State Leadership Conference

What will behavioral health care look like in 2021?

Answering that question was the goal of a plenary session at the 2011 State Leadership Conference, which had as its theme “Building a Leadership Culture.” Representatives from state government, the insurance industry, the public sector and business shared their perspectives on how health-care reform, mental health parity and other forces will affect the field for years to come.

“We worked with the Council of Executives of State, Provincial and Territorial Psychological Associations to put together a program that would provide a multifaceted perspective from the health-care industry,” said session moderator Katherine C. Nordal, PhD, executive director for professional practice at APA and the APA Practice Organization. “With four of the five industry leaders who presented at the session being psychologists, the view offered was very germane to the audience.”

Expanded coverage

Less than 1 percent of the average cost of an employee health plan goes toward behavioral health, said Dr. Ron Finch of the National Business Group on Health (credit: APA photo)Over the next two years, increasing numbers of people will qualify for government-funded health care, said Jane Cline, West Virginia’s insurance commissioner. In West Virginia alone, health-care reform could add 175,000 beneficiaries to the state’s Medicaid population. Another 178,000 residents — mostly the working poor — are likely to qualify for a new state insurance exchange and receive a tax subsidy to help cover the premiums.

The state exchanges will be competitive marketplaces that allow individuals and small businesses to easily compare and purchase insurance plans. States have the option of creating their own exchange or letting the federal government step in to create one for them. West Virginia has decided to develop its own exchange as a way of maintaining control and better serving its residents, said Cline.

“We felt it would be better to have people on the ground working with consumers,” Cline said. “We envision one portal.” Describing the portal as one-stop-shopping, Cline explained that eligible consumers would be sent to Medicaid, the Children’s Health Insurance Program or the state exchange.

The details of the state exchange are still fuzzy, said Cline, because the federal government still hasn’t outlined the essential benefits that state exchanges must cover. While the health-care reform law makes mental health and substance abuse services mandatory, the specific services that must be covered are still being worked out by the Institute of Medicine.

“Many of the rules of the 2,300-page bill are yet to be developed,” said Cline, adding that states must have their exchanges running by 2014 or risk federal government takeover.

In addition to time constraints, state health-care administrators also have to deal with the antipathy some legislators feel toward the law.

“In our view, whether you like the law or not, it is the law,” said Cline, adding that 23 of the 26 states involved in a federal lawsuit are moving forward with implementation despite their hopes for repeal by Congress or a Supreme Court victory. “We’re working as fast as we can to ensure the pieces are put in place.”

Health-care consolidation

As health insurance companies also grapple with health-care reform’s as-yet-undefined details, one thing is certain: escalating costs, said Andrew Sekel, PhD, chief executive officer of a managed-care company called OptumHealth Behavioral Solutions. The result of the industry struggling to rein in those costs will be fewer — and bigger — companies, he predicted.

“We will see significant consolidation driven by the notion that integrated systems are more efficient than large numbers of people trying to coordinate private practices,” he said, adding that hospitals and insurance companies are already busy buying provider organizations while provider organizations are buying other groups.

This shift will have a huge influence on behavioral health, he said, explaining that payers are pressuring providers to consider integrated models of care delivery.

“The consistent message is that behavioral health care can’t stand apart; it needs to be integrated into the delivery system,” said Sekel. “We believe that behavioral health practice will be more integrated into medical systems.”

To prepare for this new world, psychologists and other behavioral health professionals need to adopt electronic medical records that will allow them to communicate with physicians and other providers. “Electronic medical records are going to be the passport for being involved in these integrated systems,” said Sekel.

Mental health parity will also have a big impact — perhaps in some unexpected ways, said Bruce L. Bobbit, PhD, vice president for quality improvement at OptumHealth.

“Parity is great in principle, but complex in practice,” said Bobbit, explaining that the legislation’s goal was to make behavioral health care as easy to get as medical care. “The assumption was that medical health care was uniformly easier to access than behavioral health care, but when you look at what parity actually means, the story becomes very complex.”

In response to the law, OptumHealth has brought behavioral health policies into line with the medical policies in each of the health plans it has a relationship with. For some plans, that means that behavioral health is now subject to the same aggressive reviews medical and surgical benefits are subject to, with payers questioning whether the care requested is excessive or even medically necessary. The requirement that plans have a single deductible for all services could mean that out-of-pocket expenses for behavioral health care go up for some people. And because there will be separate administrative procedures for each of OptumHealth’s customers, the complexity that psychologists and patients face in dealing with the company may increase.

Data-driven, recovery-focused patient care

Arthur C. Evans Jr., PhD, director of the Department of Behavioral Health and Mental Retardation Services in Philadelphia, outlined other trends that will affect psychology. For one, data will increasingly drive decisions within behavioral health, he said. Payers and others are pushing for empirically proven treatment and performance measures for providers, he said.

“Twenty years ago, providers were paid on a fee-for-service basis; no one ever asked if the patient got better,” said Evans. “Those days are over.”

The definition of success is also changing, said Evans. Psychologists must embrace a movement that will bring changes he called as profound as deinstitutionalization: the shift from simply reducing symptoms to promoting long-term recovery. Take a patient with schizophrenia who spends his days watching TV in his parents’ basement. “In the traditional system, he would be considered a success, because he wasn’t in the hospital or jail, wasn’t costing a lot of money and wasn’t bothering anyone,” said Evans. Now success will mean re-integration into a productive life in the community, he said.

Dr. Eduardo Cua of Hawaii (credit: APA photo)A new focus on disparities will help ensure that more patients than ever benefit from treatment, said Evans. But efforts to reduce health disparities have to go beyond what happens in treatment, so teaching cultural competence isn’t enough. What’s also needed are more psychologists to work in underserved areas and training that prepares psychologists to work with prisons, the child welfare system and other entities, he said. Evans also urged psychologists to get involved as decisions are made about integrating behavioral health into the broader health-care system. One especially important issue is how to design services in an integrated environment. “When people talk about integration, they’re mostly talking about integrating behavioral services within primary care,” he said. “It’s also important to have primary care in behavioral health settings, especially for people with serious mental illnesses.”

Psychologists should also prepare themselves for the growing emphasis on technology, said Evans. For some, especially psychologists in public or nonprofit agencies with little capital to invest, this emphasis on technology could prove problematic. But technology also offers opportunities, said Evans, citing the use of telemedicine and social media to keep people engaged in treatment.

An aging, overtaxed work force?

Demographic and economic trends will also affect the field. As the health-care system faces dramatic changes over the next decade, it must keep up with American workers’ increasing need for behavioral health care, said Ron Finch, EdD, vice president of the National Business Group on Health.

“In the last two years, the gross domestic product has increased about 2.5 percent, except in the last year we did it with seven million fewer workers,” said Finch. “Those that are in the workplace are carrying a heavier load.”

Depression is the No. 1 health-care cost for employers, with anxiety just behind it. But direct health-care costs aren’t the only concern, said Finch. These and other behavioral health conditions also have hidden costs, decreasing productivity and increasing sick-day use, for example.

Nonetheless, said Finch, less than 1 percent of the average cost of an employee health plan goes toward behavioral health. Plus, treatment is often inadequate. “In the majority of cases, employees placed on disability for depression are only receiving antidepressants,” said Finch. Changing demographics are also increasing employers’ concerns. As the baby boom generation ages, said Finch, employers must find ways to keep these employees working since there aren’t enough younger workers to replace them. Plus, he said, younger workers often have poorer health and lower educational attainment than workers of the baby boom generation. A 2009 Department of Defense report found that three-fourths of 18- to 24-year-olds wouldn’t qualify for military service, primarily because of poor health, he said.

If that’s true for the military, said Finch, what it means for employers is that they’re about to be hit with massive health-care costs. “We understand that behavioral health folks are going to play a big role in helping us address these issues,” he said.

Rebecca A. Clay is a writer in Washington, D.C.