Why a Focus on Behavioral Health is Key to Improving Quality Measures

Tom Zaubler, MD, Chief Medical Officer of NeuroFlow

Since the passage of the Medicare Improvements for Patients & Providers Act in 2008, the U.S. healthcare system has been moving towards value-based care (VBC) which encourages health providers to improve care quality by reimbursing them based on successful outcomes rather than individual medical services. The overarching goal of VBC is to improve the patient experience, improve population health, and reduce per capita health costs.

As part of this VBC model, hospitals and health systems must store, track, and analyze a large amount of quality-related data for compliance and reimbursement purposes. Hospitals report the data to the Centers for Medicare & Medicaid Services (CMS), which uses that data to create the Overall Hospital Quality Star rating for each hospital. Rating is based on five areas: mortality, safety of care, readmission, patient experience, and timely/effective care.

Most of the data required by CMS focuses on physical issues, such as the rate of readmission for COPD patients, hospital return days for heart failure patients, or the rate of emergency department visits for patients receiving outpatient chemotherapy. While there is a wealth of research on behavioral health and physical condition comorbidities, behavioral health is still primarily treated in a silo, rather than being viewed as a critical route to improving quality measures.

With that in mind, healthcare organizations need to adopt a model of integrated care if they want to make real quality measure improvements that have a significant financial impact. Integrated care enables a holistic team-based approach to treating common mental health conditions by integrating behavioral health professionals into the care team, while simultaneously increasing the confidence and competence of physical health providers in treating these disorders. Integrated care models directly engage patients in decisions about their care and focus on prevention and early diagnosis of disease, with each provider contributing unique responsibilities and perspectives to reach a shared treatment decision. The collaborative care model is considered the gold standard of integrated care, proven to improve physical function and double the effectiveness of depression care and validated in over 90 different randomized controlled trials.

We’ve compiled the essential book for supporting integrated care, through published and validated research:

1. Impact of Behavioral Health Treatment On Total Cost of Care: An Evernorth Analysis 

Key Findings:

– Outpatient mental health care can help reduce overall health costs by as much as $3,109 per person over two years.

Health services provider Evernorth analyzed proprietary data to understand the effect that mental health treatment has on health care costs and patient outcomes. Analysts found that outpatient mental health care, such as visits to a psychologist, can help reduce overall health costs by as much as $3,109 per person over a two-year period. In particular, regular outpatient behavioral health care can reduce emergency department visits and inpatient hospitalizations. This means that outpatient behavioral health treatment pays for itself, and more.

This reduction in costs is especially important for patients with mental and physical comorbidities, who have between 2.8 and 6.2 times greater total health care costs. Behavioral health conditions may worsen physical symptoms or make it more difficult to comply with a treatment plan. This can lead to an increased use of health services, many of which may be preventable. Therefore, efforts to reduce health costs should include an integrated approach that addresses both behavioral and physical health needs.

2. Potential economic impact of integrated medical-behavioral healthcare: Updated projections for 2017, from Milliman

Key Findings:

– Integrating medical and behavioral healthcare could potentially save an estimated $38 billion to $68 billion annually.

– Integrated care for individuals with mental health or substance use disorder diagnoses could help save 9–17 percent of total additional spending.

For patients with physical health needs, costs are typically 2–3 times higher when that patient also has a behavioral health condition. The integration of medical and behavioral healthcare (IMBH) is a significant part of the effort to reduce care costs while improving patient outcomes. 

In April 2014, Milliman completed a report for the American Psychiatric Association (APA), projecting the potential annual savings that effective IMBH programs could generate. In 2018, Milliman issued an updated report with more recent data.

Analysts looked at the health care costs of individuals enrolled in commercial insurance, Medicare, and Medicaid in the United States. The data included individuals with no mental health (MH) or substance use disorder (SUD) diagnoses, those with MH diagnoses and no SUD, those with SUD alone, and those with serious and persistent mental illness.

Total U.S. spending for individuals with either mental health (MH) or substance use disorder (SUD) diagnoses is estimated to be $752 billion annually. This accounts for about 34 percent of total health care spending. Analysts calculated that effective IMBH programs could help save 9–17 percent of total additional spending. Integrated care could potentially save an estimated $38 billion to $68 billion annually.

Some of the highest health care costs came from individuals with chronic medical and comorbid MH/SUD conditions. These costs were mostly attributed to medical services, not behavioral services. The biggest opportunities for reducing added costs came from managing endocrine and metabolic disorders, arthritis, hypertension, and hypercholesterolemia with an integrated care model.

3. Evaluating the impact of integrated behavioral health intervention: Evidence from Rhode Island, from Brown University. 

Key Findings:

– Rhode Island’s Integrated Behavioral Health (IBH) program helped reduce unnecessary emergency department visits by 7 percent.

– IBH helped reduce office visits by 6 percent.

In this study, researchers evaluated the Integrated Behavioral Health (IBH) program in Rhode Island for its effect on health care use and costs. IBH was implemented across 11 primary care practices in the state under the Care Transformation Collaborative of Rhode Island in 2016.  

Data included claims from Rhode Island’s All Payers Claims Database for 42,936 unique patients who had visited participating primary care providers between 2015 and 2018. Analysis shows that, under IBH, emergency department visits and office visits declined by 7 percent and 6 percent, respectively. 

The study authors suggested that IBH helped discourage unnecessary emergency department visits. In addition, IBH may have helped the primary care practices increase the volume and quality of their services, reducing the need for emergency visits as well as office visits.

4. Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost. Intermountain Healthcare. 

Key Findings:

– Integrated, team-based care can reduce health care costs by an average $115 per patient.

– Patients with team-based care have an average of 23 percent fewer emergency department visits.

Researchers with Intermountain Healthcare compared the patient outcomes, health care use, and costs between 27 TBC medical practices and 75 traditional practices. The study included 113,452 adult patients who received care from 2003 through 2013, making this one of the largest studies of its kind.

The analysis found numerous benefits associated with the TBC model:

– TBC patients had an average of 18.1 emergency department visits, compared to 23.5 visits for traditional patients—a reduction of 23 percent.

– Average payments to providers were $3,400 for TBC patients compared to $3,515 for patients of traditional providers, demonstrating that TBC can reduce health care costs.

– More patients in the TBC model followed diabetes care protocols, such as regular blood glucose testing, than in the traditional practices.

– The TBC practices screened many more patients for depression.

These findings show that integrated, collaborative, team-based care helps get patients more proactive treatment and better clinical outcomes for chronic conditions. This approach lets providers deliver higher quality care while reducing costs, creating better outcomes for all stakeholders.

5. Use of technology for care coordination initiatives for patients with mental health issues: a systematic literature review. ODH and Otsuka America, Inc. 

Key Findings:

– Patients who receive integrated, collaborative care for depression were more adherent to treatment at 12 months.

– Patients with Alzheimer’s disease who received collaborative care supported by health technology had fewer symptoms at 12 months.

To better understand how technology can be used to improve mental health care and collaborative care, researchers set out to compare the use of technology in care coordination with care as usual (CAU) for mental health patients. The analysis included 21 studies. Most studies used health technology, such as electronic health records (EHRs), to coordinate care among patients and providers. The uses included computer-based cognitive behavior therapy, telemedicine, and Web-based communication.

The review found a variety of benefits to collaborative care supported by health technology:

– Patients receiving collaborative care for depression were more adherent at 6 months and 12 months, and were more satisfied, than patients receiving CAU.

– Among veterans receiving treatment for substance abuse, those who received coordinated care using Internet-based interventions decreased average days of alcohol use from 2.8 to 1.5.

– Of veterans involved in a study of individualized telemedicine technology, 94 percent reported satisfaction with their technology device after 12 months.

– One study of collaborative care delivered via telephone and coordinated with EHRs showed higher quality of life and improved mood in highly anxious patients compared with CAU.

– For patients with Alzheimer’s disease, a technology-supported collaborative care program led to fewer symptoms at 12 months and a more favorable opinion of their primary physician than CAU.

While there are still challenges and barriers to using health IT for care coordination, it can help improve communication among providers and between providers and patients. Health technology allows providers to conduct more structured patient assessments and to better monitor patient health and progress. The use of technology can also help patients feel more comfortable discussing their mental health issues and being more involved in their health care decisions.

Bringing Integrated Care Into the Future

These studies are a small sample of the body of research showing that integrating behavioral health and physical health leads to better patient outcomes, such as higher treatment compliance and reduced emergency visits. These improved outcomes lead to improved quality measures, which means lower costs. 

About Tom Zaubler, MD

Tom Zaubler, MD, is the Chief Medical Officer at NeuroFlow, a behavioral health integration company. Tom has 20+ years of institutional experience as the former director of psychiatry for Atlantic Health System (Morristown Medical Center, N.J.). He runs an independent counseling practice, Pegasus, and is a public advocate for the collaborative care model.