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Integrated Care

Shifting to Integrated Care Will Save Health System Huge Sums, Report Finds

Leaders at a forum hosted by the American Psychiatric Association (APA) agree that aside from addressing the suffering caused by untreated psychiatric disorders, the cost of those disorders is “too big to ignore” and is key to addressing the problem of healthcare spending.

Because of fragmented care in the current system, general medical costs for treating people with chronic medical problems, as well as mental disorders, are two to three times higher than those for treating people with physical health conditions only. Effective integration of medical and behavioral care could save $26 billion to $48 billion annually in healthcare costs, according to a newly-released analysis conducted by Milliman Inc., an international actuarial firm.

The analysis, commissioned by APA, found that most of the projected reduced spending is associated with decreased facility and emergency room use by individuals with mental health and substance use disorder issues that are addressed more effectively in treatment that integrates medical and behavioral healthcare. The analysis was contained in the report “Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry.”

The report, “Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry,” provides compelling new data for employers interested in working with their health plans to improve quality by changing how care is delivered to employees and families with mental disorders.

The report was released April 4th at a roundtable discussion in Washington, D.C., titled, “Integrated Primary and Mental Health Care: Reconnecting the Brain and the Body.” The event was hosted by APA and attended by clinicians, thought leaders, and policymakers who have championed <-->>integrated/collaborative care models> in which mental health professionals collaborate with primary care providers to improve access to high-quality care. A total of 85 representatives from mental health and substance use disorder advocacy organizations attended; a live webinar of the event was also accessed at about 300 sites and at press time had been viewed by an additional 300 people.

APA immediate past-president Jeffrey Lieberman, M.D., said some 80 randomized, controlled trials have found that collaborative care is more effective, not only in terms of cost, but also in terms of patients’ subjective experience, quality of life, and satisfaction.

“There is a compelling and growing body of research demonstrating the impact of quality integrated care that treats the brain and the body,” said Lieberman, in opening remarks at the event. “These studies have shown that concurrently treating behavioral and physical conditions not only leads to better control of depression, diabetes, and heart disease, but has been shown to reduce healthcare costs. Right now, we treat medical and mental illness as if they occur in different domains, rather than within the same person, but as we all know, there is no health without mental health,” Lieberman said.

Drawing from commercial health insurance and Medicare and Medicaid data, Milliman based its estimates on data from more than 20 million individuals in its analysis of healthcare utilization and costs from 2009 to 2012. Milliman compared data from four groups:

  • People with no mental health or substance use disorders

  • People with mental health diagnoses but no serious and persistent mental illness

  • People with serious and persistent mental illness

  • People with substance use disorder diagnoses.

Chronic medical conditions in each of these four groups were reviewed, revealing that only 14% of people with insurance are using mental health and substance use disorder services—despite the fact that this group accounts for more than 30% of overall healthcare spending.

The total U.S. spending for those with behavioral health conditions was estimated to be $525 billion; the additional healthcare costs incurred by people with behavioral comorbidities were estimated to be $293 billion in 2012, according to the report.

Milliman found that in comparing the healthcare costs of people with behavioral health conditions to those without, people with behavioral health conditions spend a greater proportion of total medical dollars on facility-based services rather than professional services, such as physician appointments.

For employers, these numbers represent additional data supporting the opportunity to work with health plans to better allocate financial resources by delivering more effective care. The new data underscore the need for employees and family members with chronic medical conditions and comorbid behavioral health conditions to receive care that addresses the individual’s physical and behavioral health needs.

The report by Milliman was commissioned to complement another report, “The Role of Psychiatrists in Health Care Reform,” submitted last year to the APA Board of Trustees. This APA report was produced by a work group chaired by APA president Paul Summergrad, M.D. The report, which was also released with the Milliman report at the April 4th roundtable, covers issues related to the rollout of the Affordable Care Act (ACA) but emphasizes that healthcare reform is broader than the ACA and includes multiple state, federal, and private patient-care delivery and payment initiatives.

The APA report noted that psychiatrists, because of their medical expertise and extensive training with patients with serious psychiatric and medical illnesses, have distinctive expertise to integrate this care, working closely with primary care, specialty physicians, and nonphysician mental health clinicians.

At the roundtable event, Summergrad discussed findings from both reports. He emphasized that integration of mental health and substance use disorder treatment and general medical care was crucial to achieving the “triple aim” of healthcare reform: better patient outcomes, increased patient satisfaction, and lower overall costs. He pointed out that a critical takeaway message from the Milliman analysis is that integrated care of psychiatric disorders is vital to tackling the overall problem of rising health costs.

Summergrad said clinicians across the specialties are needed to meet the mental health needs of patients. “We don’t have enough people to waste anyone in this effort,” he said. “We need everyone working on these issues across the medical and behavioral health spectrum.”

“We think there is compelling evidence that integrated care of mental health and substance use disorders is necessary, not only because of the considerable pain and suffering associated with them, but because there is no way we can really deal with the issues around total healthcare costs unless we reach out across the mental health and general medical care settings to ensure that we are all working together to provide that care,” Summergrad told attendees.

Michael Hogan, Ph.D., former commissioner of the New York State Office of Mental Health, noted in his keynote remarks that what he called “disintegrated care” is costly and bad for patients’ health. People wait on average nine years to seek care for a mental health problem, and since the average age of first experiencing mental health problems is 14, these delays come at a particularly bad time in individual development, he said. The delay between onset and care-seeking is particularly relevant for employers because this population represents current and future employees in need of behavioral health services.

“Primary care is slammed by these problems,” Hogan said, noting that behavioral complaints are the number-one reason for pediatric visits and account for approximately one-third of family-practice visits. But without integration, primary care is poorly equipped to respond to these issues, Hogan said.

In closing remarks, APA chief executive officer and medical director Saul Levin, M.D., M.P.A., reiterated that the current system of fragmented care is “costly, ineffective, and bad for health. . . .The Milliman report makes clear that mental health and substance use disorders are too big to ignore,” Levin said.

Levin stressed there is a critical need for reimbursement policies that make these programs sustainable. “And finally we need psychiatrists, working closely with family practice, primary care, and other behavioral healthcare providers, to help manage patients with complex, comorbid conditions.” He added, Together we can help reconnect the brain and body in medicine. The time to do it is now.

Tips for Employers

Leverage the analysis done by Milliman to engage your health plans and other health and wellness vendors in discussions about mental health:

  • Use this information to talk with your health vendor partners and explore how mental health care is currently managed in primary care settings.

  • Find out if/how your employees and their dependents are currently screened for depression, such as through health risk appraisals, in primary care settings, through employee assistance programs, and through disability management processes.

  • Ask your plans if they are working to advance integrated/collaborative care models and if so, how you can help scale these models and make them accessible to your employees and their dependents.

  • Identify other opportunities to embed mental health into health and wellness programs, including disease management programs focused on chronic diseases such as asthma, diabetes, and heart disease, which have high rates of comorbidity with depression and other mental illnesses.

  • Talk with other employers about what they are doing to advance integrated/ collaborative care models. For example, the Northeast Business Group on Health is currently implementing collaborative care through their One Voice Initiative.

  • Remember that as purchaser, your voice can make a powerful difference. By raising questions and engaging your health partners in conversations focused on mental health issues, you send the message that your company is concerned about the whole health of employees—mental and physical health.

Mark Moran is a senior staff writer for Psychiatric News. Note: this content was adapted from an article appearing in the May 2, 2014 issue of Psychiatric News.

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