Opportunities and Issues Related to BH Services in Primary Care

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Iris Knight
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1 Opportunities and Issues Related to BH Services in Primary Care Roger Kathol, MD, CPE President, Cartesian Solutions, Inc. Adjunct Professor, Internal Medicine & Psychiatry, University of Minnesota Clinical Faculty, Hennepin County Medical Center, Minneapolis, MN

2 Current Healthcare Infrastructure Private 1. Purchasers Mind Patients Body Public --Vendors --Organizations --Regulators Med Health Care Outcome Change 2. Fund Distributors MH MH Med 3. Providers --Vendors --Organizations --Regulators Kathol & Gatteau, Healing Body AND Mind, 2007

3 Where Patients Are in the Physical and Mental Health Sectors Physical Health Inpatient Sector Physical Illness Physical Health Outpatient Sector Chronic Illness Health Complexity 80% Mental Conditions 20% Mental Condition Sector ~20% of behavioral health patients ~97% of behavioral health budget ~90% of behavioral health providers Mark TL et al, Health Affairs, 30: , 2011 Mental Condition Treatment in Physical Health Sector ~80% of behavioral health patients ~3% of behavioral health budget ~10% of behavioral health providers

4 Fund Distributors (Health Plans, Government Programs*) 96% to 99% of claims All claims adjudication except mental health Review Payment/Denial Appeals Medical 1% to 4% of claims Mental Condition *inadequate mechanism to pay for case management in either medical or behavioral health sector

5 Barriers in Care Created by Segregated Reimbursement System The Wall Physical Health Mental Condition Inpatient Residential Partial Hospitalization Intensive Outpatient Outpatient Inpatient Rehabilitation Nursing Home Outpatient Home Care

6 Prevalence of Behavioral Conditions in Patients with Chronic Medical Conditions Illness Prevalence % Comorbid Behavioral Disorders All Insured 15% Arthritis 6.6% 36% Asthma 5.9% 35% Cancer 4.3% 37% Diabetes 8.9% 30% CHF 1.3% 40% Migraine 8.2% 43% COPD 8.2% 38% Cartesian Solutions, Inc. --consolidated data

7 Treatment of Patients with Mental Conditions in Current Health Care Environment Treated in Last Year 70% 60% 50% 40% 59% 41% Practitioners for the 41% Receiving Treatment 30% 20% 10% 0% MH Treatment No MH Treatment 23% 16% 12% 8% 7% Medical Practitioner Human Services Psychiatrist Non-Psychiatrist MH Specialist Alternative Health Wang PS, et al. Arch Gen Psychiatry. 2005;62: *Based on National Comorbidity Survey

8 The Quality of Treatment Minimally effective treatment of depression: 48% of those treated in MH setting 13% of those treated in medical setting <5% of all patients based on prevalence Kessler et al, 289: , JAMA, 2003

9 Claims Expenditures for 6,500 Medicaid Patients With and Without Mental Condition Service Use $ $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 2, Physical Health Services Only 5, Any Psych Illness 8, , , , Psychotic Depression Anxiety Substance Use Disorder Physical Health Claims Cost Pharmacy Claims Cost Mental Condition Claims Cost Thomas et al, Psych Serv 56: , 2005

10 Health and Cost Impact of Comorbidity & Integrated Care Patient Groups Annual Cost of Care Illness Prevalence % with Comorbid Annual Cost with Mental Condition* Mental Condition % Increase with Mental Condition All Insured $2,920 15% Arthritis $5, % 36% $10,710 94% Asthma $3, % 35% $10, % Cancer $11, % 37% $18,870 62% Diabetes $5, % 30% $12, % CHF $9, % 40% $17,200 76% Migraine $4, % 43% $10, % COPD $3, % 38% $10, % Cartesian Solutions, Inc. --consolidated health plan claims data *Approximately 10% receive evidence-based mental condition treatment

11 Annual Work Days Lost and Disability Days for Depression and Diabetes Neither Diabetes Depression Both Work Days Lost Odds Ratio (1.0) (1.5) (3.08) (3.25) Disability Bed Days Employed Unemployed Odds Ratio (1.0) (1.63) (4.0) (5.61) Egede, Diabetes Care 27: , 2004

12 Net Annual Cost of Untreated Mental Disorders in the Medical Setting* Population Annual Additional Cost Commercial $83.4-$241.2 B Medicare $49.2-$109.8 B Total $ B *Based on Medstat claims database, Melek & Norris: Chronic conditions and comorbid psychological disorders, Milliman Research Report, July 2008

13 Business Case for Behavioral Health Service Integration (Improves Outcomes and Lowers Cost) Depression and diabetes: 2 months fewer days of depression/year; projected $2.9 million/ year lower total health costs/100,000 diabetic members 1 Panic disorder in PC: 2 months fewer days of anxiety/year; projected $1.7 million/year lower total health costs/100,000 primary care patients 2 Substance use disorders with medical compromise: 14% increase in abstinence; $2,050 lower annual health care cost/patient in integrated program 3 Delirium prevention programs: 30% lower incidence of delirium; projected $16.5 million/year reduction in IP costs/30,000 admissions 4 Unexplained physical complaints: no increase in missed general medical illness or adverse events; 9% to 53% decrease in costs associated with increased healthcare service utilization 5 Case Management/Health Complexity: halved depression prevalence; statistical improvement of quality of life, perceived physical and mental health; 7% reduction in new admissions at 12 months 6 Proactive Psychiatric Consultation: doubled psychiatric involvement with.92 shorter ALOS and 4:1 to 14:1 return on investment 7 Data from 1. Katon et al, Diab Care 29: , 2006; 2. Katon et al, Psychological Med 36: , 2006; 3. Parthasarathy et al, Med Care 41: , 2003; 4. Inouye et al, Arch Int Med 163: , 2003; 5. summary of 8 experimental/control outcome studies; 6. Stiefel et al, Psychoth Psychosom 77:247, 2008; 7. Desan et al, Psychosom 52:513, 2011

14 Message Untreated BH conditions in the medical setting are common and lead to: Persistent medical and BH illness/symptoms Impairment and disability High medical care service use and cost Multiple models of integrated medical-bh service delivery lead to improved total health and lower cost

15 The Problem BH providers don t practice where the majority of their patients/clients are BH providers couldn t make a living even if they wanted to practice in the primary care setting Most BH providers do not see a need for care delivery in the medical setting As a result, BH will fail to add a necessary component to health reform s Triple Aim

16 Health Reform Creates Opportunity Parity Act for BH (MH and SA) services Mandated inclusion of parity-based BH benefits as part of Affordable Care Act (ACA) Move to risk-bearing Accountable Care Organization (ACO) delivery procedures BH benefits as a part of all Exchange products Recognition that BH is an important component of PCMHs

17 Misperceptions about Parity Parity Law insures equivalent payment for providers of patients/clients with BH needs When BH benefits are present in an insurance product, they will be accessible to patients/clients BH services will be as accessible in the medical as BH sector Coordination of medical and BH services will be possible

18 BH Provider Challenge Maintain specialty BH sector services for those with severe and persistent BH disorders Establish access to value-added BH services for the 80% of BH patients/clients that are seen only or primarily in the medical sector Coordinate outcome changing BH service delivery with medical care Bullets 1 to 3 require a reimbursement model that allows sustainable BH service delivery in all settings

19 Why Outcome Changing and Cost Lowering Integrated BH Services Are Unsustainable 1. Separate medical and BH reimbursement 2. Separate medical and BH reimbursement 3. Separate medical and BH reimbursement 4. Consequences of separate payment Perception that medical and BH problems do not interact Separation of BH professionals and practice locations Separate record documentation systems Perpetuation of BH stigma for patients/clients

20 How Separate Reimbursement Leads to Poor Access and Fragmented Care Precludes BH professionals from being in medical provider networks and practice locations Creates medical and BH communication and care coordination barriers Perpetuates UM and payment inequities Prevents incorporation of BH specialist into health reform growth areas, e.g., PCMHs, ACOs, insurance benefit products, accreditation requirements

21 An Integrated System Physical & Behavioral Health Inpatient Rehabilitation Nursing Home Outpatient Home Care Now Possible Membership in medical provider networks with contracting and reimbursement participation Coordinated inpatient and outpatient BH service delivery in the medical settings Full inclusion in PCMHs, ACOs Participation in rewards due to the effective medical-bh service delivery

22 Looking to the Future Conceptual Recognizing that mental health comorbidity drives up costs Value-added integration of medical and mental health services can improve cost and health Must have a clinical outcome and cost savings orientation Operational Development of value-added integrated inpatient and outpatient services Review of payment methodology to create a sustainable integrated financial support system Development of a timetable for change Acculturation of medical and mental health staff/faculty Introduce change systematically

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