Economic Impact of An IntegratedBehavioral Health Program
Kenneth Kushner, PhD
Professor, University of Wisconsin Department of Family Medicine
Neftali Serrano, PsyD
Director of Clinical Training, Center of Excellence for Integration,
North Carolina Foundation for Advanced Health Programs
Collaborative Family Healthcare Association 17th Annual Conference
October 15-17, 2015 Portland, Oregon U.S.A.
Session # C1
October 16, 2015
Faculty Disclosure
The presenters of this session
•currently have or have had the following relevantfinancial relationships (in any amount) during the past12 months.
Learning ObjectivesAt the conclusion of this session, the participant will be able to:
Describe the impact of insurance status on patient utilization ofhealthcare resources
Describe the main conclusions of our study in terms of the effect ofintegrated behavioral health on overall inpatient and outpatientutilization
Discuss the policy implications of the results of our study in thecontext of the larger literature on cost offset for mental healthservices
Bibliography / Reference
Egede et al. Impact of Mental Health Visits on Healthcare costs in Patients withDiabetes and Comorbid Mental Health Disorders. PLoS One, 2014
Park et al. Examining the Cost Effectiveness of Interventions to Promote thePhysical Health of People with Mental Health Problems: A Systematic Review.Public Health, 2013
Salvador-Carulla, L & Hernandez-Pena, P. Economic Context Analysis in MentalHealth Care. Usability of Health Financing and Cost of Illness Studies forInternational Comparisons. Epidemiology and Psychiatric Services, 2011.
Serrano, N. and Monden, K.The effect of behavioral health consultation on thecare/ Wisconsin Medical Journal, 2011.
•Reiss-Brennan, B. Cost and quality impact of Intermountain's mental healthintegration program. Journal of Healthcare Management, 2010
Learning Assessment
•A learning assessment is required for CEcredit.
•A question and answer period will beconducted at the end of this presentation.
Does Integrated BehavioralHealth Result in Cost Savings?
6
Medical Cost Offset
“At some point, the reduction inmedical costs may offset the cost ofproviding mental health services”
Pallak, Cummings et al (1993)
7
Cummings and Follett (1967)
•Found that overall utilization of (non-psychiatric) inpatient and outpatient medicalservices declined significantly among patientswho received psychotherapy in a pre-paidhealth plan.
•Declines persisted after the initial interview,most significantly 2 years afterwards.
•Control patients, who did not receivepsychotherapy, showed no decreaseutilization.
8
Cummings and Follette (1976)
•Found the overall costs of medical care ofpatients who received 1 to 8 managed mentalhealth treatments declined significantly,compared to matched controls, in the yearfollowing the treatments.
•The declines persisted after 5 years.
9
Pallak, Cummings et al (1993)
•Tracked medical costs for Medicaid enrolleesin Hawaii.
•They found declines in overall medical costsfor those who received managed mentalhealth services, but not for those receivingtraditional, unmanaged mental healthintervention.
10
Pallak, Cummings et al (1993-Cont.)
•Declines in the managed mental health caregroup were attributable to decreases in:
•Inpatient medical services
•Outpatient medical services
•Drug prescription
•ED visits
11
Subsequent Studies
•Chronic illness (Schlesinger et al, 1983)
•Anxiety and Depression (Fifer et al, 2003;Goldberg et al, 1996; Korff et al, 1998)
•Cancer (Carlson and Butz, 2004)
•Substance abuse (Polen et al, 2006)
•Diabetes (2014)
12
Reviews
•Cummings, O’Donahue and Ferguson (2002)
•Mumford et al (1998)
•Olfson, Sing and Schlesinger (1999)
•Shemo (1995)
13
Meta-analysis
•Chiles, Lambert and Hatch (1999).
•Found that the average savings resulting frompsychological intervention to be 20%.
•In 1/3 of the articles, the savings were“substantial” even after the costs of providingpsychological services were factored in.
14
Cost Offset and IntegratedBehavioral Health?
15
Study Parameters
•12,300 Patients From Four Medical Homes
•Selected based on having at least one encounter in amedical home with a mood disorder diagnosis between2004-2012
•Data obtained from three area hospitals and severalspecialty mental health providers
•The analysis segmented utilization into four categories:emergency department, inpatient psychiatry, inpatientmedical, outpatient specialty mental health
•The final analysis used three years of utilization pre/post,following patients from the initial three year period into thesubsequent period
16
Sample Demographics
17
Clinics
Arm
N
Age2012(sd)
%Female
Afr. Am.
Am. Ind.
White
Hispanic
None
Commercial
Medicaid
Medicare
Northeast
C
2089
50.2(15.0)
71.2
13.2
1.9
78.2
3.8
6.4
66.0
13.8
13.8
ACHC-S
I
900
46.7(13.2)
70.3
27.6
12.7
44.6
31.4
35.2
27.3
28.7
8.8
ACHC-E
I
816
46.5(12.8)
67.5
23.1
4.5
58.8
19.5
34.7
29.7
29.0
6.6
Wingra
I
1458
48.1(13.8)
71.1
25.2
4.8
60.0
15.2
11.9
52.7
24.0
11.3
Demographics
Demographics
Insurance
Insurance
Pre
Post
N
Pre
Post
N
IntegratedCare
Control
None
2.91
3.10
774
2.34
2.25
134
6.5%
-3.8%
Commercial
1.52
1.74
1257
1.11
1.23
1378
14.5%
10.8%
Medicaid
3.83
3.67
845
3.41
3.74
289
-4.2%
9.7%
Medicare
3.19
3.60
298
2.43
2.73
288
12.9%
12.3%
Totalcombined
2.63
2.76
3174
1.69
1.85
2089
4.9%
9.5%
Integrated Care
Integrated Care
Control
Control
% Change
% Change
EMERGENCY DEPARTMENT UTILIZATION
*
*
Pre
Post
N
% Change
None
3.55
3.08
348
-13.2%
Commercial
1.35
1.38
1538
2.2%
Medicaid
5.16
4.75
700
-7.9%
Medicare
2.93
3.30
330
12.6%
Total combined
2.70
2.61
2916
-3.3%
IntegratedCare
IntegratedCare
Control
Control
% Change
% Change
EMERGENCY DEPARTMENT UTILIZATION
Wingra Clinic Only, Pre/ Post
*
Pre
Post
N
Pre
Post
N
IntegratedCare
Control
None
2.95
4.97
774
3.51
3.92
134
68.47%
11.7%
Commercial
3.32
4.57
1257
4.13
4.79
1378
37.65%
16.0%
Medicaid
4.81
5.4
845
6.08
6.88
289
12.27%
13.2%
Medicare
7.1
8.29
298
7.13
10.27
288
16.76%
44.0%
Totalcombined
3.98
5.24
3174
4.78
5.78
2089
31.66%
20.9%
Integrated Care
Integrated Care
Control
Control
% Change
% Change
INPATIENT HOSPITAL UTILIZATION
Non-Psychiatric
*
*
*
*
Pre
Post
N
% Change
None
4.10
5.68
348
38.5%
Commercial
3.56
4.01
1538
12.6%
Medicaid
5.80
6.84
700
17.9%
Medicare
7.16
7.61
330
6.3%
Total combined
4.57
5.29
2916
15.8%
IntegratedCare
IntegratedCare
Control
Control
INPATIENT HOSPITAL UTILIZATION
Wingra Clinic Only, Pre/ Post
UTILIZATION COMPARISONS
Higher Overall ED Utilization
Lower Overall Inpatient Utilization
23
Financial Impact, ED Medicaid
24
Integrated Care
Control
Pre
3.83
3.41
Post
3.67
3.74
(Savings) Cost
(-$162,000)
$334,600
Estimate over a three year period, assuming per ED visit mean cost of $1200, with equivalent samples of 845 patients
*Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $1200 or the mean ED visit cost.
Financial Impact, ED Overall
25
Integrated Care
Control
Pre
2.63
1.69
Post
2.76
1.85
(Savings) Cost
$495,144
$609,408
Estimate over a three year period, assuming per ED visit mean cost of $1200, with equivalent samples of 3174 patients
*Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $1200 or the mean ED visit cost.
Financial Impact, Hospital Medicaid
26
Integrated Care
Control
Pre
4.81
6.08
Post
5.4
6.88
(Savings) Cost
$1,944,345
$2,636,400
Estimate over a three year period, assuming per hospital stay mean cost of $3900, with equivalent samples of 845 patients
*Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $3900 or the mean inpatient daily stay cost.
Financial Impact, Hospital Medicare
27
Integrated Care
Control
Pre
7.1
7.13
Post
8.29
10.27
(Savings) Cost
$1,383,018
$3,649,308
Estimate over a three year period, assuming per hospital stay mean cost of $3900, with equivalent samples of 298 patients
*Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $3900 or the mean inpatient daily stay cost.
Financial Impact, Hospital Overall
28
Integrated Care
Control
Pre
3.98
4.78
Post
5.24
5.78
(Savings) Cost
$15,597,036
$12,378,600
Estimate over a three year period, assuming per hospital stay mean cost of $3900, with equivalent samples of 298 patients
*Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $3900 or the mean inpatient daily stay cost.
More Questions Than Answers
29
Why?
•Why did the control group do better with the uninsured andthe commercial population whereas the intervention group didslightly better with the Medicaid and Medicare groups?
•Are there differences between the medical homepatient samples that were not captured by the data?
•Are sample sizes and risk exposure different betweenthe groups?
•As a medical home grows and it achieves greatersamples of these insurance subgroups does utilizationregress to the mean?
•Why is there some evidence for mitigation of ED visits andincreased hospital visits?
30
Factors To Consider
• The medical homes overall havedifferent proportions of thedifferent payer status subgroups
•It is possible that the interventiongroup medical homes had moredual eligible patients representedin the Medicare subgroup
•It is also possible that thecommercial and uninsuredpopulations differed between themedical homes due to the natureof the underserved population ofthe FQHC
31
Do medical homes develop“orientations”?
Do medical homes develop“orientations”?
Are there ways to quantify “harder"patients?
Are there ways to quantify “harder"patients?
Is a commercial patient at an FQHCdifferent than a commercial patientelsewhere?
Is a commercial patient at an FQHCdifferent than a commercial patientelsewhere?
What Does This All Mean?
•Don’t trust utilization outcomesresearch that does not identify medicalhome composition, especially insurancestatus
•The impact of integrated care programsappear to have differential impact onpatient groups and perhaps medicalhomes
•Financial significance does not alwaysequal statistical significance
•There appears to be a mitigating impactof integrated care on ED utilization,especially in high utilizing subgroupslike Medicaid but no impact on hospitalutilization (medical only)
•Significant implications for paymentreforms based on quality outcomes
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Session Evaluation
Please complete and return theevaluation form to the classroom monitorbefore leaving this session.
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