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Publications total: 16
  Apr 5th,2016

The focus on behavioral healthcare. No longer a neglected domain

Introduction:

The prevalence of behavioural health issues among the general public is extremely high and if statistics are to be believed then one out of five Americans suffer from a behavioural condition. While the conditions take a major toll on the patients the financial ramification for the healthcare sector is equally massive. It is stated that behavioural healthcare costs are at par with cancer costs and the conditions not just cause major disabilities but also loss of employment and livelihood, creating more pressure for the taxpayer (Soni, 2009). The situation is further aggravated due to lack of coordination or connectivity between primary care and behavioural healthcare. This lack of connectivity between the two forms of care has not just led to unfavourable treatment outcomes but also burgeoning healthcare costs. The unfavourable treatment outcomes are extremely common among patients who suffer for a behavioural condition along with a physical/physiological conditions. Same is also true for those patients who are undergoing treatment for drug abuse (Klein & Hostetter, 2014). Another major reason behind unfavourable treatment outcomes is the lack of adequately trained healthcare personals to deal with behavioural conditions in the primary care sector (Kathol, Melek & Sargent, 2015). It is known that an overwhelming majority of patients with behavioural issues visit their primary care centers to receive treatment and majority of the primary healthcare staff have very limited knowledge to properly identify and treat such conditions. As a result most of those patients leave the healthcare centers without receiving any appropriate treatment and do not show any signs of improvement what so ever (Kathol, Melek & Sargent, 2015). A minority of patients do visit the behavioural healthcare centers and receive the right treatment but due to lack of sufficient follow-up support patient treatment adherence becomes a major problem, leading to unfavourable treatment outcomes (Kathol, Melek & Sargent, 2015).

Due to the lack of satisfactory treatment outcomes, patients with behavioural health issues visit their healthcare centers repeatedly leading to high rates of repeat hospital admissions and high healthcare resource expenditure (Kathol, Melek & Sargent, 2015). The American Psychiatric Association has estimated that the cost to treat patients suffering from a behavioural condition along with a physical condition is up to 3 times higher than patients who just have one condition (American Psychiatric Association, 2014). So, in essence, it has become clearly evident that a proper coordination or integration between primary care and behavioural healthcare sectors can pay rich dividends both in terms of improved treatment outcome and reduced healthcare costs. So the question that arises at this stage is whether there are any barriers to this integration and if so what exactly are they?


Barriers to integration:

A quick glance at the current healthcare sector is sufficient to understand that integration between the two care sectors is very rare as of today and a good reason behind his could be the lack of any clearly perceivable financial or administrative advantage. The primary healthcare and the behavioural healthcare entities function under independent care networks and follow very different coding and billing practices. As a result unified structuring of behavioural and primary care practices becomes a real challenge and is almost impossible to achieve. Furthermore, due to the unique nature of certain behavioural healthcare services, the primary healthcare centers find it difficult to request reimbursement for the same or have to deal with very low rates of payment (Klein & Hostetter, 2014). The current privacy regulations also play a major role in preventing free sharing and dissemination of behavioural health related data between care centers, thereby affecting care delivery and treatment outcomes. Integration of primary care with behavioural healthcare requires effort from both the sectors in a way that they adapt their working protocols to achieve compatibility. Considering the fact that healthcare resources are already hard-pressed, the primary care centers often prefer to pass the burden of treating behavioural patients to the specialists and similarly psychiatrists and psychologists are often very reluctant to conduct their business in a primary healthcare setting citing alienation and incompatibility with the working environment (Klein & Hostetter, 2014).


Initiatives towards integration:

While it may be true that integration of primary care and behavioural healthcare is still at its infancy, many healthcare organizations have already taken steps towards achieving it. There aren't any dedicated government initiatives towards integration but many care centers are funding it either through their own funds or through the use of grants. In the United States many healthcare centers are covering the cost of integrating behavioural healthcare to the primary care through the waiver provisions in the Medicare and Medicaid (Croze, 2015). There are avenues within the Affordable care act and the Mental Health Parity and Addiction Equity Act that can be utilized to enhance the quality of both primary care and behavioural healthcare and integrate them for better treatment outcomes and greater cost savings. Healthcare coverage such as Medicaid are now required to include mental and substance abuse conditions in a manner that the benefits received for them are at equal levels to those received for primary medical or surgical conditions (Croze, 2015). The standard definition of the term "care" proposed by the Agency for Healthcare Research and Quality now means the outcome of the integrated services provided by primary care providers and behavioural healthcare professionals to patients in a highly systematic and cost-effective manner (Croze, 2015). Clinical trial studies carried out across the globe have also indicated the promise of integrated care delivery models in achieving better treatment outcomes and healthcare cost savings. A trial study on the effectiveness of collaborative care model called the IMPACT study involved around 1801 patients covering 18 healthcare centers spread across five states in USA ("IMPACT - Evidence Based Depression Care", 2016). The cohort members who take part in the study were comorbid for at least one behavioural condition and one medical condition and the results indicated that patients suffering from depression that received the collaborative care showed much greater improvement within a period of twelve months compared to those who received standard care (Unützer, 2013). Furthermore, the patients under the collaborative care also reported substantial improvements in the pain recovery periods and better quality of life. While the IMPACT study is highly significant, there are around 70 more clinical trial studies that have also highlighted a high efficacy of collaborative care compared to standard healthcare models. These trials have also shown that the collaborative approach is far more effective in treating behavioural conditions such a depression in patients who are also comorbid for at least another medical condition. The trials further indicated that the collaborative care models can be implemented in a very diverse range of clinical and population settings and as a matter of fact many prominent healthcare providers have already done so. Traditional billing and reimbursement models such as the fee for service is not compatible with the collaborative care model but more innovative reimbursement models have already been conceptualized and implemented to circumvent the barriers (Unützer, 2013).


Conclusion:

There is no doubt in the fact that behavioral healthcare is getting lot of attention in the recent times and the promise of collaborative care models is endorsed by a growing number of care providers from across the world. However the transition to collaborative care from independent care models will not be smooth and there are critical barriers that that will offer a real challenge to achieving the same. At present the care delivery models, the payment structure, the care network and even the work environment is very distinctive when a comparison is made between the primary care sector and the behavioural healthcare sector. So it is clearly evident that a government healthcare policy or the initiative of a single sector will not result in a successful collaboration. Different studies and clinical collaborative care trials have already highlighted the efficacy of the collaborative model and it is about time every primary and subsidiary player in the healthcare sector makes a conscientious effort toward achieving the greater goal.


References

American Psychiatric Association,. (2014). Economic Impact of Integrated Medical-Behavioral Healthcare . Denver: Milliman, Inc.

Croze, C. (2015). HEALTHCARE INTEGRATION IN THE ERA OF THE AFFORDABLE CARE ACT . Washington DC: Croze Consulting.

IMPACT - Evidence Based Depression Care. (2016). Impact-uw.org.
Retrieved 23 March 2016, from http://impact-uw.org/

Kathol, R., Melek, S., & Sargent, S. (2015). Mental Health and Substance Use Disorder Services and Professionals as a Core Part of Health in Clinically Integrated Networks. In K. Yale, C. Konschak & J. Bohn, Clinical Integration: Accountable Care & Population Health (3rd ed.). Virginia Beach, Va: Convurgent Publishing.

Klein, S., & Hostetter, M. (2014). In Focus: Integrating Behavioral Health and Primary Care .Commonwealthfund.org.
Retrieved 19 March 2016, from http://www.commonwealthfund.org/publications/newsl.../#1

Soni, A. (2009). The Five Most Costly Conditions, 1996 and 2006: Estimates for the U.S. Civilian Noninstitutionalized Population (1st ed.). Rockville: Agency for Healthcare Research and Quality.
Retrieved from http://meps.ahrq.gov/mepsweb/data_files/publicatio...

Unützer, J. (2013). The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes . Atlanta: Center for Health Care Strategies and Mathematica Policy Research.

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