Transcript Document

The Case for
Physical-Behavioral Health
Integration
Tami Mark, Ph.D.
Thomson Reuters Healthcare
July 26, 2011
Outline of Material to be Presented
 Behavioral disorders are common, costly, disabling and
deadly
 Behavioral and physical disorders commonly co-occur
 Reasons for co-occurrence are complex
 Co-occurrence leads to higher costs &worse outcomes
 Currently US healthcare addresses co-occurrence poorly
 Research suggests integration improves outcomes
 Research suggests integration is cost effective
3
Outline
 Behavioral disorders are common, costly, disabling
and deadly
 Behavioral and physical disorders commonly co-occur
 Reasons for co-occurrence are complex
 Co-occurrence leads to higher costs &worse outcomes
 Currently US healthcare addresses co-occurrence poorly
 Research suggests integration improves outcomes
 Research suggests integration is cost effective
4
Behavioral Health Disorders are Common,
Costly, Disabling, and Deadly
• Almost 50% of Medicaid beneficiaries will have diagnosable
mental health or substance abuse disorder in given year.1
• 11.5 % of Medicaid expenditures go to treating behavioral
health disorders (10% mental health, 1.5% substance use
disorders).2
• The World Health Organization ranks depression, alcohol,
and tobacco use as among the top causes of disability.3
• Persons with mental illness die, on average, 25 years earlier
than the general population and much of this gap can be
attributable to medical conditions such as cardiovascular
disease.4
5
Outline
 Behavioral disorders are common, costly, disabling and
deadly
 Behavioral and physical disorders commonly cooccur
 Reasons for co-occurrence are complex
 Co-occurrence leads to higher costs &worse outcomes
 Currently US healthcare addresses co-occurrence poorly
 Research suggests integration improves outcomes
 Research suggests integration is cost effective
6
Percentages of Adults with Mental
Disorders and/or Medical Conditions5
National Comorbidity Survey Replication, 20012003 as Reported in Druss and Walker, 2011
7
Medical Comorbidities are Higher
Among Persons with Mental Illness6
8
Physical Disorders Associated with
Chronic Alcohol Use
Cognitive disorders
CVA
Psychosis
Head, Neck, GI cancers
Neuropathies
Anemias
Nutritional Deficiencies
Liver Disease
Cirrhosis
Pancreatitis
Diabetes
Coronary Artery Disease
Cardiomyopathy
Arrhythmias
Hypertension
Stroke
Stomach ulcers
Gastritis
Duodenal ulcers
Adapted from: Schuckit MA. In: Harrison’s Principles of
Internal Medicine. New York: McGraw-Hill; 2001:2561-2566.
.
Tobacco Use
• Cigarette smoking continues to be the leading cause of preventable
disease & death in the US7
• Nearly 1 in 5 adults in US currently smokes8
• Extensive research shows psychiatric disorders and cigarette smoking
are frequently comorbid9, 10, 11, 12, 13
• Individuals diagnosed with a current psychiatric disorder smoked 46.3%
of all cigarettes consumed in the U.S. (2001-2002 National Epidemiologic
Survey on Alcohol & Related Conditions)
• Adults with lifetime depression, anxiety or major depressive episodes
were more likely to be “current smokers, smoke with higher intensity and
frequency, have more dependence, and have lower success at quitting”
compared to individuals without these psychiatric conditions (2005-2006
NSDUH)
Outline
 Behavioral disorders are common, costly, disabling and
deadly
 Behavioral and physical disorders commonly co-occur
 Reasons for co-occurrence are complex
 Co-occurrence leads to higher costs &worse outcomes
 Currently US healthcare addresses co-occurrence poorly
 Research suggests integration improves outcomes
 Research suggests integration is cost effective
11
Medical and Behavioral Illness Interact
in Complex and Important Ways
Modified from Katon, 2003,
by Druss and Walker, 2011
12
Outline
 Behavioral disorders are common, costly, disabling and
deadly
 Behavioral and physical disorders commonly co-occur
 Reasons for co-occurrence are complex
 Co-occurrence leads to higher costs &worse
outcomes
 Currently US healthcare addresses co-occurrence poorly
 Research suggests integration improves outcomes
 Research suggests integration is cost effective
13
Average Monthly Expenditures for Medicaid
Beneficiaries With and Without Co-Occurring Costly
Physical Conditions (2003)
Source: Medicaid Analytic eXtract (MAX), 2003
Substance Abuse and Mental Health Services Administration.
(2010). Mental health and substance abuse services in Medicaid ,
2003: Charts and state tables. HHS Publication No. (SMA) 10XXXX. Rockville, MD: Center for Mental Health Services,
Substance Abuse and Mental Health Services Administration.
Spending among dual eligibles with
mental and physical conditions
15
Mental Illness Worsens Diabetes
Outcomes14
• Persons with diabetes who are depressed have
increased rates of adverse health outcomes
relative to persons with diabetes who are not
depressed:
•
•
•
•
•
•
Mortality
Cardiac events
Hospitalizations
Diabetes-related complications
Functional impairment
Quality of life
16
BH Illness Complicates Treatment
• Substance abuse co-occurrence with diabetes
has been shown to significantly complicate the
diabetes treatment regime.
• The occurrence of depression in patients with
coronary heart disease substantially increases
the likelihood of poor cardiovascular prognosis.
• Patients with post-heart attack depression are
about three times more likely to die from a future
attack or other heart problem.
17
Outline
 Behavioral disorders are common, costly, disabling and
deadly
 Behavioral and physical disorders commonly co-occur
 Reasons for co-occurrence are complex
 Co-occurrence leads to higher costs &worse outcomes
 Currently US healthcare addresses co-occurrence
poorly
 Research suggests integration improves outcomes
 Research suggests integration is cost effective
18
Institute of Medicine15
• Multiple clinicians and health care organizations
serving patients in the American health care
system typically fail to coordinate their care.
• The resulting gaps in care, miscommunication,
and redundancy are sources of significant
patient suffering.
IOM: Improving the Quality of Health Care for Mental Health and
Substance-Use Conditions: Quality Chasm Series (2005)
19
IOM Report: Improving the Quality of Health Care
for Mental Health and Substance-Use Conditions:
Quality Chasm Services (2006)
Overarching Recommendation 1
Health care for general, mental, and substance-use
problems and illnesses must be delivered with an
understanding of the inherent interactions between the
mind/brain and the rest of the body.
20
President’s New Freedom
Commission16
Consumers often feel overwhelmed and
bewildered when they must access and
integrate mental health care and other services
across multiple, disconnected providers in the
public and private sectors. (2003)
21
Reasons for Readmission in
Medicaid (age 21 – 64)17
30-Day Readmission by MDC at Index Admission, Non-obstetric
Medicaid (21 - 64 yrs)
Readmission
Rate
MDC at Index Admission
Circulatory System
Mental Diseases and Disorders
Respiratory System
Alcohol/Substance abuse
Digestive System
Nervous System
Hepatobiliary System and Pancreas
Kidney & Urinary Tract
Musculoskeletal System & Connective Tissue
Endocrime, Nutritional & Metabolic
22
10%
10%
12%
11%
13%
10%
9%
11%
12%
8%
11%
% of all 30-day
readmissions
16%
16%
12%
11%
9%
9%
6%
6%
5%
5%
5%
Medicaid - Follow-up after Discharge
for Mental Illness in Reporting HMOs18
Source: HEDIS (National Committee for Quality Assurance, 2010)
23
Medicaid - Initiation and
Engagement of SUD Treatment18
Source: HEDIS (National Committee for Quality Assurance, 2010)
24
Percent of Adolescents who Received
Antidepressants and Therapy19
25
PCPs Unable to Get MH Services20
26
Provision of Medical Services by
Community Mental Health Centers21
27
What Does Integration Mean?
• Communication: Sharing of information among
providers
• Comprehensiveness: Meeting all health care needs
• Continuity of care: Timely, uninterrupted delivery of
appropriate services over time
(IOM, 2001:62)
28
How Can We Better Integrate Care for
Medical and Behavioral Conditions?
• Train behavioral health providers in screening, preventive
care, and routine medical services
• Train medical providers in behavioral health
• Leverage non-MD providers
• Increase communication between behavioral health and
medical care providers with: • Integrated medical record
• Co-location
• Telemedicine
• Enhanced referral
• Case management
• Team meetings
• Outreach and follow-up
• Verbal/Written consults
• Coordinated treatment plan
29
Outline
 Behavioral disorders are common, costly, disabling and
deadly
 Behavioral and physical disorders commonly co-occur
 Reasons for co-occurrence are complex
 Co-occurrence leads to higher costs &worse outcomes
 Currently US healthcare addresses co-occurrence poorly
 Research suggests integration improves outcomes
 Research suggests integration is cost effective
30
AHQR Technology Assessment:
Integration of MHSA with Primary Care22
• Intervention: Integrating mental health specialists into
primary care.
• Analysis: 33 RCTs examined (26 studies address
depression)
• Conclusions:
• “There is reasonably strong evidence to encourage
use of integrated services.”
• “The major obstacles to encouraging the use of
integrated services appear to be financial and
organizational.”
31
Meta-analysis: Collaborative Care for
Depression23
• Intervention: Collaborative care for Depression:
• A multifaceted intervention.
• Three distinct professionals working collaboratively within
the primary care setting: a case manager, a primary care
practitioner, and a mental health specialist.
• Analysis: 37 RCTs include 12,355 patients receiving
collaborative care.
• Conclusion: Depression outcomes were improved at
6 months and evidence of longer term benefit was
found for up to 5 years.
32
Effectiveness of Brief Alcohol
Interventions in Primary Care24
• Intervention: Feedback on alcohol use and harms,
identification of high risk situations for drinking and coping
strategies, increased motivation and the development of a
personal plan to reduce drinking. 5 to 15 minutes.
• Analysis: Cochrane Collaboration Systematic Meta-Analysis
of 29 RCTs in general practice (24) or emergency
department (5), 7000 patients.
• Conclusion: Significantly reductions in alcohol
consumption
33
Assertive Community Treatment
(ACT)25
• Intervention: Multidisciplinary team approach aimed at
keeping people with severe mental illness in contact with
services by using integrated and outreach-oriented
services.
• Analysis: Cochran Collaboration review 17 RCTs that
compared ACT to standard community care.
• Conclusion:
•
•
•
•
Reduces hospital days
Improves employment
Increases independent living
Improves quality of life
34
Discharge Planning26
• Interventions: Done while an inpatient to facilitate
transition to outpatient treatment
• Analysis: Steffen et al. (2009) Systematic Review and
Meta-Analysis of 11 studies of inpatient discharge
planning
• Conclusions:
• Reduced the relative risk of readmissions by 35%
• Increased probability of adherence to outpatient
treatment increased by 25%
35
Outline
 Behavioral disorders are common, costly, disabling and
deadly
 Behavioral and physical disorders commonly co-occur
 Reasons for co-occurrence are complex
 Co-occurrence leads to higher costs &worse outcomes
 Currently US healthcare addresses co-occurrence poorly
 Research suggests integration improves outcomes
 Research suggests integration is cost effective
36
Example: Weisner et al.. JAMA Study of Co-Location
Medical Provider within SA Providers27,28
• Study Location: Kaiser Permanente’s Chemical
Dependency Recovery Program
• Intervention: Patients in integrated care model received
primary medical care within the substance abuse
program (3 MDs, 2 nurses, 1 medical assistant).
• Analysis: Compared findings among patients in
integrated and independent groups for patients with and
without substance abuse-related medical conditions.
37
Results: Weisner et al, JAMA, 2003
•Integrated larger decline in:
•Hospitalization rates
•Inpatient Days
•ED Use
38
Example: IMPACT Trial29
• Intervention: Collaborative program for depression (applied to
other conditions)
• Screening tool
• Patient monitoring and follow-up
• Case manager who coordinates, educates, trouble shoots
• Evidence based guidelines and stepped care.
• Psychiatric Consultations
• Analysis: RCT of1801 depressed older primary care patients
from 8 healthcare systems.
• Findings: Effective in reducing depression, improving physical
functioning, improving social functioning
39
Results: IMPACT TRIAL
40
Example: NIATx Project
• Project: Process improvement model aiming to
enhance effectiveness and efficiency of behavioral
health treatment
• Findings:
• Reduced wait time from first contact to first
treatment
• Reduced no-shows
• Increased continuation of treatment
41
Need for Future Research30
• Most models integrate mental health care into
primary care, few do opposite
• Who is most likely to benefit from treatment?
• More examination of conditions other than
depression and older adults – those with SMI,
SUD, children
• More models of integrated payment needed
42
Summary
• Behavioral and physical conditions are closely
intertwined.
• Having a separate, fragmented system to
address behavioral and physical illnesses is a
bad idea.
• Evidence has identified some effective and cost
effective integration approaches.
• More research and experimentation needs to be
done.
43
References
1.
2.
3.
4.
5.
6.
Adelmann PK. Mental and substance use disorders among Medicaid recipients:
prevalence estimates from two national surveys. Adm Policy Ment Health. 2003
Nov;31(2):111-29.
Mark TL, Levit KR, Vandivort-Warren R, Buck JA, Coffey RM. Changes In US spending
on Mental Health And Substance Abuse Treatment, 1986-2005, and implications for
policy. Health Aff (Millwood). 2011 Feb;30(2):284-92.
World Health Organization
http://www.who.int/mental_health/management/depression/definition/en/
National Association of State Mental Health Program Directors (NASMHPD) Morbidity
and Mortality in People with Serious Mental Illness, 2006.
Druss BG and Walker ER. Mental Disorders and Medical Comorbidity. Robert Wood
Johnson Foundation, Research Synthesis Report No 21, February 2011.
www.policysynthesis.org
DE Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, Detraux J,
Gautam S, Möller HJ, Ndetei DM, Newcomer JW, Uwakwe R, Leucht S. Physical illness
in patients with severe mental disorders. I. Prevalence, impact of medications and
disparities in health care. World Psychiatry. 2011 Feb;10(1):52-77.
44
References, Continued
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
USDHHS, 2004
CDCP, 2010a
Dome et al, 201
Brown et al, 2008
Brown et al 2002
Degenhardt and Hall, 2001
Grant et al 2004
Markowitz SM, Gonzalez JS, Wilkinson JL, Safren SA. A review of treating depression
in diabetes: emerging findings. Psychosomatics. 2011 Jan-Feb;52(1):1-18.
Institute of Medicine. Improving the Quality of Health Care for Mental and Substance
Use Conditions. National Academies Press, Washington, DC. 2006.
President’s New Freedom on Commission on Mental Health. Achieving the Promise.
Transforming Mental Health Care in America. July 2003.3
Jiang, JH and Wier LH. All-Cause Hospital Readmissions for Non-Elderly Medicaid
Patients. 2007. HCUP Statistical Brief #89. April 2010. Agency for Healthcare
Research and Quality, Rockville, MD.
http//.hcup.us.ahrq.gov/reports/statbriefs/sb89.pdf
45
References, Continued
18.
19.
20.
21.
22.
23.
National Center for Quality Assurance. The State of Health Care Quality 2010.
http://www.ncqa.org/Portals/0/State%20of%20Health%20Care/2010/SOHC%20201
0%20-%20Full2.pdf
Mark TL. Receipt of psychotherapy by adolescents taking antidepressants.
Psychiatr Serv. 2008 Sep;59(9):963
Cunningham PJ. Beyond Parity. Primary Care Physicians’ Perspectives on Access
to Mental Health Affairs. 2009: 490 – 501.
Druss BG, Marcus SC, Campbell J, Cuffel B, Harnett J, Ingoglia C, Mauer B.
Medical services for clients in community mental health centers: results from a
national survey. Psychiatr Serv. 2008 Aug;59(8):917-20.
Butler M, Kane RL, McAlpine D, et al. Rockville (MD): Agency for Healthcare
Research and Quality (US); 2008 Oct. Integration of Mental Health/Substance
Abuse and Primary Care. Evidence Reports/Technology Assessments, No. 173.
Gilbody S, Bower P, Fletcher J, et al. Collaborative Care for Depression: A
Cumulative Meta-analysis and Review of Longer-term Outcomes. Arch Intern Med.
2006;166:2314-2321
46
References, Continued
24.
25.
26.
27.
Kaner EF.S., Dickinson HO, Beyer FR, Campbell F, Schlesinger C, Heather N,
Saunders JB, Burnand B, Pienaar ED. Effectiveness of brief alcohol interventions in
primary care populations. Cochrane Database of Systematic Reviews 2007, Issue
2. Art. No.: CD004148. DOI: 10.1002/14651858.CD004148.pub3
Marshall M, Lockwood A. Assertive community treatment for people with severe
mental disorders. Cochrane Database of Systematic Reviews. 2002.
Steffen S, Kösters M, Becker T, Puschner B. Discharge planning in mental
healthcare: a systematic review of the recent literature. Acta Psychiatr Scand. 2009
Jul;120(1):1-9. Epub 2009 Apr 8. Review. PubMed PMID: 19486329.
Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical
care with addiction treatment: a randomized controlled trial. JAMA. 2001 Oct
10;286(14):1715-23.
47
References, Continued
28.
29.
30.
Parthasarathy S, Mertens J, Moore C, Weisner C. Utilization and cost impact of
integrating substance abuse treatment and primary care. Med Care. 2003
Mar;41(3):357-67.
Unutzered J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD,
Powers D. Long-term cost effects of collaborative care for late-life depression. Am J
Manag Care. 2008 Feb;14(2):95-100.
Carey TS, Crotty KA, Morrissey JP, Jonas DE, Viswanathan M, Thaker S, Ellis AR,
Woodell C, Wines C. Future Needs for Integration of Mental Health/Substance
Abuse and Primary Care. Future Research Needs Paper No. 3. (Prepared by the
RTI International – University of North Caroline at Chapel Hill Evidence-based
Practice Center under Contract No. 290-2007-10056-I.). AHRQ Publication No. 10EHC0690EF. Rockville, MD: Agency for Healthcare Research and Quality.
September 2010.
48
QUESTIONS?
49