Studies suggest that nearly half of all physician office visits involve an underlying behavioral health issue. Further, there is no question that a large percentage of patients with a behavioral health condition seek treatment from a PCP rather than a mental health professional. However, many traditional providers feel ill-equipped or uncomfortable treating behavioral health disorders—a reality that often results in patients being undertreated or treated inappropriately for their behavioral health issue. And the inevitable result of substandard care is increased utilization, with little to show for it.
Given that this problem is well recognized, some organizations have developed novel solutions that are delivering promising results. For example, a number of state Medicaid programs are benefiting from an analytic approach developed by White Plains, NY–based Comprehensive NeuroScience (CNS) that provides decision support to providers with the aim of bringing their prescribing of behavioral health medicines in line with evidence-based guidelines. Alternatively, CIGNA Behavioral Health (CBH), based in Eden Prairie, MN, is reporting favorable clinical and financial results from a patient-directed intervention aimed at preventing ER visits and hospital admissions among patients at high risk for such utilization because of their behavioral health diagnosis.
Intervention delivers dividends
With the intention of preventing readmissions, CBH spent years investigating methods of interacting with patients who had been hospitalized with a behavioral diagnosis. “We studied things such as mailing them letters, creating Web reminders, and a whole host of options,” explains Jodi Aronson Prohofsky, PhD, LMFT, senior vice president of clinical operations at CBH. “But what we found really worked best was having a one-to-one, dedicated care advocate to help them understand their disease, their issues, what was [affecting] them, and what could cause a decompensation.” In addition, Prohofsky notes that the advocate could help patients navigate the system, especially during times of crisis.
Investigators first tested the approach in the context of a small pilot at a single site, and what they discovered was that not only did the care-advocate intervention decrease readmissions, it also had a positive effect on member satisfaction and staff satisfaction, says Prohofsky. She explains that staff appreciated the ability to follow patients on a more longitudinal basis.
At the conclusion of the pilot, CBH expanded what it now calls its Intensive Care Management (ICM) program to its entire book of business and launched a larger study aimed at taking a closer look at what factors the approach was affecting. For this yearlong study, -investigators looked at 286 participants in the ICM program who had a primary behavioral diagnosis as well as underlying medical comorbidities. In addition, every participant had at least one inpatient psychiatric hospital admission. Outcomes from this intervention group were then compared with outcomes from a matched control group of 517 CBH members who did not participate in the ICM program.
Investigators analyzed a full year of medical, behavioral, and pharmacy utilization data for participants in the intervention and control groups. What they found was that the intervention group significantly outperformed the control group on a range of measures including a 53% reduction in hospital admissions, a 52% reduction in ER visits, a 13% decrease in nonmental health outpatient visits, and per-patient savings of $3,134. In addition, medication compliance among intervention group participants increased by 14.9%, and total outpatient costs remained flat from preenrollment to postenrollment.
Care advocates connect with patients
The study targeted individuals with both behavioral diagnoses and medical comorbidities because investigators wanted to document the effect the program can have on both behavioral and medical health. “As we were beginning to work with people, and we were keeping them compliant with their behavioral program, what we were finding was that they were naturally taking that compliance to their medical program,” says Prohofsky, noting that the care advocates help patients understand the importance of coordination of care. However, Prohofsky says that a medical comorbidity is not a requirement for enrollment in the ICM program, which is primarily concerned with the behavioral health issue. Further, although the program targets members who have undergone an inpatient psychiatric admission, it also utilizes predictive modeling to identify and enroll members who are at risk for a first inpatient admission.
Even though care advocates primarily communicate with patients by phone, Prohofsky explains, they have a high degree of success in making an initial connection with patients because they make every effort to reach patients while they are still hospitalized or while they are in the doctor’s office on an outpatient visit. “Then we send the individual a follow-up letter to remind them [of] why we spoke, or if we couldn’t reach them, why we are trying to make contact,” she says. “And then from there, once the patients get connected with their care advocate, they are told that this is the person who will work with them from here on forward.”
The care advocates—typically psychologists, social workers, mental health counselors, and nurses—stay in contact with patients on a weekly or even daily basis, as needed, explains Prohofsky, noting that they schedule their phone appointments at the convenience of the individual. During these conversations, the advocate will work toward making sure that the member understands his or her diagnosis and medications. In addition, the advocate will help the member to identify early warning signs of difficulty so that he or she can take steps to address them before they become crises. Further, Prohofsky explains that the advocate and the patient will work together to identify a support system as well as important phone numbers that the member can call if he or she needs help. “It doesn’t replace the therapeutic relationship or the medical relationship, but it becomes yet another relationship for the members, and we find that they are quite connected to it,” says Prohofsky.
When issues arise, such as a troubling side effect that is preventing the member from taking medications as prescribed, the advocate will encourage and prepare the member to discuss the issue with his or her provider. If this approach fails, either through misunderstanding or other barriers, the advocate will work directly with the clinician to resolve the problem. Prohofsky says that these contacts are usually well-received by providers, because they often have no idea that the patient stopped taking the medication or that there was even a problem.
Typically, as patients develop more knowledge and self-confidence in managing their behavioral health, contacts with the care advocate will begin to decrease, and eventually the patients will graduate from the program. However, Prohofsky notes that there is no firm timetable as to when graduation occurs. “Members have their advocate’s name and number, and they can reactivate the advocate at any time they feel they need to in the future,” she says.
Program focuses on prescribing
Although the ICM program includes some interaction with providers, it is primarily a patient-centered intervention. Alternatively, the approach developed by CNS is focused exclusively on the provider, but it too is delivering impressive results in many of the 25 state Medicaid programs the company is working with.
The program goes by different names in different states, but CNS refers to it as the Behavioral Health Pharmacy Management Program. Using a set of 150 different algorithms, the approach involves evaluating all pharmacy claims for mental health medications in order to identify practices that are inconsistent with evidence-based guidelines. When a potential problem or inconsistency is identified, CNS contacts the provider to let him or her know about the issue.
“We send a notice to the physician basically saying [what we have observed], and here is a 90-day history on the patient, and here are some things that we recommend that you consider,” explains Richard Surles, PhD, senior vice president of care management technologies at CNS. Surles says the company understands that there are often special considerations that go into prescribing, so CNS is simply asking providers to review the information that the company has provided. “We start out with a letter that has backup information. If the physician doesn’t respond, we have the ability to do a psychiatric peer-to-peer consultation [by phone],” says Surles, noting that the discussion always pertains to use of the medication rather than the patient.
In many cases, Surles explains, these communications deal with prescribing that is above or below recommended dosing levels, premature switching from one medication to another, or the prescribing of multiple medications from a single class. However, he adds, a large percentage of the notifications provide important information to the provider that he or she would not otherwise know about, such as duplicative prescribing of medications by different doctors who are seeing the same patient or the failure of patients to refill their medications as directed by their provider. “We get very good feedback from pediatricians and PCPs because generally they are out there by themselves, and many times we are bringing things to their attention that they have not thought about,” says Surles.
QI intervention affects costs
Although the program was developed as a quality improvement initiative, Surles acknowledges that most customers come to CNS because they are concerned about spiraling costs related to behavioral health medications. “Antidepressants are mostly generics now, but the big expense comes from the typical antipsychotics, bipolar medications, and, interestingly enough, drugs for children,” says Surles, noting that both stimulants and nonstimulants are big cost-drivers in the government-payer world.
According to data released by several state customers who are working with CNS, the program has delivered significant dividends. In Missouri, for example, state investigators report that in a study comparing 1,911 intervention participants with a matched control group, hospital admissions declined by 43% in the intervention group and just 0.1% in the control group. In addition, there was a $1,238 decrease in costs per person in the intervention group and a $312 per-person decrease in the control group. The study period compared data from six months preintervention to six months postintervention.
In Oklahoma, investigators report that the program has helped to keep costs related to behavioral health medications relatively constant when most states are seeing steep hikes. However, Nancy Nesser, PharmD, JD, pharmacy director of the Oklahoma Health Care Authority, explains that there have been other advantages as well. “We decided to [offer the program in 2004] as an alternative to putting restrictions or prior authorization [requirements] on the antipsychotic medications,” she says. “We as an agency didn’t feel that going through the restriction process was the most beneficial thing to do for our patients, and so we opted to go an educational route.”
There are nearly 56,000 adults and 39,000 children taking behavioral medications within Oklahoma’s Medicaid program, so the program affects a significant number of recipients. Further, Nesser notes that there is evidence that providers who have received program notifications regarding their prescribing tend to change their prescribing patterns to be more in accordance with evidence-based practice over the longer term.
In Oklahoma and many other states, the CNS program is funded through grants from Eli Lilly and Company, although it is not known how long this funding will continue. In the meantime, CNS has begun to expand the program beyond the Medicaid arena. “We are moving to Medicare Advantage [programs] and also Medicare Part D, and so that is a major change for us,” explains Surles. “We have put a lot of time and effort into improving our elderly program, not only updating our indicators but also adding a falls prevention component based on the combinations of medications that can produce dizziness and nausea—symptoms that can lead to falls and injury.”