Living under reform, with its emphasis on better outcomes at lower cost, requires providers to prevent the crises that put people in emergency departments, keep them from falling so sick that they're hospitalized, and see to it that inpatients don't relapse after going home and land back in a hospital bed. A fundamental premise is that coordinated medical care and intense management of chronic illnesses will carry the day.
But that's not necessarily the case. Not unless what goes on inside patients' brains is as high a priority as what's happening to the rest of their bodies. Research on the impact of mental illness and substance abuse on medical outcomes should rein in trustees before they race ahead with performance-based contracts that put their systems at risk. Chances are good that their targets can't be achieved without integrating behavioral health into their plans, experts warn.
"When you're depressed, by nature you become hopeless and you don't think anything is going to help, no matter what you do," says Jennifer Nolan, who heads up a behavioral health enterprise of KentuckyOne Health, a Louisville-based system. "And so, these types of patients are less likely to follow through, whether it's their medication regimen or the follow-up appointment with their doctor." They're among the most often readmitted, typically because they neglected recovery instructions, and they frequent the ED disproportionately to the general population, she says.
This reality means that for clinicians and hospital executives armed with innovative care approaches, their best-laid plans might contain a big hole. Whether it's highly thought-out cardiac care, diabetes vigilance or illness prevention, the physical dimension is only part of the whole story. But until the passage of health care reform, the field generally hasn't recognized the importance of the mind-body linkage.
"I tell people in my best Taylor Swift imitation, don't ever, ever, ever think that behavioral health is as sexy as cardiology. It's not. But it does have an important role in heart disease, and cancer, and all physical diseases," says David Deopere, a vice president at UnityPoint Health–Trinity, a regional health system that serves the Quad Cities area of Illinois and Iowa, and president of its behavioral health provider, the Robert Young Center for Community Mental Health. "We know that it exacerbates all physical disease, and we know physical disease exacerbates behavioral disorders. And we know that it can save money if we treat the behavioral aspect. So, what's the problem? Let's connect the dots."
UnityPoint–Trinity has connected them for a long time. A 2012 study of 30-day readmissions — a Medicare quality metric that carries payment penalties — found that 79 percent of readmitted patients had a behavioral disorder complicating their physical conditions. Clinicians intervened earlier to address those behavioral issues, and the readmission rate fell 8 percent in just two months.
Here's another example, from Intermountain Healthcare in Utah: Depressed patients, when treated in primary care clinics comprising both medical and behavioral professionals, went to the ED 54 percent less than those not using that treatment option. "We've standardized a team care process, and this team includes mental health as a normal part of a routine medical encounter," says Brenda Reiss-Brennan, mental health integration director for primary care clinical programs. Besides better patient care, the approach saved Intermountain's Select Health health plan $700 per year per patient, she says.
Consequences of Separation
These and other examples of the beneficial effects of combined physical-behavioral services should finally put integration on trustees' short lists for consideration, says Benjamin Miller, director of the Office of Integrated Healthcare Research and Policy at the University of Colorado School of Medicine, Denver. But health care as a whole isn't positioned to incorporate such a shift without more basic integration of two different worlds. "Historical fragmentation has divided the mental health system from the physical health system," he says.
The U.S. approach to treating behavioral disorders, first in state-run mental health hospitals dating to the 1800s and shifting to community-based behavioral health centers in the 1960s, grew to encompass its own culture, workforce and funding, all separate from medical care. Health plans in the 1990s increased the separation by "carving out" behavioral coverage from general medical insurance.
"Having two separate systems to take care of patients' medical and behavioral health needs really can result in high cost, lower satisfaction [and] poor outcomes including premature mortality," says Miller, a top researcher in this area and advocate of ending that division. "In spite of what we know, and the indisputable facts, we still have that bifurcation in our training, in how we pay for care and how we deliver care."
Community behavioral health settings are oriented toward specialty mental health, providing intensive treatment for people diagnosed as seriously and persistently mentally ill, or SPMI. These people need to see therapists and take potent medications regularly to avoid going into crisis, which often leads to emergency treatment or admission to medical or psychiatric hospitals. Statistics abound on the health and cost consequences of the SPMI population. For example, people diagnosed with major mental illness comprised 11 percent of total enrollees in California's Medicaid program in 2007, but they accounted for 39 percent of its expenditures.
And that's if they find their way into treatment. Patients referred to mental health or substance abuse care don't make their first appointment 30 to 50 percent of the time, depending on the study. And an estimated two-thirds of people with a behavioral health disorder don't ever get treatment, according to Health & Human Services' Substance Abuse and Mental Health Services Administration.
The consequences? Several recent studies conclude that people with serious mental illness die prematurely — on average, 25 years earlier than the general population — and 60 percent of premature deaths are from underlying chronic diseases such as diabetes that health systems now are supposed to get under control.
As dire as that sounds, it gets worse. People with serious behavioral disorders comprise only about 6 percent of the population. Including illnesses like depression, about one in four Americans 18 and older suffer from a mental illness in any given year, according to the Census Bureau. The vast majority rely solely on their medical doctor, says Miller, who calls primary care a de facto mental health system. But in many cases, it's ill-prepared for the responsibility.
If health systems and payers are to improve care processes and reap measurably better results, the current wisdom is that they have to build and financially support clinically integrated networks of care, particularly through development of physician-managed, patient-centered medical homes. "For anyone considering those types of models, you absolutely have to have someone who can screen for more of the behavioral-psychiatric issues, or you're going to miss the boat and waste your time," Nolan says.
Diabetes and heart disease are challenging enough to manage without the specter of mental illness or substance abuse casting its shadow over the diseases. And it's a long shadow. A 2008 scholarly study says depressed people have a 37 percent greater chance of developing diabetes. And a 2001 study concludes that the reverse is also true: the presence of diabetes doubles the odds of developing depression. Other research has found that people with heart disease are more likely to be depressed than otherwise healthy people, and that depression is linked to angina and heart attacks.
Clearly, medical and behavioral care cannot tackle these mind-body relationships if done separately, Miller says. But the solution involves "not just bringing providers together and having them sit in the same room. It really does require hard work. We need to have culture change within our practices to understand that the main way of delivering health care is about an entirely different and unifying construct, which is health — not mental health, not physical, but just health."
The same unifying approach has to roll through the reimbursement system. "By definition, primary care needs to tackle the comprehensiveness of care," he says. "But by payment, primary care is often not supported, rewarded, encouraged to address that mental health piece."
That may be changing through the Affordable Care Act. "Under the health reform and accountable care arrangements, there's tremendous promise that we're going to finally be able to blend those [medical and behavioral] funding streams together for the benefit of a lot of these patients," says Henry Chung, M.D., a psychiatrist who leads efforts to build holistic approaches to care delivery at Montefiore Medical Center, New York City. "And coincidentally improve value and savings as a result of doing that."
Montefiore began about seven years ago to identify people with simultaneous needs for chronic-illness management and behavioral health services, and to assemble expertise in both areas working together. In its first year as a participant in Medicare's Pioneer ACO program, that mind-body teamwork engineered the highest financial performance among the 32 Pioneer ACOs nationwide, netting it about $14 million of the savings it generated for the Medicare program. The savings represent a 7 percent reduction in its cost of care against a pre-ACO comparison benchmark.
As ACOs gain momentum, Chung says he's noting "suddenly much more interest now than ever before" in the idea of building care processes around the whole person. He recommends such a move before beginning any accountable care initiative.
Intermountain has been integrating behavioral care into its primary care clinics for 15 years, spreading it naturally from practice to practice for most of that time. Lately, however, the economics of the ACA spurred the system to pick up the pace, Reiss-Brennan says. The program started when one medical group appealed for help in managing all the mental health issues it found, especially in the chronic-disease population. A process now known as Mental Health Integration sprang from that plea; it's currently in 90 clinics serving more than 800,000 people.
The Whole Picture
Assessing everything about people at one time — "[putting] the mind and body back together," as Reiss-Brennan puts it — has underscored just how inseparable medical and behavioral dimensions are. Much of the physical self-neglect clinicians see in chronically ill people, once frustrating or puzzling, becomes clearer and more resolvable when behavioral factors are unearthed and addressed.
"We didn't just do depression; we didn't just do diabetes," she says. "We put everything together and said, ‘This is how families walk in, they don't walk in separately as a disease; they walk in with their whole family life.' … Whatever they walk in and tell us, we can understand and be better trained to deal with the complexity of it, and then call in the right person on the team who is needed to help us."
It's a bigger, more illuminating picture. For example, alcohol or drugs may become a way for people to cope with a chronic illness, or even escape from events in life that have compromised their ability to cope. "They appear to be these substance-abusing patients when really, if you go back down through what the issue is, it's because they can't afford their meds anymore — they lost their job." Reiss-Brennan says clinicians have to consider such scenarios "rather than [concluding], ‘Oh, this is a drug-seeking person,' or ‘This is a diabetic person not doing what they're told.' "
Depression based on a recent diagnosis of chronic illness may not be as obvious as a serious mental illness, says Nolan, a therapist and the president and CEO of Our Lady of Peace in Louisville, Ky., one of the largest behavioral health hospitals in the country. But not everybody can sense at a glance the problem lurking inside. Some patients have a few down days and get past it; others can't, whether it's lack of social support, lack of sufficient education to get information about what they're facing, or isolation, she says. "They don't have the energy to follow up with appointments; they don't see the need to get out of this funk, if you will, because they don't think it's going to help."
Because chronically ill people with depression may not be willing to go out of their way to seek behavioral services, they need to have "something convenient, in a one-stop shop where there truly is a team effort — a team of professionals working together to address all the needs of the patient: mind, spirit and body," Nolan says.
Montefiore already had such teams, plus patient care managers mobilized and trained to screen for depression, when the Pioneer ACO program was launched, says Chung, who is chief medical officer of the ACO as well as vice president of a centralized care-management department for the medical center. But trying to convince people with depression to follow their treatment plans was particularly difficult, so care managers received intense training in interviewing approaches to figure out what might motivate patients to take charge of their own lives.
The overall value in integrating health care, then, is addressing the whole situation before it can spin out of control, Miller says. For example, a patient comes in, is obese, not eating right, not managing stress, not exercising, and he's told he's at risk of developing diabetes, but doesn't seem willing to change. "At that moment in time — not after they've been diagnosed with diabetes — is where the power of integration can be seen."
The right team member then can screen for depression and figure out if the lethargy and inactivity are due to underlying depression, or if the patient just needs a bit of motivation to start losing weight and see that it's important to address unhealthy behaviors. "The comorbidity of depression and diabetes is so profound, so why wait until it's already a problem? Let's go ahead and head it off at the pass," Miller urges.
A Plan for Crises
For the subset of any population with more than depression or anxiety, a plan has to be in place to escalate the intensity of behavioral care, bringing in psychiatrists, master's level therapists and referral arrangements with behavioral health facilities. About 80 percent of mental health care at Intermountain is provided by the primary care physician, Reiss-Brennan says, but those doctors in consultation with the right mix of professionals always have to decide whether a person can get well in this setting or whether he has to be stabilized in a more intensive mental health or substance-abuse care environment. Early intervention and prevention are critical in managing the health of a population but a complete continuum of psychiatric care also demands inpatient, partial hospitalization and residential treatment.
Once in such an environment, patients can continue to benefit from integrated mind-body care. At UnityPoint–Trinity's Robert Young Center, a collaboration between its community mental health center and a federally qualified health center covering the Quad Cities recorded significant reductions in ED visits, admissions and costs through coordinated care between medical and behavioral clinicians.
The program included dedicating a Robert Young behavioral therapist for the FQHC's multiple offices, training primary care physicians and dentists to screen for behavioral disorders, and placing a nurse practitioner in a Robert Young drop-in center to offer primary care. "For a lot of these people, this is the first time they ever had a physical," Deopere says.
Central to the approach was a protocol to refer the highest-risk patients for intensive care coordination, almost on a daily basis at first, he says. Assigned to a case manager and nurse, patients were guided to come up with a plan on what to do in moments of medical or mental crisis. That included working through physical diseases to understand their signs and symptoms and how to respond to changes in their condition. "Some things are a crisis that makes you go to the hospital, and for some things you may need to just reach out to your medical doctor or your nurse or your case manager," says Vicki Zude, a clinical nurse manager with the program.
Those steps contributed to a 46 percent reduction in ED visits over the course of the two-year project. Enrolled patients also had a 50 percent drop in psychiatric admissions, a 28 percent decrease in medical admissions and a 92 percent reduction in payments for medical admissions. Meanwhile, a measure of improvement in quality of life increased 131 percent.
John Morrissey is a writer in Mount Prospect, Ill.
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