Markian Hawryluk
The Bulletin

Physical and behavioral health have traditionally operated as two realms of the health care system.

But there’s an emerging understanding among insurance plans and health providers that behavioral health issues can have a direct impact on physical health issues, and that investing in behavioral health up front could provide much better patient outcomes and save money.

“Our contracts are increasingly set up to put behavioral health as the tip of the spear, to say we’ve got to do that first,” said Dr. Mike Franz, medical director of behavioral health for PacificSource Health Plans in Bend. “We know that unless we do that, we’re going to have a real hard time managing their chronic conditions.”

Franz gives the example of a pediatrician treating a child for abdominal pain. If that stomach pain is brought on primarily by the child’s anxiety, treating the physical condition is unlikely to resolve the issue.

Health clinics in Central Oregon now have embedded behavioral health clinicians who can be pulled into primary care appointments to address those sorts of scenarios.

“Not only does the child’s anxiety improve, but they wouldn’t be going to the emergency room for this abdominal pain of unclear and unidentified etiology,” Franz said.

PacificSource, which runs the coordinated care organization that provides care to Oregon Health Plan members in Central Oregon, has been working to improve access to behavioral health care services in the region. Starting in 2016, the health plan allowed primary care clinics that meet set criteria to bill for behavioral health services, and provided them bonus payments if they reach certain metrics. In 2018, that included having at least 5% of their patients meet with a behavioral health clinician. In 2019, they’re doubling that requirement to 10% of patients.

“We have the prevalence data to suggest that ought to be above 20%,” Franz said.

As a result, PacificSource members have gone from an average of 2.4 behavioral health visits in 2016 to 3.3 visits in 2018, and the percentage of members receiving behavioral health services increased from 14% in 2016 to 21% in 2018.

“I think there’s much more demand there than has been broadly assumed,” said Rick Treleaven, executive director of Best Care Treatment Services, which provides mental health and substance use treatment services throughout Central Oregon.

Treleaven said the No. 1 primary care cost driver for the CCO is untreated depression, which ends up impacting a host of other chronic conditions.

“Lots of medical conditions cause depression, and depression makes many medical conditions worse,” he said.

About 90% of Medicaid patients in the region are assigned to primary care practices that have integrated behavioral health care. PacificSource is trying to extend that model to women’s health clinics and other types of providers, as well as to its Medicare and commercial insurance plans.

Unlike Medicaid patients under OHP, Medicare and commercial insurance patients face copays with each appointment. They must pay one copay to see the health provider, and then another if a behavioral health clinician sees them during the same visit. PacificSource is now considering whether it can eliminate those behavioral health copays.

“If you don’t have that kid going to an emergency room or being admitted to the hospital for yet another diabetic ketoacidosis because they were depressed, that’s a great investment,” Franz said, “That’s worth removing that copay.”

PacificSource has also removed other barriers such as requiring patients to go through an assessment before seeing a behavioral health clinician. The plan opened up its panel of providers to more behavioral health practitioners in the community and added more specialists that deal with issues such as autism or gender dysphoria. It added more psychiatrists and more Spanish-speaking providers.

Mike Conner, a Bend psychologist in private practice, said there was a genuine need for more access in Central Oregon, and by opening up its panel, PacificSource bucked the trend among insurance companies.

“The traditional way to manage costs is by limiting access, but what you’re really doing is pushing the behavioral health money to the medical side,” Conner said. “Restricted access saves behavioral health dollars, but then you have a two-and-a-half fold increase in patients’ medical costs.”

Franz said PacificSource doesn’t have the local data yet to prove that investing in behavioral health will lower medical costs. But company leaders have been receptive to that notion, and haven’t tried to reduce the growing volume of behavioral health services provided to its members.

“Instead of your default being, ‘Oh increased utilization? Bad thing,’ we looked at increased utilization and said, ‘Hey, this could be a really good thing,” he said.

Most of the major primary care and pediatric clinics in Central Oregon now have embedded behavioral health clinicians within their walls. High Lakes Health Care, for example, sees up to 500 patients with mental health or substance abuse issues per month. That puts additional stress on their primary care providers to handle complex behavioral health issues in addition to physical health issues, all within a 20-minute appointment.

In 2018, High Lakes committed to behavioral health integration, and has now hired two and a half full-time behavioral health clinicians to serve its five clinics. They see four to six patients per day, with a goal of moving up to 8 to 10 patients per day. They make another 30 to 40 referrals per month to behavioral health specialists outside their clinic.

“The truth is no matter how well we implement this model, we really need to be integrating into the larger community, we need to be able to connect with a larger number of providers to be able to meet our patients’ needs,” said Dr. Jason Prinster, director of primary care behavioral health at High Lakes. “Sooner or later the numbers catch up with us.”

Efforts are underway in the region to take the merger of physical and behavioral health care to the next level, mainly through better coordination between primary care practices and the behavioral health specialists in the community.

Last year, the Central Oregon Health Council funded a $500,000, two-year project with the lofty goal of identifying all patients with behavioral health care needs and connecting them with effective and timely services.

The project is headed by health consultant Dawn Creach who spent months talking to local providers to get a sense of what barriers to that coordination existed in the community. She found that up to 60% of patients with behavioral health issues are being treated solely by primary care practitioners.

“Primary care has often been called the de facto mental health system,” she said.

But when the needs of patients exceed what could be provided within primary care clinics, they struggle to find behavioral health specialists who could provide a higher level of care. Creach is now working with clinics and private practitioners in the community to create a better system of communications, so patients can access specialty care quickly and then can return to their primary care providers once their treatment is completed.

“Many behavioral health providers are already stepping up. I have people calling me out of the blue to say we feel like we can do something different,” she said. “This work is tough. This is going to be breaking down silos, building relationships, it’s going to be difficult work. It’s going to take a community working together to try to solve this issue.”

— Reporter: 541-633-2162, mhawryluk@bendbulletin.com

Editor’s note: This article has been corrected. The original version misstated PacificSource’s policy on behavioral and medical copays.

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