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Is transformative investment on the horizon for behavioral healthcare?

December 17, 2018
Behavioral health conditions are highly prevalent. They are disabling. They are costly, both on their own and when co-occurring with other chronic conditions. They can result in the tragedy of suicide, or at times, interpersonal violence. Conditions like depression and alcoholism have come out of the shadows, and they are now widely recognized for the ways in which they ruin lives and degrade the productivity of a workforce. It might be expected that in the debates about healthcare – especially what to fund as a priority – that behavioral healthcare would be moving into the spotlight as a critical focus. One might expect a dramatic increase in both public and private funding. A powerful, data-driven argument has been made for this many times, and yet it is still not likely that behavioral healthcare will get the attention and funding it merits any time soon. The tragedies of mass shootings and the opioid epidemic have resulted in the allocation of some public funding. However, the behavioral healthcare infrastructure will not be transformed in any way by these initiatives. In the realm of private funding, we have seen private equity companies move some of their money into the substance use disorder industry in order to roll up existing small programs into a larger, more profitable enterprise. Yet this activity, driven by insurance parity regulations that bring more money into the system, is not intended to alter the delivery system. It is just a reasonable investment based on expanded insurance benefits. Health plans have long recognized that behavioral health conditions account for a substantial percentage of claims costs (around 20% of total healthcare costs according to Milliman’s gold standard analysis in 2008). Yet the growing number of accountable care organizations (ACOs) being created for commercial, Medicare and Medicaid members have very limited resources available for the treatment of behavioral health disorders. Chronic medical conditions get the most focus since they account for roughly 50% of all costs. It is also important to note that doctors are more comfortable treating chronic medical conditions than behavioral health conditions, and so little is likely to change for some time. The main point is this: Behavioral health conditions complicate every other medical condition and they are devastating in their own right. We understand the impact now on employee productivity, total healthcare costs, disability, and misery. However, we are not inclined to change much in this country with regard to the funding or the infrastructure for behavioral healthcare. We should understand the reasons for this, since eventual change can only occur when we are able to respond to these realities. Let me be clear about where the changes need to take place, namely, at the payer level. There are many payers. At the governmental level we have Medicare, Medicaid and veterans funding streams. States also are payers, especially as partners for the Medicaid population. Commercial health plans are significant payers who cascade funding down to internal or external behavioral healthcare entities. Employers started paying for health insurance decades ago as a way to attract and retain workers, and now they are trying to determine how they can increase the productivity of their workforces with health and wellness benefits. They know that behavioral health issues are paramount, but every day they hear about numerous paramount health issues that need more funding. They are frustrated after years of sensible investments that have not reduced healthcare costs or improved worker productivity. The most recent numbers are staggering. Healthcare expenditures amounted to $3.5 trillion in the U.S. in 2017, with behavioral healthcare costs at about $240 billion. Every healthcare segment wants a bigger slice of the pie. Decisions on resource allocation are often not made based on relative need, disease burden, clinical impact or rationality. Greed, influence and power are mighty determinants. Here are five key realities to understand and accept: Despite advancement in the understanding of behavioral health conditions, a minority of people see alcoholism as being like cancer, a blameless disease, and no one feels zero shame for experiencing a suicidal depression or a debilitating level of anxiety. People try to hide the embarrassment of their negative moods, thoughts, and behaviors. Primary care physicians make their living by recommending medical tests and medications, and unfortunately, they have few definitive tests or effective medicines for behavioral health disorders. The findings on antidepressant medications suggest an impact little more than placebo (see The Emperor’s New Drugs by Irving Kirsch), and so doctors lack the powerful tools they want in a primary care setting. They have good medicines for cholesterol, blood pressure, enlarged prostates and so on, but they have mediocre drugs for depression, the most prevalent behavioral health disorder. While psychotherapy is remarkably efficacious, it is not in the wheelhouse of the PCP. They are instead left with second-rate medicines. When roughly 50% of healthcare costs are due to chronic medical conditions that doctors understand and hope to treat in more effective and efficient ways, this will be their focus. Period. Behavioral healthcare will not pre-empt this focus. While some investment capital will flow into behavioral healthcare, specifically SUD care, due to the increase in insurance funding and the astronomical gap in care (roughly 90% of those impacted get no care for various reasons), we can expect that the behavioral healthcare industry will be under-funded for generations. Governments (especially through Medicaid) have provided better funding for behavioral healthcare, but an increased level of investment is not likely given the budgetary challenges for state and federal government in the coming decades. The main way that behavioral health conditions can receive serious attention is through a focus on co-morbidities. Chronic medical conditions are two to three times more expensive when a co-occurring behavioral health condition is present. These patients are unable to get on a pathway toward recovery when they have one of the common and debilitating behavioral healthcare disorders. If we can effectively address the comorbid behavioral health conditions impacting people with chronic medical conditions, we can then advance the fundamental case for behavioral healthcare. This is not intended as a negative story about the status of behavioral healthcare, but rather as a therapeutic intervention for the field. Let’s embrace the impact we can have on people with co-occurring medical and behavioral health disorders. Let’s drive as many dollars and programming ideas as we can to this population. I recommend this recent analysis by Milliman. Once we have demonstrated our clinical and economic impact for this population, we can broaden our focus to all consumers and to the behavioral healthcare industry in general. Consumers, healthcare leaders and payers will be ready at that point to hear our overall value proposition. They are not now. This is the best starting point for a genuine transformation in the funding and the infrastructure for behavioral healthcare. Today’s policy discussions are simply debating minor investments, with an incremental impact at best. We need a transformative vision and a sound strategy to get to large solutions. We need large solutions, not incremental change. Ed Jones, PhD, is senior vice president of strategic planning for the Institute for Health and Productivity Management.
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