Report Estimates Substantial Economic Impact of Integrated Care

Effective integration of general medical and behavioral health care could save $26 to $48 billion in U.S. health care costs each year, according to a report by Milliman, Inc., that was commissioned by the American Psychiatric Association (APA) and released at a roundtable event held April 4 in downtown Washington, D.C. The estimated savings would come from lower costs of care for people with chronic general medical conditions who also have a behavioral disorder and from reductions in use of facility-based care (hospitals and emergency rooms) by individuals with behavioral disorders whose care is not adequately coordinated in the primary or specialty setting.

Speakers at the APA roundtable—“Integrated Primary and Mental Health Care: Reconnecting the Brain and the Body”—agreed that integrated care has impacts beyond cost savings. Integration means an end to the “Don’t ask, don’t tell” de facto policy that has held sway in primary care in regard to mental illness, said keynote speaker Michael F. Hogan, Ph.D., former commissioner of the New York State Office of Mental Health. Greater integration and better access under the Affordable Care Act and national parity legislation will help reduce the nine-year lag that most Americans experience between first experiencing psychiatric symptoms and receiving a diagnosis, he predicted. Integrated care is not “a shift and shaft,” he said, referring to the well-documented shortcomings of deinstitutionalization, which moved patients from state hospitals into communities where services were lacking. Integrated care involves conscious formation of multidisciplinary teams in primary care and “warm handoffs” of patients to mental health clinicians, he noted.

But integrating primary and behavioral health care is not easy, as Dr. Hogan and others noted. For example, Richard Frank, Ph.D., a Harvard health economist, underlined the potential economic benefits of integrated care but also described some barriers to integration, focusing particularly on incentives. Although organizing services under a single, prospectively set budget allows a clinical entity, such as an accountable care organization or patient-centered health home, a great deal of flexibility in allocating resources, it also creates “incentives to do less,” he noted. These incentives are typically offset by measuring quality and attaching the measurements to payments or to shares in savings. The degree to which programs based on the new care models practice cost-effective integrated care will depend on the degree to which quality measures are used to hold them accountable for doing the right thing. Whereas some programs make effective use of quality mechanisms, others have not sufficiently done so. That is due in part to the need for better quality measurement in behavioral health. “The bottom line is that rewarding the benefits of integration is key to making integration happen,” Dr. Frank said.

APA President-Elect Paul Summergrad, M.D., explained the context of the Milliman report, which grew out of an APA Board of Trustees work group that he chaired and that delineated the role of psychiatry in health care reform, which is summarized in a second report released at the roundtable event. Dr. Summergrad spoke of the need to move toward integrated care to relieve the suffering that results from untreated behavioral health disorders and to achieve the “triple aim” of reform: a better care experience for patients, healthier populations, and lower costs. He described the Milliman report’s methodology, which examined claims data for more than 20 million insured patients (private or public plans) in four groups: those with no behavioral health diagnoses, those with mental health diagnoses but no serious mental illness, those with serious mental illness, and those with substance use disorder diagnoses. The study determined costs for patients with a chronic general medical condition in each category. A key finding was that the patients who were receiving treatment for a behavioral disorder represented 14% of the overall group, but they accounted for 30% of total health care spending. Because of fragmented care, costs for patients with chronic medical conditions were two to three times higher if those patients had comorbid mental or substance use disorders. The higher cost was mostly attributable to medical services, rather than to behavioral services, which creates a substantial opportunity for savings on the medical side through integration of care, Dr. Summergrad noted.

Other speakers described implementing integrated care in real-world settings, and several sought to put a human face on these system issues by describing the differences that integrated approaches have made for their patients and themselves. An archived Webcast of the two-hour roundtable, along with the 39-page Milliman report and the 58-page report on psychiatry’s role in health care reform, are available on the APA Web site at www.psych.org/practice/professional-interests/integrated-care/integrated-care-reconnecting-the-brain-and-the-body.