In a trend that has the power to significantly improve patient care, health systems are becoming more proactive about identifying patients’ behavioral health needs earlier on, investing in strategies ranging from providing apps and telemedicine to promoting more routine screening during primary-care visits.
The best efforts, say proponents, treat emerging behavioral health issues before they reach the level of a clinical diagnosis.
“Providers are recognizing the significant benefit, obviously on behalf of the patients but also from an operations and financial perspective, of addressing behavioral health issues and really treating the whole person,” says Joseph Miller, PhD, who chairs the American Hospital Association’s Section for Psychiatric and Substance Abuse Services. It means, for example, if a patient has anxiety and a chronic cardiac condition, they can get treatment to improve both, potentially shortening their hospital stay, he says.
Treating someone for a physical condition who also has a behavioral health condition can double or triple the bill, according to a 2014 report that Milliman Inc. prepared for the American Psychiatric Association. If behavioral health services were to be fully integrated with physical treatment, the savings to the American health-care system could be vast—$26 billion to $48 billion annuallyopens in new window, the firm calculated.
At this point, that level of integration remains a steep climb given the chronic shortage of mental health providers. One federal analysis projected a shortage of as many as 57,490 psychologistsopens in new window by 2025. According to data from the National Council for Behavioral Health and the Cohen Veterans Network, nearly 4 in 10 Americans report waiting longer than a week to get mental health treatment.
Innovative solutions
But health organizations are striving to intervene sooner, bringing behavioral health services closer to the patient, and sometimes into the patient’s home. In 2019, Northern California–based Livongo Health, which has developed technology to assist people with better managing diabetes and other physical conditions, acquired Denver-based myStrength. That company’s web- and mobile-based behavioral health-care platform, created with input from psychologists, already was contracting with more than 120 health organizations, including hospital systems.
Meanwhile, more health systems are working to flag behavioral health or substance use concerns during physical checkups. In one example, New Jersey’s Hackensack Meridian Health partnered with Cooper University Health Care to launch a pediatric psychiatry collaborative that now includes more than 500 pediatricians statewide. When those pediatricians identify a potential concern, they have a network of psychologists and other clinicians to which they can immediately refer that patient.
Moving forward, some of the best potential for return on investment will likely stem from such efforts to more frequently tap psychologists’ expertise to help better manage depression, anxiety and other mental health challenges that can sabotage physical conditions such as diabetes, says Stephen Gillaspy, PhD, APA’s senior director for the Office of Health Care Financing.
“We’ve got great treatments,” Gillaspy says. “The problem is that a lot of times the patients aren’t too compliant with those treatments. I think that there’s going to be an increasing role for psychologists to work with medical teams to improve compliance, which then improves their outcomes,” such as fewer emergency room visits, he says.
Moreover, he adds: “There are psychological and behavioral processes that can impact your medical management that don’t have to meet criteria for a mental health diagnosis,” such as low-level anxiety undercutting diabetes control. “I think that is the sweet spot.”
Catching subclinical issues
Cherokee Health Systems, which has blended behavioral health with primary care for years, emphasizes immediate follow-up. If a health provider identifies a potential behavioral health or substance use concern, the goal is to get the patient a further assessment during that same visit, says Parinda Khatri, PhD, chief clinical officer at the Knoxville, Tennessee–based nonprofit health organization, which treated 69,000 patients in 2018.
“If they have to wait a day or the next week, that is a fail in our mind,” Khatri says. Not only might some patients be unable to return for the follow-up visit, she says, but the interventional window might have closed by then.
“Particularly with substance misuse,” she says. “When someone is ready, they’re ready. And they may not feel the same way the next day. You have to optimize that opportunity.”
Cherokee Health was among the systems that shared return-on-investment results in an American Hospital Association report about behavioral health initiativesopens in new window published in 2019. Their behavioral health co-management with primary care, they reported, reduced emergency department visits by 68%. The report also describes the investment payoff at other facilities, including at Yale New Haven Psychiatric Hospital in Connecticut and Utah’s Intermountain Healthcare.
Since its acquisition by Livongo, myStrength has added roughly 20 more health organizations to its client roster, says Scott Cousino, myStrength’s co-founder and Livongo’s senior vice president of behavioral health. Several psychologists were consulted in the creation and expansion of the various components available to users through the digital platform, including personalized assessments and various behavioral management and motivational tools.
The inherent privacy that virtual behavioral support provides might reach individuals struggling with a subclinical issue—such as overmedicating a bit with alcohol—who might not otherwise seek out care, Cousino says. (myStrength’s data show that more than 65% of users aren’t currently seeing a therapist.) Through its virtual platform, myStrength also promotes the benefits of therapy, including with psychologists, he says. And when a user is believed to be at elevated risk, based on the platform’s periodic mood tracking and assessments, they’re encouraged to seek out a mental health clinician.
Bringing care closer
Providing more timely interventions before a patient feels forced to seek out costly emergency care is where health systems are moving, says Miller, who is also vice president of behavioral health-care transformation services at Hackensack Meridian. Not only does that save money, but frequently it’s better for the patient, he says. “Probably the worst place to be in the midst of a behavioral health crisis is an emergency room.”
In 2019, Hackensack Meridian opened an urgent care center with expanded behavioral health services after its own data found that nearly half of patients with behavioral issues didn’t require an emergency department level of care, Miller says. Patients will receive a medical screening first to check, for instance, that the symptoms of a possible panic attack are not those of a heart attack, he says. As of fall 2018, the state-funded pediatric psychiatry collaborative that Hackensack Meridian launched has already screened more than 130,000 children and referred 7,120 for further assessment or treatment. Some of the most common concerns include anxiety, depression and attention-deficit disorders. When children are believed to be on the autism spectrum, psychologists can provide additional testing.
Despite encouraging progress in innovation, reimbursement remains a sticking point, particularly for nontraditional interventions, whether that’s touching base by phone or even a text exchange. Also, since a diagnosis is typically required, there’s no payment for steps taken to avert a subclinical issue before it worsens, Khatri adds.
But some progress has been achieved recently, in the form of higher reimbursement through the health behavior assessment and intervention codes. APA advocated for those payments to be raised to a comparable level to psychotherapy services, federal officials agreed and the changes went into effect Jan. 1 (see "New codes and better reimbursement").
If those higher rates hold, psychologists will be better compensated for their role in improving compliance for patients with diabetes, hypertension or another medical condition, even if that patient doesn’t have a mental health diagnosis, Gillaspy says. “That should open up the door and make it easier for psychologists to do that work even in a fee-for-service market,” he says.
