Healthcare outcomes are determined by a range of factors. An actual medical intervention accounts for only approximately 20 percent of the variance in outcomes. Population health variables including poverty, education, employment, and housing situation account for as much as 40 percent of variance in outcomes. While the healthcare industry has traditionally prioritized the medical intervention component of the health outcomes equation, we know that if we want to make big improvements in the health of people in our communities, we need to think more broadly. The best clinical care must pay attention to a wide range of non-medical and social supports as well as more traditional medical interventions.

Increasingly, it has become clear that the best clinical care must include behavioral health services. People with multiple chronic conditions are an expensive population for providers and payers. The most expensive five percent of the U.S. population, typically people with multiple chronic conditions, account for 49 percent of all healthcare spending. Almost invariable, people with multiple chronic conditions have one or more behavioral health issues. When it comes to managing chronic conditions such as asthma, heart failure, diabetes or hypertension, the addition of a behavioral health condition increases healthcare costs by two to 300 percent. Management of behavioral health problems will be essential in achieving optimal outcomes for other chronic conditions and in reducing costs of care.

Unique Bridge

Behavioral health services provide a unique bridge between clinical health services and population health variables. Behavioral health services include overtly clinical interventions such as medications, outpatient therapy and clinical crisis management. However, behavioral health interventions, such as motivational interviewing, can be used in primary care or psychiatric settings to increase a person’s willingness and ability to participate in self-management or prevention of chronic diseases or to increase the likelihood that someone will be able to implement positive health behaviors such as smoking cessation or exercise. Additionally, for people with the most disabling behavioral health conditions (and frequently significant co-occurring medical problems), behavioral health services often will include sophisticated care management strategies and evidence based interventions that attend to needs like housing, employment, education, and poverty that are usually not seen as clinical problems but which affect clinical outcomes.

Social supports such as supported housing, supported employment, supported education and peer support services are critical in helping individuals with significant behavioral health needs improve both their quality of life and their clinical status. In fact, there is a great deal of evidence that helping someone with a disabling mental illness gain employment leads to greater clinical improvement than more traditional clinical interventions. Supported employment typically costs about $5000 annually but it leads to improvements that reduce utilization of more expensive medical and behavioral health services, particularly emergency room and hospitalization.

Traditional Healthcare

While the research is clear that behavioral health interventions are essential in improving clinical outcomes and quality of life and reducing costs, the ability to provide such interventions is increasingly difficult in a traditional medical fee-for-service environment. Traditional healthcare systems tend to be driven by high cost, high tech interventions and low tech behavioral health work is often seen as not clinically interesting or financially attractive as a focus for a medical health system. Even insurance companies, which should recognize the potential of behavioral health interventions to reduce overall spending, often see behavioral health services as discretionary add-ons rather than the center of the healthcare puzzle. There is also a lingering stigma associated with mental illness that impacts the way that behavioral health interventions are valued by the healthcare system. Overcoming the structural barriers to better access to behavioral health services is an essential step in improving outcomes and reducing costs.

Some elements of healthcare reform may help to provide a clear picture of the benefits of behavioral health interventions. Improved data management capacity and analytics help providers to see the overall cost to the healthcare system in an unbiased way that reveals the prominent role that behavioral health problems play in illness, recovery and self-management. This allows us to model changes in the system with an emphasis on reducing dependence on fee-for-service and moving towards capitated reimbursement, increasing the attractiveness of lower cost behavioral health interventions to healthcare systems.

Behavioral Health Homes

Behavioral health homes for people with serious mental illnesses provide another opportunity for more effective care integration. Supporting the delivery of primary care and integrated care management in behavioral health settings improves outcomes and access while reducing costs. For example, a pilot of Behavioral Health homes in Missouri resulted in a 16.3 percent reduction in total Medicaid spending for the population while improving health outcomes.

The era of using evidence based behavioral interventions in healthcare settings as a way to improve outcomes and lower costs is dawning. In order for the promise of health improvement in communities to be realized, we must find ways to attend to both traditional medical interventions and the population health variables that so often are the difference between success and failure. Behavioral health services have the potential to improve integrated clinical care through more robust access to and use of social supports and structures.

 An Expensive Population

• The most expensive five percent of the U.S. population, typically people with multiple chronic conditions, account for 49 percent of all healthcare spending.

• Almost invariable, people with multiple chronic conditions have one or more behavioral health issues.

• When it comes to managing chronic conditions such as asthma, heart failure, diabetes or hypertension, the addition of a behavioral health condition increases healthcare costs by two to 300 percent.

• Management of behavioral health problems will be essential in achieving optimal outcomes for other chronic conditions and in reducing costs of care. 

-Catherine Batscha, DNP, PMHCNS-BC, PMHNP-BC, is assistant professor at the U of L School of Nursing.  Anthony Zipple, ScD, MBA is president & CEO at Seven Counties Services in Louisville, Ky.