Behavioral health care and the Triple Aim – Is it working?

April 8, 2016 / By Steve Delaronde

The integration of behavioral health and primary care is a critical factor for healthcare systems to achieve the Triple Aim (lower cost, better outcomes and a positive patient experience), yet effective screening, treatment and collaborative care for patients with behavioral health conditions remains a challenge.

A March 2016 article in Health Affairs highlights how the care management of depression in primary care practices has not kept up with the care management processes available for asthma, heart disease and diabetes.  In spite of the wider recognition of the prevalence and seriousness of depression as a chronic illness, the average number of care management processes used by practices of all sizes to address this condition has not changed in the past 10 years, while large practices have significantly increased the use of diabetes care management.

The importance of recognizing and treating behavioral health conditions on a population health level is three-fold:

• First, behavioral health issues – particularly depression, anxiety and substance abuse – are widespread and occur in 20-25 percent of primary care patients.
• Second, behavioral health conditions often co-occur and complicate the treatment of such chronic conditions as diabetes, heart disease and cancer.
• Finally, patients with behavioral health diagnoses have higher medical costs, more unexplained symptoms, and utilize more medical services than other patients.

There are still two, mostly independent, care systems in the United States – one that treats the physical manifestation of disease and the other treats behavioral health conditions.  Primary care is often a first point of contact for patients with depression, anxiety and substance abuse, but the lack of effective and widely used screening tools, as well as the lack of time, training and resources among primary care providers, has often resulted in missed identification and treatment opportunities.

However, even when behavioral health conditions are identified, the path to effective treatment is tenuous.  Patients referred for psychotherapy to treat depression often don’t make their first appointment and among those that do get treated, the mean number of appointments completed is two.

This means that most patients treated for depression forego psychotherapy and rely on anti-depressant medication prescribed by their primary care physician.  Pharmacotherapy has become the most common form of treatment for depression.  However, among patients prescribed an anti-depressant, low adherence rates and premature discontinuation remain major hindrances to obtaining favorable outcomes.

The Affordable Care Act has helped by 1) requiring health plans to cover depression screening for adults and behavioral assessments for children, and 2) promoting the use of Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs).  These structures are well-suited to implement collaborative care approaches for treating behavior health issues, which is based on chronic disease management models.

The challenge, however, is the effective implementation of collaborative care targeted to patients that will receive the greatest benefit.  Patients with multiple co-morbid psychiatric and medical conditions are the most complex and expensive.  The care management processes cited by Tara Bishop and colleagues in the recent Health Affairs article – patient registries, nurse case management, quality feedback, patient reminders and patient educators – all need to be adopted and routinely used by primary care practices, particularly among those patients with chronic and complex medication conditions.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.