Over the course of the many years that I have been involved in healthcare, I have heard complaints about the adequacy of services for people with mental-health and substance-abuse problems. Most of those reading this column will have heard about or even directly experienced these problems — trying to find a compatible mental-health provider for a family member in distress or talking with a friend or family member who is a mental-health provider complaining about challenges paying practice expenses in light of low insurer payment rates.
A new report by the Center for State Health Policy puts a fine point on the importance of ensuring accessibility of behavioral health services that are well coordinated and integrated with physical healthcare. The report examined the extent of behavioral health diagnoses among high users of hospital care and people with potentially avoidable hospitalizations.
High users of hospitals, those with multiple inpatient stays or emergency department (ED) visits, are often people for whom the healthcare system has failed. They tend to have multiple chronic conditions that are hard to manage, like diabetes, chronic lung disease, and heart failure. Solid care in the community can help such individuals manage their conditions and prevent acute exacerbations that lead to repeat hospital stays. For other patients, particularly repeat users of EDs, complex social circumstances such as inadequate housing, are also important drivers of avoidable utilization.
This chart shows strikingly high prevalence of behavioral health diagnoses among inpatient high users in 13 low-income areas of New Jersey. These patients had four or more hospital stays over the four-year study period. Three-fourths of patients meeting our high-user definition also had behavioral health conditions. This does not mean that these conditions caused the admissions, but simply that behavioral health conditions were recorded as present during at least one hospital contact. But these conditions can complicate the treatment of medical conditions of these patients. Especially challenging are patients with severe mental illness, the most disabling mental-health conditions including schizophrenia and bipolar disorder. Fully a quarter of high users have these conditions, over three times the rate of people who are not high users.
At first glance, addressing complications of patients who represent only 5 percent of hospital users does not seem like an urgent public-policy priority. But there is no question that this is a very serious problem that we should all be concerned about. Related research shows that the highest-cost 5 percent of the general population consumes about half of all healthcare resources. Arguably, the high prevalence of behavioral health problems among hospital high users is a key underlying driver of our nation’s healthcare-cost problem. We all pay these costs through our taxes and insurance premiums.
This problem is not limited to Medicaid or uninsured patients, our report shows that 72 percent of privately insured inpatient high users have behavioral health diagnoses. In fact, the public sector may be at least a bit ahead of private insurers in working to integrate behavioral and physical healthcare. Under New Jersey’s comprehensive Medicaid waiver the state will reorganize the way it funds behavioral health services for its beneficiaries, moving toward a more accountable system. The state is also experimenting with new models of care for those with severe mental illness, along with complex physical health problems.
As more New Jerseyans gain coverage under the Affordable Care Act, close attention needs to be paid to the adequacy of behavioral health-provider networks available to health-plan enrollees. But health insurers, public programs, and healthcare providers all need to work to break down longstanding barriers between the physical health and the behavioral health systems. Collaborative approaches to care are needed where the whole person is the focus of care.