New services, new ways of delivering them, and new ways of managing insurance benefits for mental health and substance abuse disorders are transforming the behavioral health sector. Long-term inpatient psychiatric treatment has been long gone, but traditional outpatient counseling and psychotherapy are also disappearing in favor of evidence-based, goal-oriented programs and adjunctive services.
Two of the driving forces behind these changes are an emphasis on integration of behavioral and physical health services and greater emphasis on case management with accountability for treatment outcomes.
“The integration of physical and behavioral health is based on greater understanding of the strong interrelationship between the two,” says Mark Covall, president and CEO of the National Association of Psychiatric Health Systems. “Historically, mental health conditions have not been dealt with during medical treatment. Likewise, people with mental health conditions have not had their medical conditions managed.”
Shorter stays for mental health patients over the last decade can be attributed to medications, says Mark Covall, president and CEO of the National Association of Psychiatric Health Systems.
In addition, “There is a cultural change encouraging people to get help if they need it; the players are all in — employers, the public, and certainly providers,” says Hal Levine, DO, chief medical officer of Value Options, a managed behavioral health organization. “Greater acceptance of behavioral disorders has led to an increased demand for treatment, particularly in the affective disorders such as depression and anxiety. But we have not seen a significant increase in the diagnosis of psychoses, except in the situation of co-occurring conditions with substance abuse disorders.”
“The integration of behavioral and physical health includes an emphasis on streamlining access,” says Suzanne Gelber Rinaldo, PhD, a recognized authority on mental health policy and president of the Avisa Group, a consulting company. “Employers are starting to allow access to mental health and substance abuse services in a primary care setting. They recognize the impact of these disorders on their businesses and they understand that if employees can access services either through their primary care physician or behavioral health providers, they may avoid more serious deterioration later on.”
“Primary care physicians are writing about one third of the prescriptions for mental health and substance abuse disorders,” says Suzanne Gelber Rinaldo, PhD. Primary care physicians might not use the best screening tools.
Integration is part of the latest round of health care delivery system reforms. “Patient-centered medical homes [PCMHs] and accountable care organizations [ACOs] are offering a lot more longitudinal oversight of behavioral health treatment, with primary care physicians watching you from beginning to end,” says Levine. “You have an organization that is taking the long-term view of what your needs are, and this is increasing the likelihood of greater continuity in care.
“It’s too early to see the outcomes, but this is happening nationally.”
Even though PCMHs and ACOs may be incorporating behavioral health into their organizations, there are shortcomings with integration.
“Primary care physicians are writing about one third of the prescriptions for mental health and substance abuse disorders,” says Rinaldo. “They don’t necessarily do it the way the evidence-based protocols would have them do it, but that number indicates the extent to which basic treatment has moved into physician offices.”
Accurate screenings needed
Physicians don’t necessarily reach out to identify and treat mental health and substance abuse disorders. “Coordinated care starts with accurate screenings, and they should be done every year, but it’s not happening routinely,” says Rinaldo. Physician practices may use patient checklists to ask about behavioral health issues, but that provides an easy out for patients. Rinaldo says real assessments are important, such as direct questions about alcohol use by patients with diabetes. “This screening, followed by a referral for a brief intervention like three to five counseling sessions, would be a rather simple way for primary care practices to move to integration in dealing with behavioral health problems.”
Treatment and changing services
The treatment of mental and substance abuse disorders continues to move away from the historical inpatient or residential treatment and long-term psychotherapy.
Treatment is being pushed toward evidence-based outpatient therapies and a wide range of supportive services. “Medications, of course, are effective,” says Rinaldo. “In addition, there is evidence for short-term protocol-driven counseling such as cognitive behavioral therapy [CBT], family systems therapy, or motivational interviewing. All have been shown to be cost-effective.”
Other evidence-based and emerging best practices include integrated dual-disorder treatment, supported employment, assertive community treatment, and wellness management and recovery.
The American Psychiatric Association says that e–mental health use is expanding and showing promise. It cites recent studies of how the Internet is being used in four areas of mental health care: providing information; screening, assessment, and monitoring; therapist-assisted CBT; and social support. The APA says there is rigorous research supporting the effectiveness of all of these Internet-based interventions.
“Employers are behind many of the changes in behavioral health,” says Rinaldo. “They are really pushing technology as a way to make access easier.”
Internet access to therapy is great for the increased demand coming from 18- to 26-year-olds who now have employer-sponsored coverage, says Gary Henschen, MD, the behavioral health chief medical officer at Magellan Health Services. “There is demand for depression and substance abuse services from this age group, but young people don’t plug into traditional case management — they don’t answer the phone — so digital forms of interventions have been critically important.”
“Young people don’t plug into traditional case management — they don’t answer the phone — so digital forms of interventions have been critically important,” says Gary Henschen, MD, the behavioral health chief medical officer at Magellan Health Services.
Internet interventions offer knowledge, awareness, and treatment. “Payers are starting to realize they need to get to this age group through new avenues, and another example of their efforts is telepsychiatry,” says Henschen. “Our experience is that health plans may sponsor the sites, sometimes at no cost to patients whose benefits have been verified.”
Then there’s the recovery movement.
“It’s a peer approach where someone the patient identifies with helps the individual overcome challenges that pop up,” says Henschen.
Recovery programs also help with employment and housing, which have been shown to improve community tenure — defined as the amount of time the patient spends out of the hospital, he says.
“In our programs involving recovery techniques, we even work with psychiatrists on how they treat patients and their own attitudes about serious mental illness,” says Henschen.
Rinaldo says that “Adjunct therapies like mindfulness meditation, yoga, exercise programs, or nutrition counseling are covered in more situations. Managed behavioral health organizations are becoming smarter about the role of these services and are moving in this direction, but the health plans are generally taking a little longer to get there.”
While new community-based treatments are expanding, the National Institute of Mental Health (NIMH) is moving in a different direction. “Some of the most exciting developments in treatment are in neuroscience,” says Rinaldo.
The National Institute of Mental Health’s director is committed to rooting out the neurobiological impact and causes of mental and substance abuse disorders. Rinaldo says that the most interesting progress is with addictive disorders. The scope of NIMH’s research includes genetic, biological, behavioral, and environmental mechanisms associated with complex social behavior.
Complex mental disorders
Many recent developments apply to routine situations — mild to moderate affective disorders — where people are able to function in the community. But there are patients with serious and persistent mental illnesses — schizophrenia, bipolar disorder, delusional behaviors, and complex personality disorders. These disorders require more intensive services, and these individuals may have a greater need for crisis treatment or acute short-term inpatient admissions.
“Crisis behavioral health services fall between the cracks in both the public and private sectors,” says Rinaldo. “The emergency room is not the place to be if you can avoid it. Emergency treatment and management of patients in crisis depends on whether the hospital has developed relationships with behavioral health providers and facilities and whether short-term admissions are required.”
Some experts say that the number of mental health and substance abuse crisis cases is stable, but contrary data also exist. A June 2013 report by the Centers for Disease Control and Prevention looked at the incidence of emergency department visits in North Carolina from 2008 to 2010 by patients with mental health disorders.
From 2008 to 2010, the number of ER visits increased by 5% while mental-health-related ER visits increased by 18%. In 2010, mental health visits accounted for 9% of all ER visits, and 31% of those visits resulted in hospital admissions, compared with an admission rate of 14% for all ER visits.
Stress, anxiety, and depression were diagnosed in 61% of the ER visits. The rate of ER visits for people ages 65 or older was nearly twice that of people ages 25 to 64. Half of people ages 65 or older with mental health diagnoses were admitted to the hospital.
The expansion of outpatient treatment approaches has led to a decrease in the number of state and private psychiatric hospital beds that provided treatment for complex psychotic patients.
“The standard of psychiatric hospital care today is crisis management, stabilization, and then transfer to outpatient care,” says Covall. “There is a gap in the availability of longer-term psychiatric beds for the extremely difficult psychotic conditions, but that is a small subset of the population.”
Changes in approach and managed care efforts have led to fewer inpatient or residential admissions, and the length of stay across all populations and all payers is between 9 and 10 days, says Covall. That has been stable for about the last decade. The shorter length of stay is due to improved medications.
“We conducted a study of Medicare patients who are covered by the inpatient psychiatric perspective payment system and found that 71% of patients who were admitted to psychiatric hospitals did not return within the calendar year,” says Covall. “This shows that the majority of patients can be stabilized, discharged, and returned to outpatient services with indications that they will do very well.”
In lieu of inpatient treatment, demand is increasing for partial hospitalization and intensive outpatient care.
Partial hospitalization programs are designed for two types of mental health or substance abuse patients: those who maintain themselves in the community at a minimum-to-moderate level of functioning and present no imminent harm to themselves or others, and those who are making the transition from inpatient care back into the community.
These daytime programs are conducted Monday through Friday for about six hours per day. Intensive outpatient programs involve two or three sessions a week, each lasting about three hours.
Child and adolescent psychiatry is another area where treatment resources are a problem, because the providers are few and far between. “There’s a national shortage that results in young people going to the emergency room because they don’t have another source of care,” says Rinaldo.
Experts are concerned about prescribing of psychotropic drugs for children and adolescents. Rinaldo adds that there is a problem with the availability of short-term acute inpatient beds for adolescents.
MBHOs change their focus
Utilization review gives way to case management
Managed behavioral health organizations (MBHOs), both independent contractors and units within health plans, are changing dramatically in response to the ways in which the behavioral health sector is changing. In some cases they are leading change — particularly in the area of new services — and in other situations they are responding to new standards and expectations.
Historically, MBHOs have been viewed by patients and providers as gatekeeping utilization managers. “Another view is that they weren’t engaged in true utilization management; many people felt they often set arbitrary treatment or benefit limitations,” says Tricia Barrett, MHSA, vice president for product development at the National Committee for Quality Assurance (NCQA).
“The challenge is that there is insufficient evidence about many treatment approaches,” says Tricia Barrett, MHSA, vice president for product development at the National Committee for Quality Assurance.
“Under parity, those limitations have to go away, so by necessity that is leading to case management or a supportive role.”
Suzanne Gelber Rinaldo, PhD, an authority on mental health policy, says that “Payers on the private side are starting to pay for real case management rather than utilization management. MBHOs are being held accountable for quality-of-care performance measures.”
Hal Levine, DO, chief medical officer of Value Options, a managed behavioral health organization, says that “For a long period, our clinical professionals functioned in more of a traditional utilization management role, but they have moved into case management. Their efforts are focused on shaping care with evidence-based guidelines plus assessments of patient status, and extend to which treatment protocols are working. We look to the American Society of Addictive Medicine criteria and APA guidelines, so the discussion is not about the level of care; it’s about patient progress under treatment protocols.”
Gary Henschen, MD, of Magellan Health Services, says that “Now we find that care coordination is far more important than utilization management. In some situations our case managers are located within the health plans, so they can coordinate with the health plan’s case managers. We have 56 employees onsite at one health plan.”
As the focus shifts from utilization management to case management, the mantra is evidence-based treatment. “The challenge is that there is insufficient evidence about many treatment approaches,” says Barrett. “That makes it very difficult to determine the appropriateness of the treatments being used. That is where patient-reported outcome measures are going to play an important role. One of the expectations in our MBHO accreditation program is for these organizations to find a way to use the PHQ9 assessment tool, which was designed for diagnosis, to monitor treatment and determine the point at which the patient can be transitioned to the primary care setting. Some organizations say they have their own mechanisms for tracking treatment outcomes, but the PHQ9 has a strong evidence base behind it and there are limited alternatives for tracking treatment and outcomes.”
MBHOs are being pushed into performance-based case management programs by the Affordable Care Act, which has requirements for care transitions, chronic disease management, and patient satisfaction. Employers have similar expectations, and health plans are implementing performance measures for MBHOs.
The NCQA has an MBHO accreditation program, and its case management measures include follow up after a mental illness hospitalization, adherence to antipsychotic medications for people with schizophrenia, diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications, and hospital readmissions.
MBHOs are even taking a leading role in transforming services. “Managed behavioral health organizations are increasingly relying on telehealth and more medication management combined with case management,” says Rinaldo. “The third piece is more use of inexpensive adjunctive therapies like yoga, support group exercise, and so on. They are becoming smarter about those things. Health plans are taking a little longer to get there.”
Levine says that “Our new programs, like our focus on recovery and community tenure, have been particularly successful in the Medicaid programs that offer them. We often have more flexibility to develop supportive services in Medicaid programs than in commercial plans.”