AMERICAN HOSPITAL ASSOCIATION MAY 2019 TRENDWATCH Increasing Access to Behavioral Health Care Advances Value for Patients, Providers and Communities Hospitals’ roles in their communities This TrendWatch shares ways Key Messages: as providers of emergency, inpatient that hospitals and health systems • Behavioral health is essential and outpatient care, as well as their are identifying and addressing to individual and population relationships with community-based behavioral health care needs in their health. organizations, have made them communities, the strategies they • Timely access to affordable central to addressing community- are using to increase access and the services remains a challenge wide behavioral health care needs. barriers to broader progress. The for many Americans. Many are designing and implementing report explores how unmet behavioral innovative strategies that support health care needs among adults have • Increasing access to behavioral efforts to improve care, promote increased demands on hospitals health services can improve population health and lower costs of and health systems across the outcomes and lower costs. health care. continuum of care. The TrendWatch • Hospitals and health systems are implementing innovative strategies to increase access Despite the need for behavioral health services, access is still limited. to behavioral health care in their communities. Chart 1: Behavioral Health Disorders in U.S. Adults and Access to • However, policymakers need Services, 2016 (in millions) to address barriers, such as 44.7M inadequate reimbursement and workforce shortages, and fully implement the mental health parity law to support replication 57% of successful health system strategies. 19.9M Behavioral health disorders affect nearly one in five Americans and have community-wide impacts.1 Despite 10.4M 89% 43% 8.2M the prevalence of these disorders, 36% 52% behavioral health care needs often 64% go unmet. In 2016, only 43 percent 11% 48% of the 44.7 million adults with any Any Mental Serious Substance Use Co-occuring mental health disorder received Illness Mental Illness Disorders treatment, and less than 11 percent of ■ % Adults Receiving Services ■ % Adults Not Receiving Services adults with a substance use disorder Source: Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey and Drug Use and Health (HHS Publication No. received treatment (see Chart 1).2 SMA 17-5044, NSDUH Series H-52). www.aha.org 1 TRENDWATCH also shares the findings from four disorders seeking care in hospitals case studies, showcasing Cambridge that have been designed for short- Definition: Behavioral Health Health Alliance (Somerville, Mass.), stay medical care.8 To address these Disorders3 Lee Health (Fort Myers, Fla.), issues, hospitals and health systems In this TrendWatch, behavioral Mission Health (Asheville, N.C.) and are examining ways to increase health disorders include both PeaceHealth (Friday Harbor, Wash.) access to care in more appropriate mental illness and substance use and how they are increasing access to settings through forging community disorders. Mental illnesses are care and advancing value for patients, partnerships, integrating physical and specific, diagnosable disorders providers and communities. behavioral health care in primary care characterized by intense settings, and re-examining the role of alterations in thinking, mood and/ Hospitals and Health Systems EDs. or behavior over time. Substance Address Behavioral Health use disorders are conditions Care Needs Across the Care Community Partnerships: Hospitals resulting from the inappropriate Continuum and health systems are developing use of alcohol or drugs, including new and strengthening current medications. Persons with With one in every five American community-based partnerships to behavioral health care needs may adults living with a behavioral health prevent and address behavioral health suffer from either or both types disorder, there is widespread need issues outside of the four walls of of conditions as well as physical for behavioral health services.4 a hospital or physician’s office. For co-morbidities. Additionally, many people with instance, hospitals and health systems behavioral health disorders have are partnering with law enforcement, co-occurring physical conditions that community mental health clinics providing an always-accessible site further complicate care, negatively (CMHCs), community behavioral of care for individuals with behavioral impact outcomes and increase overall health clinics (CBHCs), federally health care needs. However, these costs. The prevalence of behavioral qualified health centers (FQHCs), facilities often are not well suited to health issues and their interactions academic medical centers, churches, provide comprehensive and ongoing with – and impact on – physical health community advocacy groups and behavioral health care. Specifically, have created an increasing demand on other social service agencies to EDs may be limited by the lack of hospitals and health systems across connect people with behavioral health psychiatrists, high demand and the continuum of care.5 disorders with care and resources. busyness. Patients present with behavioral Primary Care: Primary care settings Approximately one in eight ED health care needs in almost every are a “gateway” to care for many visits involves behavioral health setting across the continuum, individuals with behavioral health conditions.10 The rate of behavioral including emergency departments care needs.9 Many hospitals and health-related ED visits increased 44.1 (EDs), acute inpatient units (such as health systems are coordinating percent between 2006 and 2014, oncology, cardiology and orthopedics), or integrating behavioral health with the number of visits related to specialized psychiatric and substance assessments and services into suicidal ideation growing the most.11 use disorder, geriatric, eating disorder primary care, as well as supporting In communities where access to and medical/psychiatric disorder units, behavioral health training and behavioral health care is limited, EDs and physician offices and outpatient education for primary care providers. are often where patients await the clinics. Additionally, one out of four Health systems are using patient- availability of an appropriate inpatient patients admitted to a general hospital centered medical homes (PCMHs), psychiatric bed, sometimes for many also has a behavioral health diagnosis.6 case managers, behavioral health hours or even days.12 As a result, professionals and other clinicians hospitals and health systems are Hospitals and health systems are also in primary care settings to provide focusing on how to reduce these often the “safety nets” for behavioral assessments, consultations and “boarding” stays and connecting health care – especially when treatment. these patients with appropriate, timely community-based services are in short care. supply.7 At times, this can lead to EDs: EDs are a major stop-gap in the patients with chronic behavioral health behavioral health delivery system, 2 www.aha.org INCREASING ACCESS TO BEHAVIORAL HEALTH CARE Patient and Community Impacts conditions than for those without a • Approximately 30 percent of co-occurring mental health diagnosis.21 Behavioral health disorders have adults with a medical condition In Medicaid, the cost of care is two significant impacts on individual also have a behavioral health to three times higher for beneficiaries and community health, utilization disorder. with co-occurring behavioral health of services and costs. People with • Close to 70 percent of and chronic conditions.22 Patients behavioral health disorders are more behavioral health patients have with behavioral health disorders also likely to have other chronic medical a medical co-morbidity.13 have significantly greater spending conditions such as asthma, diabetes, for general medical conditions than heart disease, high blood pressure patients without a behavioral health and stroke than those without a Impact of Co-Morbidities: Care disorder.23 mental illness.14 In addition, those for people with behavioral health with physical health conditions (e.g., disorders is often complicated by the Disparities: Studies have asthma or diabetes) also report higher presence of comorbid and chronic demonstrated disparities in behavioral rates of substance use disorders and conditions. For instance, 15 percent health care access for various “serious psychological distress.”15 As to 30 percent of people with diabetes populations, including racial and a result, those with behavioral health also have depression, often resulting ethnic minority groups, the LGBTQ disorders – and co-occurring physical in worse outcomes such as increased community, military service members health conditions – are likely to use risk of other conditions (e.g., coronary and veterans, and rural residents. more services, such as hospital and artery disease and microvascular These disparities continue to result in ED care, which increases costs.16 complications).17,18 Among Medicare, poorer health outcomes and increased Medicaid and dually eligible costs across the health care system.24 While this TrendWatch primarily populations, more than 50 percent of focuses on behavioral health care adults treated for a behavioral health Disparities in behavioral health needs among adults generally, there disorder had four or more comorbid care access are well-documented are unique population-specific needs. physical conditions.19 Many mental for racial and ethnic minorities. For For instance, all of the interviewed health diagnoses also are associated example, one study found that 48 health systems highlighted outreach with a reduction in life expectancy by percent of white adults with mental and treatment for children and 7 to 24 years compared to individuals illness received services in 2015; adolescents as a focus of current without such disorders – greater than however, only 31 percent of African- and future efforts to improve access the estimated 8 to 10 years of reduced American and Hispanic adults with to behavioral health services. Other life expectancy from heavy smoking.20 mental illness and only 22 percent of populations with unique needs include Asian-American adults with mental geriatric, veteran and LGBTQ groups Costs are also 75 percent higher for illness received services that year.25 as well as rural populations. people diagnosed with both behavioral Additionally, American Indians and health and other common chronic Alaska Natives have low rates of Increased number of co-occurring physical and behavioral health conditions drives health spending. Chart 2: Impact of Co-occurring Behavioral Health and Physical Health Disorders on Health Spending Average Annual Spending, 2010-2013 (in billions) BH Disorder One Two Three Four or More Only Co-occurring Co-occurring Co-occurring Co-occurring Condition Conditions Conditions Conditions Depression $5.49B $13.79B $18.85B $34.31B $354.02B All BH Disorders $12.13B $27.44B $39.56B $52.61B $540.62B Source: Thorpe, K. Jain, S., & Joski, P (2017). Prevalence and Spending Associated with Patients Who Have A Behavioral Health Disorder and Other Conditions. Health Affairs, 36(1), . 124-132, doi: 10.1377/hlthaff.2016.0875. www.aha.org 3 TRENDWATCH use of mental health services and behavioral health conditions seek it, Economic Impacts elevated suicide rates.26 There are but only slightly more than half who also racial and ethnic disparities in receive treatment receive adequate In 2013, expenditures for treatment of the treatment of substance use care.33 mental health disorders reached $201 disorders. Although studies have billion, surpassing spending for heart found similar rates of access to • LGBTQ Individuals: While LGBTQ conditions by $54 billion and cancer substance use treatment among individuals have higher rates of by $79 billion.38 According to recent populations, there are differences in behavioral health service use than estimates, spending for behavioral the course of care and completion their heterosexual counterparts, health treatments is expected to total of treatment.27,28 For example, one they are more likely to attempt $280.5 billion in 2020, an increase study found that African-American and or commit suicide, particularly from $171.7 billion in 2009.39 These Hispanic individuals were less likely during adolescence.34,35,36 LGBTQ projected expenditures reflect the to complete substance use disorder individuals may also face stigma or need for institutional services and the treatment. discrimination in accessing care. high rate of growth in spending on behavioral health disorders.40 This disparity was largely attributable • Rural Populations: While the to socioeconomic factors, prevalence of behavioral health Behavioral health disorders also have underscoring the complex nature of conditions is generally similar in broad indirect economic impacts behavioral health disorders and access rural and urban populations, rural on households and communities to care.29 Numerous factors contribute populations are less likely to receive including reduced productivity, to racial and ethnic disparities in any or an insufficient level of poorer educational outcomes and behavioral health care access and treatment due to lack of access and legal issues. Serious mental illness treatment. These can include difficulty less anonymity for those seeking (mental health conditions that cause finding and paying for care because of care in small communities.37 serious functional impairment such lack of insurance or underinsurance, as major depression, schizophrenia lack of culturally competent providers, and bipolar disorder) costs the United Spending for behavioral health and inadequate availability and support States $193.2 billion in lost earnings treatments is expected to of safety net providers.30 However, per year.41,42 More than one-third of increase. other factors have to do with long- students ages 14 to 21 who have standing and cultural differences a mental health condition and are Chart 3: Estimated spending for toward behavioral health conditions served by special education drop behavioral health treatments. including issues with stigma about out – the highest dropout rate of mental illness or distrust of the health $280.5B any disability group.43 Inadequate care system.31 access to mental health services also contributes to the overcrowding of Other examples of populations facing jails and state prisons.44 Approximately disparities in behavioral health access 16 percent of those in prison have include: $171.7B a mental illness or substance use disorder, and repeated incarceration is • Military Service Members and common for those who lack access to Veterans: The suicide rate for behavioral health services.45,46,47 veterans and military service members is higher than that for Increasing Access to Advance the general population; 20 percent Value of all suicides are by veterans.32 Additionally, the Substance Abuse Increased access to behavioral health and Mental Health Services services is associated with improved 2009 2020 Administration (SAMHSA) health outcomes and quality as Substance Abuse and Mental Health Services Administration estimates that approximately (SAMHSA). (2014). Projections of National Expenditures for well as lower overall health costs. 50 percent of returning service Treatment of Mental and Substance Use Disorders, 2010–2020. Research demonstrates that models HHS Publication No. SMA-14-4883. https://store.samhsa.gov/ members who need treatment for shin/content/SMA14-4883/SMA14-4883.pdf that incorporate behavioral health 4 www.aha.org INCREASING ACCESS TO BEHAVIORAL HEALTH CARE An analysis of more than 20 million people with commercial insurance, Medicare and Medicaid found that medical and behavioral health integration could save $26-$48 billion annually. into other medical settings through Reducing Utilization of Acute than as-needed consultation – can collaborative or integrated care Services: reduce LOS and was also was models are associated with positive associated with decreased time to impacts on behavioral and physical • Yale New Haven Psychiatric consultation.54 health outcomes as well as reductions Hospital has developed a in use of acute services. multidisciplinary inpatient Reducing Costs/ROI: Behavioral Intervention Team (BIT) Improving Quality and Outcomes: model, which is associated with • A recent 10-year study of a significant reduction of length Intermountain Healthcare’s • A 2012 analysis of nearly 80 of stay (LOS) and utilization of integrated team-based care research trials found that patients constant companions. Findings practices demonstrated key with depression and anxiety had also demonstrated a return on improvements in screenings, significantly better outcomes under investment (ROI) of 1.7:1 even quality, utilization and cost when a collaborative care model than with additional personnel costs.51 behavioral health services were those receiving standard primary integrated into primary care care. There was also evidence of • Robert Young Center for settings. Based on Intermountain benefit in secondary outcomes Community Mental Health, a Healthcare’s experiences, it is including medication use, mental hospital-based community mental estimated that the United States health, quality of life and patient health center and affiliate of would save at least $4 billion a satisfaction.48 UnityPoint Health-Trinity in Rock year in health care costs if the Island, Ill., implemented PCMHs model were used nationally.57 • A study of collaborative care in their hospital. The Center was interventions for patients with able to reduce ED visits by 46 • A study on the Improving Mood – opioid or alcohol use disorders percent, psychiatric admissions by Promoting Access to Collaborative demonstrated significant increases 50 percent, and medical admissions Treatment (IMPACT) model, a in the likelihood of receiving for patients with behavioral health team-based collaborative treatment treatment and abstaining from diagnoses by nearly 17 percent.52 model used in primary care alcohol and drugs. At six months, settings, found that elderly patients 39.0 percent of the intervention • Cherokee Health Systems in with depression receiving the group received treatment compared Knoxville, Tenn., co-located intervention had approximately 10 with 16.8 percent in the usual care behavioral health professionals in percent lower total health care group. Additionally, 32.8 percent of primary care settings to enable real- costs than those receiving usual the intervention group reported that time consultations. These include care.58 they had abstained from opioids behavioral health screenings and or alcohol in the previous month tracking high-need patients for • An April 2016 World Health compared with 22.3 percent of treatment adherence. As a result, Organization-led study estimated a those in the usual care group.49 Cherokee Health Systems reduced 4:1 ROI from improved health and ED visits by 68 percent, hospital ability to work if the United States • A non-pharmacologic delirium care by 37 percent and overall increased spending on treatment prevention program used in a costs by 22 percent.53 for depression and anxiety hospital demonstrated 30 percent disorders by approximately $10 lower incidence of delirium and a • Recent studies also have billion per year for 15 years.59 projected $16.5 million per year demonstrated that proactive reduction in inpatient costs per psychiatric involvement in • A study examining collaborative 30,000 admissions.50 the hospital setting – ongoing care models found that patients psychiatrist participation with with diabetes and depression had general medical teams rather 115 fewer days of depression per www.aha.org 5 TRENDWATCH year. They also estimated savings suggest that many mental health and primary care integration models of $2.9 million annually in lower conditions develop early, with half of for younger patients to increase total health costs per 100,000 all mental health conditions beginning access in pediatrics. Their interest diabetic patients.60 by age 14, and three-quarters of in addressing issues in the youth mental health conditions developing population is supported by the state’s • Research on collaborative care by age 24.62 Efforts to improve focus on care for this population models for patients suffering from screenings for behavioral health through the Medicaid program. panic disorder found reductions disorders can help promote earlier Under the Medicaid program, states in the number of days of reported assistance and treatment. must cover the Early and Periodic anxiety each year and projected Screening, Diagnostic and Treatment savings of $1.7 million in reduced The Cambridge Health Alliance (CHA) (EPSDT) benefit, which includes health costs annually per 100,000 conducts annual screenings during screening and treatment for behavioral primary care patients.61 primary care visits to identify high- health issues. prevalence conditions such as anxiety, Strategies for Improving depression and alcohol/substance Finally, some health systems are Behavioral Health Access use disorder. Brief interventions can using community-wide assessments be provided for low-acuity needs, to better identify behavioral health Hospitals and health systems are and referrals are made for those with care needs at a population level. deploying a broad range of efforts to greater needs to ensure appropriate For example, Mission Health uses increase access to behavioral health connections with behavioral community health needs assessments services in the communities they health resources. At PeaceHealth, (CHNAs), a strategic-planning process serve (see Chart 4). Case studies primary care physicians screen for required by the Affordable Care Act with profiled organizations identify a behavioral health care needs and can (ACA), to identify partners and to number of key strategies and provide immediately refer to social workers design behavioral health programs. details on these efforts. onsite to conduct further assessment if needed. Strategy 2. Coordination and Strategy 1. Identification, Prevention Integration: The health systems and Screening: Identification and Interviewed health systems also profiled in this report also cited the screening are foundational elements mentioned the need to encourage need to integrate behavioral health of improving access to behavioral more screening for behavioral health services into primary care. For health services – and can support early issues in child and adolescent instance, CHA’s integration efforts intervention efforts for children and populations. CHA is considering equip primary care teams to provide adolescents in particular. Estimates greater implementation of screening basic care such as brief behavioral Hospitals and health systems use multiple strategies for increasing behavioral health services access. Chart 4: Strategies Identified from Health System Case Studies to Increase Access to Behavioral Health Services Hospital or Health System Identification, Coordination Community Workforce Infrastructure De-stigmatizing Prevention and and Integration Partnerships Development Development Behavioral Screening Health 6 www.aha.org INCREASING ACCESS TO BEHAVIORAL HEALTH CARE members dedicated to patient follow- increase access. In Florida, Lee Perspectives on Identification, up, scheduling and coordination. Health opened a triage center Screening, and Referral from Many hospitals have learned that supported by grant funding, drawing the ED such integrated and expanded teams law enforcement, local charitable Lee Health in Fort Myers, Fla., improve patient compliance and organizations and other providers observed that its ED was often improve outcomes. together to provide jail diversion the general point of entry to care services for those with behavioral for patients with behavioral health Hospitalization represents an health conditions. The center started conditions – and often co-morbid unrecognized opportunity to optimize with 18 beds and has expanded to 58 medical conditions as well. The both mental and physical health beds; it offers social work and case system now has a consultation outcomes. At Cedars-Sinai Medical management services, as well as team in place that conducts a full Center in Los Angeles, 95 percent medication management and nutritional evaluation of a patient’s needs of patients admitted to the hospital supports such as a food pantry. in the ED. Providers care for all receive screening and evaluation for identified medical issues – and depression. Massachusetts General patients with behavioral health Hospital in Boston has implemented Perspectives on Partnering conditions that can be treated a collaborative care model improving to Create a Telepsychiatry in an outpatient setting are cancer care for patients with serious Program from PeaceHealth referred to community partners. mental illness. In their efforts to bring PeaceHealth’s Peace Island Lee Health has also developed a the care to the patient, rather than Medical Center (PHPIMC) is partnership with a local inpatient the other way around, Northwell located on San Juan Island in psychiatric facility that helps Health embedded two hospitalists in Washington State. Patients on address acute psychiatric needs. the neighboring inpatient psychiatric the island previously had limited hospital; when patients need medical access to psychiatric services, treatment, they can receive it without and going to the mainland health interventions. Early outcomes interrupting their behavioral health required a ferry ride and could indicate that patients with acute treatment. As a result, patients who take all day. To remedy this, depression in integrated models are used to end up in their ED don’t PHPIMC partnered with the receiving more follow-up care and anymore, and their 30-day readmission University of Washington to offer have better depression scores than rate has fallen by 50 percent. telepsychiatry services to island patients in usual care settings. CHA residents. Telepsychiatry enables has observed a significant change in Strategy 3. Community patients to access behavioral primary care provider knowledge and Partnerships: Hospitals and health specialists remotely confidence to support patients with health systems are partnering with through video conferencing, behavioral health disorders. CHA also stakeholders in their communities, allowing regular access to health has added behavioral health care to its including other hospitals and care providers who are trained PCMHs. academic medical centers, providers to work with patients and local such as CMHCs and FQHCs, clinicians to treat behavioral While there is a focus on integrating community groups and social service health care needs. PHPIMC behavioral health services into organizations. Partnerships help pool received a Health Resources and settings such as primary care or EDs, community resources to expand Services Administration (HRSA) there is also a movement to include access to behavioral health services. telehealth grant to establish the behavioral health care in physical program; now patients on the health care settings beyond primary For instance, PeaceHealth is island have reliable access to care.63 Indeed, CHA and PeaceHealth partnering with an academic medical psychiatrists. described the importance of team center to use telepsychiatry to “Implementing an integration model takes time, but you stick with it and you have to believe it is worth it. It requires planning, but it also requires flexibility. ” – Primary Care Behavioral Health Integration Program Manager at CHA www.aha.org 7 TRENDWATCH that supports care coordination and Profiled organizations also cited Perspectives on Creating patient follow-up. The system also the important role of HIT systems Behavioral Health Urgent Care works with community leaders in facilitating behavioral health Centers from Mission Health and resources, such as pastors assessments and information Mission Health in North Carolina and peer support specialists. Lee exchange. However, while integrating addressed the high demand that Health employs psychiatric liaisons, behavioral health data into electronic behavioral health care needs who often work in primary care and medical records (EMRs) improves placed on their EDs by partnering outpatient specialty clinics and use coordination, updates are often with community groups to build collaborative care models to address complex, expensive and time a behavioral health urgent care the needs of patients with co-morbid intensive. center that provides services 24 behavioral health and physical health hours a day, 7 days a week. The conditions. Strategy 6. De-stigmatizing center includes assessments, Behavioral Health: Hospitals and intake and psychiatric evaluations, Mission Health has focused on health systems have also developed peer support, and pharmacy recruiting new behavioral health strategies to combat the stigma services. The staff also assess providers, as well as addressing often attached to behavioral health physical health needs. Currently, burnout for existing providers by disorders. CHA and PeaceHealth the center serves 200 people implementing a behavioral health found that primary care co-location a month – and it has improved response team (BERT) to address facilitated more immediate care and access to care for individuals behavioral health escalations in conveys that behavioral health is a with behavioral health disorders acute settings and improve safety for core component of a patient’s well- as well as for non-psychiatric providers. being. Profiled organizations also patients seeking care in their EDs. cited the creation of educational and Strategy 5. Infrastructure other resources that are more patient- Development: Interviewees identified friendly, as well as engagement Mission Health worked with the need to develop infrastructure, in anti-stigma campaigns that can community leaders and organizations including physical space, telemedicine include community engagement to open a family justice center, which capabilities and health information discussions or offering more patient- provides wraparound services for technology (HIT) to deliver services friendly venues for “fireside chats” health care and has established a and monitor behavioral health care discussing issues such as loneliness cancer survivorship program to meet needs. Mission Health and Lee among seniors. patients’ psycho-social needs. Mission Health have developed stand-alone Health also helped open a child crisis behavioral health centers to improve Barriers to and Opportunities for facility that provides residential care timely access to care. Primary care Increasing Access for children, including pediatric and integration efforts are also leading psychiatry staff to provide medication. to new uses of space that increase Traditional and longstanding barriers patient access to care. For instance, to behavioral health access – such Strategy 4. Workforce Development: PeaceHealth has private, devoted as lack of coverage and inadequate All profiled organizations highlighted rooms for screening and discussion of reimbursement – remain challenges the importance of strengthening the needs, where clinicians can conduct for hospitals, health systems and workforce to address behavioral health immediate assessments and follow- patients. Legislation, regulations and workforce shortages and provider up with patients. Lee Health has policy trends provide opportunities to burnout, while increasing access increased timely access to behavioral expand services and increase access to behavioral health care. CHA has health specialists through the use and reimbursement for behavioral developed a bachelor’s degree-level of telepsychiatry in community health care. While recent laws are Mental Health Care Partner position behavioral health clinics. either limited in scope and/or are “Our partnership with the University of Washington is important, and they are a reliable and helpful partner. They want this to succeed as much as we do. ” – Senior Administrator at PeaceHealth 8 www.aha.org INCREASING ACCESS TO BEHAVIORAL HEALTH CARE inadequately enforced to fully address may be limited due to high out-of- health care such as coordinating care the need for, and access to, behavioral pocket costs or narrow networks. across providers and settings or for health care, increased focus on Further, coverage for behavioral health non-face-to-face care management strengthening enforcement of these is not required to be included in short- (referrals, case management, etc.). laws and building on their successes term insurance or association health will help address longstanding issues. plans. These low reimbursement rates for behavioral health services also impact Inadequate Coverage: Despite The Medicaid and Medicare access.72 A recent study demonstrated passage of the Mental Health Parity programs also have coverage rules that behavioral health providers are and Addiction Equity Act (MHPAEA) and limitations that may impact still reimbursed less than primary in 2008, access to equal behavioral access to behavioral health services. care providers by approximately health benefits is still a problem for While Medicaid requires coverage 20 percent.73 The reimbursement many insured Americans.64 While of medically necessary behavioral issues reflect the undervaluing of MHPAEA requires health insurers health services, states have some behavioral health services, which and group health plans that cover flexibility in how they define medical often require more evaluation and behavioral health services to necessity, which can create variability time than procedural services.74 In provide the same level of benefits in coverage.70 Further, states may also addition, separate funding streams for mental health and/or substance provide some services as optional and benefit structures for psychiatric use treatment and services that benefits (e.g., rehabilitation, therapy, and substance use disorders they do for medical/surgical care, medication management and peer create barriers and limit integration, it does not require coverage of supports). Coverage of these optional especially in the Medicaid program – behavioral health services.65 In services varies widely among states, the largest payer of behavioral health addition, strict enforcement of these but many are critical to support care – where payment levels and requirements has been lacking, improved health and recovery.71 For models can vary from state to state. although the Department of Health example, treatment in institutions of and Human Services (HHS) released a mental disease (IMDs) is an optional In Medicaid, the IMD exclusion congressionally-mandated action plan service coverage for children and mentioned above has traditionally for enforcement of the law in April adolescents with behavioral health prohibited states from receiving 2018.66 disorders up to 21 years of age – federal matching payments despite their potential to help with for services for adult Medicaid An online survey conducted by the recovery efforts for youth. Medicare beneficiaries ages 21 to 64 receiving National Alliance on Mental Illness also imposes coverage restrictions care in inpatient or residential (NAMI) found that patients seeking on some behavioral health services behavioral health facilities with more mental health care were twice by limiting payments for inpatient than 16 beds. While the recently as likely to be denied care based care in psychiatric hospitals to 190 passed Substance Use-Disorder on “medical necessity” compared days in a beneficiary’s lifetime. This Prevention that Promotes Opioid with other services – 29 percent restricts access to needed care for Recovery and Treatment (SUPPORT) compared with 14 percent.67 Some beneficiaries – especially those with for Patients and Communities Act has plans also continue to use other serious mental illness. loosened this prohibition, it only gives limits on treatments – such as prior state Medicaid programs the option authorization – or requirements for Inadequate Payment: Significant to receive federal matching payments provider admission to networks that under-funding of state mental health for substance use disorder treatment are stricter for behavioral health care agencies historically responsible provided in certain IMDs for up to 30 than medical and surgical care.68 for behavioral health care has been days over a 12-month period – and the a longstanding issue. Traditional, provision expires in 2023.75 The ACA also further expanded fee-for-service payment systems coverage requirements by ensuring also have inadequately reimbursed In addition, the lack of adequate that qualified plans offered in Health providers across the behavioral health funding for community mental health Insurance Marketplaces cover service continuum. Fee-for-service centers – especially following the behavioral health treatments and payment structures rarely reimburse closure of many state psychiatric services.69 Still, access to services for important elements of behavioral hospitals – has left some communities www.aha.org 9 TRENDWATCH without sufficient resources to number of reasons, including upfront based payments, including improving address increased behavioral health cost, maintenance of systems and quality and controlling the total cost care needs.76 These barriers related issues with consent required to share of care across all conditions and to payment contribute to gaps in the records.81 Additionally, laws meant to settings.88 While transitioning to new continuum of care. address fraud, waste and abuse such payment models creates opportunities as the Anti-kickback Statute and the to include or integrate services for Workforce Shortages: There is a law limiting physician self-referral, behavioral health, new alternative significant shortage of mental health also known as the Stark Law, require payment models have not focused on professionals (i.e., federally designated modernization to ensure they do not behavioral health and integration. Mental Health Professional Shortage create barriers to care coordination Areas). An analysis found that and value-based care.82 Access Issues Result in National in 2017, the United States only Challenges fulfilled an estimated 33 percent Stigma: Even with increased of its needs for mental health access to behavioral health services, Current epidemics in behavioral health professionals. 77 Psychiatry shortages patients may still have difficulty are creating increased pressure on are fueled by the gap between newly seeking services or discussing their hospitals and health systems and trained physicians entering psychiatry needs. While public understanding increased demand for behavioral and growing behavioral health care of behavioral health disorders health services. In November 2018, needs.78 In addition, since 1998, and their causes has increased, CMS indicated additional flexibility for the number of Medicare-supported stigma unfortunately remains Medicaid programs to provide short- residency positions has been frozen at prevalent. Certain conditions, such term residential treatment for mental 1996 levels.79 as schizophrenia and substance use illness which will likely promote disorders, are associated with even access to care;86 however, further A recent analysis by HRSA projects higher levels of stigma than other innovations will be necessary to meet that the behavioral health workforce behavioral health conditions.83 the growing need for behavioral health shortage is expected to continue, services. with significant shortages by 2025 of Opportunities to Address psychiatrists, psychologists, family Longstanding Barriers: Recently, Opioid Epidemic: Drug overdose and marriage counselors, and social Congress enacted legislation designed deaths continue to increase in the workers.80 to improve access to behavioral health United States, with 115 Americans services. The 21st Century Cures dying each day from an opioid Care Coordination and Regulatory Act contained provisions to combat overdose on average.87 From 1999 to Impediments: The lack of physical and opioid addiction, strengthen mental 2016, more than 630,000 people died behavioral health integration creates health parity rules, and establish from a drug overdose.88 In 2016, the barriers to comprehensive care. Care grants to increase the mental health number of overdose deaths involving coordination and integration can be care workforce.84 However, many of opioids was five times higher than particularly difficult for substance use the law’s provisions have not been in 1999 – totaling more than 42,000 disorder treatment where separate fully implemented, making its impact people.89 confidentiality standards for medical difficult to assess. Further, the newly records – found in title 42 of the Code passed SUPPORT Act includes Suicide Rate: According to the of Federal Regulations (CFR), Part provisions to increase prevention, Centers for Disease Control and 2 – impede the responsible sharing improve access to treatment of opioid Prevention, suicide is now the 10th of substance use disorder treatment use disorder, promote the use of leading cause of death for Americans. records between providers. As of alternatives to opioids, and encourage Suicide rates have increased by 30 January 2019. Congress has yet to safe prescribing. percent in half of states since 1999, enact legislation aligning 42 CFR Part and nearly 45,000 Americans died by 2 with Health Insurance Portability Last, the physician payment changes suicide in 2016.90,91 While 45 percent and Accountability Act (HIPAA) under the 2015 Medicare Access and of those who died by suicide saw legislation. In addition, the rate of CHIP Reauthorization Act underscored a physician in the 30 days prior to HIT adoption has been low among the growing emphasis on the their death, more than half of cases behavioral health providers for a transition from volume-based to value- involved a person who did not have a 10 www.aha.org INCREASING ACCESS TO BEHAVIORAL HEALTH CARE known mental health condition.92,93 Health System in Detroit, which reduced the rate of suicide among launched the Perfect Depression Care patients receiving behavioral health In response, hospitals and health (PDC) initiative to address depression care from an average of 96 people systems across the country have by focusing on safety, effectiveness, per 100,000 in 1999-2000 to 24 per launched suicide-prevention initiatives. patient-centeredness, timeliness, 100,000 from 2001-2010 — a 75 A leading example is the Henry Ford efficiency and equity.94 The system percent reduction.95 Policy Recommendations to Support Hospitals and Health Systems in Improving Access Hospital and Health Policy Recommendations to Support Strategies System Strategies Identification, Reimburse for Screening and Monitoring of Behavioral Health Conditions: Prevention and Screening and monitoring of behavioral health care needs is foundational to improving population health. Reimbursement for these activities is necessary to support Screening prevention and early identification of needs. Coordination and Include Behavioral Health in Value-based Payment or Total Cost of Care Models: Integration As health systems are asked to take on greater risk for caring for populations through value-based payment models, behavioral health services should be included to encourage integration of care across settings. Eliminate Regulatory Barriers to Care Coordination: Policymakers must address the barriers to coordinated, effective care posed by the restrictions under 42 CFR Part 2, which limits the ability of providers to share important information regarding care and treatment for substance use disorders. Reimburse for Transitional Care: Transitional care that helps patients from inpatient to home and community-based settings is insufficiently reimbursed despite its importance in reducing readmissions and maintaining individuals in community-based settings. Provide Access to the Full Continuum of Services: Congress should eliminate the 190-day limit on care in inpatient psychiatric facilities in Medicare and eliminate or permanently limit the scope of the Medicaid IMD exclusion to ensure access to inpatient and residential behavioral health care when clinically appropriate. Community Support New Provider Partnerships. Policymakers should create compensation Partnerships exceptions to the Stark Law to allow hospitals and physician practices to coordinate and deliver comprehensive care for patients. Current barriers related to the Stark Law are impeding the development of value-based payment models that should drive integration across settings. www.aha.org 11 TRENDWATCH Hospital and Health Policy Recommendations to Support Strategies System Strategies Workforce Encourage Greater Availability of Telehealth/Telepsychiatry: While telehealth Development is a powerful strategy to extend access to services, it is underused due to existing barriers, including lack of reimbursement. Expanding reimbursement for telehealth services can support more comprehensive, integrated care models and address barriers to access. Increase Funding for Training and Development: Policymakers should consider additional funding and/or student loan forgiveness to support training for health professionals at all levels to reduce workforce shortages. Address Variability of Scope of Practice Laws: Policymakers should reduce variability of scope of practice laws and support changes that drive integration of care teams. Infrastructure Provide Funding for Infrastructure Development: Policymakers should consider Development increasing funding and creating more flexible opportunities for hospitals and health systems to invest in physical space, training workforce, and adapting IT systems to better address behavioral health care needs. De-stigmatizing Engage Communities on Behavioral Health Issues: Policymakers should work with Behavioral Health community organizations, patients, and caregivers to identify and expand programs that reduce stigma and combat barriers to care. Funding could support public service campaigns or other programs to reduce stigma associated with obtaining behavioral health services. Conclusion identified and treated – and how and community-based organizations, patients are supported – through to develop policies that address While nearly one in five Americans changes in their EDs, inpatient and the social, structural, and financial is affected by a behavioral health outpatient settings, as well as via barriers that constrain appropriate disorder, many individuals are unable community partnerships. These access and use of behavioral health to access the services they need. strategies improve the overall services. As Dr. Brock Chisholm, the Hospitals and health systems play value of health care and can lead to first Director-General of the World a central role in meeting the health improvements in patient outcomes, Health Organization, famously stated, needs of their communities. Many quality of care, and total costs. To “Without mental health there can be hospitals and health systems are support these efforts, policymakers no true physical health. 96 ” leading innovations in the way should work with hospitals and behavioral health disorders are health systems, as well as patients 12 www.aha.org INCREASING ACCESS TO BEHAVIORAL HEALTH CARE Policy Questions 1. What ways can reimbursement mechanisms for behavioral health services support health system strategies for increasing access? 2. How can policymakers better support hospitals and health systems in addressing the behavioral health care needs of specific populations such as children and adolescents, geriatric, veteran, and racial and ethnic minority communities? 3. How can payment models and care delivery approaches drive behavioral health integration? 4. What types of supports should be made available to hospitals and health systems to help form partnerships that address social determinants of health – and drive value and population health across the system? 5. What are potential policy-related strategies to address stigma? Other AHA Resources on Behavioral Health www.aha.org/behavioralhealth Previous TrendWatches • TrendWatch, Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes, (01/26/2012) • TrendWatch, Community Hospitals: Addressing Behavioral Health Care Needs, (2/20/2007) Guides/Reports • Guide/Report, 7 Steps to Expand the Behavioral Health Capabilities of Your Workforce, (10/4/2016) • Guide (AHA/HRET), Triple Aim Strategies to Improve Behavioral Health Care, (2/29/2016) • Guide (AHA/HRET), Integrating Behavioral Health Across the Continuum of Care, (2/27/2014) • Guide/Report, Behavioral Health Challenges in the General Hospital, (9/13/2007) www.aha.org 13 TRENDWATCH Endnotes 1. Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.pdf 2. Ibid. 3. American Hospital Association (AHA). (2007). TrendWatch: Community Hospitals: Addressing Behavioral Health Care Needs. https://www.aha. org/system/files/2018-02/twfeb2007behavhealth.pdf 4. National Institute of Mental Health (NIMH). (2017). Prevalence of Any Mental Illness (AMI) Among Adults. http://www.nimh.nih.gov/health/ statistics/prevalence/any-mental-illness-ami-among-adults.shtml 5. American Hospital Association (AHA). (2014). Chicago, IL: Health Research & Educational Trust. Integrating Behavioral Health Across the Continuum of Care. http://www.hpoe.org/Reports-HPOE/Behavioral%20health%20FINAL.pdf 6. Helsin KC, et al. (2015). Agency for Healthcare Research and Quality. Hospitalizations Involving Mental and Substance Use Disorders Among Adults 2012. HCUP Statistical Brief #191. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb191-Hospitalization-Mental-Substance-Use- Disorders-2012.pdf 7. American Hospital Association (AHA). (2007). Behavioral Health Challenges in the General Hospital: Practical Help for Hospital Leaders- Recommendations for the Behavioral Health Task Force. https://www.aha.org/system/files/content/00-10/07bhtask-recommendations.pdf 8. Ibid. 9. Substance Abuse and Mental Health Services Administration (SAMHSA). Behavioral Health in Primary Care: Integrating Behavioral Health into Primary Care. https://www.integration.samhsa.gov/integrated-care-models/behavioral-health-in-primary-care 10. Owens P et al. (2010). Agency for Healthcare Research and Quality. Mental Health and Substance Abuse-Related Emergency Department .L., Visits among Adults, 2007 (HCUP Statistical Brief #92). http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf. 11. Moore BJ, et al. (2017). Agency for Healthcare Research and Quality. Trends in Emergency Department Visits, 2006-2014 (HCUP Statistical Brief #227). www.hcup-us.ahrq.gov/reports/statbriefs/sb227-Emergency-Department-Visit-Trends.pdf. 12. American Hospital Association (AHA). (2007). Behavioral Health Challenges in the General Hospital: Practical Help for Hospital Leaders- Recommendations for the Behavioral Health Task Force. https://www.aha.org/system/files/content/00-10/07bhtask-recommendations.pdf 13. Robert Wood Johnson Foundation (RWJF). (2013). Substance Abuse and Mental Health Services Administration (SAMHSA). The Synthesis Project-Mental Disorders and Medical Comorbidity. https://www.integration.samhsa.gov/workforce/mental_disorders_and_medical_ comorbidity.pdf 14. Substance Abuse and Mental Health Services Administration (SAMHSA). (2018). Health Care and Health Systems Integration. https://www. samhsa.gov/health-care-health-systems-integration 15. Ibid. 16. Ibid. 17 Ali S, et al. (2006). The Prevalence of Co-Morbid Depression in Adults with Type 2 Diabetes: A Systematic Review and Meta-Analysis. . Diabetes Med. https://www.ncbi.nlm.nih.gov/pubmed/17054590 18. Anderson RJ, et al. (2001). The Prevalence of Comorbid Depression in Adults with Diabetes: A Meta-Analysis. Diabetes Care. https://www. ncbi.nlm.nih.gov/pubmed/11375373 19. Thorpe, K., et al. (2017). Prevalence and Spending Associated with Patients Who Have A Behavioral Health Disorder and Other Conditions. Health Affairs. https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0875 20. Chesney, E., et al. (2014). Risks of all-cause suicide mortality in mental disorders: a meta-review. World Psychiatry. https://www.ncbi.nlm.nih. gov/pubmed/24890068 21. Substance Abuse and Mental Health Services Administration (SAMHSA). (2018). Health Care and Health Systems Integration. https://www. samhsa.gov/health-care-health-systems-integration 22. Ibid. 23. Thorpe, K., et al. (2017). Prevalence and Spending Associated with Patients Who Have a Behavioral Health Disorder and Other Conditions. Health Affairs. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0875?journalCode=hlthaff 24. National Conference for State Legislature (NCSL). (2018). The Costs and Consequences of Disparities in Behavioral Health Care. http://www. ncsl.org/Portals/1/HTML_LargeReports/DisparitiesBehHealth_Final.htm 25. American Psychiatric Association (APA). (2017). Mental Health Disparities: Diverse Populations-FAQ: Mental Health Facts for Diverse Populations. https://www.psychiatry.org/psychiatrists/cultural-competency/mental-health-disparities 26. American Psychiatric Association (APA). (2017). Mental Health Disparities: American Indians and Alaska Natives. https://www.psychiatry.org/ psychiatrists/cultural-competency/mental-health-disparities 27 Lê Cook, B. and Alegría, M. (2011). Racial-Ethnic Disparities in Substance Abuse Treatment: The Role of Criminal History and Socioeconomic . Status. Psychiatric Services. https://ps.psychiatryonline.org/doi/full/10.1176/ps.62.11.pss6211_1273 28. Mennis, J., and Stahler, G. (2016). Racial and Ethnic Disparities in Outpatient Substance Use Disorder Treatment Episode Completion for Different Substances. Journal Of Substance Abuse Treatment. https://www.sciencedirect.com/science/article/pii/S0740547215003177 29. Saloner B, et al. (2012). Blacks and Hispanics Are Less Likely Than Whites to Complete Addiction Treatment, Largely Due to Socioeconomic Factors. Health Affairs. https://www.healthaffairs.org/doi/10.1377/hlthaff.2011.0983 14 www.aha.org INCREASING ACCESS TO BEHAVIORAL HEALTH CARE 30. American Psychiatric Association (APA). (2017). Mental Health Disparities: Diverse Populations-FAQ: Mental Health Facts for Diverse Populations. https://www.psychiatry.org/psychiatrists/cultural-competency/mental-health-disparities 31. Ibid. 32. Substance Abuse and Mental Health Services Administration (SAMHSA). Critical Issues Facing Veterans and Military Families. https://www. samhsa.gov/veterans-military-families/critical-issues 33. Substance Abuse and Mental Health Services Administration (SAMHSA). Topics-Veterans and Military Families. https://www.samhsa.gov/ veterans-military-families 34. Platt, L., et al. (2017). Patterns of Mental Health Care Utilization Among Sexual Orientation Minority Groups. Journal of Homosexuality. https:// www.ncbi.nlm.nih.gov/pubmed/28346079 35. Haas, A. P et al. (2011). Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and Recommendations. ., Journal of Homosexuality. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662085/ 36. Centers for Disease Control and Prevention (CDC). (2017). Lesbian, Gay, Bisexual, and Transgender Health-LGBT Youth. https://www.cdc.gov/ lgbthealth/youth.htm 37 U. S. Department of Health and Human Services Health Resources and Services Administration (HRSA) Office of Rural Health Policy . (ORHP). (2011). Rural Behavioral Health Programs and Promising Practices. https://www.hrsa.gov/sites/default/files/ruralhealth/pdf/ ruralbehavioralmanual05312011.pdf 38. Roahrig, C. (2016). Mental Disorders Top the List of The Most Costly Conditions In The United States: $201 Billion. https://static1.squarespace. com/static/55f9afdfe4b0f520d4e4ff43/t/574748a007eaa0c831d7d1da/1464289441778/Health+Aff-2016-Roehrig-hlthaff.2015.1659.pdf 39. Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020. HHS Publication No. SMA-14-4883. https://store.samhsa.gov/shin/content/SMA14-4883/SMA14- 4883.pdf 40. Ibid 41. Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Mental and Substance Use Disorders. https://www.samhsa. gov/disorders. 42. Insel, T.R. (2008). Assessing the Economic Costs of Serious Mental Illness. The American Journal of Psychiatry. https://ajp.psychiatryonline. org/doi/abs/10.1176/appi.ajp.2008.08030366?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed 43. U.S. Department of Education. (2014). 35th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act, 2013. http://www2.ed.gov/about/reports/annual/osep/2013/parts-b-c/35th-idea-arc.pdf 44. National Council for Community Behavioral Healthcare. (2010). State Spending on Untreated Mental Illnesses and Substance Use Disorders. http://www.ncdsv.org/images/NCCBH_StateSpendingUntreatedMenIllness_2010.pdf 45. Ibid. 46. Morrissey, J., et. al. (2007). The Role of Medicaid Enrollment and Outpatient Service Use in Jail Recidivism Among Persons with Severe Mental Illness. Psychiatric Services. https://ps.psychiatryonline.org/doi/abs/10.1176/ps.2007.58.6.794 47 Kardish, C. (2013). How Medicaid Expansion Can Lower Prison Costs, Recidivism. Governing. http://www.governing.com/news/headlines/ . How-Medicaid-Expansion-Lowers-Prison-Costs-Recidivism.html 48. Archer J, et al. (2012) Collaborative Care for Depression and Anxiety Problems. Cochrane Database of Systematic Reviews. https://www. cochrane.org/CD006525/DEPRESSN_collaborative-care-for-people-with-depression-and-anxiety 49. Slomski A. (2017). Primary Care Treatment of Substance Use Disorder Reaches More Patients. JAMA. https://jamanetwork.com/journals/jama/ article-abstract/2664454 50. Inouye SK, Bogardus ST, Williams CS, Leo-Summers L, Agostini JV. (2003). The Role of Adherence on the Effectiveness of Nonpharmacologic Interventions Evidence from the Delirium Prevention Trial. Arch Intern. Med. https://jamanetwork.com/journals/jamainternalmedicine/ fullarticle/215416 51. Lee, H. (2017). Yale Behavioral Intervention Team (BIT) Model study: Results from the Two-year Implementation of a Proactive CL Psychiatric Service at the Yale New Haven Hospital. Journal of Psychosomatic Research. https://www.jpsychores.com/article/S0022-3999(17)30651-7/ fulltext 52. American Hospital Association (AHA). (2014). Integrating behavioral health across the continuum of care. Health Research & Educational Trust. http://www.hpoe.org/Reports-HPOE/Behavioral%20health%20FINAL.pdf 53. Ibid. 54. Bui, M., et al. (2018). Hospital Length of Stay with a Proactive Psychiatric Consultation Model in the Medical Intensive Care Unit: A Prospective Cohort Analysis. Psychosomatics. https://www.psychosomaticsjournal.com/article/S0033-3182(18)30413-4/fulltext 55. Melek, S., et al. (2014). Milliman. Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry. http://www. milliman.com/uploadedFiles/insight/2018/Potential-Economic-Impact-Integrated-Healthcare.pdf 56. Reiss-Brennan, B., et al. (2016). Association of Integrated Team-Based Care with Health Care Quality, Utilization, and Cost. JAMA. https:// www.ncbi.nlm.nih.gov/pubmed/27552616 57 Finnegan, J. (2017). Intermountain Cuts Costs, Improves Care by Integrating Mental Health into Primary Care. Fierce Healthcare. https:// . www.fiercehealthcare.com/practices/intermountain-cuts-costs-improves-care-by-integrating-mental-health-into-primary-care www.aha.org 15 TRENDWATCH 58. Jurgen, U., et al. (2008). Long-term Cost Effects of Collaborative Care for Late-life Depression. American Journal of Managed Care. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3810022/ 59. World Health Organization and World Bank Group. (2016). Investing in Treatment for Depression and Anxiety Leads to Four-Fold Return-Press Release. http://www.who.int/news-room/detail/13-04-2016-investing-in-treatment-for-depression-and-anxiety-leads-to-fourfold-return 60. Katon, W., et. al. (2006). Cost-Effectiveness and Net Benefit of Enhanced Treatment of Depression for Older Adults with Diabetes and Depression. Diabetes Care. http://care.diabetesjournals.org/content/29/2/265 61. Katon, W., et. al. (2006). Incremental Cost-Effectiveness of a Collaborative Care Intervention for Panic Disorder. Psychological Medicine. https://www.ncbi.nlm.nih.gov/pubmed/16403243 62. National Alliance on Mental Illness (NAMI). Mental Health Conditions. https://www.nami.org/Learn-More/Mental-Health-Conditions 63. SAMHSA-HRSA Center for Integrated Health Solutions. (2018). Primary Care in Behavioral Health. https://www.integration.samhsa.gov/ integrated-care-models/primary-care-in-behavioral-health 64. Civic Impulse. (2018). H.R. 6983 — 110th Congress: Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. https://www.govtrack.us/congress/bills/110/hr6983 65. Civic Impulse. (2018). H.R. 6983 — 110th Congress: Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. https://www.govtrack.us/congress/bills/110/hr6983 66. U.S. Department of Health and Human Services (HHS). (2018). 21st Century Cure Act: Section 13002 Action Plan for Enhanced Enforcement of Mental Health and Substance Use Disorder Coverage. https://www.hhs.gov/sites/default/files/parity-action-plan-b.pdf 67 National Alliance on Mental Illness (NAMI). (2015). A Long Road Ahead: Achieving True Parity in Mental Health and Substance Use Care. . https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/A-Long-Road-Ahead/2015-ALongRoadAhead.pdf 68. National Alliance on Mental Illness (NAMI). (2015). A Long Road Ahead: Achieving True Parity in Mental Health and Substance Use Care. https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/A-Long-Road-Ahead/2015-ALongRoadAhead.pdf 69. Civic Impulse. (2018). H.R. 3590 — 111th Congress: Patient Protection and Affordable Care Act. https://www.govtrack.us/congress/bills/111/ hr3590 70. Medicaid and CHIP Payment and Access Commission (MACPAC). (2018). Behavioral Health Services Covered Under State Plan Authority. https://www.macpac.gov/subtopic/behavioral-health-services-covered-under-state-plan-authority/ 71. Ibid. 72. Melek, S., et al. (2017). Milliman. Addiction and Mental Health Vs. Physical Health: Analyzing Disparities in Network Use and Provider Reimbursement Rates. http://www.milliman.com/NQTLDisparityAnalysis/ 73. Ibid. 74. Knickman, J., et al. (2016). National Academy of Medicine. Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders. Discussion Paper, Vital Directions for Health and Health Care Series. https://nam.edu/improving-access-to-effective- care-for-people-who-have-mental-health-and-substance-use-disorders-a-vital-direction-for-health-and-health-care/ 75. H.R. 6 — 115th Congress: SUPPORT for Patients and Communities Act. www.GovTrack.us. 2018. https://www.govtrack.us/congress/ ” bills/115/hr6 76. National Alliance on Mental Illness (NAMI). (2011). State Mental Health Cuts: A National Crisis. https://www.nami.org/getattachment/About- NAMI/Publications/Reports/NAMIStateBudgetCrisis2011.pdf 77 Kaiser Family Foundation (KFF). (2017). State Health Data-Mental Health Care Health Professional Shortage Areas (HPSAs). https://www.kff. . org/other/state-indicator/mental-health-care-health-professional-shortage-areas-hpsas/ 78. Merritt Hawkins. (2017). 2017 Review of Physician and Advanced Practitioner Recruiting Incentives https://www.merritthawkins.com/ uploadedFiles/MerrittHawkins/Pdf/2017_Physician_Incentive_Review_Merritt_Hawkins.pdf 79. Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services; Institute of Medicine. (2014). Graduate Medical Education That Meets the Nation’s Health Needs. Washington (DC): National Academies Press (US); GME Financing. https://www.ncbi.nlm.nih.gov/books/NBK248024/ 80. Health Resources and Services Administration (HRSA)/National Center for Health Workforce Analysis; Substance Abuse and Mental Health Services Administration (SAMHSA)/Office of Policy, Planning, and Innovation (OPPI). (2015). National Projections of Supply and Demand for Behavioral Health Practitioners: 2013-2025. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/ behavioral-health2013-2025.pdf 81. Office of the National Coordinator for Health Information Technology. (2017). Behavioral Health Clinical Quality Measures. https://www. healthit.gov/resource/behavioral-health-clinical-quality-measures 82. American Hospital Association. (2017). Legal (Fraud and Abuse) Barriers to Care Transformation and How to Address Them. https://www.aha. org/system/files/content/16/barrierstocare-full.pdf 83. National Academies of Sciences, Engineering, and Medicine. (2016). The National Academies Press. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. http://www.apa.org/monitor/2016/07-08/upfront-destigmatizing. aspx 84. Civic Impulse. (2018). H.R. 6 — 114th Congress: 21st Century Cures Act. https://www.govtrack.us/congress/bills/114/hr6 85. Civic Impulse. (2018). H.R. 2 — 114th Congress: Medicare Access and CHIP Reauthorization Act of 2015. https://www.govtrack.us/congress/ bills/114/hr2 16 www.aha.org INCREASING ACCESS TO BEHAVIORAL HEALTH CARE 86. Centers for Medicare and Medicaid Services (2018). CMS Announces New Medicaid Demonstration Opportunity to Expand Mental Health Treatment Services. https://www.cms.gov/newsroom/press-releases/cms-announces-new-medicaid-demonstration-opportunity-expand- mental-health-treatment-services 87 Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control, Division of Unintentional Injury . Prevention. (2018). Understanding the Epidemic | Drug Overdose | CDC Injury Center. https://www.cdc.gov/drugoverdose/epidemic/index.html 88. Ibid. 89. Ibid. 90. Stone, D. M., et al. (2018). Vital Signs: Trends in State Suicide Rates — United States, 1999–2016 and Circumstances Contributing to Suicide — 27 States, 2015. MMWR. Morbidity and Mortality Weekly Report. https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?s_ cid=mm6722a1_w 91. Hofmann, P B., and Reed, J. (2016). Hospitals and Health Networks. Why Suicide Prevention Is Part of Population Health Strategy. https:// . www.hhnmag.com/articles/7174-why-suicide-prevention-is-part-of-population-health-strategy 92. Ibid. 93. Stone, D. M., et al. (2018). Vital Signs: Trends in State Suicide Rates — United States, 1999–2016 and Circumstances Contributing to Suicide — 27 States, 2015. MMWR. Morbidity and Mortality Weekly Report. https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?s_ cid=mm6722a1_w 94. Hofmann, P B., and Reed, J. (2016). Why Suicide Prevention Is Part of Population Health Strategy. Hospitals and Health Networks. https:// . www.hhnmag.com/articles/7174-why-suicide-prevention-is-part-of-population-health-strategy 95. Ibid. 96. Kolappa, K., et. al. (2013). No Physical Health Without Mental Health: Lessons Unlearned?. Bulletin Of The World Health Organization. http:// www.who.int/bulletin/volumes/91/1/12-115063/en/ TrendWatch, produced by the American Hospital American Hospital Association Association, highlights important trends in the 800 Tenth Street, NW hospital and health care field. Sappho Health Two CityCenter, Suite 400 supplied research and analytic support for this issue. Washington, DC 20001-4956 TrendWatch — May 2019 202.638.1100 Copyright ©2019 by the American Hospital www.aha.org Association. All Rights Reserved www.aha.org 17