FINANCIAL AND

TREATMENT ISSUES IN Arthur C. Evans, Jr., PhD

Chief Executive Officer / Executive Vice President

BEHAVIORAL HEALTH American Psychological Association

Twitter @ArthurCEvans

National Press Foundation

Advancing psychology to improve lives 1
July 25, 2017
Behavioral Health Conditions
Behavioral Health Conditions

Behavioral Health Conditions

Mental Health Disorders and Substance Use Disorders (Behavioral Health)
occur on a continuum (Population Based)
Behavioral Health issues are ubiquitous, complex and have a significant
impact on communities & society at large
Behavioral Health issues are misunderstood by the public and as a result,
public policy does not always reflect our best scientific and professional
understanding of these issues
Many of the challenges that we face in addressing behavioral health issues
can be effectively addressed
Financing models are a powerful way to address the challenges in addressing
behavioral health problems
Advancing psychology to improve lives 7
Behavioral Health Conditions

Behavioral Determinants
5
of Health Advancing psychology to improve lives
Behavioral Health Conditions

Serious Mental Illness: Vermont Psychiatric Hospital Study

Studied outcomes for 269 severely disabled patients discharged during the
mid-1950s
34% achieved full recovery
Additional 34% had improved significantly in social functioning and psychiatric
status
Findings replicated in WHO study where 45-63% of persons with schizophrenia
recovered and only 20-25% showed classical deteriorating course of illness.

Relevant Mental
6
Health Research Advancing psychology to improve lives
Behavioral Health Conditions

Substance Use Disorders: National Treatment Improvement Evaluation Study

5-year study of addiction treatment effectiveness of almost 4500 addiction
clients nationwide
Reduced substance use by 50%
Reduced criminal activity up to 80%
Increased employment and reduced homelessness
Improved physical and mental health
New research concludes that the longer a person is in treatment for addiction,
the better the odds that the patient will cut down on drug use.
(Zhang, Zhiwei, Friedmann, Peter D., Gerstein, Dean R. (2003). Does Retention Matter? Treatment Duration And Improvement In Drug Use, Addiction, 98 (5);
673-684.)

Researcher Bill White has documented spontaneous recovery of individuals who

do not come into the formal Tx System.
Relevant Substance
7
Abuse Research Advancing psychology to improve lives
Behavioral Health Conditions

Adapted from Figure 2: Melek, S. P., Norris, D. T., & Paulus, J. (2014). Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry. Milliman
America Psychiatric Assocation. Denver: Milliman Inc.
Monthly 2012 Health Expenditures per Person, for Chronic
Conditions, with and without Comorbid Behavioral Health
Conditions Advancing psychology to improve lives 9
Financing Behavioral Health
Financing Behavioral Health

Health Care Spending as a Percentage of GDP,

19802014
18 United States (16.6%)
Switzerland (11.4%)
16 Sweden (11.2%)
France (11.1%)
14 Germany (11.0%)
Netherlands (10.9%)
12 Canada (10.0%)
United Kingdom
10 (9.9%)
New Zealand (9.4%)
8 Norway (9.3%)
Australia (9.0%)
6

0
8 0 8 2 8 4 8 6 8 8 9 0 9 2 9 4 9 6 9 8 0 0 0 2 0 4 0 6 0 8 1 0 1 2 1 4
19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20

GDP refers to gross domestic product. Data in legend are for 2014.
Source: OECD Health Data 2016. Data are for current spending only, and exclude spending on capital formation of health care providers.

Advancing psychology to improve lives 10

Financing Behavioral Health
Total Health Expenditures

3.42%
13.88%

3.42%
Medical
Behavioral
Medical Rx
Behavioral Rx

79.28%

Adapted from Figure 2: Melek, S. P., Norris, D. T., & Paulus, J. (2014). Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry. Milliman
America Psychiatric Assocation. Denver: Milliman Inc.

Advancing psychology to improve lives 10

Financing Behavioral Health

7; 14.00%
1; 10.00%

MH Spending =
6; 5.00% $179 Billion

2; 26.00%

5; 29.00%

3; 2.00%

4; 14.00%

Distribution of MH Spending
Advancing psychology to improve lives 11
By Payer, 2014
Financing Behavioral Health

Private insurers influenced by

Medicare decisions
Some insurers are moving away from
fee-for-service.
Moving toward value-based
contracts where emphasis is on
quality care. Insurers provide
financial incentives to providers.
Insurers starting to recognize
importance of mental health
professionals for reaching cost and
efficiency

Private Insurance Advancing psychology to improve lives 17

Critical Systems and Policy Issues
Impact of Humana Rate Cuts Illinois Ohio Georgia

Surveyed psychologists who left the Humana 57% 40.7% 45%

network because of the rate cut

Percentage of psychologists still deciding

whether to leave the network at the time of 30% 29.6% n/a
the survey

Psychologists reporting disruptions in patient 69% 49.1% 43%

care

Psychologists reporting patients dropping out 46.5% 44.9% 28%

of treatment completely

From January 8, 2014 APA Practice Organization Letter to Federal Parity Enforcement Agencies

Private Insurance: Parity

24
Enforcement Still An Issue Advancing psychology to improve lives
Financing Behavioral Health
MEDICARE
is an insurance program
is a federal program, basically
the same everywhere in the
United States.
serves people over 65 primarily, serves low-income people of
whatever their income; and
serves younger disabled people
and dialysis patients
Patients pay part of costs
through deductibles and small
monthly premiums are required
Medicare vs.
MEDICAID
is an assistance program
is a state and federal program.
It is run by state and local
governments within federal
guidelines. It varies from state
to state.
every age
Patients usually pay no part of
costs for covered medical
expenses
Advancing psychology to improve lives 11
Financing Behavioral Health

Community Mental Health Services Center for Substance Abuse Treatment

Grants cover comprehensive, community-
based mental health services to adults with
SMI and to children with serious emotional
disturbances and to monitor progress in
implementing a comprehensive,
community-based mental health system.
Promotes community-based substance use
treatment and recovery services.
Covers outpatient services, residential services
and inpatient substance use detoxification.

Two SAMHSA block grants equaled $3.1 billion for fiscal year 2014

Funding accounted for 9% of total mental health public financing and

about 16 % of total substance abuse public health financing in U.S.

SAMHSA block grant funds are commingled with other public funds, as
well as with Medicaid, health care insurance, and private payments.
https://www.samhsa.gov/data/sites/default/files/report_2080/ShortReport-2080.html
https://www.samhsa.gov/grants/block-grants

15
SAMHSA Block Grants Advancing psychology to improve lives
Financing Behavioral Health

5,000+ psychologists
work in VA
VA spending on mental
health is $7.927 billion
Active duty military
separated under any
condition other than
dishonorable
Special focus on
suicide and trauma
Veterans Affairs Advancing psychology to improve lives 16
Financing Behavioral Health

Fee-for-service

18
Changing the Paradigm
Traditional Treatment Model
Our Current Treatment System

5% Severe Mental Illness

20% Diagnosable Mental Disorder

Everyone Else
75%
Factors that Influence Health Status

HEALTH
CARE 10%

ENVIRONMENT LIFESTYLE
19%
51%
Smoking
Obesity
Stress
Nutrition

HUMAN
20%


Blood Pressure
Alcohol
Drug Use
BIOLOGY
Case Studies and Policy Issues
Critical Systems and Policy Issues

Alternative
Payment
Arrangement

Improving
Efficiency

Improving
Effectiveness

Controlling spending Advancing psychology to improve lives 29

Case Studies and Policy Issues
Serious Mental Illness
Symptom
Focus

Recovery/
Resilience

Arthur C. Evans Jr.

Day Treatment Transformation
36% Decrease in Crisis Utilization for Those with at Least
1 Year in Program
All Agencies

295

189

Before During
Arthur C. Evans Jr.
Day Treatment Transformation
Lower Cost of Inpatient Psychiatric Services
Initial 3 Agencies

$982,895

$561,011

Year Prior Year

During Arthur C. Evans Jr.
Case Studies and Policy Issues
Homelessness and Mental Health
Multiple Pathways to End Homelessness
Housing First
Targeted outreach to individuals with longest histories of homelessness,
collaboration with the Veterans Administration

Journey of Hope
Specialized residential substance abuse treatment programs for people
experiencing long-term homelessness

Safe Havens / Shelters

Referrals exclusively for persons experiencing chronic street homelessness
In 2015, 554 persons served, 239 discharged to a positive next step, primarily
supportive housing
Average Annual Cost per Person over Time
(n=255)
Note: Average cost calculated by total (sum) cost/number of individuals for each referral source at each time point.

$70,000
$64,229

$60,000
$56,009
$52,763
$50,584
$50,000
Cost per Person

$40,000
$35,509
$30,872 $31,478
$30,000

$19,241
$20,000 $16,369
$14,738 $13,781
$11,011 $11,830
$10,305
$10,000 $6,745 $6,558

$-
Safe Haven (n=94) Journey of Hope (n=93) Residential Pilot (n=68) Total (n=255)

Referral Source

Year 2 Before Voucher Issuance (n=244) Year 1 Before Voucher Issuance (n=255)
During (n=252) Year 1 After Lease-Up (n=231)

R E C O V E RY , R E S I L I E N C E & S E L F - D E T E R M I N AT I O N Arthur C. Evans Jr.

Successful PSH Client
AND PHILLIES
FAN
Case Studies and Policy Issues
Evidence Based Practices
EBPs on Extended Acute Inpatient Units
Recovery Oriented Cognitive Therapy (CT) Developed by Dr. Aaron
T. Beck and colleagues in response to implementing CT in Philadelphia
Behavioral health System

Extended Acute Units:

Individuals experiencing the most serve mental illnesses
Long Lengths of Stay

Clinical Outcomes:
Length of stay reduced by half
Assaults reduced by 60%
Use of restraints lowered by two orders of magnitude
Use of intramuscular PRN medications reduced by 2/3 Arthur C. Evans Jr.
Financing Behavioral Health

Evidence-based Treatments Advancing psychology to improve lives 21

Case Studies and Policy Issues
Value-Based Payment
Financing Behavioral Health

Pay for Performance

Advancing psychology to improve lives 20

Mental Health Outpatient CHILD
Drop Out
Access to Rate
Services:
(Retention):
PercentPercent
of Appointments
of Episodes
Available
Having 2
Within
or Fewer
7 Days
Services
of Referral

60%
70%
63.12% 55.1%
60% 2011
50% 55.01% 46.6% 2012
42.7% 2013
50%
40%
40% 38.61%
30% 30.0%
30% 27.73% 25.9%
20%
20%

10%

0%
0%
2011 ASD 2012 Non-ASD
2013
Arthur C. Evans Jr.
Case Studies and Policy Issues
Other Policy Issues
Critical Systems and Policy Issues

Reducing Disparities 27
Critical Systems and Policy Issues

Opioid Crisis and Serious Mental Illness 26

Critical Systems and Policy Issues

APAs three-pronged approach to overcome barriers to bringing

psychological services to underserved Medicaid populations
Independent Practice of Psychology: Reimbursement for services
outside a facility (e.g., rural health work where there is no nearby
facility)
Doctoral Psychology Intern Reimbursement: Interns tend to stay
in the geographic and service area where they trained, thus
building a pipeline of providers
Health and Behavior Code Reimbursement: Lets psychologists
treat the behavioral component of medical conditions, and
promotes goal of integrated physical and behavioral health care.

Barriers to Psychologists
28
Performing Service Advancing psychology to improve lives
Psychologists in Health Care System
Psychologists in Health Care System

Conducting Psychosocial Promoting patient

Assessments responsibility and resilience

Treating more complex, Addressing interpersonal

complicated patients barriers to behavior change

Applying motivational and Understanding environmental

behavioral principles to determinants of behavior,
modify health-risk factors including impact of families
and systems

Advancing psychology to improve lives 32

Psychologists in Health Care System

Bending the Cost Curve & Improving Outcomes

After a heart attack, 40% of patients experience depression and are

more likely to have another heart attack.

Greater medical utilization rates by depressed heart attack survivors

add to the cost of their care.

Screening for depression is recommended for patients in primary and

cardiac care, but rates of screening are low, as are rates of referral for
follow-up mental health care.
Role of Psychology in Health Care: Heart Disease and Depression, www.apa.org/health/briefs/heart-disease-depression.pdf

Heart Disease Advancing psychology to improve lives 33

Psychologists in Health Care System

Bending the Cost Curve & Improving Outcomes

Anxiety, depression, and decreased quality of life are common concerns of cancer
patients.

1 in 4 people with cancer struggles with clinical depression.

Chemotherapy and radiation therapy cause and/or exacerbate psychological

distress in up to 40% of all cancer patients.

When psychological distress is untreated, it can adversely influence treatment

adherence and the patients ability to engage in selfcare and lead to increased
hospital stays and utilization of medical services.
Role of Psychology in Health Care: Adult Cancer, http://www.apa.org/health/briefs/adult-cancer.pdf

Adult Cancer Advancing psychology to improve lives 34

Psychologists in Health Care System

Bending the Cost Curve & Improving Outcomes

Patients receiving 2-4 visits show broad improvement in symptoms,

functioning and well-being
Improvements seen in both mild and severe presentations
More severely impaired may improve faster
Changes are robust and stable at 2 years
Improved adherence to evidence-based depression guidelines
More appropriate antidepressant prescribing
Improved completion of anticipatory guidance in well-child checks

Summary of Patient Outcomes Advancing psychology to improve lives 35

Resources from the APA

www.apa.org

Staff experts

Media Referral Service

PsycINFO

90+ journals

APA Center for Psychology and

Health, apa.org/health

Advancing psychology to improve lives 39

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Advancing psychology to improve lives 44

Thank You
Arthur C. Evans, Ph.D.
@ArthurCEvans
aevans@apa.org

aevans@apa.org

aevans@apa.org