Integration in Behavioral Health: New Opportunities and Challenges

1. Integration in Behavioral Health: New Opportunities and Challenges Richard G. Frank Harvard University

2. Overview of Presentation • What is integration and why do we like the idea? • What is the basis for believing more integration will improve behavioral health care? • What stands in the way of adoption of evidence based approaches to integration? • What are the opportunities offered by the ACA?

3. Aspirations for Integration • “…evidence of a link between mental and substance use illnesses and general health is very strong …improving the nation’s general health and resolving quality problems…will require attending to the quality problems in mental and substance use care”---IOM Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders (2006) • Surgeon General Satcher referred to mending the destructive split between physical and mental health (1999)

4. Integration: Meaning • A brief search in “google scholar” leads one to understand behavioral health integration as involving the incorporation of evidence based mental health care into primary care practice • If meeting the health needs of individuals and families, as stated in our National Quality Strategy (2011), is to be a central goal of U.S. health care then a broader view of integration is called for

5. A Refined View Integration • A commitment to patient centered care calls for “meeting people where they are” • Heightened importance for populations that have heterogeneous needs and face impediments to negotiation of a complex health system • Implication: bringing general medical care to specialty behavioral health settings is central as incorporating behavioral health in primary care practices

6. Importance Of Increased Integration Of Behavioral Health Into Primary Care • Growth in treated prevalence has come from primary care • Share of primary care in mental health care has grown to 53% of cases • Advances in pharmaco-therapies and manualized psychotherapies especially significant for PCPs • PCP historically weak in recognizing and treating behavioral health disorders

7. Need to Integrating Medical Care into Behavioral Health • People with SPMI frequently suffer from poor general health • Relative risk of premature mortality for people with SPMI is roughly 4x that of otherwise similar people (Druss 2011) • Poverty, behavioral health treatment and illness features are sources of elevated risk • Average Medicaid spending on behavioral health for people with schizophrenia = $11,900 plus $5700 in other medical care compared to $4000 for average adult beneficiary

8. What Do We Know About Making Integration Work? • Primary Care Settings • Extensive research focused on depression and anxiety disorders • Specialty Behavioral Health Settings • Limited evidence • Promising Models • Major investments in demonstrations (ACA)

9. Elements of Evidence Based Treatment in PCP: Depression • Physician time • Care manager services • Specialty consultation • Registry-decision support

10. Learning About Impacts of Evidence Based Care • Effectiveness: Meta Analysis (Gilbody et al Arch Int Med 2006) • Six month gains ~ 0.25 • Five year gains ~ 0.15 • Key elements of treatment • Medication adherence • Credentials and supervision of care managers

11. Primary Care Depression $3,500.00 QALY = $100,000 QALY = $50,000 QALY = $25,000 AJ $3,000.00 $2,500.00 $2,000.00 R $1,500.00 T B Incremental Cost AQ AI AA AN AH $1,000.00 AB K Q Y Z U AC N AM O L AE P $500.00 X M AG J G AF AD AO F I H AK $0.00 A -AP -0.06 -0.04 -0.02 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 AL ($500.00) ($1,000.00) QALY Cost Effectiveness of Evidence Based Care for Depression in Primary Care

12. Cost-Effectiveness Evidence based treatment increases treatment costs and improves outcomes • Estimates of incremental costs per QALY $11,270 to $19,510 when Canadian cut offs were $20,000 to $30,000 (Lave et al 1998) • Little evidence of general medical offsets • Results in improved work outcomes; probability of working; hours of work (Timbie et al, 2006) • Finding replicated in several different settings

13. Usual Care for Depression Differs from EBT • PCPs still frequently fail to recognize depression • PCPs visit duration increases by 1.8 minutes with cases of depression/anxiety (Frank and Zeckhauser, 2007) • High percentages of usual care patients do not have follow-up contact • Typical PCP treating depression adjusts treatment according to level of symptoms not change in symptoms (Henke et al, 2007)

14. What Stands In The Way Of Adoption Of Evidence Based Treatment? • PCP attitudes and habits • Organization of PCP practices • Implementation of quality improvement efforts • Payment policies • Use of decision supports • Note integration has succeeded in resource lean settings

15. Attitudes and Habits • Physicians do not devote extra time • Average visit 17 minutes; depression cases get less than 19 minutes on average • When mental health problems are raised with PCP; video tape evidence suggests subject is changed in about 1 minute (Tai-Seale et al, 2007) • Cases of depression less likely to have return visits than other chronic conditions

16. Organization of Physician Practice • Approximately 30% of PCPs are in solo practice and 20% to 30% more are in small groups (<5) • The costs of a care manager are typically higher in small groups and solo practices • Difficult to spread quasi fixed cost of care manager • Small groups less likely to use electronic records

17. Payment Policies • Carve-outs can be an impediment to evidence based treatment in primary care • Some plans that carve-out behavioral health do not pay PCPs for treatment of mental disorders • Referral networks between PCP and carve-out may not overlap (although this is a declining problem) • Medicare and other payers do not pay for care management or some types of consults • Payment system are frequently inflexible

18. Integration in Specialty Setting • Main point of contact with health care delivery system for people with severe behavioral health disorders • Established relationships • Simple referral methods do not work; care is easily disrupted (New Freedom Commission) • Primary care settings often a poor fit for people with SPMI

19. Models of Integration in Specialty Settings • Fully Integrated • VA • FQHCs • Cherokee and Crider (Missouri) • Economic viability • Partnership with FQHCs • Nurse placement in CBHC • Nurse case manager in CBHC

20. Evidence to Date • The organizational approach less important to outcomes than the quality of clinical services and training of the key personnel • Small randomized trial in VA showed promising outcomes wrt quality of medical care and health outcomes • Early Partnership Evaluations (PCARE) show positive results • Improved receipt of evidence based preventative care and improved care for cardiometabolic dx

21. Towards Renewed Improvement: Care Management • Spreading costs/ training are key • Generic chronic disease care managers • Experiences in 6 major demonstrations suggest case loads of 40-80 patients per care manager • Use of carve-outs for virtual/telephonic care management • UCSF-UBH-BCBS Model • Only virtual model compatible with solo/small group practices

22. Physician Time • Altering scheduling is very difficult • UCSF experimented with adjustment to productivity formula to give PCP more time for depression care • Adjustment allowed 30 minute depression visit to count as two visits • Few PCPs availed themselves of extra time • Suspect that since only a share of patients were eligible for adjustment habits did not change (Feldman et al 2006)

23. Behavioral Health in the ACA • Guiding Principles • Improved insurance through parity/coverage expansion (mostly Medicaid) • Integration • Prevention

24. Opportunities for Expanded Efforts in the ACA • Primary Care Integration Demonstration (SAMHSA) • Initial investment $50 million > expanding • FQHC Integration M/SUD • SAMHSA Technical Assistance investment • Medicaid Health Home option • Recognizes CBHC as health homes; prioritizes SPMI; sees SUD as chronic condition • ACOs

25. Meaning of Opportunities • Integration Demos • Rigorous test of models of integration into specialty settings • ACOs flexible funding (gain sharing) and integrated delivery system • Health Homes • Offers flexible payment systems and generous matching for coordination such as care management for chronic conditions

26. Decision Support • Behavioral health lags in adoption of HIT • Partly a policy problem; partly a management issue; benefits to expanded HIT potentially big • PCPs do not typically measure symptoms/progress longitudinally • Convenient tools exist • Tracking symptoms appears to alter treatment adjustment behavior

27. Bottom Line • We have learned a great deal about how to bring behavioral health to primary care settings in a cost-effective manner • Important progress has been made in learning how to incorporate medical care into specialty behavioral health settings • More understanding is imminent • The ACA offers organization and financing arrangements that can overcome some significant impediments to integration • The opportunity should not be wasted