red and blue balloons floating up to the heavens

The election is over. We have a new President-Elect. A new Cabinet is being assembled; presidential appointees are being considered. President-Elect Trump’s key message throughout his campaign was to “Make America Great Again!”

As the incoming administration confronts a host of foreign and domestic issues facing America, there is no question that health care in America looms large.

There are some certainties on the horizon for health care, one of which is: health care policies will change.

There. I said it. Well, no real surprise there.

Regardless of politics, the design, delivery, and financing of high quality health care and improved health outcomes is something we can all agree on. At stake is the health and wellness of some of the most vulnerable people in our country: persons with multiple, chronic health conditions, including behavioral health.

A timely and must read post comes from our friends at the Commonwealth Fund titled, “The Impact of a Behavioral Health Condition on High-Need Adults” (posted 11/22/2016). This population is defined as persons with three or more chronic health conditions and a functional limitation—who have a diagnosed behavioral health condition among their multiple chronic conditions. The data suggest that persons with complex health care conditions with a behavioral health condition use health care services at a higher rate than their persons with complex health care conditions without a behavioral health condition, leading to higher costs that persist over time (2009–2011 Medical Expenditure Panel Survey).

And despite much higher health-care spending, this population is more challenged to get the care they need and report negative patient services experiences.

Approximately 1 in 20 US Adults (or 12 million) people have three of more chronic health conditions and a functional limitation that impacts their ability to care for themselves and live independently.

More than half of persons with multiple, chronic health conditions also have a behavioral health condition (depression, anxiety, alcohol and/or substance use disorder, or serious mental illness). Emergency room (ER) usage is higher for persons with chronic health conditions with a behavioral health condition. This population also has more office visits and use more home care than persons without a behavioral health condition.

Approximately one-third of adults with a behavioral health condition (34 percent) remained in the top 10 percent of spending over two years compared to less than a quarter of those without a behavioral health condition (23 percent). Annual per-person spending on health care for this population use is four times the average for all US adults.

A significant factor that contributes to this dilemma is that behavioral health conditions often go unscreened, undiagnosed or untreated in primary care settings.

A positive is that nearly half of adults with both chronic health conditions and behavioral health conditions had a usual source of care with components of a medical home. However, despite having a source of care, the needs of this population were not identified or treated with any measure of success.

Conclusion: this is not a failure of the individual seeking needed health care services; it is a failure of our health care system. Our health care system still does not adequately address the health care needs of persons with chronic health care conditions with a behavioral health condition.

So you may be asking, “How can we improve our efforts to design and deliver high quality, effective behavioral health care services to persons with multiple, chronic health conditions to that lead to improved health outcomes?”

  • Screen all persons for behavioral health conditions.
  • Provide immediate/short-term behavioral health treatment on site (versus refer out to external providers); embed behavioral health professionals to work alongside staff in a “team-based” care approach.
  • Build in a care coordination component.
  • “High touch”/frequent contacts and interactions initially, transitioning to “low touch” when health status improves.
  • Data collection; metrics to demonstrate program and cost effectiveness will be essential for evaluation purposes.
  • Advocate for and support health care transformations at the local level, system, state, and federal level that “integrate” primary care and behavioral health for persons with multiple, chronic health and behavioral health conditions.
  • Strengthen the public health safety net; continuously assess network integrity of and network sufficiency.
  • Negotiate with payers to reimburse for integrated health care. There is a growing recognition among payers and providers that this population has unique characteristics that must be taken into account when designing programs to improve health care delivery, produce positive outcomes and reduce costs. Incentivize for outcomes; pay for performance.
  • Here’s a final novel idea: ask your patients and families: “Are you happy with your care? What are we doing right? What do we need to do to get it right to meet your health care needs?”

Integrated health care is the most promising strategy to bring enhanced cohesion and coordination of health care to persons with both physical health and behavioral health conditions.

My experience is that the true innovators and early adopters of integrated health care took the plunge to coordinate care through integration. Some had the opportunity to transform their systems through grant funds; some didn’t. They didn’t wait for policies to be promulgated. They just did it. And those who have figured it out and made it work have left “usual treatment” far behind in their rear view mirror.

We have made progress to bring greater cohesion to a historically fragmented health care system. But there is still much work to be done to improve health care for all.

We have learned a few things over the past several years from demonstration projects funded by foundations, health plans, the  SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) and the CMS Innovation Center at the Centers for Medicare & Medicaid Services. We know that adults with mental health conditions may benefit from the enhanced access to care and service coordination that patient-centered medical homes provide. Medical homes also provide an architectural platform to deliver integrated, coordinated behavioral health services and primary care services. Health care payers, including Medicaid (the nation’s largest payer for behavioral health services) can influence the continued momentum towards integration as a standard of care. To date, 19 states and the District of Columbia have supported the creation of “health homes” for adult Medicaid enrollees with multiple chronic conditions that include a behavioral health condition. So we have made some strides to improve health care for persons with multiple, physical health and behavioral health conditions.

The authors of the Commonwealth Fund post conclude that behavioral health integration is more than just integrating behavioral health and primary care: behavioral health should be embedded and addressed across the continuum of care—from the hospital emergency department to home-based care settings—to achieve the Triple Aim of increased patient engagement, improved health outcomes and better overall health at lower cost.

As with past administrations, stakeholders will need to work with the new administration, be engaged in dialogue, debate, negotiation, and shared decision making on health care policies that will have a significant impact on many Americans, especially our most vulnerable and under-served populations. To achieve this, there must be mutual respect and mutual trust among all stakeholders to find the common ground on policies that strengthen the health care system in order to meet the needs of persons with chronic physical health and behavioral health conditions.

Access to care.

Quality health care.

Improved health outcomes.

Healthy families, healthy communities, and a healthy nation.

Let’s Make Mental Health and Behavioral Health Great!