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Hospitals seek behavioral partners to reduce Medicare readmissions

September 8, 2015
by Joanne Sammer
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For behavioral health organizations, the emerging movement among acute care hospitals to reduce readmissions represents both a challenge and an opportunity. The opportunity comes from the growing recognition that behavioral issues contribute to many of these hospital readmissions. If behavioral healthcare organizations can find ways to collaborate with hospitals, they can open a new avenue to grow their businesses.

The Hospital Readmission Reduction Program (HRRP), which was enacted in 2012 as part of the Affordable Care Act (ACA), is a federal initiative that financially penalizes hospitals for what are considered “avoidable” readmissions among Medicare patients. The Centers for Medicare and Medicaid Services (CMS) assessed an estimated $428 million in financial penalties for avoidable readmissions this year.

Acute care hospitals are quite motivated to reduce their risk for costly penalties, and consequently, could be eager to find behavioral health partners to help them manage their Medicare patients.

“The problem is that the medical community is not aware of the enormity of the problem,” says John Dyben, DHSc, CAP, CMHP, director of older adult services at the Hanley Center at Origins in West Palm Beach, Fla. “And the behavioral healthcare community is not really talking to the doctors about the issue.”

Dyben recalls one hospital’s patient who had chronic coronary disease. Despite long and repeated hospitalizations, the root cause of the patient’s repeat trips to the hospital was not uncovered until he admitted to having a $100,000-a-year cocaine habit.

The challenge

Of course, integration is where the challenge comes in. There are plenty of reasons why behavioral healthcare organizations are not already integrated into Medicare’s network of acute care: lack of clear reimbursement; the unacknowledged prevalence of behavioral conditions among Medicare patients; and many behavioral healthcare organizations’ own lack of experience working with older patients.

Framing the opportunity is the first step.

“Everyone recognizes the facts around co-morbidity and that people with behavioral health conditions often do not comply with doctors’ orders or have a lifestyle that is contributing to their health issues,” says Ed Jones, senior vice president of strategic planning for the Institute for Health and Productivity Management in Scottsdale, Ariz. “However, doing something about it is a completely different issue.”

When confronted with the fact that readmissions for patients who have co-morbid substance abuse or mental health disorders is two to three times greater than the average, medical providers are likely to sit up and take notice.

“Bringing that rate down can help hospitals financially, and behavioral healthcare organizations know how to do that,” says Raymond V. Tamasi, president and CEO Gosnold on Cape Cod in Falmouth, Mass. “That becomes the big selling point, and when phrased and packaged appropriately, that is a message the healthcare system is going to want to hear.”

Making connections

Behavioral healthcare organizations that want to play a more active role in integrated care for the growing Medicare populations as a way to help reduce hospital readmissions—and gain additional business for themselves—need to connect with the right people and organizations.

For example, there is more opportunity to collaboratively treat behavioral health issues among those who have Medicare Advantage plans that are operated by commercial insurers because of the inherent managed care aspect of the plans, according to Jones. Medicare Advantage represents about one-third of the 52 million Medicare beneficiaries and growing. Under the traditional fee-for-service Medicare program, by contrast, there is less patient management and less opportunity for behavioral providers to seek reimbursement.

There is plenty of work to be done. Jones notes that three criteria will impact a patient’s risk of a hospital readmission:

  1. The quality of the inpatient care they receive.
  2. The appropriate timing of the discharge.
  3. Access to adequate outpatient care after discharge.

Behavioral healthcare organizations have an important role to play in the quality of inpatient care and access to outpatient care after discharge. Jones says that Medicare patients with behavioral healthcare issues have historically had low rates of outpatient service utilization.

“Fewer than 2 percent of people on Medicare use behavioral health services on an outpatient basis,” he says. “What are we going to do about getting these folks with chronic conditions, whether it is diabetes or depression or whatever, the help they need?”

Tamasi urges behavioral health providers to begin a conversation with hospital systems, the growing class of accountable care organizations (ACOs), and providers with patient-centered medical home models. Discuss how collaborating with behavioral healthcare can add value and improve patients’ overall health and their ability to manage their own care. As a classic example, in the case of a patient with diabetes, depression might cause poor adherence to doctor’s orders and repeat trips to the hospital.

“The relationship between behavioral health and individuals’ inability to manage their health and specific conditions is pretty well-documented,” Tamasi says. “That data then opens up opportunities for behavioral health companies to assist and improve readmission rates.”