Earlier this year, Gov. Chris Christie announced a nearly 40 percent increase in beds for the treatment of substance-abuse and mental health disorders in New Jersey. One look at the numbers, and the severity of the state’s problem is obvious. From 2004 to 2016, more than 6,000 people died from drug overdoses, with 1,587 in 2015 alone, and it’s estimated that 128,000 people in the state are addicted to heroin. According to the New Jersey Hospital Association, emergency department (ED) visits increased by more than 117,000 patients from 2014 to 2015, with nearly 54,000 of those cases including a mental health or substance-abuse disorder diagnosis.
But just adding more beds — while a step in the right direction — won’t solve the problem; patients need improved access to behavioral health and providers need payment reform.
Effective behavioral health care — encompassing mental health and substance-abuse disorders — is more about outpatient therapy and timely access to treatment and medication, than expensive, avoidable inpatient care. Treating patients before their conditions deteriorate to the point of a hospitalization results in better outcomes and lower costs. The majority of behavioral health patients, however, never even visit a hospital. They need assistance managing conditions such as moderate depression or anxiety not severe enough for hospitalization, but which can have a negative effect on chronic medical conditions like diabetes and heart disease, job performance, and overall wellbeing.
Pushed into private practice
Payment for behavioral health, even through commercial insurance, is so poor that it drives many providers to private practice, some declining to accept insurance at all — pushing access to care further out of reach for patients. For many, the out-of-pocket costs associated with these practices simply aren’t an option, so they end up delaying or deferring treatment altogether. And while the New Jersey Department of Human Services announced some rate increases for mental health services earlier this year, more needs to be done.
If we’re to improve access, we need to provide scalable, effective, outpatient treatment. Here are three areas that need to be addressed:
Provider retraining and certification
The need for behavioral healthcare outweighs the capacity to treat it; there simply aren’t enough providers. Offering a meaningful certification program that, once completed, qualifies behavioral health providers to participate in outcomes-based incentive payments would elevate the importance of treating these issues and encourage existing providers to participate, expanding access to more patients. And the incentive payments should be significant, placing behavioral health payment at the forefront of outpatient treatment revenue streams. States already spend significant dollars in this space, but are not growing the needed network coverage nor achieving desired outcomes.
More effective referral agreements
Likewise, specialists need more effective referral agreements, such as bundled payment arrangements that would incent them to invest in expanded treatment offerings, while minimizing expensive pharmacy and inpatient options. Consider that six months of intensive outpatient therapy costs less than a 30-day admission to an inpatient facility in Florida for New Jersey residents, where the recidivism rate is extremely high.
Proactively engage payers
Inextricably linked to the access problem is payment reform, which has shown no signs of moving forward. There must be a financial incentive for providers in this space. We must make behavioral health as much of a priority as heart health — something that is not stigmatized and has very good payment systems in place.
One solution within reach for organizations is to proactively engage payers in creating new programs. If the program is successful in driving down costs and improving outcomes, it’s then something the payer can implement with all their covered locations. While this is by no means a small task, health centers/systems can take the first step by approaching the payer first as a medical home, asking for payer data to review as part of research. Understanding how the payer is spending money to keep the population healthy is key. Using that information, the organization can quantify the value it can offer by better managing members through integrated behavioral health. It’s a conversation that needs to be had more widely.
Champion public payment reform
My advice to Gov. Christie is that he act as a champion for behavioral health incentives. It may not be a governmental issue, but state and federal government need to be part of the conversation. New Jersey Medicaid patients struggle to find providers who will even take their insurance, and they’re among the most in need of care. We need to create a payment model for Medicaid patients with behavioral health issues to incentivize providers to treat them.
On the federal level, Medicare needs the same kind of aggressive thinking demanded of Medicaid. If you’re a senior with behavioral health issues, you need a much more complex set of interventions. Second, federal block grants should impress upon the states to adopt payment models that create provider incentives — for example, here’s your block grant and 25 percent must go toward behavioral health.
Expanding inpatient bed capacity will offer some relief in New Jersey, but it’s not the only answer. We must improve patient access to timely and appropriate care, especially at the outpatient level, while elevating the importance of treating behavioral conditions through payment reform. Once we do, patients will begin receiving the right care in the right care setting, outcomes will improve, and costs will go down.