New Study Bolsters Case for Coordinating Mental-Health Treatment with Healthcare

Andrew Kitchenman | November 21, 2014 | Health Care
Statistics show 75 percent of frequent hospital users in New Jersey have behavioral or substance-use issues

behavioral health costs
As New Jersey officials plan how to coordinate behavioral or mental-health treatment with other medical care, a new report makes clear how this approach can reduce the number of avoidable hospitalizations.

The study provides the first statewide, comprehensive look at an issue that has received increased focus from healthcare advocates: how chronic health conditions are linked to disproportionate healthcare costs and mental-health or substance-abuse issues.

Among people who had the most hospital stays, 74.9 percent had behavioral health conditions, compared with a rate of 32.3 percent for all patients who had hospital stays, according to a Rutgers Center for State Health Policy study.

“Overall these findings point to the need to coordinate physical healthcare services as well as behavioral healthcare services,” said Sujoy Chakravarty, an assistant research professor at the center and the study’s lead author.

For example, patients with diabetes are more likely to repeatedly visit hospital emergency departments if they have untreated depression or drug addiction.

“Inadequate management for one could potentially worsen the other,” Chakravarty said.

The study of state hospital discharge data from 2008 to 2011 found that the overlap between behavioral health issues and frequent hospital stays was even greater for low-income Medicaid recipients.

For example, 44.4 percent of Medicaid recipients who had at least four inpatient hospital admissions during the period covered by the study had severe mental illnesses – defined as a high level of functional impairment. In contrast, only 9.6 percent of those with fewer hospital stays had such illnesses.

While the study’s authors expected to see higher-than-average rates of behavioral-health conditions among those who use hospitals the most, “We were surprised with how high it was,” Chakravarty said.

Of the 74.9 percent of frequent hospital visitors with behavioral-health conditions, 36.9 percent had only mental-health conditions; 11 percent had substance-abuse disorders, and 26.9 percent had both mental-health and substance-abuse issues.

The study is one of a series funded by the Nicholson Foundation, which is aiming to improve the health of the state’s most vulnerable residents.

Chakravarty said the data will be useful in designing strategies to reduce avoidable hospitalizations for people with chronic conditions, as well for the sickest residents with the most complex medical problems.

Some healthcare advocates are pushing for the state to integrate management of behavioral healthcare with other healthcare. They point to Tennessee’s Medicaid program – in which each Medicaid managed care insurer manages the behavioral healthcare of its members — as a potential model.

The strong connection between behavioral health and other health conditions points to the need to integrate treatments, Chakravarty said.

As part of a five-year waiver from federal Medicaid rules, the state has been planning to name a separate administrative services organization to manage the behavioral healthcare of all Medicaid recipients.

For example, primary-care providers could screen patients for behavioral-health conditions and refer them to the appropriate behavioral-health providers, Chakravarty said.

The related issue of state regulations that require behavioral health facilities to be physically separate from medical offices has been the focus of policy debates. A bill advancing in the Legislature would allow community clinics, such as the state’s federally qualified health centers, to be licensed to provide behavioral healthcare along with other care.

“If these were co-located, then certainly both these types of services could be provided in a seamless fashion,” Chakravarty said.

The study confirms suspicions that policymakers and clinicians have had about the link between behavioral health conditions and frequent hospital use, said Rachel Cahill, Director of Health Care Improvement and Transformation with the Nicholson Foundation.

“We try whenever possible to have a data-driven and evidence-based approach,” Cahill said in explaining the importance of funding the study.

She noted that behavioral-health treatment can be difficult to access, with some psychiatrists having months-long waiting lists. The data in the study underscores the urgent need to address the problem.

The study could prove to be particularly useful for the state’s Medicaid accountable care organizations — local groups that are coordinating care between different healthcare providers. The study includes detailed data on each of 13 low-income areas that the Rutgers center has been studying to help improve healthcare quality and reduce healthcare costs.

Chakravarty said having the new data will allow policymakers to make better-informed decisions. While both state and national healthcare policies are increasingly looking to integrate behavioral healthcare with other care, the study “really creates the evidence base, the justification for that policy.”