The Need for Integrated Behavioral Health Care in the US Module

The Need for Integrated Behavioral Health Care in the US Module 1 Shirley Porterfield, PhD School of Social Work University of Missouri - St. Louis

Overview Integrated Behavioral Health, including models and origins, is defined There is a high prevalence of mental health and substance abuse disorders that are comorbid with physical health conditions. Health care costs are high and expected to continue to rise over the foreseeable future Studies suggest that many patients served in integrated behavioral health systems receive more effective treatment at a lower cost

What is Integrated Behavioral Health? Integrated behavioral health (IBH) care occurs when primary medical care and mental and/or substance use disorders treatment coexist in the same health services setting Primary care and mental health practitioners work together to provide care, and to coordinate care from other medical specialists The integrated behavioral health model reflects the ecological framework and strengths perspective inherent in social work practice

IBH Models Integrated behavioral health occurs when Behavioral health services are added into the primary care setting, or Primary health care services are added into the behavioral health setting Most patients with serious mental illness (SMI) or addictions are treated by behavioral health specialists in a psychiatric or community setting so adding primary care services to this setting makes sense for these patients Most patients with less serious mental illness or substance use disorders are treated by generalist physicians in a primary care setting so adding behavioral health services to this setting makes sense for these patients

IBH Origins The concept of the Patient-Centered Medical Home (PCMH) originated with the American Academy of Pediatrics in 1967 Defined as care that is accessible, family-centered, coordinated, comprehensive, continuous, compassionate, and culturally effective1 Research on the PCMH finds the care coordination piece is critical for better health outcomes, lower overall and out-of pocket costs, and reduced family impacts234

Why Integrated Behavioral Health Services? Prevalence of mental disorders and substance use disorders Incidence of co-morbid conditions Costs associated with these two conditions in particular Costs of treatment Improved outcomes and cost savings with integrated health services

How prevalent are mental disorders? How are mental health issues typically treated? MENTAL DISORDERS

Defining Mental Illness Mental illness (MI) is “characterized by sustained, abnormal alterations in thinking, mood, or behavior associated with distress and impaired functioning”5,6 Mental disorders are more disabling than any other group of illnesses, including cancer and heart disease (MI is the 3rd or 4th most costly condition) Many mental and physical health disorders coexist (called co-morbidity)

Prevalence of Mental Disorders7 46.4% of Americans will experience some form of mental illness in their lifetime8 20% of women and 13% of men are affected by major depressive disorder each year; 6% of women and 3% of men are diagnosed with panic disorder; 9.7% of women and 3.6% of men are diagnosed with PTSD Men have higher rates of impulse-control disorders, substance use disorders, and suicide completion than women

Serious Mental Illness 9 (SMI) The National Survey on Drug Use and H ealth (NSDUH) defines SMI as: A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) Diagnosable currently or within the past year Of sufficient duration to meet diagnostic criteria specified within the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.

Impact10 Mental disorders are disabling and can affect all aspects of life: Physical health Parenting Work Finances Care giving Relationships with family and friends Common daily activities

Burden of Disease: Disability-Adjusted Life Years (DALYs)11 DALYs represent the total number of years lost to illness, disability, or premature death within a given population. They are calculated by adding the number of years of life lost to the number of years lived with disability for a certain disease or disorder. Neuropsychiatric disorders are the leading contributor to DALYs in the US & Canada, and they contribute nearly twice as many DALYS as cardiovascular diseases and cancers.

Treatment In 2008,13.4 percent of adults in the United States received treatment for a mental health problem. Just over half (58.7 percent) of adults in the United States with a serious mental illness (SMI) received treatment for a mental health problem. Treatment rates for SMI differed across age groups, and the most common types of treatment were outpatient services and prescription medication.

Changing Service Patterns12 More drugs prescribed Shorter hospital stays

How prevalent are substance use disorders? What are comorbid conditions and how prevalent are they? In what setting are mental health and/or addiction issues typically treated? SUBSTANCE USE AND COOCCURRING DISORDERS

Substance Use Substance use disorders (SUDs) “occur when the recurrent use of alcohol or other drugs (or both) causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.13 Just over 8% of the people in the US ages 12 and older have a SUD. 6.4% have an alcohol use disorder; 2.7% have an illicit drug use disorder; about 1% have both 13 Substance use prevalence rates are higher among persons with mental illness, traumatic brain injuries, spinal cord injuries, and many chronic health conditions (see slide 19). 14

Epidemiology of Co-morbidity15, 16 16.8% of the US adult population has both a mental disorder and a medical condition 30% of adults with a chronic medical condition have a co-morbid mental health condition Source: http://www.rwjf.org

Epidemiology of Co-morbidity17 Odds of alcohol/drug problems Series1 Odds ratio of alcohol/ drug disorders is 2.7 times more if any mental disorder exists This is 10-20 times greater than expected for schizophrenia, mania, antisocial personality disorder general if any MI Series1 Series1 if major MI

Co-morbidity & Chronic Health Conditions18 Prior Diagnostic History Patients with Risk Scores 50 * NYC Residents Percent of Patients with Co-Occurring Condition Cereb Vasc Dis AMI Ischemic Heart Dis CHF Hypertension Diabetes Asthma COPD Renal Disease Sickle Cell Alc/Subst Use Mental Illness 5.0% 6.0% 22.4% 16.2% 50.9% 29.0% 36.3% 20.8% 6.3% 2.9% 72.8% 66.2% CVD AMI 100.0% 12.5% 11.1% 11.2% 8.0% 8.9% 4.9% 6.0% 10.8% 5.0% 3.9% 4.7% 15.0% 100.0% 21.7% 19.8% 10.6% 11.7% 6.7% 9.1% 16.5% 4.2% 4.5% 5.1% Ischemic Heart Dis 49.5% 80.9% 100.0% 62.8% 38.3% 41.8% 25.9% 32.5% 46.7% 15.7% 16.5% 19.7% CHF 36.2% 53.3% 45.3% 100.0% 28.4% 31.7% 19.0% 27.2% 52.8% 14.9% 10.7% 11.7% HyperDiabetes Asthma tension 81.6% 90.1% 86.9% 89.5% 100.0% 81.3% 57.5% 62.2% 93.3% 31.3% 44.1% 48.3% 51.7% 56.6% 54.0% 56.9% 46.2% 100.0% 32.9% 33.3% 59.6% 14.0% 22.0% 27.4% 35.3% 40.4% 42.0% 42.7% 41.0% 41.2% 100.0% 56.7% 24.3% 28.2% 36.4% 38.4% COPD 24.8% 31.5% 30.2% 34.9% 25.4% 23.9% 32.5% 100.0% 19.8% 12.3% 21.2% 20.6% Renal Disease 13.7% 17.4% 13.2% 20.7% 11.6% 13.0% 4.3% 6.0% 100.0% 4.7% 3.2% 3.6% Sickle Cell 2.9% 2.1% 2.1% 2.7% 1.8% 1.4% 2.3% 1.7% 2.2% 100.0% 2.0% Alc/Subst Mental HIV/AIDS Abuse Illness 56.4% 55.2% 53.5% 48.4% 63.1% 55.4% 72.9% 74.2% 36.6% 48.9% 100.0% 62.7% 56.2% 58.4% 48.0% 62.9% 62.7% 70.0% 65.6% 37.4% 50.7% 70.9% * High Risk of Future Inpatient Admission Source: NYU Wagner School, NYS OHIP, 2009. 13.7% 13.5% 14.0% 13.4% 20.0% 15.6% 29.6% 29.9% 18.0% 15.0% 33.4%

Treatment19 Two thirds of adults with mental disorders and/or addictive disorders are treated for these conditions in a general medical setting Nearly 70% receive no mental health treatment Adults with co-morbid conditions whose mental health conditions are untreated incur higher medical costs Less likely to undertake beneficial self care activities Less likely to adhere to treatment regime

Why do we spend so much on health care? What role does government play in this system? If government reduces its reimbursement rates, who wins and who loses? Can you think of policy changes that might lead to lower costs without lowering reimbursement rates? HEALTH CARE COSTS

Costs of MI Mental illness cost the United States an estimated 300 billion annually (2002-2003)20 Direct costs – Health care, care giving, and specialized equipment Indirect costs – – – – – – Decreased productivity Absenteeism Lost jobs and wages Pain and suffering Unraveling of families and friendships Suicide

Costs Over Time Over the 1996-2006 decade, Americans paying for mental health services increased 87.6 percent and total expenditures increased 63.4 percent. The average cost per person for mental health services slightly decreased during this period.

Costs of SA An average physician office visit in 2008 cost 199, compared to 922 for an Emergency Department visit (median was 89 for doctor's visit, vs. 422 for ED)22 Estimates of the total overall costs of addiction in the United States, including productivity and health- and crime-related costs, exceed 600 billion annually. This includes approximately 181 billion for illicit drugs (2002), 193 billion for tobacco (2007), and 235 billion for alcohol (2003)23

Why Do We Spend So Much on Medical Care?24, 25 Because we can Price increases are a small part of the story Quantity and quality increases are a large part Example: Changes in Medical Care for People with Depression 1950 Standard – Mental institutions for very ill; little for others – Lobotomy, ECT, Insulin therapy Today’s Standard – SSRIs; various types of therapy

4.9 million uninsured with SMI 5.5 million uninsured with addiction and/or substance use disorders * Figures do not add to 100% as some payer categories are not included in this chart. Percent of Spending by Payer, 2005 Mental Health Substance Abuse 40% Percent of Total Spending* Who Pays for Treatment?26 30% 36% 27% 28% 21% 20% 18% 12% 12% 6% 10% 0% i Pr te a v In ra u s e nc ed M i i ca d a St t L e/ o ca 't v o lG Type of Payer -o t u O o -f P e ck t

Uncompensated Care27 In 2008 doctors, hospitals, and other providers incurred 42.7 billion for patients who did not pay their bills The uninsured pay on average 37% of their costs Gov’t programs and charities pay another 26%

Hidden Health Tax27 Providers must recoup the costs of caring for the uninsured from their paying customers in the form of higher insurance premiums and taxes Premium increases make it harder for businesses to initiate or continue health insurance, as a result adding to the number of uninsured In 2008, insured persons paid a "hidden health tax" for family and individual coverage of 1,017 and 368 respectively

Why might it be cost effective to treat all health conditions in the same setting and with the same team of health professionals? Is this model cost effective for everyone, or only for people with certain conditions? THE RATIONALE FOR INTEGRATED BEHAVIORAL HEALTH

Health Care is Important To Americans28 Percent reporting importance of having one place/doctor responsible for primary care and coordinating care 100 75 93 29 93 93 21 41 Important Very important 92 93 94 29 26 24 64 67 69 South West Dem 89 30 94 30 50 64 72 52 25 59 63 Rep Ind 0 Total NE NC U.S. region NE Northeast; NC North–Central; Dem Democrat; Rep Republican; Ind Independent. Political affiliation

The Model Matters29, 30 Outcomes are poor if behavioral health care is provided solely by a primary care clinician Problems with diagnosis, dosage, duration of treatment, lack of follow-up treatment Outcomes worse for minority and lower-income patients The model has to include a team approach, incorporating a variety of medical professionals Must include systematic screening and coordination of care by a care manager with a specific mental health background Must include frequent follow up for chronic conditions Must include education to empower patients to aid in medical decision making and self care

Outcomes in an Integrated Care Model31, 32 Outcomes are significantly better if care is provided by a team of health professionals that includes a mental health/addictive disorders professional (integrated care) Medication adherence significantly improved Outcomes for minority and lower-income patients the same or better than those for white, higher-income patients For patients with co-morbid chronic health conditions and depression, overall health improves when both conditions are treated in an integrated care environment Patient satisfaction with care is higher

Cost Evidence is Mixed33, 34, 35, 36, 37 Most studies examine co-morbid depression/anxiety (rather than SMI or addiction) with chronic health conditions Screening for mental health disorders, such as depression, increases the duration (and cost) of primary care physician visits Care management is expensive, but costs are offset by reduced hospitalizations and emergency department visits Cost savings tend to accrue to payers rather than primary care providers (clinics and physicians) Important to pay attention to incentives inherent in this system of care

Is this a model that could easily be replicated elsewhere? Why or why not? What are the main elements of the medical home model in this case study? CASE STUDY: INTERMOUNTAIN HEALTH

Case Study: Intermountain Healthcare37, 38, 39 Nonprofit, integrated health system with 22 hospital facilities and 130 ambulatory clinics, operating in both rural and urban areas within Utah and Idaho, with a mix of commercial, Medicare, Medicaid and uninsured/selfpay patients Mental Health Integration (MHI) program implemented in 69 clinics, and in 4 uninsured school-based clinics Team-based approach including primary care physicians and their staff, mental health professionals, care management, community resources, and the patient and his/her family

Case Study: Intermountain Healthcare40 Study design Compare outcomes in MHI (n 5) vs matched nonMHI (n 8) clinics, adults with depression only, no Medicare patients Follow patients and compare costs from 12 months pre to 12 months post diagnosis with depression

Case Study: Intermountain Healthcare41 Results Patients in MHI treatment group had overall average annual per-patient charges in 2005 that were 667 lower than those in the usual care group Largest cost savings were reductions in inpatient, emergency department, and office visits for treatment of medical conditions – Patients with depression treated in an MHI clinic were 54% less likely to have an ED visit and half as likely to use inpatient psychiatry than similar patients treated in non-MHI clinics Lower rate of growth in costs of all service lines except outpatient psychiatry/counseling and antidepressant prescriptions Largest savings seen among those with depression and one or more co-morbid conditions

Need For More Evidence Few studies examine the impact of integrated behavioral health services on those with serious mental illness or substance use disorders Examples of programs that have adopted this model and have been subjects of study include – Pathways to Housing, Inc (New York & Philadelphia) – Paxton House (Chicago) Still need to know which payment structures for physicians and clinics are supportive of this care model Important to consider incentives for all participants

Conclusions Mental health issues represent a significant problem in the US, affecting more than a quarter of adults Substance use disorders affect at least 15% of the population of adults in the US Quality of care, medical and mental health outcomes, and patient satisfaction are improved in an integrated behavioral health system Many studies also show lower costs with this care model Successful integrated behavioral health care includes patient education, follow-up, and coordination of care by a care manager with a specific mental health and/or addictions background

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