The nation's economically disadvantaged suffer from behavioral health conditions at a much higher rate than the general population. Rising unemployment is driving greater numbers of people toward Medicaid and government-subsidized health plans. Such economic problems can also add to, and are themselves, psychosocial issues that contribute to higher health care costs. Additionally, as the baby-boom generation reaches retirement age, a growing percentage of the U.S. population is joining the Medicare ranks. As a result, more and more government and not-for-profit plans will bear an increasing share of the healthcare burden to treat America's elderly and lower-income individuals and families.

For those with even the best health insurance, access to mental health services is often worse than access to physical health services. For those who are uninsured or covered by Medicaid, Medicare or other health coverage programs, access can be especially difficult. Without proper integration of a behavioral health management strategy, members and participating physicians of public health plans will most likely experience challenges in accessing and coordinating care, causing delays in treatment or disconnects between the member's primary care approach and mental health management. There are workable solutions to overcome these challenges.

Engage Primary Care Physicians

L.A. Care Health Plan, the largest public health plan in the United States, has recently partnered with Health Integrated to implement a new behavioral health management pilot program to strengthen services for primary care physicians who provide care to members with behavioral health conditions enrolled in L.A. Care's Medi-Cal, Healthy Families, Healthy Kids and Medicare Advantage Special Needs Plan. This 18-month pilot program will help L.A. Care evaluate the effectiveness of integrated physical and behavioral health care in a primary-care setting.

For L.A. Care members, mental health services are carved out to a specialty mental health vendor or to the County Department of Mental Health, depending on the program. In focus groups and surveys, L.A. Care providers have identified the gap between the primary care services they provide and specialty mental health services as one of the biggest sources of dissatisfaction with participation in Medi-Cal managed care.

Primary care physicians (PCPs) may not be ideally equipped to treat patients struggling with behavioral health barriers. PCPs are not always trained to recognize many of these conditions, and may not be aware of the latest pharmacological options. To bolster its support of PCPs, L.A. Care is using Health Integrated's behavioral health management strategies.

Health Integrated works within the PCP's treatment approach to better provide the support those physicians need to most effectively treat patients with medical and psychosocial issues. Through the program, L.A. Care's PCPs now have hotline access to board-certified Health Integrated behavioral health specialists for consultation on diagnosis, patient management, medication regimens and referral assistance to behavioral health specialists when necessary. This peer-to-peer interaction is key to success, as PCPs will be able to leverage a proactive and credible resource to discuss treatment approaches, appropriate drug regimens and other important patient management issues, as well as referrals, as appropriate, to California's Department of Mental Health or the PacifiCare Behavioral Health Network.

For those with even the best health insurance, access to mental health services is often worse than access to physical health services.

By mining important administrative, clinical and patient data, Health Integrated also identifies opportunities for PCPs to improve diagnoses of behavioral health conditions, enhance treatment plans, or provide additional clinical resources in managing the member holistically.

Closing the Gaps: L.A. Care Program Components

In addition to a toll-free provider telephone line and email availability for provider behavioral healthcare consultation and assistance, Health Integrated will provide L.A. Care PCPs with several other means of support, including:

analysis of administrative data to identify and reach out to providers who could benefit from assistance with management of members with behavioral health conditions.
assistance with identification of behavioral health conditions and treatments.
assistance with medication management.
assistance with the design of treatment plans.
identification of gaps in care.
assistance with access/referrals to behavioral health specialists.
provision of basic care management, if requested by the PCP, or if the need for care management is identified by Health Integrated. This includes member outreach, education and medication compliance.
participation in educational seminars and availability for in-office visits by Health Integrated clinicians.
incorporation of nationally accepted behavioral health diagnostic screening tools and educational materials for various behavioral health conditions, as needed.

While the 18-month L.A. Care program is still early in its implementation, according to Elaine Batchlor, MD, Chief Medical Officer of L.A. Care, the program “gives doctors the support they need to strengthen the integration of physical and behavioral health care in a primary care setting.”

Knowledge is Power

A behavioral health management integration strategy offers many benefits to the PCP, including:

access to information regarding other medical and social services accessed by the member
assurance that the member understands their plan of care
the ability to work with non-compliant members to develop more “acceptable” plans of care
easier access to the latest research in Best Practices
useful reminders of critical appointments, reducing no-show rates and improving health outcomes
monitoring of treatment plan compliance through regularly scheduled assessments and valuable Care Coaching follow-up, and,
the establishment of a single point of coordination of healthcare needs for members who take a disproportionate share of time in the physician's practice, thus reducing inappropriate use of physician on-call time.

Addressing the Critical Interplay

Another example of Health Integrated services is the Synergy Targeted Population Management® program. This program identifies and assists individuals with co-occurring chronic illness and behavioral health conditions. While these patients are a relatively small group in a typical health plan's population, they often represent a disproportionately large percentage of plan costs.

A New York-based managed care organization with a large Medicaid population selected Health Integrated to integrate a targeted population program for the chronically ill that improves clinical outcomes and lowers avoidable utilization by addressing the critical interplay between psychological, social and physical health. Rather than focus condition by condition, the Synergy program looks at all of the issues a member faces and addresses them holistically.

This targeted approach is effective because it helps individuals to overcome psychosocial barriers that stand in the way of improved medical health. Are these individuals suffering from depression that impacts their motivation to be healthier? Do they have transportation to healthcare providers? Are there language complexities that prevent them from following a health regimen or lead them to use expensive resources, such as the ER, more than is necessary? As the program removes obstacles like these, it focuses the physician and patient on achieving health-related goals.

After just 12 months in the program, members showed dramatic improvements in care quality and health outcomes, while the health plan reduced costs through reduced admissions and ER visits. Conventional disease management programs cannot achieve results like these because of their undifferentiated approach across chronically ill segments, where the presence of behavioral health conditions and other psychological or social barriers can add 50% to 100% to the cost of care.

Care Coordination and Coaching

We have found that the Synergy program is highly effective in identifying, engaging and empowering particularly complex members. In one powerful example (from another public health plan), member “Jane Doe” was identified as being eligible for enrollment in the Synergy program as a result of claims data mining that identified her utilization for the diagnoses of major depression, congestive heart failure, diabetes and hypertension. Jane's claim costs totaled more than $32,000 for the 12-month period prior to her engagement in Synergy (Figure). Further review of the data revealed that the member utilization included an acute inpatient service event and one ER visit.

After engaging in the Synergy program through her public health plan, “Jane Doe” increased her quality of life, improved her health outcomes and decreased utilization of unnecessary healthcare services.

Jane was engaged in a Synergy program for 17 months, receiving a total of 12 coaching calls and other communications, and graduating from the program with a goal achievement rate of 95 percent. Coaching interventions with Jane focused on:

identification of the symptoms
awareness of treatment and self-care options
appropriate utilization of health care resources, and
demonstration of sustained condition self-management behaviors.

Through coaching, Jane Doe was able to recognize the impact depression had on her quality of life, and she experienced the way consistent psychopharmacotherapy improved her ability to manage the other areas of her life, including other health conditions. Jane became receptive to additional specialty provider referrals and was connected with an endocrinologist and nutritionist to assist her with management of her diabetes. She has lost weight gradually by following a prescribed diet and exercise plan. On a more personal level, Jane reported “going great guns” with a home project that she had delayed for five years.

Due to her lifestyle changes, Jane no longer requires medication to manage her diabetes. She has not used any urgent, emergent or acute health care services. Her utilization costs decreased from more than $32,000 prior to coaching to just $1,800 in the 12 months after coaching (see Figure).

Health plans that identify behavioral health factors in their lower-income, elderly or chronically ill members and implement integrated health management programs benefit from a healthier base of members and lower healthcare utilization costs.

Treating the Whole Patient

Left unchecked, co-morbid psychosocial and behavioral health conditions damage patients' health and add significantly to healthcare costs. Health plans that identify behavioral health factors in their lower-income, elderly or chronically ill members and implement integrated health management programs benefit from a healthier base of members and lower healthcare utilization costs. A holistic approach toward patient treatment, backed by services to both members and providers, supports close integration of medical and behavioral condition management, increases quality of life, and improves health outcomes.