Improving Behavioral Health Through ACOs and Integrated Care

What are the costs associated with behavioral health disorders—both societal and financial?

The costs are gigantic; with estimates ranging from $200 to $500 billion a year for a variety of treated and untreated behavioral health issues. Exacerbating these costs are the stigma of disease, the difficulty severe behavioral health patients have finding and complying with care, and the complexity of multiple comorbidities.

Do patients with behavioral health disorders cost more to cover? Are these conditions in line with the cost-stigma associated with other medical pre-existing conditions?

Yes, these patients cost more for a number of reasons. They are more likely to be nonadherent and more likely to be hospitalized for some comorbidities. Their access to care is poor and their care across physical and mental health is fragmented. Regarding the cost-stigma, these patients may have it worse as their behavioral health issues also are associated with higher general health care costs.

Is the number of patients with behavioral health disorders growing? If so, why do you think that is happening?

Maybe—but my hunch is that the medical industry is doing a better job of screening for and identifying patients with behavioral health issues.

What is the quality of care like for most patients with behavioral health disorders?

Well, we know that patients only get recommended care based on quality initiatives about half of the time, whether due to clinical judgement, patient noncompliance or splintered care, and other barriers to access. A recent article in Health Affairs called for expansion and improvement in quality measures in behavioral health.

What factors make behavioral health disorders difficult to treat? Is patient identification a factor? Are comorbidities a factor?

All of the above. Comorbidities become more prevalent and harder to treat. Patients often have lower socioeconomic status, which limits access to care. Access to behavioral health facilities is limited, even for outpatient services and there are even more mundane barriers, like access to transportation.

Can integrated delivery networks and ACOs help to alleviate the burden associated with behavioral health disorders, while also providing quality care? How so?

Yes —and we’re seeing some examples of that. Crystal Run Healthcare, an ACO in New York, has moved its psychiatrists into a building with the medical specialists and formed a multidisciplinary team for comanagement of patients. The Pioneer ACOs showed savings in behavioral health in the first year, although that wasn’t sustained.

Behavioral health disorders include substance abuse disorders—can ACOs help to alleviate the immense burden of opioid misuse in America?

Only if the incentives become aligned. Of course, reduction of opioid misuse is a huge public health problem and requires provider input, but right now it seems as if there is more of an effort to stop prescriptions in general than using multidisciplinary care in an ACO to solve these problems.

Does improved care for patients with behavioral health disorders reduce health care utilization?

Yes—Missouri’s Chronic Care Improvement Program integrated care for patients with severe mental illness and showed over $8 million in savings. Kaiser Sacramento saw a 50% per-patient per-month decrease in cost in its chemical dependency program, with declines in hospitalization rates.

What complications are associated with delivering quality care to patients with behavioral health disorders through ACOs?

Most behavioral health providers didn’t qualify for “meaningful use,” so many have limited ability to integrate their electronic medical records for sharing data across an ACO. Also, sharing that data about drug and alcohol issues can require patient consent beyond basic HIPAA.

Is there anything else you would like to add?

One of the first people who taught me about managed care back in the 90s said that the best way to be successful at medical management is to add a component of behavioral health management for complex patients. All of my experiences since then have convinced me that he was right—20 years ago.