Around the world, people with mental illness die up to 20 years earlier than the general population, and a comprehensive new report suggests that governments and health care providers must do more to stop the deaths,” CNN noted in a report on July 16, noting the publication of a new report in The Lancet.
"The disparities in physical health outcomes for people with mental illness are currently regarded as a human rights scandal," said Joseph Firth, Ph.D., a research fellow at the University of Manchester and chairman of the Lancet Psychiatry Commission, which published the research.
His team analyzed nearly 100 studies and found that most people with mental illness die early not because of suicide -- although those account for about 17% of unnatural deaths -- but because of "poor physical health" that could be largely preventable.
And as Dr. Firth and his fellow researchers wrote in The Lancet article, “The poor physical health of people with mental illness is a multifaceted, transdiagnostic, and global problem. People with mental illness have an increased risk of physical disease, as well as reduced access to adequate health care. As a result, physical health disparities are observed across the entire spectrum of mental illnesses in low-income, middle-income, and high-income countries. The high rate of physical comorbidity, which often has poor clinical management, drastically reduces life expectancy for people with mental illness, and also increases the personal, social, and economic burden of mental illness across the lifespan.”
In that same spirit of identifying mental illness factors that affect physical health status and can trigger hospitalizations and emergency department visits, the clinician leaders at the Peoria, Arizona-based Partners in Recovery have cut psychiatric admissions by nearly 50 percent and reduced the monthly cost of Emergency Department visits for its members from $2,265 to $875 in the last year.
Partners in Recovery is a 425-staff behavioral healthcare services agency that has been applying mental and physical care and population health management strategies, using technology from the Irving, Texas-based Lightbeam Health Solutions that identifies patients at risk of a hospitalization, before an acute event. That allows caregivers to intervene to get patients the care they need early, preventing an acute event and saving money.
One of the key challenges that Partners in Recovery addresses is the fact that people with severe mental illness rarely visit primary care physicians. In fact, 40 percent of Partners in Recovery’s patients had not seen a primary care physician in years, and were often using the ED as a regular treatment site. Unfortunately, the specialty psychiatrists that they see more often are prone to overlook their patients’ medical conditions. The Lancet researchers found that those with mental illness were not only more likely to die younger but also more likely to be living with obesity, diabetes and cardiovascular disease.
Partners in Recovery is using population health analytics from Lightbeam to integrate behavioral health services with primary care for its 8,000 Medicaid/non-Medicaid patients. Its clinic supports a learning model unique to populations with cognitive impairments. It’s addressing high users of ED visits, high-cost/high-need patients, care gaps and care management, while giving patients more choices to help them lead normal lives.
During calendar year 2018, the clinicians at Partners in Recovery reduced psychiatric admissions by 50 percent per 1,000 patients; achieved total facility savings of $119,000 in ED visits, per 1,000 patients; reduced ED visits costs by $875 per member per month from $2,265 PMPM; and, in the period from October 2017 through September 2018, achieved a cost savings of $375,000 on high-risk patients.
Partners in Recovery CEO Christy Dye notes that one-third of adults with a medical condition also suffer from a mental disorder; that 52 percent of disabled individuals with dual eligibility for Medicare and Medicaid have a psychiatric illness; and that the average monthly expense for a person with a chronic disease and depression is $560 more than for a person without depression.
Recently, Dye spoke with Healthcare Innovation Editor-in-Chief Mark Hagland about her organization’s work in this important area. Below are excerpts from that interview.
You’re essentially a behavioral healthcare eservices agency?
Our primary focus is behavioral healthcare services, but we also provide primary care services.
So that involves case management services, correct?
Yes, and psychiatry; on our clinical staff, we’ve got 34 psychiatrists and psychiatric nurse practitioners, as well as five primary care physicians, and about 20 mental health nurses.
With what types of organizations do you contract?
We’re contracted with Mercy Care, a health plan here in Maricopa County, the Phoenix area, that focuses on Medicaid, Medicare, and substance abuse coverage in this area, for care for serious mental health issues. We deliver most services ourselves, or do it through referrals.
How many plan members or patients do you serve?
We’re responsible for about 9,000 lives, and of that group, we probably see 6,500 on an ongoing basis; the other 2,000-plus remain on our panel, because they might have relapses but aren’t currently in care.
How were you able to reduce readmissions and lower ED costs?
Just on the ED visit side, when we started our population health management process, which started around 2017, since then, we’ve brought the number of ED visits down 1,000 per year… when we first started getting ED data, it was in 2016, and we were seeing about 9,000 visits a year.
What’s the core of your strategy?
It starts with creating a high-risk registry, so we have criteria that we set, mostly utilization-based, for people we consider high utilizers—folks who go regularly to the ED or who have multiple inpatient psychiatric admissions per year. It’s about 90-100 individuals altogether, across seven different campuses, so typically, it’s maybe 15 or so per campus. We pull together their psychiatrist, nurse case manager, and everyone on the team, to find out why the person is going to the ED 50 times a year. What’s the need? In some cases, it might be the summer heat in AZ. Or they might live next door to the hospital. Or they have an undiagnosed condition. So we figure out what’s going on, look at medications they’re on, work intensively with their PCP, so we work that out with them, until they roll off the list, and someone else comes on.
Often, no one knew?
Because we have the case management, we tend to know what’s happening with these folks; it’s not as though we’re losing track of them. But prior to engaging in this process, we might not have had eyes on in particular, on this particular group.
Tell me about the technology involved?
It starts with being able to get utilization data; if you don’t have utilization data, you don’t know what’s going on. And before we started getting access to ED utilization or hospital admissions, we literally didn’t know, unless the person actually told us. So quite frankly, when the data first came in from Mercy Care, it was a surprise to us how frequently people were coming into the Eds and hospitals; and then we were able to assign people to specific clinicians on teams. And we brought on the Lightbeam product, which provides large-scale analytics, which we weren’t even able to use before. We get data on utilization, including with other providers, which we weren’t seeing before. And we’re getting data on costs across six months to a year or longer, and that helps us.
You’ve built a comprehensive data warehouse to support all of this, correct?
Yes, that’s part of the solution set from Lightbeam. Right now, it’s fed by Mercy Care. But we’re reaching out to other health plans as well, to get a bigger picture. Right now, the best data we have is for the Medicaid population in Arizona, because Mercy Care is the Medicaid health plan in Maricopa County. But a large number of people, 1,500 to 2,000, who aren’t on Medicaid, whom we serve. They’re on Medicare or commercial; in some cases, it’s a spouse.
What proportion of your population is Medicare, and what proportion is commercial?
I’d say maybe 40 percent Medicare. And Medicare is very different, because we bill the federal government directly for that, so getting claims data is harder; there isn’t any intermediary health plan for Medicare beneficiaries.
What have been the biggest challenges so far in this initiative?
There have been several. First, even being aware that these things are going on. And unless you have the data, you don’t even know. So that was the initial challenge. So once you have the data, how do you manage it so that it’s actionable to staff? It’s one thing to produce data and reports. But it’s building that team to manage high-risk individuals. We produce monthly snapshots on the individuals and also on the cohorts. Those were some of the big ones around the data process. Last
Another element is that, for the Medicaid individuals, we can restrict access to specific pharmacies; but for the Medicare population, we can’t. So how the case management teams actually manage people, is a challenge. And working with providers on housing issues is significant, too.
What have been the biggest lessons learned so far in this initiative?
I think there are a couple that are important. You have to have data, but once you have data, you have to give up on the idea that it will perfect. And also, if you’re a provider, just start—you can’t really go wrong. Too often, people want to make it perfect, and you let a lot of time go by.
Also, in terms of value-based purchasing, an increasingly important element in healthcare in general is the shift towards value-based contracting, there will be more pressure to improve outcomes. Our value-based contracts run for 12 months; but if you have a patient you’re responsible for, for whom progress might take three years, you’ll need to have the kind of relationship with the health plan, where you can explain the situation on a patient with a complex or challenging situation.. And the health plan wants to achieve long-term good results as well, for when they’re bidding on contracts as well—and that means that everybody wins.
