How Health Plans Promote Health IT to Improve Behavioral Health Care

Amity E. Quinn, PhD; Sharon Reif, PhD; Brooke Evans, MA, MSW; Timothy B. Creedon, MA; Maureen T. Stewart, PhD; Deborah W. Garnick, ScD; and Constance M. Horgan, ScD

Rapid developments in health information technology (IT) are changing the medical and behavioral health care services landscape. With the goals of improving healthcare quality, cost, efficiency, and access,1-6 health IT is the use of electronic information systems that store, retrieve, share, and enable the use of health data to support and streamline healthcare processes. Health IT innovations include a breadth of technologies, from electronic health records (EHRs) and electronic health tools, such as clinical reminders, patient portals, and mobile health applications, to broader tools that enhance patient activation and enable patient-reported outcomes. Although a large-scale investment in health IT adoption and implementation is taking place across the country, behavioral health has largely been left out of the initial wave of infrastructure development.7
 
Most behavioral health providers were not eligible for federal EHR “Meaningful Use” incentives under the Health Information Technology for Economic and Clinical Health (HITECH) Act.7 Additionally, many remain ineligible for incentives under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which supplements the Meaningful Use program and emphasizes the role of health IT in supporting quality improvement and payment reform.8,9 Although MACRA is Medicare-specific, commercial health plans often take up innovations promulgated through Medicare first. Behavioral health providers generally trail in the adoption, implementation, and use of EHRs.10-13 Moreover, behavioral health providers—particularly specialty addiction treatment organizations—often lack the resources and infrastructure to implement health IT initiatives,11,14-16 resulting in a growing health IT divide between general medical and behavioral health.7,13,17
 
Expanding the reach of health IT in substance use and mental health treatment is likely to be a key facilitator for coordinating and integrating behavioral health and general medical care.16,18,19 The Affordable Care Act of 2010 encourages investment in integrated healthcare systems, such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs), which require continued momentum toward expanding the reach of health IT into behavioral health. A premise of HITECH, and the broader movement toward EHR adoption and implementation, is that EHR systems will facilitate coordination and integration of care.3,16 Accomplishing these goals will likely require incorporating behavioral health into the health IT environment,10 particularly by establishing EHR interoperability and linking clinical data within and between healthcare facilities.16,19 Much remains unclear regarding the overall scope of health IT progress in meeting the goals of improving healthcare quality and decreasing healthcare costs,6,20 and especially, to what extent the investment in health IT will alter or improve how behavioral health care is accessed and delivered, and how it ultimately improves patient outcomes.7,21
 
As healthcare quality stakeholders, and given the large number of providers and enrollees that they reach, health plans have a key role in encouraging health IT to improve healthcare delivery. Health IT research to date has primarily centered on the role of providers and hospitals; the extent to which health plans influence health IT use to facilitate the delivery of care is still relatively unknown. Two studies found a weak relationship between payer mix and health IT adoption in hospitals, noting no significant associations with commercial insurance.22,23 Few, if any, studies directly examine the relationship of health plans and health IT as it pertains to behavioral health.
 
In this analysis, we explored how commercial health plans encourage health IT as a way to support providers, facilitate access to behavioral health care, and increase opportunities for behavioral health assessment and treatment. We examined how these strategies vary by how behavioral health care is managed, as having multiple organizations involved may create complexities in implementing health IT approaches. Behavioral health care management may be contracted to an organization outside of the health plan. Some arrangements may promote a specialized focus on behavioral health, while others may promote connections between behavioral health and medical care. Knowing the role that health plans might play in promoting health IT in behavioral health care is critical for moving health IT implementation efforts forward, as health plans often influence the activities of providers in their networks.
 
METHODS
Data Source

Data are from the third round of a nationally representative telephone survey of commercial health plans regarding administrative and clinical dimensions of alcohol, drug, and mental health services.24 The survey used a panel design with replacement, as described in previous research.24 The primary sampling units were 60 nationally representative market areas.25 The second stage sampled health plans within market areas.
 
Senior health plan executives were asked about their top 3 commercial products—based on enrollment—for the 2010 benefit year. The sample included 438 eligible plans, of which: 389 responded to the administrative module (89% response rate), reporting on 939 products; and 385 responded to the clinical module (88%), reporting on 925 products. Results are reported at the product level and weighted based on responses to the clinical module (n = 8427). Health plans were ineligible if they had fewer than 300 individuals (600 covered lives) enrolled, did not offer behavioral health benefits or comprehensive products, or only offered Medicaid/Medicare products. The study was approved by the Institutional Review Board of Brandeis University.
 
Variables
Health IT variables. Plans were asked about several health IT approaches within the domains of provider support, access to care, and assessment and treatment as examples of how health plans can encourage the use of health IT to improve care delivery. Approaches to support providers included 2 strategies that health plans may use to attract and retain providers in health plan networks (financial support for EHRs and technical assistance for health IT), and whether primary care providers are allowed to bill for e-mail contact with patients specifically regarding behavioral health issues. Approaches to facilitating member access to behavioral health care included offering an online provider directory, online appointment scheduling, online referral system, and provision by the health plan for members to e-mail providers. Approaches to improve behavioral health care delivery addressed both assessment and treatment strategies, and included online self-assessment tools, online personalized responses to questions or problems, and online counseling.
 
Contracting arrangement. Products were categorized by their approach to managing behavioral health services. Four arrangements were identified: 1) products with specialty external arrangements contracted with a managed behavioral health organization for the delivery and management of behavioral health services; 2) products with hybrid-internal arrangements used a specialty behavioral health organization that is part of the same parent organization as the health plan to manage behavioral health services—these internal behavioral health organizations also have external contracts with other health plans; 3) internal products directly administered behavioral health services; and 4) comprehensive products contracted with a single vendor for both general medical and behavioral health provider networks. Comprehensive contracts, which were reported by only 4 products in 2010, are included in the Table in the total column only.
 
Statistical Analyses
The findings reported are national estimates. The data are weighted to be representative of plans’ commercial managed care products in the United States. SUDAAN software version 11 (RTI International, Research Triangle Park, North Carolina) was used for estimation of the sampling variance given the complex sampling design. The results reported are based on nonmissing values; missing is less than 5%, unless otherwise noted in the Table. Significant differences by contracting arrangement are based on pairwise t tests with a .05 significance level, adjusted for multiple tests using the Bonferroni correction.
 
RESULTS
Provider Support

To encourage providers to join and remain in their networks, about a quarter of products offered financial support for EHRs, but only 4.5% of products offered technical assistance for health IT needs. These strategies were not specific to behavioral health providers, and may have applied to all providers in the network. Internal and hybrid-internal products were more likely than specialty external to provide financial support for EHRs, while internal and specialty external products were more likely than hybrid-internal products to provide technical assistance for health IT needs.
 
Many products supported electronic communication between providers and patients, with 27.8% of products that could answer this question allowing primary care providers to bill for e-mail contact with patients specifically for behavioral health problems. However, 34% of products did not know if billing for e-mail contact was allowed. Products with hybrid-internal contracts were more likely to support e-mail contact (38.3%) than products with internal (2.0%) or specialty external (0.8%) contracts.
 
Access to Care
Products also promoted health IT to facilitate member access to behavioral health services and patient interaction with providers. About 90% of products offered an online provider directory for behavioral health care, and approximately 70% of products offered an online referral system or online personalized responses to questions or problems; few offered member–provider e-mail and none offered online appointment scheduling. Health IT strategies to improve access to care varied significantly by contracting arrangement and product type. Hybrid-internal and internal products were more likely to offer these services than specialty external products.
 
Fewer than 10% of products facilitated members e-mailing providers for behavioral health problems. This trend was primarily driven by specialty external products, with 66.3% facilitating member–provider e-mails. None of the hybrid-internal products, and only 7.5% of internal products, offered member–provider e-mail for behavioral health problems.
 
Care Delivery
Overall, a majority of products were engaged in strategies to improve assessment and treatment services using health IT. Nearly all products offered enrollees an online self-assessment tool (94.9%). Fewer offered online personalized responses to questions or problems (70%). Online counseling was offered by 60% of products. Products with hybrid-internal contracts were significantly more likely to offer online personalized responses and online counseling (over 80%) than products with specialty external and internal contracts; fewer than 10% of specialty external and internal products offered online counseling. However, specialty external (19.4%) and internal products (58.7%) offered online personalized responses more frequently than online counseling.
 
DISCUSSION
This study provides a baseline of health plans’ promotion of health IT strategies at a pivotal point for US health and behavioral health care policy, and fills a gap in the literature around how health IT was utilized in behavioral health care early in the post-HITECH era. Although a limited amount of literature specific to behavioral health and health IT is available, research in general medical settings suggests that health IT has a positive effect on quality, efficiency, and provider satisfaction.26 This research has implications for behavioral health. A 2011 review identified the importance of strong leadership and staff buy-in for successful health IT implementation, and that smaller providers—not only those in large integrated care organizations—can benefit from health IT.26 More leadership for health IT in behavioral health, which has been slower to adopt health IT, could improve behavioral health care quality, efficiency, and coordination between behavioral health and general medical care.
 
Our findings illustrate that health plans are promoting health IT for behavioral health. However, health plans are limited in how much they can spur adoption of health IT for behavioral health more broadly, because health IT overall still has many limitations (eg, standardization of data, interoperability within healthcare systems, operability outside healthcare environments, lack of or insufficient inclusion of behavioral health data elements) that prevent adequate incorporation and clinical use of behavioral health information.7,20,27 Addressing the limits of health IT to meaningfully incorporate behavioral health information is likely to be a key ingredient in order to successfully integrate medical and behavioral care.7 For example, 2 large payers—Kaiser Permanente of Northern California and the Veteran’s Health Administration—have been leaders in using EHRs to address risky alcohol use in primary care, primarily by using a standardized EHR that includes recommended alcohol screening questions, tracking performance, using clinical alerts/decision support software, and providing positive leadership.28-33 In 2010, commercial health plans were engaging in health IT in all 3 areas that we examined to support providers, facilitate access to care, and improve care delivery. Among provider support strategies, financial strategies were more common than technical assistance strategies. Across the 3 domains, health IT approaches that facilitated access, assessment, and treatment were generally used more often than provider support strategies.
 
E-mailing providers and online appointment scheduling were infrequent among this survey of health plans. However, both of these approaches are more likely to be activities that provider systems, rather than health plans, operate and encourage; thus, this finding is unsurprising. With increased uptake of patient portals,34 the role of commercial health plans in encouraging access to care and care delivery through portals may grow over time. In the changing healthcare marketplace, health plans are not only payers, but can also play an important role in helping patients to manage their health and healthcare.
 
Approaches varied by behavioral health contracting arrangement, which points to the influence of health plan organizational characteristics on their health IT strategies. Products with hybrid-internal arrangements were more likely to support health IT for behavioral health than specialty external and internal products. This may result from their unique organizational structure that offers both specialization in behavioral health and a closer relationship between behavioral health and medical care management because of common ownership of the behavioral health organization and the health plan. It may also reflect the challenges that interoperability requires when multiple organizations are involved, as for plans with other behavioral health contracting arrangements.
 
Compared with a similar study in 2003,35 there has been a large increase in health plans’ health IT strategies in the domains of access and assessment and treatment. In 2003, two-thirds of health plan products offered self-assessment tools, half provided online referrals, one-third provided personalized responses to problems, and only 2% offered online counseling. Most strikingly, in 2010, 60% of products offered online counseling. As health IT moves toward new innovations, like smartphone applications,36 it will be interesting to observe how health plans’ assessment and treatment health IT strategies evolve.
 
Limitations
Data were self-reported by health plan executives and may not fully reflect what was happening in practice. Provider support strategies had high rates of missing data and were not all specific to behavioral health. Further, it is possible that online appointment scheduling and e-mailing between patients and providers is available to patients at the provider organization level. Additional research is needed to assess what inroads have been made by health plans to promote health IT for behavioral health care since 2010 and in the new MACRA era, including implementation studies to assess which strategies and settings are effective.
 
CONCLUSIONS
These results suggest important implications for health IT implementation and improvement in the behavioral health sector. Given the current focus on integrating physical and behavioral health care, health IT strategies and EHR interoperability are likely to be important facilitators.37 The success of PCMH and ACO delivery system transformation efforts rests, in large part, on health IT infrastructure development,37 and to what extent behavioral health is included. Moreover, given the low rates of EHR uptake and implementation among providers who were excluded under HITECH12,38,39—which includes many behavioral health providers—it will be important to support behavioral health providers in EHR development and use in the MACRA environment.
 
Health plans are likely to be key stakeholders in encouraging health IT-oriented activities for behavioral health, and in the shift toward integrated care. Our results indicate that health plans specifically support the use of health IT in integrated care delivery by allowing primary care providers to bill for e-mailing patients about behavioral health issues. As these findings suggest, health plans played an important health IT role in 2010 to facilitate behavioral health care delivery. Health plans may also have a pivotal role moving forward to improve how health IT strategies incorporate behavioral health information and improve the quality of behavioral health care. 
 

Acknowledgments
The authors wish to acknowledge the contributions of Pat Nemeth, Frank Potter and staff at Mathematica Policy Research, Inc. (survey design, statistical consultation and data collection), Grant Ritter (statistical consultation), and Galina Zolutusky (statistical programming).
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