Addressing behavioral health​ to​ improve​ all​ health

Editor's​ note:​ This​ article​ was​ edited​ to​ appear​ in​ the​ print​ edition​ of​ Modern​ Healthcare.​ Experience​ the​ multimedia​ version​ of​ this​ special​ report.

Each year, the nation's health system spends billions of dollars trying to treat, manage and prevent an array of avoidable conditions that only continue to grow in prevalence.

The numbers are staggering: Nearly two-thirds of all deaths annually are attributable to chronic conditions. Patients with chronic conditions account for 81% of all hospital admissions, 91% of all prescriptions filled and 76% of all physician visits. Roughly 86% of the $2.9 trillion spent on healthcare in 2013 was related to chronic disease.

More than 190 million Americans—58% of the population—have at least one chronic condition, while more than 30 million have three or more. Projections indicate that the number of people living with multiple chronic illnesses will more than double by 2050 to 83 million if current trends continue.

Yet the effort to stem or even reverse the rising numbers of Americans who develop chronic illness has fallen short.

It's a problem the healthcare system remains mostly unprepared to effectively address. Years of research and initiatives focused on prevention and promoting healthier behaviors have missed the mark because they fail to tackle arguably the single greatest contributor to the chronic disease epidemic—mental illness.

For years, behavioral health was largely ignored when it came to determining the factors involved in physical health. Primary-care physicians traditionally shied away from considering emotional or mental health as a root cause of chronic diseases. Yet, data show that the two are closely linked.

More than one-quarter of adults in the U.S. experience some type of behavioral health disorder in a given year, according to the Centers for Disease Control and Prevention. While 29% of adults with a medical condition also have some type of mental health disorder, close to 70% of behavioral health patients have a medical co-morbidity.

Both conditions often act as a driver for one another, heightening the risk that a person with a chronic disease will develop a mental health disorder and vice versa. The presence of both mental and chronic health conditions in a patient often increase their healthcare costs. Patients with untreated depression and a chronic illness have monthly healthcare costs that average $560 higher than those with just a chronic disease, according to the American Hospital Association.

Other studies have estimated it can cost as much as three times more to treat the physical health of a patient with underlying behavioral health issues than it does to treat the same physical health issues in a patient without a mental health disorder.

"The co-occurrence of chronic illness and depression is really striking," said Dr. Alexander Blount, professor of clinical psychology at Antioch University New England. "If somebody is diagnosed with a chronic illness, they are twice as likely to have a behavioral health illness. But it's true the other way around; someone with a mental health diagnosis is more likely to have a chronic illness."

As healthcare migrates toward a value-based, coordinated-care model, a growing number of providers are trying to address the behavioral health needs of all patients as a means of improving their general health outcomes, albeit with varying degrees of success.

"For the most part, providers do a good job managing hypertension and diabetes, but they still have patients that show up to the emergency room," said Dr. Will Lopez, senior medical director for insurer Cigna Healthcare's behavioral health division. "I think providers are at a point where they're going to have to start addressing the other factors that are affecting their patients' bid to be successful in treatment, and behavioral health is at the top of that list."

The current trend toward integrating behavioral and physical health is, in many ways, a response to a mental health system that has struggled to meet the demand for such care.

An estimated 44 million adults in the U.S. are living with a mental illness, according to the National Alliance on Mental Illness, a patient advocacy organization, yet nearly 60% of those with a mental health disorder didn't receive treatment in the previous year. This is despite the fact that spending on mental health hit $221 billion in 2014, making it the single most expensive medical condition in the U.S.

"What we're seeing now is the culmination of years of neglecting the mental health system," said Dr. Brian Dixon, an independent pediatric psychiatrist based in Fort Worth, Texas. "If you don't think very well of yourself because of anxiety or depression, it's going to be hard for you to be compliant with your medical care—the two are intimately and completely tied together."

Problems with access to behavioral healthcare services persist despite the considerable attention given to the issue from lawmakers in recent years. Mental health services became part of the Affordable Care Act's 10 essential health benefits that all health plans are required to cover, while mental health parity rules restrict insurers from placing higher limits on mental health services than ones applied to medical and surgical services.

Still, evidence points to a mental healthcare system that is still offering less access even as the number of people in need of such care is on the rise. A recent study conducted by researchers at NYU Langone Medical Center found that the number of American adults who experience severe distress or feelings of worthlessness and sadness intense enough to negatively impact their physical health increased from 3% of the population in 2006 to 3.5% by 2014, totaling more than 8 million. Of that number, 9.5% in 2014 reported not having sufficient health coverage to access care from a behavioral health specialist, compared with 9% in 2006.

The study also found the number of distressed adults who reported delaying getting treatment because of costs rose to 10.5 % in 2014, compared with 9.5% in 2006. The number of those who reported they could not afford psychiatric medications also increased.

Compounding the problem is a workforce without enough psychiatrists and counselors to fully meet the demand for services.

An analysis from the Kaiser Family Foundation found the U.S. as a whole was only fulfilling around 44% of its total need for mental healthcare professionals and that an additional 3,300 would be needed to eliminate the shortage.

A huge challenge has been the disjointed nature of healthcare. The health system has traditionally reimbursed mental health services separately and at a lower rate, which some say encourages providers to coordinate behavioral and physical health.

"Our payment system has really perpetuated this fragmentation of the mind from the body," said Mara Laderman, a senior research associate at the Institute for Healthcare Improvement. "It makes it really difficult for healthcare organizations that are paid through fee-for-service to figure out how financially they are going to afford to hire a behavioral health specialist to work in the primary-care practice."

Blount, the Antioch psychology professor, estimated that nearly 75% of patients identified as having a behavioral health disorder while in primary care would not accept a referral to see a specialist. Several factors contribute to such a high level of reluctance. At most hospitals, referral systems are still inadequate. Plus, stigma associated with mental illness can deter patients from seeking treatment once they have left the doctor's office. Without timely access to a behavioral health specialist, it's more likely a patient will postpone treatment, a 2015 report by the Institute of Medicine concluded.

"They're going to get their substance abuse treatment or mental health treatment in primary care or nowhere," Blount said.

Such was the case with Drew, a 43-year-old from Wilmington, Del., who requested his last name not be used. Drew had always led a healthy lifestyle, remaining physically active and had no issues with stress. So, it came as a surprise when in 2016 he suddenly found himself feeling extremely fatigued, sleeping erratically, and experiencing a tightness in his chest.

"All of those things really started to affect my general, overall health," Drew said. He went to see his primary-care physician, an internal medicine specialist at Christiana Care Health System, a two-hospital, 1,100-bed not-for-profit network based in Wilmington. After a battery of tests to find physical causes turned up negative, Drew's physician gave him a mental health screening where it was discovered that he was experiencing anxiety. Drew's doctor then mentioned a behavioral health program offered at Christiana Care.

"When he asked if I would like to speak to one of their behavioral health physicians I immediately said 'No.' I just didn't feel I needed it," he said.

Since 2014, Christiana Care has embedded behavioral health consultants within at least 11 of its primary-care practices and one specialty-care practice. The program's focus is on collaboration between patients and providers in real time to avoid the risk that a patient might skip an appointment with a behavioral healthcare specialist. The program has since expanded to integrate behavioral health within Christiana Care's cancer, cardiac and pediatric programs, as well as its intensive-care unit.

Drew ultimately agreed to see David York, a clinical psychologist at Christiana Care. After a 15-minute session with Drew, York was able to trace the source of his anxiety back to a childhood trauma that he had repressed.

"At the conclusion of that conversation I truly felt like this overwhelming weight had been lifted off my body that I didn't know had existed," Drew said. After two weeks, which included a follow-up session with York, Drew's physical symptoms had subsided.

Had it not been for his meeting with the psychologist during his primary-care visit, Drew is convinced he would have never called to make an appointment.

"If I had left that office and didn't see Dr. York, I am 150,000% convinced that right now I would be taking whatever was prescribed to me to deal with the symptoms of the anxiety," Drew said. "Having him be right there and having the trust of my primary-care physician was ultimately for me the most powerful thing."