Like the much better reported changes in other parts of the health and medical care sector, the recent changes in behavioral health care financing and organization have been profound - if anything, probably even more profound than the changes occurring in medical care. Why is this happening? Most fundamentally, there is a reasonably broad bipartisan policy consensus that the current health and medical sector cost is already unsustainable. When addressing the prescriptions for changing that, however, this consensus mainly breaks down along partisan lines.
What does this have to do with behavioral health care (behavioral health is a term used to span mental health and substance use disorders)? After all, behavioral health spending as a proportion of total spending is tiny at about 7 percent of total cost. It turns out that underspending on behavioral health drives higher, more wasteful spending for physical health issues, particularly in public programs. A small minority of people, often cited to be about 5 percent of the population, drive more than 50 percent of total expense. And nearly all of these super utilizers have either or both a mental health or substance disorder.
Since the days of substantially increasing public spending to address the underfunding of services are long past, the only way forward is to increase efficiency - get more value for the money we do spend. In the current system the value proposition is often lacking -- the individual with schizophrenia or alcoholism may make multiple trips to the emergency room because the underlying condition is essentially untreated. Since the crisis response is far more expensive than the primary treatment, total costs go up.
Part of the problem here is the way we have structured the health and medical sector. More often than not, funding sources for behavioral health and even the delivery systems for this care are totally separate and operate under different incentives. The head goes in one waiting room and the body to another. But this is just beginning to change, across the nation, and here in Whatcom County. Health reform has been the catalyst but that reform itself is a byproduct of a pervasive sense of unsustainable health systems.
Our Legislature passed this session, on a bipartisan basis, legislation, SB 6312 and HB2572, which will gradually integrate the funding streams for public substance abuse, mental health and physical health services. In theory, this funding integration will allow money to follow the needs of the person rather than to be siloed into separate impermeable buckets. So, for example, the money that might have been used for a crisis emergency room visit is used instead for schizophrenia medications or case management more preventive or primary services.
The vehicle for integrating all these dollars across sectors will be health plans, as is the case already for commercial insurance. This makes many of us nervous since health plans are not universally known for protecting the public interest. But with the proper safeguards and oversight, this scenario is more workable than the status quo. Here in Whatcom, many mental health providers are betting on this integration scenario and, as result, changing the kinds of services they offer and the way they offer them.
Over the past couple of years significant local changes in behavioral health services integration have been occurring. For example, both Whatcom Counseling and Psychiatric Clinic and Lake Whatcom Residential and Treatment Center have added medical treatment services, and Whatcom Counseling has added substance abuse services. At Lake Whatcom Center, service integration has also spurred additional staff training to allow the center to function more effectively as health care home, serving patients with both mental and physical health needs.
Meanwhile, both community clinics, SeaMar and Interfaith, have been expanding the amount and depth of their on-site behavioral health services. Even private providers such as Family Care Network are beginning to create joint ventures to add whole person behavioral health services - in their case at their Ferndale Clinic. This is part of what is called "bi-directional health home integration." Medical clinics are adding behavioral services and vice versa.
WHAT ABOUT CAPACITY?
Since the beginning of 2014, as a result of health reform, in Whatcom county alone, more than 9,169 persons who used to be uninsured have signed up for Medicaid (health insurance for low-income individuals) and another 4,320 have signed on for subsidized insurance on the exchange - creating an increase of nearly 40 percent in people trying to use the public mental health system. Of course, Obamacare is supposed to increase enrollment and therefore demand for care. What happens when all of these people try to use their new insurance benefits for behavioral health services? Whatcom Counseling reports the number of new patients seen daily has more than doubled since the beginning of the year. At the same time, capacity (people and money) to see these patients has only modestly expanded. Lake Whatcom Center reports that their number of intake appointments has also more than doubled this year compared to the first two months of 2013.
Clearly, in the trenches of our mental health system, all this new enrollment has not, at least yet, translated to substantially greater capacity for treatment.
ABOUT THE AUTHORS
Larry Thompson is the executive director of the Whatcom Alliance for Health Advancement. Mike Watson is CEO of the Lake Whatcom Center and Jan Bodily is CEO of Whatcom Counseling and Psychiatric Clinic.