Future Developments in Behavioral Health Care

Recent survey results indicate that as many as 24 million Americans may need mental health treatment but are not getting it. Some of the reasons for this are cost, lack of insurance, stigma, and not understanding what behavioral insurance covers. Although the stigma associated with mental health care is fading, some individuals are still concerned that employers, coworkers, or friends will think less of them for seeing a therapist. Others are skeptical that therapy is effective and actually solves problems. And some people simply cannot find, or do not know how to find a therapist who works well with them.

The costs for not accessing needed behavioral treatment are many. Depression can complicate a patient's recovery from a major illness. Patients with chronic or serious mental illnesses who do not have appropriate outpatient care can bounce in and out of inpatient facilities, while families and patients suffer from poor outcomes and mounting insurance bills. Finally, lack of care can lead to the most serious outcome possible: death of the patient through suicide.

Broadening Care Access

Radical new approaches to reaching those in need of mental health care are needed—and fortunately, are either in development or in use already. They include:

• Proactive disease management programs that operate on several fronts: working with employers to reach out to employees through the workplace, and with health plans to identify patients taking psychotropic medications who need additional support; and reaching out to patients with other diseases like diabetes or cardiac conditions who may also suffer from mental illness.
• Outreach to people who want treatment but do not know how to access it or to find a therapist who is best for them. One's choice of a psychotherapist is primarily impacted by a physician's recommendation, the health plan network, and the location of the clinician's office. Offering information about clinicians online, even identifying those within a network with specializations or a track record of producing the best outcomes, can help people make more informed choices. Just as health plans publish physician "report cards" to educate consumers, so psychotherapist report cards might help people choose the best therapist for their needs.
• New ways of delivering therapy that are more accessible and cost effective. For example, patients with mild to moderate levels of distress can benefit from a "coach" who offers counseling over the telephone or via the Internet. The Internet can also play an important role in promoting compliance with treatment, and augment other treatment offerings.

Productivity

One of the challenges of managed behavioral healthcare organizations is the ability to demonstrate to purchasers that the benefits they deliver result in increased workplace productivity. Studies of this type are usually collaborative efforts between an employer group and MBHO, and results are often skewed by nuances of the individual group. In 2003, PacifiCare Behavioral Health, a leading national managed behavioral health care organization, reported the results of a four-year study of nearly 20,000 of its members in behavioral treatment representing multiple employer groups and health plans across the country. By measuring the degree of work impairment through a patient survey tool administered in clinicians' offices at the beginning and at multiple points during psychotherapy, the MBHO was able to track patient improvement. Five questions on the survey assessed degrees of work impairment. The MBHO found that 31 percent of people accessing behavioral services met criteria for being work impaired—meaning their day-to-day functioning was impaired. After only three weeks of treatment, the percentage of work-impaired patients dropped to 18 percent, and after nine weeks, it dropped to 15 percent. Generally, patients who still appear work-impaired after a few months of treatment are those with chronic behavioral health conditions that need more intensive services with careful monitoring and typically are enrolled in a disease management program.

If an employer knew that nearly one-third of its employees accessing its behavioral health benefits were work-impaired, that employer would undoubtedly see treatment as a worthwhile investment if half of those starting treatment work-impaired are able to return to nonimpaired status. U.S. employers report that they suffer $24 billion a year in losses due to absenteeism and presenteeism (working, but not functioning at full capacity) from depression in the workforce, while the cost of substance use disorders is estimated at $100 billion. If these costs can be reduced substantially with treatment, then behavioral health care services would rank as one of the most worthwhile investments an organization's management can make.

Claims Review, Preventive Care, Encouragement of External Cost-Control Systems

Claims Review
There is no doubt that claims review can generate substantial cost savings. In general, this review is done not by the employer but by the provider of medical expense benefits, a third-party administrator, or some independent outside organization. At a minimum, claims should be reviewed for patient eligibility, eligibility of the services provided, duplicate policies, and charges that are in excess of the usual, customary, and reasonable amounts. Many medical expense plans routinely audit hospital bills, particularly those that exceed some stipulated amount, such as $5,000 or $10,000. They check for errors in such items as length of stay, services performed, and billed charges. Many insurance companies have found that each dollar spent on this type of review results in two or three dollars of savings.

A newer trend in claims review is utilization review or case management, which may be done on a prospective basis, a concurrent basis, a retrospective basis, or a combination of the three. A prospective review involves analyzing a case to see what type of treatment is necessary. Hospital preadmission authorization, second surgical opinions, and predetermination of dental benefits fall into this category. However, when a patient is hospitalized, concurrent review can lead to shorter stays and the use of less expensive facilities. Concurrent review is normally carried out by a registered nurse and typically begins with precertification of a hospital stay for an initial specified length of time. The nurse then works with the patient's physician to monitor the length of stay and to determine whether other alternatives to hospitalization—such as hospice or home health care—can be used. Many providers of medical expense benefits pay for these alternative forms of treatment even if they are not specifically covered under the medical expense plan, as long as their cost is lower than the cost of continued hospitalization.

A retrospective review involves an analysis of care after the fact to determine if it was appropriate. Such a review may lead to a denial of claims, but its purpose is often to monitor trends so that future actions can be taken in high-cost areas. For example, a retrospective review may lead to the establishment of a concurrent review program for a hospital with excessive lengths of stay.

Health and Preventive Care
There is little doubt that persons who lead healthy lifestyles tend to have fewer medical bills, particularly at younger ages. It is also evident that healthier employees save an employer money by taking fewer sick days and having fewer disability claims. For these reasons, employers are increasingly establishing wellness programs and employee-assistance plans. With increasing health awareness among the general population, the existence of these programs has a positive side effect—the improvement of employee morale.

Encouragement of External Cost-Control Systems
While a certain degree of cost containment is within the control of employers, the proper control of costs is an ongoing process that requires participation by consumers (both employers and individuals), government, and the providers of health care services. Many agencies and committees of the Department of Health and Human Services carry out these activities at the federal level. This government department has the primary responsibility for identifying health care needs, monitoring resources, establishing priorities, recommending courses of action, and overseeing laws that pertain to health care.

At the state and local level, many employers are active in coalitions whose purpose is to control costs and improve the quality of health care. These groups—which may also involve unions, providers of health care, insurance companies, and regulators—are often the catalyst for legislation, such as laws authorizing PPOs and establishing hospital budget-review programs. Some coalitions act as purchasing groups to negotiate lower-cost coverage for members. For example, one midwestern coalition consists of several large corporations and offers a uniform health plan to the 50,000 employees of its members. The plan is self-funded by the coalition and utilizes the services of about 1,000 primary care physicians and 4,000 specialists. Another coalition, an example of a different approach, represents over 10,000 companies with fewer than 150 employees each. The coalition negotiates with providers of medical expense coverage and offers its members a choice of about a dozen different group plans. The annual increase in cost to coalition members has been significantly less than the annual increase in cost for other companies in the area that do not belong to the coalition.

COST CONTAINMENT AND MANAGED CARE

Between 1970 and the early 1990s, the average annual increases in the cost of medical care were approximately twice the average annual increases in the consumer price index. No single factor accounts for these increases. Rather, it was a combination of the following reasons:

Technological advances. In the last few years, many exciting technological advances have taken place. Numerous lives are now being saved by such techniques as CAT scans, MRIs, fetal monitoring, and organ transplants. As miraculous as many of these techniques are, they are also very expensive. Technological advances can also prolong the life of the terminally ill and increase associated medical expenses.

Increasing malpractice suits. The providers of care are much more likely to be sued than in the past, and malpractice awards have outpaced the general rate of inflation. This development has resulted in higher malpractice insurance premiums, a cost that is ultimately passed on to consumers. The increase in malpractice suits has also led to an increase in defensive medicine, with routine tests likely to be performed more often.

Increases in third-party payments. A growing portion of the country's health care expenditures is now paid by private health insurers or the government. Patients and providers of health care often have no financial incentives to economize on the use of health care service.

Underutilization of medical facilities. Currently, the United States has an overabundance of hospital beds, and a surplus of physicians is also beginning to develop. Empty hospital beds are expensive to maintain, and an oversupply of physicians tends to drive up the average costs of medical procedures so that physicians' average income does not drop.

Design of medical expense plans. Many medical expense plans now provide first-dollar coverage for many health care costs. There is often little incentive for patients to avoid the most expensive forms of treatment.

AIDS. The continuing increase in the number of AIDS cases over the past 10 years has resulted in increasing costs to employers. Costs in excess of $100,000 for an employee with AIDS are not unusual.

An aging population. The incidence of illness increases with age. Current demographics indicate that this trend will be a source of cost increases for several years to come.

During the period from 1994 to 1996, several factors caused the cost of medical expense coverage to remain uncharacteristically stable, particularly for managed care plans. Many providers of medical services and medical expense plans were reluctant to raise costs while the Clinton health care proposal was being debated. In addition, managed care plans were holding down premiums while actively increasing enrollments.

However, the late 1990s started to see significant increases in health care costs, particularly because of skyrocketing costs for prescription drugs. There is a feeling among benefit consultants that expanding managed care plans have saturated the market to the point that savings resulting from additional employees moving to managed care plans will be modest. There is also an interesting trend occurring among medical providers. The large number of mergers of hospitals and other providers of medical services in many parts of the country may in fact shift the balance of bargaining power to these providers from managed care plans and other buyers of medical services. In addition, costs will increase somewhat because of federal and state legislation that continues to mandate benefits.

Increasing health care costs have become the concern of almost everyone—government, labor, employers, and consumers. In this introduction to cost containment, many of the measures employers use are enumerated.