Assessing the Gaps in Your Behavioral Health Strategy

As downward cost pressures mount and systems strive to make population health tangible, mental health has increasingly become a priority for hospital administrators. Mental health conditions are ubiquitous and pervasive across the US, affecting 1 in 4 Americans each year. Furthermore, mental health and substance abuse patients are some of the most costly for hospitals to treat. Recidivism, ED use and comorbidity complications associated with this population make actionable, near-term solutions for mental health integration an imperative.

Provider Shortages Today, Increased Demand Tomorrow
Challenges to formulating and implementing these solutions are multifaceted. Like primary care, behavioral health is facing severe provider shortages in most markets (28% of Americans live in federally designated Mental Health Professional Shortage Areas). Compounding this lack of qualified providers, Sg2 forecasts increased demand for behavioral health over the next 5 years across the System of CARE, varying from 7% growth in the inpatient setting, to as high as 17% growth in partial hospitalization programs (PHPs).

Payment Remains Problematic Despite Recent Progress
In addition to this supply and demand issue, navigating payment protocols has historically proven challenging, and programmatic costs have risen amid steady erosion of reimbursement rates. Among the hardest-hit providers over the last 15 years, psychologists saw Medicare reimbursement rates for a 45-minute psychotherapy session (one of the most common mental health services among Medicare beneficiaries) drop from $102 to $84.74. The resulting departures of psychologists from federal and state reimbursement programs have exacerbated access issues for vulnerable patient populations.

In contrast, a variety of more recent payment and policy reforms—from federal approval of regional addiction treatment continuums in California to Medicaid expansion to broadened support of telehealth payment—improve the potential for behavioral health investment. And, for those health systems that are taking on payment risk and moving to manage the health of populations, the business case becomes even more compelling.

Ambulatory Sites Emerge, Extending Impact Into Communities
A spectrum of channels has evolved to identify and manage behavioral health patients at varying levels of acuity. In the ambulatory setting, PHPs, intensive outpatient programs (IOPs) and residential programs serve patient needs in less expensive settings and help networks extend their impact into communities.

In July, the Association for Ambulatory Behavioral Health (AABH) hosted clinicians and administrators from more than 150 US organizations to discuss local and national mental health trends regarding both established and emerging sites of care. Successful programs, such as Pine Rest’s PHP network in Grand Rapids, MI, shared best practices for achieving financial sustainability, using a critical assessment of service mix, clinical and administrative protocols, and staffing models. Pine Rest Clinical Services Director Gretchen Johnson conveyed the importance of prioritizing initiatives based on local factors, such as scope of practice limitations, provider partnerships and patient profiles. Despite endemic resource challenges and residual stigmas around psychiatric patients, AABH attendees were optimistic about the role of behavioral health in their respective organizations’ strategies.

Specialty IOPs—such as mother and baby, opioid addiction, adolescent, and geriatric programs—are on the rise as networks seek cost-effective solutions to differentiate their programs and become destination centers with regional pull. Though PHPs saw marked declines in the 1990s, proposed Medicare reimbursement rates include increases of up to 18% for some PHP services from 2015 to 2016, signaling a brighter future for these therapeutically intensive facilities. Finally, behavioral health providers are increasingly becoming integrated into primary care through patient-centered medical home models and telehealth consults. Across settings, the appetite for data is growing, as mental health providers strive to demonstrate value to both parent networks and payers.

Assess Local Needs as a Key First Step
In considering implementation of PHP, IOP, telehealth or primary care integration, a localized evaluation process that takes into consideration several key factors is critical:

  • Staffing and facility constraints
  • Target population (eg, substance abuse, mental/physical comorbidities)
  • Availability of local resources and community partners (county mental health centers, private treatment centers, competitor assets, wraparound services, etc)
  • Payer partnerships (employer, county and managed care contracting)
  • Primary care integration and assessment training
  • Clinical protocols (triage system, activation of behavioral health team, case management)
  • Administrative protocols (degree of transparency and internal monitoring systems)

Sg2’s suite of solutions can help your organization identify high-priority assets and gaps in your market. Additionally, Sg2 offers custom solutions, such as a System of CARE gap and financial impact analysis, that can further support decision making. Completing a thorough local assessment can inform appropriate strategies to alleviate the mental health burden across EDs and inpatient facilities, driving intelligent investment and promising downstream return across the care continuum. Most importantly, this work will position you to deliver maximum value for a high-cost, underserved patient population.

Sg2 Senior Analyst Claire Pawlik contributed to this post.

Sources: National Alliance on Mental Illness. Mental Illness Facts and Numbers.; CMS website. Accessed July 2015; Andrews M. Mental health parity rule clarifies standards for treatment limits, coverage of intermediate care. Kaiser Health News. December 3, 2013; American Psychological Association Practice Organization. Medicare’s Shrinking Psychologist Reimbursement Rates. March 2015; Sg2 Analysis, 2015.

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As of February 11, 2016, Vizient, Inc. has completed its purchase of MedAssets Sg2 and spend and clinical resource management segments from Pamplona Capital Management, LLC. MedAssets revenue cycle business will continue to operate as a wholly-owned subsidiary of Pamplona Capital Management LLP.

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