A Tough Nut to Crack: Leveraging MH Care to Improve Patient Outcomes and Bottom Line

I knew coming into the job that this was going to be a tough problem. I had said to the Dean: “No one in the country has figured out how to do this stuff in an open system such as ours. I’m pretty smart and persistent, but guaranteed that I am not the smartest and most persistent psychiatrist in the country. A lot of brilliant and creative departmental chairs have really tried to fix this, to no avail.”

For most departmental chairs across the country, one of the more vexing challenges is developing a strategy to maximize access to psychiatric services while not breaking the bank. Physicians from all specialties are clamoring for our help, but the pay structure makes it all but impossible to deliver.

A key message for medical centers and hospitals is that the value of mental health care cannot simply be measured in dollars and cents. That thinking completely misses the boat. We have to look at different types of outcomes, and we have to assign values to them.

What are some of the outcomes that might contribute to the bottom line or to the quality of care that you might discuss with the health system leadership? There are many, and there is a developing literature on them, although usually implemented in “closed systems” like the Kaiser Permanantes or Intermountain Healthcares of the world. Some have postulated that mental health services may result in shorter hospitalizations. We all know that those with psychiatric conditions are more difficult to place in rehabilitation or nursing home settings. Others have suggested that re-admissions might be averted. After all, if you treat the diabetic’s depression, the patient will have a much better chance at exercising, sticking to the right diet, adhering to medication, and even attending medical appointments.

Of note, a study from Intermountain published in JAMA last September documented statistically significant improvements in adherence to a five-step diabetes bundle, including low HbA1c, in practices with team-based integrated care compared with regular practices. The researchers also noted fewer ER visits, fewer admissions, fewer visits to PCPs, but not fewer specialty visits or urgent care visits. Nonetheless, the team-based practices had lower revenue from patient care. This is a perfect example. Surely the patients are doing better if their diabetes is in better control, and they go to the hospital and see their PCP less often. But if you look only at the dollars, that point gets lost.

Another point is that patients might also be more satisfied with their care if they also receive care for their psychiatric conditions. Medical centers around the country are obsessed with the outcomes of their surveys: How are the patients rating us? Can we improve on the likelihood that patients will refer others to our center? Thus, showing that patient satisfaction improves when their psychiatric needs are tended to is another valuable outcome that may lead to increased revenue downstream.

Addressing psychiatric issues may enhance the satisfaction of not only patients but also staff. Staff who do not have specialty training in mental health often find psychiatric problems overwhelming and stressful, and experiencing work as a crushing experience has been linked to staff burnout. Lately, much attention has been focused on wellness at medical centers, which are equally interested in addressing burnout in physicians and staff. Might team-based integrated care lead to less burnout? This too may enhance the bottom line in terms of decreased staff turnover and increased productivity.

Still, these are back-of-the-envelope calculations. Figuring out the details of how to actually do this in open systems like the ones in which most of us operate will take significant business planning. But just as importantly, it will take recognition from health system leadership that some things are worth spending money on because they satisfy a key aspect of our mission. The World Health Organization’s mantra of “There is no health without mental health” is a good one. Surely, health systems are in the business of, well, health. As such, mental health should be a key part of the mission. ■