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The American Journal of Accountable Care December 2016
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Treating Behavioral Health Disorders in an Accountable Care Organization
Neil D. Minkoff, MD

Treating Behavioral Health Disorders in an Accountable Care Organization

Neil D. Minkoff, MD
Integrating behavioral and physical health services within an accountable care organization offers a significant opportunity to address both behavioral health conditions and substance use disorders, as well as to improve outcomes and reduce costs.

Mental health conditions and substance use disorders (SUDs), referred to as behavioral health conditions, are a leading cause of global disability.1 In the United States, an estimated 1 in 3 adults suffers from one or both of these disorders.2 These individuals die, on average, 25 years earlier than the general population as a result of suicide or comorbid physical conditions, such as cardiovascular disease, diabetes, respiratory distress, or infectious disease (HIV/AIDS). They also incur significantly higher medical and societal costs.3

Estimated spending on behavioral health conditions varies depending on the study. One analysis based on 41 million individuals covered under Medicare, Medicaid, or commercial health plans who were treated for a behavioral health condition in 2012 estimated a cost of $525 billion, nearly half of the $1.7 trillion spent that year on all health-related expenditures.4 Another analysis estimated a lower cost: $201 billion in 2013.5 Both analyses, however, noted that spending on behavioral health conditions was the highest category of any other medical condition in the United States, topping cardiovascular disease and trauma (Figure 15).

The number of people seeking services for behavioral health conditions is expected to increase over the next decade due to the Affordable Care Act, which mandates that insurance companies cover screening and other services for mental health and substance abuse conditions, and the Mental Health Parity and Addiction Equity Act, which requires that insurers provide equal coverage for behavioral and physical health conditions.6,7

Despite the physical, economic, and societal consequences of behavioral health conditions, about one-third of individuals with these disorders receive no treatment, and the vast majority of the rest receive substandard treatment. This gap between needed care and received care increased by about two-thirds between 1997 and 2010.8 Indeed, 70% of Americans in a recent poll from the Kennedy Forum felt that the country needed significant changes in the way it manages behavioral health conditions.9

Today, many individuals with behavioral health disorders receive care in the primary care or medical specialty, not behavioral health, setting.10,11 Of those, up to 80% receive no treatment or substandard treatment for their behavioral health disorder.10 This includes prescribing antidepressants for mild depressive symptoms, which are relatively ineffective, and the use of psychotropic medications with no documented behavioral health diagnosis.12 Psychosocial approaches, which studies find can be just as effective as medication, are also underutilized.9,13

Prevalence of Comorbid Physical Conditions

Approximately 68% of those with behavioral health issues have comorbid physical conditions, typically chronic conditions such as asthma, low back pain, and diabetes.14,15 These individuals have higher morbidity and mortality rates and are more likely to be nonadherent with medication than those with only a behavioral or physical health condition.14,16 For instance, 21% of patients with chronic kidney disease (CKD) have comorbid depression regardless of their disease stage.17 These patients are twice as likely to be hospitalized and have a 41% increased risk of all-cause mortality compared with patients with CKD who do not have depression.18 Patients on hemodialysis have a 2-fold increased risk of death.19

Patients seen in the behavioral health setting who also require services for comorbid physical conditions report difficulties accessing medical care.14 In one survey of 1670 adults with mental illness, one-third had difficulties accessing primary care, with 13% attributing this to stigma around their behavioral health condition.20 Further, the care received is less likely to include prevention and screening, and this limited clinician time may lead to less time spent on psychosocial issues.14 A review of the Veterans Affairs National Psychosis Registry showed poor adherence to medications for both psychiatric and medical conditions in patients with serious mental illness.14 Not surprisingly, individuals with comorbid mental and physical health conditions use more health-related services than those without, even when controlling for the higher prevalence of physical health conditions among those with behavioral disorders.16

The Need for Integrated Care

Behavioral health disorders require long-term, chronic-care management similar to that needed for chronic physical conditions such as hypertension, diabetes, and asthma.21,22 Such conditions respond best to management under a chronic-care model, which promotes enhanced access and care continuity, uses clinical information systems and decision support tools to identify and manage patient populations, provides self-management support to patients, and links patients to community resources. Under this model, providers also track and coordinate care and measure performance changes over time. Study results suggest this model can be implemented cost-effectively and even demonstrate some savings.22,23

In the behavioral health setting, a chronic care model requires integrating mental and substance abuse treatment with physical health management. This “integrated” model is described as “the care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.”24

Settings may involve embedding behavioral health professions in a primary care setting or primary care providers in a behavioral setting, or developing a close relationship between behavioral and primary care practices despite different physical locations, even using telemedicine (Table 125).25

Despite the robust literature demonstrating the benefits of integrated care models,16 behavioral and physical healthcare delivery have traditionally operated in separate spheres.22 Bringing the two together could not only improve outcomes, but also reduce costs.26 Indeed, analyses suggest that integrating medical and behavioral services in Medicaid populations could save states between $3 and $9 billion, while integration could save all payers (including commercial) between $26.3 and $48.3 billion (2012 dollars)

(Table 24,15).4,15 Updating benefit designs to reflect these improvements needs to be part of the move to accountable care organization (ACO) behavioral health integration.

These savings are already occurring at the state level. For instance, Missouri’s Chronic Care Improvement Program, an integrative model designed for individuals with severe mental illness, such as schizophrenia, saved $8.3 million in its first year managing 6757 members, even with a $775,000 increase in outpatient costs.15 In addition, the state’s Community Mental Health Center healthcare homes (similar to patient-centered medical homes) for Medicaid-eligible individuals with severe and persistent mental illness, comorbid SUDs, and certain chronic health conditions reduced overall healthcare costs by 8.1% while significantly improving individual and societal outcomes.4 When Kaiser Sacramento integrated medical and substance use treatments in primary care clinics for individuals in an outpatient chemical dependency recovery program, per-member-per-month (PMPM) costs dropped more than 50%, with significant declines in hospitalization rates, inpatient days, and emergency department use.27

Opportunities for Improvement

The Affordable Care Act created a pathway for greater integration of physical and behavioral health services when it expanded the development and use of ACOs. These integrated models of care are typically built around patient-centered medical homes. Payment is typically linked to the quality and cost of care, with value-based, rather than fee-for-service–based, reimbursement. A common reimbursement model is shared savings, in which the ACO shares in any savings with the payer over a defined timeline. In some instances, ACOs assume the risk for spending more than the financial target. Other ACOs take on even greater risk under capitation: such reimbursement models provide a financial incentive to hire case managers, social workers, pharmacists, and other allied health professionals to work with patients with comorbid behavioral health issues.28

ACOs are charged with managing the health of a patient population, which requires robust data systems, predictive analytics, and coordinated care. The goal is to achieve the Triple Aim of healthcare today: improved outcomes, improved patient experience, and reduced cost.29 In 2015, 70% of Americans had access to an ACO, 44% to 2 or more, and between 15% and 17% (49 to 59 million) received care from an ACO.30

Integrating behavioral health management with physical health management in an ACO model could significantly improve population health management and outcomes, contributing to an ACO’s ability to survive and thrive under risk-based reimbursement models.29 This approach also fits with the ACO’s team-based, coordinated care approach.31

Some ACOs are improving their delivery of behavioral health care. For example, Crystal Run Healthcare ACO in New York, which participates in the Medicare Shared Savings Program (MSSP), has 3 psychiatrists in its medical building. These psychiatrists share a waiting room with their medical colleagues and use a connected electronic health record (EHR) system. They also formed a mental health assessment team comprising of primary care and specialty physicians who meet with mental health specialists to discuss cases requiring comanagement.32

The norm, however, is a continuation of siloed care. A survey queried 257 nationally representative Medicare, Medicaid, and commercial ACOs between 2012 and 2014, and was augmented with qualitative data from structured interviews with clinical leaders at 16 ACOs. It found that just 14% had fully integrated behavioral health and primary care teams and just 42% included behavioral health specialists among their providers.29 Another survey found that more than one-third of ACOs had no formal relationship with behavioral health providers despite the fact that the majority of contracts included behavioral health metrics. Although 84% of ACOs had at least 1 contract with a payer that included responsibility for behavioral health services, just 66% of the largest commercial contracts included behavioral health services in the total cost of care.29

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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