A 55-year-old patient with high cholesterol, high blood pressure and chronic depression potentially may have three entities overseeing his health care – his employer-sponsored health plan, a behavioral health manager and a pharmacy benefits manager.
If only the entities communicated with each other.
An example of how this scenario might play out is if the patient’s depression worsens and he ignores a message from his pharmacy benefits manager to replenish his supply of ACE-inhibitors and beta blockers prescribed by his primary care physician. The patient then becomes suicidal and ends up in the emergency room where his Managed Behavioral Healthcare Organization coordinates his admission to an inpatient psychiatric unit. There, his antidepressants are adjusted and an internist consult addresses his ACE-inhibitor and Beta-blocker use.
Upon discharge the man goes back to being treated by his primary care physician and his psychiatrist, but because the health-care entities are not communicating with each other, nothing changes to avoid a repeat of this costly episode.
It’s one hypothetical example from an Oct. 7 presentation at Suffolk University Law School by the Office of Massachusetts Attorney General Martha Coakley during the state’s Health Policy Commission’s annual cost trends hearing.
The independent 11-member board formed in 2012 is responsible for slowing growth in medical spending, improving access to care, and creating better ways to pay for care. A commission report released last July found spending for patients with comorbid behavioral health and chronic medical conditions is two to two and a half times higher than that for patients with only a chronic medical condition. Much of the cost is concentrated in emergency departments and inpatient care.
Commercial insurers attributed 3.8 percent of their total medical expenditures to behavioral health services in 2013, compared to 10.4 percent for Medicaid Managed Care Organizations and 18.7 percent for Medicaid Primary Care Clinician Plans (PCC), the attorney general’s staff reported.
“I was so struck by it,” said Massachusetts Association of Behavioral Health Systems, Inc., Executive Director David Matteodo, who attended the cost trends hearing. “Behavioral health is micromanaged more than I think any other service and they only spend 3.8 percent of their dollar.”
Commercial insurers have 75 percent of the market but account for only 42 percent of behavioral health spending. MassHealth Primary Care Clinician plans, which require patients to receive referrals from their primary care doctor, make up 8 percent of the market but 29 percent of behavioral health costs. Comparing behavioral health care spending is difficult because there is no common definition for behavioral health and no consistent way to report behavioral health spending, according to attorney general staff.
In 2013, estimated unadjusted behavioral health costs per member per month were higher for people on public insurance plans rather than commercial – $16 a month for those on commercial plans, $93 a month for those on MassHealth PCC plans.
“We have to ask the question that why is it that in the commercial market, given what we know to be the incidence of mental illness, why is it that their expenditures are so low? It’s such a small piece of what they’re paying,” said Health Policy Commission member Marylou Sudders.
Sudders, a former state mental health commissioner, said Governor-elect Charlie Baker should direct the commissioner of insurance and the Department of Health and Human Services to require a common definition of behavioral health across all payers, public and commercial.
“I see 2014 as a transition year into full compliance with parity and I’m hoping that this time next year we will start to see a difference in payer performance,” Sudders said.
Matteodo was less optimistic, saying the transition to a new administration would mean major changes in behavioral health wouldn’t occur for at least six months or “maybe a year or two year down the road.”
“I’m taking the approach that it’s good to get the awareness out there. We’re bringing a lot more attention to mental health and substance abuse. But there are structural issues that are going to take a lot more time to address,” Matteodo said.
More than 70 organizations submitted written testimony before the hearing, including SEIU Local 509 of the Massachusetts Human Service Workers Union, which represents more than 17,000 human services workers and educators in the state. President Susan Tousignant, a rehabilitation counselor for 30 years, says the system needs to be less complicated for the patient to navigate.
“It’s very difficult to find clients the help that they need. You can spend days making phone calls trying to get people hooked up with the right services,” Tousignant said.
By Janine Weisman