It is no mystery that the U.S. health care system is moving in an entirely new direction due to a universal desire to slow down the escalation in health care spending and improve the quality of care. Most care delivery systems get it.
It is also no secret that the best health care systems are the ones that focus on tertiary prevention:
- Preventing people with serious chronic conditions from having their conditions exacerbated;
- Preventing side effects from treatment that require hospitalizations, and
- Preventing other expensive interventions.
Avoiding repeat emergency department visits and hospitalizations for preventable problems is becoming a major focus of cost control efforts. Only now are payers and purchasers focusing on mental health conditions and the impact on their costs. I believe these folks are just waking up to the fact that mental illness is one of the leading drivers of rising health care costs.
Mental illness drives up health care costs for two reasons:
- First, consider very expensive mental illnesses such as schizophrenia, bipolar disorders, and major depression. Treatment of these illnesses is not well coordinated, their meds are expensive, and the hospitalizations that result from exacerbations of these illnesses can be prolonged.
- Second, many patients with chronic illnesses become depressed because of their health problems. Their depression or anxiety then increases their other illnesses because they fail to take their meds, or exercise consistently, or to adhere to a treatment plan or other health programs.
In addition, patients with very serious illnesses such as cancer and heart disease become anxious. Anxious, physically ill people tend to go to the ER at the first sign of a troubling symptom, or because they are reassured by frequent check-ups and imaging tests. When these individuals become isolated and depressed, they over-utilize the health care system because it provides attention and meaningful social interactions.
Let’s face it: the view (or perception) of insurance company execs is that patients with mental health issues are expensive and high-utilizers (also known as frequent fliers). That is the perception—whether it is true or not. But new data that insurers are now collecting spotlight the problem. Perception has become reality.
Addressing the perception of insurance companies is a major challenge—and opportunity—for the clinical mental health counseling (CMHC) profession. Why? Because of the need to treat the whole person and the team-based care approach imperative.
Although there has been some progress, the health care system currently responds poorly to individuals with chronic diseases and mental health conditions such as depression. The magnitude of the problem is evident in these data from the Substance Abuse and Mental Health Services Administration (SAMHSA):
- Only about a third of people with a mental health condition receive treatment.
- Only about a third of those folks—12 percent overall—actually receive adequate treatment.
- Why? Primary care practices and providers usually do not like dealing with mental health conditions. So they refer patients to mental health providers, typically psychiatrists. But for new patients, especially ones who have Medicare, Medicaid, or inadequate health insurance, getting an appointment with a psychiatrist can take three to four months. Delays of this nature are not good—especially for already anxious patients!
And these people need more than just the care of a psychiatrist; they need to be connected to social services and to be engaged in social activities that replace the meaningful but expensive attention they receive from nurses. In other words, integration needs are dynamic and comprehensive.
A number of health care systems have begun to figure out how to institute or integrate tertiary preventive care for chronically ill patients, or they are focusing on it and will find solutions soon. But only a handful of health care systems are beginning to attend to the mental health conditions experienced by their regular patients, particularly the depression, the anxiety disorders, and the social isolation they are confronted with daily.
Health plans need to combine routine screening of patients for depression and dementia not with a referral to a psychiatrist, but with immediate intervention by other mental health workforce providers, such as CMHCs.
Early implementers, innovators, and adopters of new primary-care delivery systems will begin experimenting soon on how to address patients with co-morbid conditions (co-occurring medical and mental health conditions).
Integration of mental health with physical health and overall parity will finally happen—not because of any new legislative mandates—but because health system executives realize it’s necessary to improve quality and reduce total health care costs.