Behavioral health and value-based care: Is it time?

August 28th, 2017 / By Steve Delaronde

The trend towards value-based payments has been accelerating. There is a significant opportunity for reducing spending while improving quality across many areas of health care, including primary care, oncology, orthopedic surgery and pharmacy. Behavioral healthcare has been surprisingly absent in this conversation, even though it accounts for more than $200 billion in annual spending nationally. There are good reasons why behavioral health has not entered the mainstream of value-based care, but this may change if some key issues are addressed.

The opportunity for cost savings in behavioral health is not as well-established as it is for other medical conditions. While examples of over-diagnosis and over-treatment are cited in many areas of health care, under-identification, under-treatment, gaps in care transitions, and poor coordination across the healthcare system seem to be more serious issues for behavioral healthcare. For example, patients referred for psychotherapy to treat depression often don’t make their first appointment, and among those that do initiate treatment, early dropout is common. One study showed that the average number of therapy sessions completed is only two.

Performance measures for behavioral health conditions remain a stumbling block, as well. The desirable outcome for many behavioral health conditions is improved social or functional status, which is difficult to measure. While the PHQ-9 and other assessment tools are easily administered for screening, diagnosing, monitoring and measuring depression, it is neither uniformly used, nor is it recorded in administrative claims systems. There is opportunity to extract important information from electronic medical records, but that requires an approach to integrate unstructured data into data structures and reporting.

Increasing screening rates for depression and substance abuse, as well as improving medication adherence rates for chronic behavior health conditions like depression, schizophrenia or bipolar disorder can be accomplished in primary care and pharmacy settings. While successful implementation of these approaches can increase pharmacy and outpatient treatment costs, more intensive mental health services can be avoided. Cognitive behavioral therapy (CBT) has been shown to be clinically and cost effective in treating patients with depression that have not responded to pharmacotherapy. Addressing the availability, access and affordability of outpatient services for patients is critical.

Additionally, behavioral health conditions frequently co-occur with chronic diseases, such as asthma, arthritis, cardiovascular disease, cancer, diabetes, and obesity. This can result in poorer management and higher costs for treating the physical effects of these diseases than they would be if behavioral health issues were not present. Collaborative care approaches to treating depression in people with diabetes have demonstrated cost-effectiveness compared to usual care.

All behavioral health conditions are not the same. Targeting high-cost mental healthcare patients may be more effective at reducing total cost for this patient segment than approaches that span across the entire population. A recent study found that high-cost mental health patients incur over 30 percent more costs than other high-cost patients. Identifying patients with persistently high behavioral health costs, which may include frequent inpatient or emergency room visits, may be more effective at reducing the overall cost of behavioral health treatment through care management, medication management and lower intensity services.

Population-based approaches to improve quality and reduce costs are possible, but the tendency for providers to favor low severity patients in their attributed patient population must be addressed. A risk adjustment methodology that works for behavioral health conditions is an important accompaniment to any attribution methodology. Unfortunately, attribution is typically based on healthcare utilization. Any method which is intended to identify behavior health conditions according to treatment history will not include those who have not received treatment.  Providers who screen more of their patients will typically identify patients with lower severity conditions, thereby furthering the need for risk- adjustment.

The benefits of treating mental health and substance abuse disorders extends beyond the medical system. One study estimated that $1,583 of substance abuse treatment costs was associated with a monetary benefit to society of $11,487.  While this benefit included reduced costs associated with injury or illness, the primary reason was a reduction in crime and increase in employment earnings. This means that programs which extend beyond the healthcare system and take into account the socioeconomic determinants of health may be most successful.

Value-based behavioral health programs can certainly address under-diagnosis, under-treatment, poor medication adherence, as well as poor coordination and care transitions. The impact on total cost of care may be significant for patients with the highest severity conditions, as well as those with co-morbid physical chronic conditions, such as diabetes, heart disease and cancer. Ultimately, the most successful programs will be those that extend beyond the healthcare system and address the social and community impacts of behavioral health and substance abuse treatment.

Steve Delaronde is director of analytics for populations and payment solutions at 3M Health Information Systems.