Research Paper: Cost Analysis of Integrated Behavioral Health in a Large Primary Care Practice
March 31, 2022
A residency-based Family Medicine outpatient clinic chose to implement an integrated behavioral health care program in a large primary care clinic in the Southeast to improve patient access to behavioral health care. We hypothesized that embedding a BHP in a primary care setting would be a cost neutral intervention. We implemented a prospective cohort design and included expenses from both inpatient and outpatient visits. We implemented a mixed effects linear regression model to evaluate pre- and post-BHP exposure costs. A total of 1256 patients were identified in the post-BHP exposure period that had more than one-year post-exposure. After applying exclusion criteria, there were 926 patients included in analysis. These patients had an average total cost during the one-year pre-BHP exposure period of $5113 (SD = 7712) and one-year post-BHP exposure period of $5462 (SD = 7813). Our analysis shows a relatively cost neutral impact following the introduction of BHPs in a primary care setting. The results of this study provide a gauge for future planning of services.
Integrated care, the coordination of physical and behavioral health care by collaborating providers at point of care, is recommended in primary care settings as best practice, especially for patient populations with dual (mental health and substance use) diagnoses [Substance Abuse & Mental Health Services Administration–Health Resources Service Administration (SAMHSA), 2020]. Transforming primary care to address patients’ medical and behavioral needs must also account for the financial sustainability of these operational processes. A number of researchers/authors have worked to describe methods of quantifying cost savings/ expenses/offsets resulting from the implementation of integrated care into primary care settings and have advocated for payment reform to support these models (Breslau et al., 2019; Hubley & Miller, 2016; Miller et al., 2017; Vogel et al., 2017). Since 2009, on a national level, SAMHSA has funded select primary care clinics seeking to integrated behavioral health services into primary care through the Primary and Behavioral Health Care Integration grants program. This large-scale grant program has also generated considerable data related to financial questions surrounding integrated care sustainability.
The difficulty of economically quantifying the benefits of integrated care has also been cited (Tsiachristas et al., 2016). Approaches to demonstrating financial sustainability (or lack thereof) include cost-benefit, cost-utility, and cost-effectiveness analyses (Kaplan et al., 2019). For the last two decades, integrated care researchers have debated the theory of medical cost offset, which posits that improved access to behavioral health care decreases more costly medical expenditures, specifically involving emergency department visits and/or inpatient admissions and stays (Cummings et al., 2009; Peterson et al., 2017; Sturm, 2001). Utilization ratios, as a proxy to cost-effectiveness, have shown impressive reduction of emergency and specialty care in some integrated primary care study settings (i.e., 11.3 percent reduction in Emergency Department to primary care visits ratio following the implementation of the Primary Care Behavioral Health model [Serrano et al., 2018]; in Cherokee Health Systems, a “68% reduction in emergency care, 42% reduction in specialty care, and 37% reduction in hospitalizations when compared with other clinicians in the region” [Franko, 2015]). Cherokee Health Systems’ behavioral enhanced patient-centered medical home practice also reported an overall reduction of 22% in [total health care] costs over a 3-year period.” A RAND report on Primary and Behavioral Health Care Integration grantee clinic data concurred that outcomes “suggest that the program can be successful in two of its primary aims: reducing frequent use of emergency department and inpatient services for PH [Physical Health] care services and reducing total costs of care” (Breslau et al., p. 33). There is also compelling financial data to support integrated care as a time-saving intervention for medical providers who, after handing patients of to behavioral health providers, are able to see more patients in less time (Gouge et al., 2016).
Notably, there is also a growing body of literature on integrated care cost-effectiveness for programs serving specific patient populations, rather than the general primary care population at large. For example, the Sustaining Healthcare Across Integrated Primary Care Efforts for diabetes patients showed a reduction in cost on a practice-level ($1.08 million net cost savings across three practices when compared to three practices without this program) (Ross et al., 2018). In contrast, the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics demonstrated increased utilization of primary care for low-income children with behavioral health needs, but no overall decreases in cost through emergency visits, inpatient admissions, or otherwise (Cole et al., 2019).
With lack of consensus on both the mechanism of savings and cost effective integrated care models for general primary care populations, this study investigates the value of embedding a Behavioral Health Provider (BHP) in a primary care setting. We hypothesized that embedding a BHP in a primary care setting would be a cost neutral intervention. Our study contributes to the integrated care literature with an analysis that utilizes inpatient/outpatient claims and the cost associated with introducing BHPs into primary care. We will address the value of the BHP in a primary care setting by analyzing the impact following the clinic transformation to include onsite BHPs at the point of care.