Behavioral Health in Primary Care: Impact on Medical Utilization and Medical Cost ‐ Offset Sean M. O’Dell, PhD 1 Tawnya Meadows, PhD 1 Rachel Valleley, PhD 2 Shelley Hosterman, PhD 1 1 Geisinger Medical Center 2 University of Nebraska Medical Center Collaborative Family Healthcare Association 15 th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Session #__ ___ Friday, October 11, 2013

Faculty Disclosure We 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 Institute University 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

Scheduled for Intake Jan 1, 2011 – Dec 31, 2011 N = 123 VGP Patients N = 94 Completed Intake N = 67 > RTN Appt N = 55 No RTN Appt N = 12 Did Not Complete Intake N = 27 Outside Referrals N = 29 Completed Intake N = 28 > RTN Appt N = 24 No RTN Appt N = 4 Did Not Complete Intake N = 1

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 CLINIC Geisinger Medical Center

Integrated Primary Care Clinics 3 Primary Care practices in rural Pennsylvania – Clinic A: FTE FTE, FTE – Clinic B: FTE FTE, FTE – Clinic C: FTE, FTE FTE, FTE

Process Metrics: Measuring Cost and Effectiveness Percent of underlying population with conditions that are detected Percent of those patients detected that received treatment Of those patients treated, the average percent improvement by condition Average cost by condition to provide the treatment 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