By Randena Hulstrand, Vizient
While behavioral health conditions — including major depression, anxiety and substance use disorder — continue to grow post the COVID-19 pandemic, accessing care remains increasingly difficult, especially among vulnerable populations.
Inequities in insurance coverage contribute to healthcare disparities. As a result, economically vulnerable patients have very different experiences with healthcare compared to economically advantaged patients that results in variations in care and outcomes.
To better understand these inequities in behavioral health, the Vizient Research Institute conducted a study, “Closing the Gap — Improving Access to Behavioral Health Care for Vulnerable Populations," exploring the underdiagnosis and undertreatment of behavioral health conditions among patients with private insurance compared to Medicaid patients.
Results indicate that in addition to variation in access to psychotherapy between the two groups, there is variation in treatment, with Medicaid behavioral health patients receiving prescriptions in lieu of psychotherapy and making trips to the ER more often. Additionally, the study shows that not only are private insurance patients more likely to receive psychotherapy than Medicaid patients overall, but private insurance patients have more psychotherapy encounters per person compared to Medicaid patients. Reasons could be attributed to drugs being cheaper than paying for each psychotherapy visit, providers limiting the number of Medicaid patients they will see for psychotherapy and Medicaid patients may not have regular transportation to get to psychotherapy appointments.
“The implications for disparities in diagnosing and managing behavioral health conditions are numerous for the patient, community and health organizations,” said Erika Johnson, vice president, strategic research at Vizient. “When early diagnosing and routine management of behavioral health conditions do not occur, higher utilization of more costly resources can result such as emergency department visits and/or inpatient hospitalizations, and because behavioral health conditions are commonly a comorbidity to other complex chronic conditions, high-cost healthcare spending increases across the care continuum.”
Strategizing for improvement
According to Sg2’s 2023 Behavioral Health Service Line Snapshot, over the next decade inpatient discharge will increase more than any other healthcare service line due to heightened patient acuity and a growing number of patients with multiple comorbidities. And outpatient growth will continue as patients and providers seek to manage symptoms proactively in lower-acuity settings.
To get ahead of these challenges facing access to behavioral health, Stephanie Snider, consulting director, intelligence at Sg2, a Vizient company, says it’s important for organizations to strategize for better operational flow, patient outcomes and address social determinants of health, which can add value to their healthcare system and society at large.
“Assessing current demands of behavioral health and identifying gaps at their organization is key,” Snider said. “For example, do they lack outpatient services? What are the demographics of the patients they’re serving? This arms leaders with data points to know where they need to improve and direct patient care. Then, they can identify models and workstreams that will work best for their organization.”
Expanding providers and virtual visits
There currently are not enough psychiatrists or psychologists to meet the current demand for psychotherapy services and studies have shown that the country’s medical schools will not be able to train enough providers to meet the demand for the next 20 years.
“In response, health systems can rethink options to meet this demand, including integrating crucial behavioral health offerings within other service lines such as women’s health, cancer or pediatrics and deploying team-based care,” Snider said. “Many systems have embraced a move toward the Collaborative Care model developed at the University of Washington — a team of primary care or specialty providers, embedded behavioral health staff and a psychiatric consultant.”
She adds that other organizations also are utilizing social workers, nurse practitioners and physician assistants to expand access to address low acuity behavioral health needs.
“Integrated care is the best way to address low to moderate acuity behavioral health concerns as emergency departments are overwhelmed,” she said. “This provides early access, whether it be psychotherapy, counseling and/or medication management that helps prevent more serious cases that could develop over time.”
During the pandemic, the use of virtual care increased significantly especially for behavioral health conditions and has continued at a higher rate for the psychiatry service line compared to other service lines. Over 50% of psychotherapy services are still being delivered virtually across providers whereas other service lines are seeing the majority of their patients in person again.
“Virtual visits are preferred by many patients including those who are economically disadvantaged patients because they help solve for transportation and childcare issues,” Snider said. “Increasing access to virtual visits can be valuable in helping to meet the demand and reduce disparities.”
In-patient and out-patient services partnerships in the community are invaluable for organizations providing behavioral healthcare. Community stakeholders are seeking better collaboration among health system competitors, government agencies, law enforcement and schools to provide the needed infrastructure to secure additional federal funding and long-term support.
“Frenemy partnerships between competing health systems can help them pool their expertise and work collectively to increase patient access and reduce their individual costs,” Snider said. “They’re in it together so they might as well work together. It’s a win-win for all.”
Additionally, evidence is emerging of improved patient outcomes for those in a mental health crisis when community partnership models are leveraged as an option to incarceration, emergency departments and in-patient care.
“By making improvements in throughput in the emergency department, outpatient care and enhanced services like intensive outpatient treatment and partial hospital programs, we start to see other improvements throughout the community such as better employment rates, reduced use of law enforcement, lower rates of child and elder abuse and neglect, and less substance abuse,” Snider said. “Getting ahead of these behavioral health issues and access to care really goes beyond the hospital walls.”
The Vizient Research Institute study will be shared with participants in November in all Vizient Member Networks. Email Vizient Member Networks to learn how to join and to access this and other resources provided by the Vizient Research Institute.
To access Sg2’s 2023 Behavioral Health Service Line Snapshot, additional service line insights or to learn more about Sg2’s broader solutions, contact membercenter@Sg2.com.