Behavioral Health in Primary Care: Impact on Medical Utilization and

Medical Cost‐OffsetSean M. O’Dell, PhD1

Tawnya Meadows, PhD1

Rachel Valleley, PhD2

Shelley Hosterman, PhD1

1Geisinger Medical Center2University of Nebraska Medical Center

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session #__2260779___ Friday, October 11, 2013

Faculty DisclosureWe have not had any relevant financial relationships

during the past 12 months.

Objectives

• Provide brief overview of tenets of integrated behavioral health in pediatric primary care as well as supporting research

• Describe aspects of medical utilization and associated costs in two clinics – Urban co-located clinic: 1 year pre/post

presenting for first behavioral health visit– Rural integrated clinic: cost and effectiveness of

integrated care across 2 years of a 3 year project

Background and Significance• Behavioral health services are a vital resource that helps to

meet a significant public health need

• Primary care physicians are the de facto first line mental health providers in the pediatric population

• However, behavioral health carve outs typically show service penetration of 6%

Continuum of Collaborative Care (Blount, 2003)

• Traditional: PCP and mental health professional located at different sites

• Co-located: Behavioral health providers and PCPs located in the same practice

• Integrated Care: Tightly integrated, on-site teamwork between behavioral health providers and PCPs resulting in a unified treatment plan

Establishing Effective and Efficient Practice

Collaborative Care Outcomes: Pediatric Primary Care Setting

• Promising outcomes related to clinically relevant outcomes:– Increased use of psychological services– Clinical improvements in patients presenting with panic disorder

• Less information is available related to cost and operational outcomes– Less medical utilization for behavioral health concerns

• Lacking in terms of use of process metrics to measure both cost and effectiveness

Finney, et al., 1991; Graves & Hastrup, 1981; Katon et al., 2002

Summary

• Effective and efficient practice must consider three world view to succeed

• More research is needed to determine facets related to applications to integrated pediatric primary care

• Considering process metrics may help measure outcomes in ways that are meaningful across all three “worlds”

CO-LOCATED CLINIC

Munroe-Meyer InstituteUniversity of Nebraska Medical Center

Co-located Clinic

• Physician owned practice in Omaha, NE, suburb– Mid to high SES

• 7 pediatricians on staff– 5 full time, 2 part time

• 1 psychologist, 1 predoctoral intern – 2 days per week

• 1 post-doctoral fellow– 1 day per week

Patient Demographic Information• Age at first session

– 8.7 years old (SD = 4.8 yrs)• Number of psychological visits

– Avg = 4.35 (SD = 3.31)

Summary

• Relatively brief (M = 4.35 sessions) therapy was able to be implemented for a variety of behavioral health concerns

• Medical cost from pre-intervention to post-intervention was relatively stable overall when comparing the whole sample

• Anxiety as a presenting concern and attendance at 4 or more sessions was associated with an average medical cost savings from pre-intervention to post-intervention

INTEGRATED PRIMARY CARE CLINICGeisinger Medical Center

Integrated Primary Care Clinics

• 3 Primary Care practices in rural Pennsylvania– Clinic A:

• 3 PCPs @ 1.0 FTE• 1 LP @ 0.6 FTE, 1 Post-Doc @ 0.6 FTE

– Clinic B:• 4 PCPs @ 1.0 FTE• 1 LP @ 0.6 FTE, 1 Post-Doc @ 0.6 FTE

– Clinic C:• 4 PCPs @ 1.0 FTE, 1 PA-C @ 1.0 FTE• 1 LP @ 1.0 FTE, 2 Post-Doc @ 0.6 FTE

Process Metrics: Measuring Cost and Effectiveness

Miller et al., 2009

Percent of Underlying Population with Conditions that are Detected

• 10.5% of patients in IPC clinics have a psychiatric diagnosis

Percent of those Patients Detected that Received Treatment

• Number of Patients Referred– 2,382

• Number of Patients Presenting for ≥ 1 session– 1,832 (77% of those referred)

• Overall Show Rate for those presenting for ≥ 1 session – 84.3%

Of those Patients Treated, the Average Percent Improvement by Condition

Disruptive Behavior Primary Presenting Problem

Percent Improvement By Rater

Parent: 29.6%

Child: 29.4%

Clinician: 30.4%

Of those Patients Treated, the Average Percent Improvement by Condition

Percent Improvement By Rater

Parent: 40.6%

Child: 36.2%

Clinician: 39.6%

Anxiety as Primary Presenting Problem

Of those Patients Treated, the Average Percent Improvement by Condition

Percent Improvement By Rater

Parent: 44.6%

Child: 40.2%

Clinician: 42.4%

Depression Primary Presenting Problem

Average Cost by Condition to Provide the Treatment

Summary

• IPC reach (10.4%) is higher than observed in traditional models (~6%)

• Significant patient and clinician rated clinical improvements were reported for DB, anxiety, and depression

• Treatment of DBDs in IPC settings generated $97 per session on average, while average cost of treating other presenting problems ranged from $5 to $97 per session

Future Directions

• Further investigating aspects related to BH service utilization and the treatment of anxiety disorders

• Gaining a comprehensive understanding of how revenue generation and patient flow have been affected in IPC sites since integration

Learning Assessment

Audience Question & Answer