care across sites. Substantial establish a relationship. After that immediate hands-on care and evaluate resources are required to support the visit, patients are offered the option the patient for appropriate care. technology and infrastructure as well of receiving follow-up sessions using The number of VA rural sites as to train health care workers to use telepsychiatry. Before a telepsychiatry using telepsychiatry is skyrocketing. the equipment. The VA home telepsy- session begins, there is a reconciliation Patients are very satisfied with the use chiatry program served approximately of all critical patient information from of telepsychiatry especially because it 35,000 patients in 2009 and had $72 the electronic medical record and from can reduce their time spent driving to million in expenditures. By 2011, recent tests and medication adjust- a medical care session by as much as expenditures reached $163 million. Integrating Behavioral Health into the Broader Care Continuum Can Reduce Costs and Improve Outcomes The delivery of behavioral health the medical and behavioral health care Another study of administration of a services is usually separate from and needs of a particular patient. Integration brief screening and intervention for sub- uncoordinated with the broader health entails both improving the screening stance abuse among patients admitted care delivery system. For individuals and treatment for behavioral health care to a large urban hospital found a nearly with comorbid behavioral and physical needs within primary, acute and post- 50 percent reduction in re-injuries health conditions, this fragmentation acute care settings, as well as improving requiring an ED visit and in injuries compromises quality of care and clinical the medical care of people receiving ser- requiring a hospital readmission within outcomes. Integration of care between vices in behavioral health care settings. three years.70 the behavioral health and general One study of an integrated care Similarly, individuals with serious medical care treatment settings and model found that 44 percent of adults mental illness enrolled in a Veterans providers, can reduce costs and improve with a serious mental illness who Affairs mental health clinic who were outcomes for these patients. received primary care services within randomized to receive integrated care Integration of care can range from the mental health setting had diabetes were more likely to receive primary brief screening and intervention for and hypertension screenings, while and preventive care, and demonstrated comorbid conditions, to coordinated none of the patients without integrated superior outcomes compared to their communication between medical and care were screened. Additionally, ED counterparts not receiving integrated care. behavioral health providers, to full visits were 42 percent lower among the Integrated care included primary care integration of care delivery across the group that received integrated primary and case management given on site at the care continuum with respect to all of care services.69 mental health clinic, patient education 7 bringing behavioral health into the care continuum and close collaboration between physical Integration of behavioral and physical health care can improve and mental health providers.71 access to appropriate care. A substantial body of clinical evi- dence has demonstrated the benefits Chart 8: Receipt of Preventive Care Services in 12 Months among Patients with Serious of collaborative care for patients with Psychiatric Illness Receiving Integrated Care vs. Patients Receiving Usual Care depression, in particular. A literature review of 45 studies found that patients Medication 86% with major depressive disorder treated Listed in Chart 64% with collaborative care interventions Educated About Smoking 85% experienced enhanced treatment 64% outcomes—including reduced finan- Blood Pressure Tested 85% 66% cial burden, substantial increases in treatment adherence, and long-term Educated About Nutrition 83% 62% improvement in depression symptoms 81% and functional outcomes—compared Educated About Exercise 53% with those receiving usual care.72 Cholesterol Screening 80% Integration of care across treatment 57% settings can reduce readmission rates 71% Screened for Diabetes for patients with behavioral health 46% conditions. In Florida, eight psychiatric 32% Received Flu Vaccine Integrated Care hospitals partnered with a health 12% Usual Care plan to improve patients’ transitions to outpatient care, with the goal of Source: Druss, B., et al. (2001). Integrated Medical Care for Patients with Serious Psychiatric Illness. A Randomized Trial. reducing preventable readmissions. Archives of General Psychiatry, 58, 861-868. Mayo Clinic, Rochester, MN The Mayo Clinic in Rochester, MN At the initial mental health visit, registered nurse care coordinators. The is delivering integrated primary and patients complete self-rated scales— care coordinators monitor the patient’s behavioral health care to more than known as the PHQ-9 and used in a condition, share their findings with 140,000 patients—including clinic variety of health care settings nation- the patient’s psychiatrist and the health employees, their dependents and other wide—for depression, anxiety, bi-polar care team, assist patients with refer- patients seen by Mayo’s primary disorder and substance abuse which rals to other community resources and care physicians—using a team-based help assess the severity and urgency of develop a relapse prevention plan with approach.73 Mayo’s employed primary the patient’s condition. The patient’s the patient. The patients also have the care physicians, clinical nurse special- score on the PHQ-9 helps inform the opportunity to participate in a depres- ists, psychiatrists, psychologists, nurses, health care team of the type of care sion improvement program offered social workers and clinic administra- the patient requires. The PHQ-9 also in Minnesota known as DIAMOND tors make up the patient’s health care is completed at all follow-up visits for (Depression Improvement Across team. This team collaborates using a patients with depression. The health Minnesota Offering a New Direction). common patient screening tool and care team can adjust the patient’s Mayo’s implementation of the team- electronic health record to ensure the medication, start or increase therapy based approach, the use of the PHQ-9 patient is receiving comprehensive and address suicide risks based on the and the registered nurse care coordinators primary and behavioral health care. patient’s score. Patients that receive a have significantly improved outcomes The team also is linked with existing score of 10 or higher on the PHQ-9 are and continuity of care for patients. In community-based services to ensure added to a registry and monitored for 2010, two of Mayo’s clinics reported the continuity of care for the patient. up to 12 months by one of Mayo’s 11 best patient outcomes in the state. 8 TRENDWATCH The hospitals focused on coordinat- Coordination of care can reduce costs for individuals with behavioral ing care in the inpatient setting with health conditions. support services post-discharge. Their efforts cut readmission rates at the Chart 9: Total Costs at 1 and 2 Years for Patients with Serious and Persistent Mental Illnesses eight hospitals. After implementing the Receiving a Medical Care Management Intervention vs. Usual Care program, the readmission rate among the participating hospitals fell from $8,934 $8,715 17.7 percent to 10.4 percent.74 Intervention Beyond improving quality of care and Usual Care outcomes for patients, integrating care $6,840 also can save money. In the Florida pro- gram, instituting a visit from a physician $5,908 on the day of discharge reduced costs by 14 percent. Another study of a care coordination and education program, which deployed medical case managers to assist psychiatric outpatients at a com- munity mental health center, found that participating patients had lower costs Year 1 Year 2 by the second year of the program than non-participating patients.75 Further, integration has been shown to Source: Druss, B.G., et al. (2011). Budget Impact and Sustainability of Medical Care Management for Persons with Serious Mental Illness. American Journal of Psychiatry, AiA, 1-8. reduce health care costs in the long term. One study found that older patients with depression who received collaborative care across four years compared with patients bid major depression through a nurse management from both a primary care receiving usual primary care.76 Another intervention reduced 5-year mean total physician and a nurse or psychologist care study found that coordinating care medical costs by $3,907, compared with manager had lower mean health care costs for patients with diabetes and comor- patients receiving usual primary care.77 St. Anthony Hospital, Oklahoma, OK St. Anthony Hospital in Oklahoma prior to bed placement in the ED. sional decreased from two hours to City, OK is an acute care inpatient De-escalation training was conducted 20 minutes, and patients now see a hospital that serves as a regional referral for all ED and security staff and the mental health professional before see- facility in behavioral medicine and Oklahoma City Police Department ing an ED physician. Additionally, the also offers residential inpatient care for was enlisted to improve and assist in average wait time for patients in the adolescents and children. In 2008, St. the transfer of patients to the behav- ED has decreased from 44 minutes to Anthony initiated a number of changes ioral health crisis center. St. Anthony 28 minutes. Furthermore, the average to its internal processes to address the also focused on avoiding unneces- length of stay in the ED for mental high rates of behavioral health patients sary admissions and readmissions of health patients has dropped from 254 admitted through its ED and to reduce behavioral health patients by ensuring minutes to 177 minutes. the time mentally ill patients spent in patients are connected with the right Although St. Anthony has recently the ED in a crisis situation.78 resources and provided the appropri- seen an increase in patients seeking ser- The hospital established a men- ate care in the appropriate setting. vices through the ED—on average 83 tal health admissions office in the As a result of these changes St. more patients a month seek care in the ED and began conducting behav- Anthony’s average wait time for ED—they have experienced a 12-20 ioral health evaluations of patients patients to see a mental health profes- percent reduction in admissions. 9 bringing behavioral health into the care continuum Affordable Care Act Provisions Will Promote Service Integration, Quality Enhancement and Improved Access for Those with Behavioral Health Care Needs Overall, the health care system has been A substantial number of uninsured adults with mental health needs shifting toward a focus on value and will gain coverage under health reform. accountability. The Patient Protection and Affordable Care Act (ACA)79 furthers these Chart 10: Simulated Change in Coverage After Reform Among Adults with Probable efforts by promoting new care delivery Depression or Serious Psychological Distress models and creating new imperatives for providers to better integrate care. These 15.0% 36.7% Uninsured ACA reforms, in addition to coverage Uninsured expansion, and the previously enacted 49.3% mental health parity law should facilitate Private Insurance 39.2% the integration of behavioral health care Private Insurance into the broader care continuum. While Medicaid 12.8% 24.5% Medicaid many of the ACA delivery system reforms apply to Medicare and Medicaid, private Medicare 11.2% 11.2% Medicare insurers often adopt similar reforms once Baseline Post-Reform tested and found to be effective. First, the ACA supports emerging Note: Based on data for adults ages 18-64 in the 2004-2006 Medical Expenditure Panel Surveys. Source: Garfield, R., et al. (2011). The Impact of National Health Care Reform on Adults With Severe Mental Disorders. models of care delivery—specifically American Journal of Psychiatry, 168(5): 486-494. accountable care organizations (ACOs) and patient-centered medical homes—that aim Second, the ACA creates new incen- Third, the ACA sets new standards for to coordinate and manage the full spec- tives for providers to better manage quality of behavioral health care. The law trum of health care needs of an individual. patients’ transitions among settings and establishes new quality measures focused ACOs join physicians, hospitals and other providers of care and the community. on mental health care to be used in a providers to manage and be held account- The Hospital Readmissions Reduction psychiatric hospital public reporting pro- able for the quality and costs of care for Program lowers Medicare payment to gram in Medicare. Beginning with rate their patients. While ACOs are already hospitals with greater than expected year 2014, psychiatric hospitals that do being tested by private payers, the ACA readmissions. In the initial years, the not submit their data will be subject to a adds the model to Medicare, giving partici- program includes measures of all-cause 2 percent payment penalty.84 The ACA pating providers an opportunity to share in readmissions for heart failure, heart attack also establishes a Psychiatric Hospital cost savings if they meet quality goals.80 and pneumonia.82 Given the role that Value-based Purchasing pilot program in In the Medicaid program, the ACA behavioral health needs play in compli- Medicare that will test the use of incen- creates a health home program to pro- ance with care regimens and care seeking tive payments for hospitals that meet mote integrated care for beneficiaries with behaviors, and the greater likelihood certain performance standards.85 Finally, chronic ailments, including behavioral of readmission among patients with a the ACA should help improve access to health conditions. Beneficiaries with a comorbid behavioral health condition, behavioral health services by expanding serious and persistent mental illness, or identifying and addressing behavioral insurance coverage for all Americans86 with a mental health or substance abuse health needs pre-discharge will be crucial and supporting workforce87 develop- disorder and a comorbid chronic medical for hospitals looking to reduce their read- ment grants and other efforts to expand condition, are eligible to participate in the mission rates. the behavioral health care workforce. In health home program. Each health home Likewise, the ACA encourages the use addition to the ACA changes, the Mental will include a team of physicians and other of bundled payment rates across acute Health Parity and Addiction Equity Act of providers, including behavioral health and post-acute providers for specified 2008 also improves coverage by requiring care professionals. In addition to medical episodes of care in both Medicare and health insurers to apply treatment limita- services, the team will deliver comprehen- Medicaid.83 By promoting coordination tions, enrollee financial responsibility sive care management, care coordination, across these providers, this program also requirements, and in-network versus out- health promotion and other patient and could help improve care transitions for of-network benefits equally to behavioral family support.81 patients with behavioral health needs. health and physical health care.88 10 TRENDWATCH Conclusion Policy Questions As providers take on shared accountability for health care across the continuum, they should not overlook patients’ behav- •  ow can policymakers further promote integration of behavioral and physical H ioral health care needs. Behavioral health health care? disorders are prevalent among U.S. adults, and the consequences of not addressing •  ill the behavioral health provider workforce be adequate to accommodate the W these conditions in a coordinated fashion expected influx of new patients following coverage expansions in 2014? are poorer physical and mental health •  ow will the distribution of behavioral health financing change under health H outcomes and higher health care costs. reform? Will public payers continue to account for the majority of spending? Health care organizations and provid- •  ow will delivery system reforms account for the unique needs of behavioral H ers that can effectively integrate care across health patients? And how can they be leveraged to spur improved integration treatment settings as well as between the of physical and behavioral health care? behavioral and physical health care systems should realize gains in quality and out- comes, and reduced treatment costs. Endnotes 1 K  essler, R.C., et al. (2005). Prevalence, Severity and Comorbidity of 12-Month 18 Russell, L. (October 2010). Mental Health Care Services in Primary Care Tackling the DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Issues in the Context of Health Care Reform. Washington, DC: Center for American Psychiatry, 62, 617-627. Progress. 2  gency for Healthcare Research and Quality. (2009). Healthcare Cost and Utilization A 19  ogg Foundation for Mental Health/Methodist Healthcare Ministries. (March 2011). H Project (HCUP) Nationwide Inpatient Sample (NIS), 2009. Rockville, MD. Crisis Point: Mental Health Workforce Shortages in Texas. 3  eighted national estimates from HCUP Nationwide Inpatient Sample (NIS), 2009, W http://www.hogg.utexas.edu/uploads/documents/Mental_Health_Crisis_final_032111.pdf. Agency for Healthcare Research and Quality (AHRQ), based on data collected by 20  gency for Healthcare Research and Quality. (September 2009). Mental Health A individual States and provided to AHRQ by the States. Total number of weighted Research Findings. Rockville, MD. discharges in the U.S. based on HCUP NIS = 39,434,956. 21  ttp://meps.ahrq.gov/mepsweb/data_files/publications/st331/stat331.pdf; and Russell, h 4 U.S. Department of Health and Human Services. (1999). Mental Health: A Report L. (October 2010). Mental Health Care Services in Primary Care Tackling the Issues in of the Surgeon General. Rockville, MD: Department of Health and Human Services, the Context of Health Care Reform. Washington, DC: Center for American Progress. Substance Abuse and Mental Health Services Administration, Center for Mental Health 22 Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health  Services, National Institutes of Health, National Institute of Mental Health. Financing in the United States: A Primer. Washington, DC. 5  merican Society of Addiction Medicine. (April 2011). Public Policy Statement: A 23 Druss, B.G., and Walker, E.R. (February 2011). Mental Disorders and Medical  Definition of Addiction. http://www.asam.org/DefinitionofAddiction-LongVersion.html. Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood 6  essler, R.C., et al. (2005). Lifetime Prevalence and Age-of-Onset Distributions of K Johnson Foundation. DSM-IV Disorders in the National Cormorbidity Survey Replication. Archives of General 24 Carney, C.P., and Jones, L.E. (2006). Medical Comorbidity in Women and Men with Psychiatry, 62, 593-602. Bipolar Disorders: A Population-based Controlled Study. Psychosomatic Medicine, 68, 7 The Alliance for Health Reform. Covering Health Issues Sixth Edition, Chapter 11: 684-691. Mental Health and Substance Abuse. 25 New York State Health Foundation. (April 2011). Grant Outcomes Report: Improving 8  essler, R.C., et al. (1994). 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Health Affairs, 25(3), 707-19. for Noncompliance with Medical Treatment: Meta-analysis of the Effects of Anxiety and 11 Ireys, H., et al. (September 2010). Medicaid Beneficiaries Using Mental Health or Depression on Patient Adherence. Archives of Internal Medicine, 160, 2101-2107. Substance Abuse Services in Fee-for-Service Plans in 13 States, 2003. Psychiatric 29 Carney, C.P., and Jones, L.E. (2006). Medical Comorbidity in Women and Men with Services, 61(9), 871-877. Bipolar Disorders: A Population-based Controlled Study. Psychosomatic Medicine, 12 Russell, L. (October 2010). Mental Health Care Services in Primary Care Tackling 68: 684-691. the Issues in the Context of Health Care Reform. Washington, DC: Center for 30 Melek, S., and Norris, D. (2008). Chronic Conditions and Comorbid Psychological American Progress. Disorders. Cited in: Druss, B.G., and Walker, E.R. (February 2011). Mental 13  merican Hospital Association. (February 2007). 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