The U.S. health care system has struggled to stem the rise in chronic health conditions in part because efforts have failed to address a key contributor to chronic illnesses—mental health, Steven Ross Johnson and Harris Meyer report for Modern Healthcare.
Despite legislative efforts to improve mental health parity and provider efforts to increase access to care, the National Alliance on Mental Illness estimates nearly 60 percent of the 44 million U.S. adults living with a mental illness do not receive treatment in a given year.
The association between mental and physical health
Researchers and providers increasingly are finding a connection between behavioral and physical health.
Data from the Robert Wood Johnson Foundation show about 68 percent of behavioral health patients have a medical co-morbidity, and according to Modern Healthcare, nearly 30 percent of adults with a non-mental health medical condition also have a mental health condition. Further, research shows individuals with mental health conditions on average die 25 years younger, generally due to other untreated chronic illnesses, than those without such conditions.
Alexander Blount, a professor of clinical psychology at Antioch University New England, said, "The co-occurrence of chronic illness and depression is really striking." He added, "If somebody is diagnosed with a chronic illness, they are twice as likely to have a behavioral health illness. But it's true the other way around; someone with a mental health diagnosis is more likely to have a chronic illness."
According to Modern Healthcare:
- Between 15 percent and 25 percent of patients with cancer suffer from comorbid depression;
- Between 15 percent and 30 percent of patients with diabetes also have depression; and
- Up to 33 percent of patients who experience a heart attack later develop depression.
How providers are tackling the problem
As the health care system moves toward value-based payment models, providers increasingly are adopting approaches that aim to address patients' behavioral health care needs, Modern Healthcare reports.
For instance, Advocate HealthCare began embedding a behavioral health specialist at two of its outpatient primary care practices after it discovered in 2012 that 26 percent of its medical inpatients had a behavioral health condition. According to Modern Healthcare, those patients accounted for $26 million in annual excess health care costs and extended patients' lengths of stay by an average of 1.07 days. The system also screens hospital inpatients and those in the ED for mental health conditions
Mission Health, meanwhile, created four special holding areas in the ED that function similar to psychiatric units. Richard Zenn, Mission Hospital's medical director for behavioral health, said the holding areas and new ED psychiatrist have improved discharge times for patients with mental health conditions and improved overall patient care. According to Modern Healthcare, the initiatives helped the health system reduce its "left-without-being-seen" rate for ED patients to 0.27 percent in March, down from the mid-single digits.
The health system also recently hired its first full-time ED psychiatrist, created a behavioral emergency response team, and launched a telepsychiatry program to evaluate ED patients at its five regional hospitals. Mission Health also is reaching out to the North Carolina Medicaid program to try to address a key barrier to providing behavioral health care to patients: low or no reimbursement.
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Experts also say that community-based behavioral and addiction services will play a critical role. The federal government is testing a new multidisciplinary model for delivering community-based mental health and addiction treatment. The two-year demonstration project, according to Modern Healthcare, includes dozens of centers in eight states.
Congressional action and potential barriers
Lawmakers in the past year also have taken steps to improve mental health and substance misuse treatment, but some experts are concerned that pending staffing vacancies and Republicans' Affordable Care Act (ACA) repeal efforts could thwart that progress, Modern Healthcare reports.
For instance, the 21st Center Cures Act, signed into law last December, included numerous reforms and grants targeting mental health care. Among other things, the law established:
- A new HHS assistant secretary position to focus on mental health reforms;
- A committee made up of members across federal agencies to make recommendations to Congress for better care coordination for individuals with a serious mental illness; and
- A National Mental Health and Substance Use Policy Laboratory to promote evidence-based service delivery models.
The law also strengthens federal enforcement of insurers' compliance with mental health parity rules and calls for clarity and further training on when providers may disclose health information related to treatment of an adult with a mental health or substance abuse disorder.
According to Modern Healthcare, experts say the Trump administration's delay in filling key positions at Substance Abuse and Mental Health Services Administration has slowed the agency's pace in implementing the law. President Trump in late April nominated Elinore McCance-Katz, an addiction psychiatrist and former medical director at the Substance Abuse and Mental Health Services Administration, for the new HHS assistant secretary position, but she has yet to be confirmed by the Senate.
Funding also is a concern, according to Modern Healthcare. While lawmakers in May passed a fiscal year 2017 appropriations bill that rejected a number of Trump's proposed cuts to health and social services programs, the outlook for fiscal year 2018 is uncertain.
Further, some experts say Republican efforts to repeal and replace the ACA could roll back the law's Medicaid expansion, which covers mental health and substance misuse treatment for about 1.3 million people. The House-approved American Health Care Act also would allow states to opt out of the law's essential health benefits, which includes mental health care in its list of 10 services health insurers are required to cover (Ross Johnson/Meyer, Modern Healthcare, 5/27).
Six steps to integrate behavioral health with other care
Behavioral health issues can exacerbate other health conditions and make patients less likely to comply with important care plan aspects. Since most patients are diagnosed in the primary care setting, integrated behavioral health models can ensure patients follow through with referrals to mental health care.
Download our toolkit to find resources to effectively address six critical components of an integrated behavioral health program.