Annual visits to a primary care provider can be more than simply a physical check-up. Innovative health practices are starting to also examine patients for underlying mental health problems that often go untreated. And there’s a big payoff. Integrating behavioral health services with primary care often catches conditions before they progress into poorer health and higher costs for patients and purchasers.
This topic was the focus of the December 2016 Healthcare Value column by James H. Landman, director of healthcare finance policy, perspectives and analysis, for HFMA. a Landman discusses the behavioral health challenge facing the nation and explores one solution developed by a healthcare organization in the Northeast. This column carries the discussion further, providing case examples of how health plan members of the Washington, D.C.-based Alliance of Community Health Plans (ACHP) have met the challenge of integrating behavioral health services and primary care to deliver greater value to individuals with mental health conditions.
The Need for Improved Behavioral Health Care
Mental health conditions take many forms, from mild depression to severe disorders that often lead to or coincide with substance abuse. According to government data, about one in five Americans aged 18 or older—or 43.4 million adults—experience a diagnosable mental illness. Yet fewer than half of these individuals receive ongoing treatment in a given year.
Being able to identify and treat mental health conditions early is critical. Delaying or delivering fragmented mental healthcare services is counter to promoting the best outcomes—more likely the result will be that patients’ conditions will deteriorate, given that mental health conditions often worsen if left untreated. A failure to address mental health issues early is even more likely to result in poor outcomes where behavioral health conditions coexist with medical issues, because mental health issues can interfere with a patients’ ability to comply with physicians’ treatment recommendations. Meanwhile, worsening conditions tend to require more complex and costly interventions. b
The various ways to integrate mental and physical health services at an early stage can be viewed on a spectrum. On one end, the mental health provider and primary care clinician are part of the same team, delivering fully integrated care. On the other end, primary care providers may be stationed in a psychiatric specialty setting to monitor patients’ physical health. In a partly integrated system, mental health professionals and primary care clinicians work in the same location and share some systems, such as appointment scheduling or medical records.
Some challenges to integrating services have been identified. For instance, payment for telehealth services (e.g., telephone, electronic communications) in behavioral health is limited. Moreover, fee-for-service payment is often inadequate for fully integrated models because many of the combined activities do not easily fit into a specific billable category or code and billing for behavioral health services is restricted to a specific type of clinician.
Health Plan Strategies
Many health plan members of ACHP have launched integration initiatives that have resulted in reduced emergency department visits and hospital admissions, high cost savings, increased use of screening tools and tracking systems for mental health, adherence to treatment recommendations, and enhanced quality of life.
Such successful initiatives to treat the mind and the body as one are worth a closer look.
Capital District Physicians’ Health Plan (CDPHP). CDPHP in Albany, New York, has moved away from the fee-for-service model and has embedded three behavioral health care managers in seven primary care offices. This fully integrated approach allows the behavioral health staff to provide their services in the same exam room following the physical health examination. CDPHP uses a global payment model with significant bonus opportunity in lieu of fee for service. As a result of its efforts, the health plan has seen a greater ROI and higher patient engagement in treatment regimens, with 83 percent of its patients who experience an intervention avoiding another hospital admission in the following year, and almost half avoiding emergency department visits in a year’s time. These reductions have led to an average annual cost saving of $1,154 per person in the program.
UPMC Health Plan. The approach adopted by Pittsburgh-based UPMC was based, in part, on recognition that behavioral health issues create an increased workload for primary care physicians who already face high demands on their time. Having behavioral health specialists on site is an alternative that allows these physicians to take a greater role in the mental health of their patients. The health plan is exploring “reverse colocation” programs to ease workloads. This effort includes the creation of physical health and wellness programs at 50 mental health sites throughout Pennsylvania. UPMC notes that members focus more on their primary care needs if that care is addressed in their behavioral health provider site. A rigorous, federally funded assessment of this program is underway.
Group Health Cooperative. Seamless workflow management—integrating behavioral screening and treatment into routine practice without disruption—also can pose a challenge. Seattle-based Group Health Cooperative has developed a “close collaboration, partly integrated approach” that includes the colocation of five of its eight specialty behavioral health clinics in medical centers offering primary and specialty care. The group’s electronic health record allows for a coordination of care through an established communications channel and referral protocols.
Although these health plans have adopted different approaches to behavioral and primary health integration, the success of these approaches is in large part due to commonalities:
- The willingness of providers to participate
- The use of performance feedback and quality metrics to encourage partners to take an ownership role in the process
- Transparent data collection that can help clinicians better understand the true behavioral health needs of their patients
Ultimately, community collaboration is crucial to sharing and understanding best practices. Successful effort to integrate health services have set a precedent by improving health outcomes and reducing overall costs for both patients and the overall healthcare system.
Ongoing efforts to reform the system cannot ignore the value in encouraging a healthy mind-body continuum of care.
Ceci Connolly is president and CEO, Alliance of Community Health Plans.
a. Landman, J.H., “The Value of Behavioral Health,” hfm, December 2016.
b. See, for example, American Hospital Association, “Bringing Behavioral Health Into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes,” TrendWatch, January 2012; Gionfriddo, P., Nguyen, T., and Counts, N., “Reducing Health Care Costs Through Early Intervention on Mental Illness,” Health Affairs Blog, Jan. 25, 2016; and Substance Abuse and Mental Health Services Administration, “Health Care and Health Systems Integration,” March 7, 2016.