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Behavioral Health as an Agent of Change, Part I: Preventable Costs

March 30, 2020

As the healthcare sector grows to 18% of the gross domestic product (GDP) with no reversal in sight, demands for change are increasingly dire. We hear many proposals for reform, some requiring fundamental changes, and ultimately every specialty will be asked to play some role in transforming our healthcare system. How can behavioral healthcare help solve the dilemma of healthcare costs?

Our high costs don’t seem to produce top quality, at least according to most objective measures of health and mortality. It should be noted that experts long ago defined health as a state of wellbeing, not just the absence of disease. Wellbeing remains elusive, even as many diseases have been cured or controlled. Wellbeing can be enhanced, but only with behavioral healthcare as a key participant.

The question of what role our field can play in the larger healthcare crisis depends on whether it is regarded as a primary or specialty healthcare service. Psychosocial factors are clearly important in determining health status and driving primary care visits. If we are prepared, the primacy of behavior change in health improvement could place our field on the frontlines of healthcare delivery.

Three successive articles will tackle these issues. This first piece is devoted to preventable costs, the second to health improvement, and the third to primary care redesign. The conclusions reached are dramatic. Our field can prevent many unnecessary healthcare costs, improve the health and wellbeing of the population, and succeed most fully by becoming a primary care service.

Disease prevention and health promotion

When the day of reckoning comes for the healthcare industry, it will rediscover the concept of prevention. This clinical concept has a powerful financial dimension. The idea is best understood as moving progressively upstream. Start by reducing the impact of high cost conditions. Catch them early and prevent them from advancing. Keep people healthy in the first place.

These simple ideas have been shrouded in the pedantic language of primary, secondary and tertiary prevention. Whatever the terms, those deriving income and profit from the healthcare industry have long resisted the way prevention would reduce services. When GDP alarms ring and sizeable profits can be made through prevention, everything will change. Our field should be ready.

Chronic medical conditions have been a focus for the healthcare industry for many years, and the ways behavioral health conditions impede clinical progress and increase costs are well-known. Milliman released a definitive cost analysis a dozen years ago. Yet the focus in practice on comorbidity is still inadequate. We need to take the lead. We have had insight into the problem with inaction for too long.

There are two ways to view chronic care, as a short-term business opportunity and as a long-term strategic focus that will reprioritize everything else in healthcare. Both are in the early stages today. I know the short-term opportunity first-hand. After consulting for many years with a successful company in the digital behavioral healthcare space, it was acquired by a chronic condition management company.

Chronic conditions account for over 50% of total healthcare costs. A company cannot adequately manage these conditions without addressing the comorbid behavioral health problems that greatly drive up costs. Behavior change is necessary for effectively managing conditions like diabetes and heart disease, and we can show how this has been the missing piece in healthcare for generations.

The problem is even bigger than studies show today. Research gives us conservative estimates for two reasons. It typically focuses on the impact of the most common diagnoses like depression and anxiety, ignoring other complicating disorders. Secondly, claims databases underestimate the prevalence of behavioral disorders since many cases go undiagnosed or don’t meet full diagnostic criteria.

The need to change our approach has been apparent for many years, but movement from treatment providers has been slow. Physicians focus on the chronic conditions alone since this is what they know best. Behavioral health professionals focus on patients presenting for their specialty services. Collaboration occurs occasionally at the program level, not the national level.

We know from the Milliman studies that behavioral conditions are driving more than 20% of total healthcare costs based on comorbidity. Our field can reduce national healthcare costs by shifting its focus to this problem. Our clinical focus should include not only behavioral health conditions, but also health behaviors, along with better compliance with physician recommendations.

The focus must then expand to the millions of people on a path to chronicity, specifically those pre-clinical and early phase patients needing to stop disease progression. For example, 85 million people are pre-diabetic, and behavioral health clinicians can help greatly by focusing on their health behaviors. Their primary care physician has little to do until patients meet full criteria for diabetes.

We need a massive shift of our resources to meet this problem. HRSA (Health Resources & Services Administration) provides estimates of the national behavioral health workforce. Growth in the workforce for social workers alone from 2016 to 2030 is estimated to go from 232,900 FTEs to 520,450. Let’s prioritize a national plan to deploy many of those graduates to meet the challenges described here.

The crowning piece of this plan should be health promotion. It is best integrated within the primary care setting as the first step in prevention. It would fall to the behavioral health clinicians in that setting to engage patients to stay healthy. An urgency about wellness and wellbeing must begin in primary care, and the behavior change experts in that setting must use the full range of their psychosocial skills.

Healthcare professionals naturally focus on treating disorders, both early and appropriately, but this may be the wrong focus from a cost perspective. Esteemed health management pioneer Dee Edington completed his career with a single, somber message: Keep the healthy people healthy! This was based on our failure to reverse course for the sick, and more favorable prospects for helping the well.

Disease prevention and health promotion are the right clinical focus for solving the healthcare crisis. We can save billions of dollars in healthcare costs in the process. Our field can lead the way, transform the primary care setting, and create new career paths for our clinicians. We should not expect leaders from government or healthcare to tell us to take these steps. The initiative is ours alone to seize.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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