by Christopher Dennis

Summer 2015 – There is a complexity crisis looming in American healthcare. As the population ages, healthcare providers, employers, insurers as well as federal, state and local governments will need to develop and deploy strategies to manage poly-chronic, highly comorbid patient populations. This subset of high-risk patients represents a small percentage of the total but consumes an outsized percentage of medical and financial resources. Over time, demographic trends will increase the percentage of high-risk patients, further stressing an already fragmented and under-resourced system of care.

Patients with complex needs are more likely to go to hospitals, emergency rooms, and long-term care facilities, and are more likely to need ancillary services to support activities of daily living or to arrange for transportation to and from medical facilities.1

Remarkable advances in technology ensure that we are living longer, although not necessarily healthier, lives. One of the by-products of this extended longevity is the emergence of a group of patients with complex chronic conditions. These patients constitute the highest-risk segment of the poly-chronic population and typically have five or more chronic conditions. Many are bedbound, homebound or reside in institutional settings, which complicates regular access to primary care. These patients often have substantial behavioral health needs, struggle to maintain adherence, and require support in navigating a complex health system.

Current care delivery models do not comprehensively meet the significant and varied needs of this highest-acuity segment. Inconsistent and fragmented access to office-based care prevents these complex patients from receiving the longitudinal, comprehensive care they require. Formidable clinical, social, financial and behavioral barriers prevent these highly frail, chronically ill individuals from accessing in-office primary care on a regular basis. How are we as an industry, and a country, expected to manage this growing need with a healthcare workforce that is already overwhelmed, and with a system that has well documented issues surrounding access and availability?

The Affordable Care Act has spurred growth of the development of novel, more accountable models of care, but this is not nearly enough to address this crisis going forward. While alternative approaches to in-office care, such as patient-centered medical homes, telephonic case management, and post-acute transitional programs can be helpful, they do not provide the longitudinal care and clinical intensity that the most chronically ill patients require. As a result, the primary point of entry into the healthcare system for our most frail and neediest patients continues to be through the acute care setting, generating a large volume of preventable ED visits, hospital admissions, and nursing home stays.

There are, however, promising developments in non-traditional models of care that bring interdisciplinary teams of providers together to manage these patients wherever they reside. These models provide concierge level service to patients not based on their ability to pay, but on clinical risk and acuity. Early results from Home Based Primary Care Models are promising, and more mature models have begun to show value. Additionally there have been attempts at the development of technological solutions to this issue, with web and app based platforms linking providers and patients.

One area which receives far too little attention, however, is the impact of behavioral health on the management of these chronic populations. In the 2003 National Comorbidity Survey Replication (NCS-R), more than 68% of adults with a mental disorder had at least one medical condition and 29% of those with a medical disorder had a comorbid mental health condition.2 Medical disorders may lead to behavioral health disorders; behavioral health conditions may place a person at risk for certain medical disorders; and behavioral health and medical disorders may share common risk factors. Comorbid medical and behavioral health issues are a significant burden, driving poor outcomes and high costs. One analysis found that 30 percent of diabetics, 38 percent of patients with chronic lung disease, and 40 percent of patients with heart failure had a co-occurring behavioral condition. These comorbidities increased the annual cost of caring for these patients considerably — by 124 percent, 186 percent, and 76 percent, respectively.3 In fact, it is not uncommon to see the costs of caring for patients with co-morbid behavioral health issues exceeding three times the cost of the average patient.

Organizations are increasingly realizing that achieving the Triple Aim – improving the individual experience of care, improving the health of populations, and reducing the per capita costs of care for populations – without an integrated behavioral health strategy is not possible.4 Deploying collaborative care models that offer a multidisciplinary team have been shown to provide effective treatment for persons with comorbid physical and behavioral health conditions.5 As a practicing psychiatrist who strongly supports, and delivers, high quality, integrated, collaborative care, I have witnessed the impact that such a focus has had on adherence, functional status, symptom improvement and quality of life for these complex patients

This complexity crisis that we are facing will require the application of both proven and as yet unidentified methods of collaboration, integration and cooperation. It is a crisis that I remain confident we can slow and hopefully resolve.

1 Rich E, Lipson D, Libersky J, Parchman M. Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I/HHSA29032005T). AHRQ Publication No. 12-0010-EF.Rockville, MD: Agency for Healthcare Research and Quality. January 2012.

2 Alegria M, Jackson JS, Kessler RC, Takeuchi D. National Comorbidity Survey Replication (NCS-R), 2001–2003. Ann Arbor: Inter-university Consortium for Political and Social Research, 2003.

3 Kathol R. Cartesian Solutions, Inc.™ July 2013 analysis based on consolidated health plan claims data

4 HI 90-Day R&D Project Final Summary Report: Integrating Behavioral Health and Primary Care. Cambridge, MA: Institute for Healthcare Improvement; March 2014.

5 Goodell S, Druss BG, and Walker ER. Mental Disorders and Medical Comorbidity, Feb-11 The Synthesis Project


About the Author

Dr. Dennis is the Chief Behavioral Health Officer of Landmark Health – a provider group that takes on risk for the above described highest-acuity patients. Their mobile providers and supporting clinicians, collectively named ComplexivistsTM, deliver care to patients in their place of residence, oversee acute episodes in the hospital or skilled nursing facility, and collaborate and communicate with other providers in the community. Previously, Dr. Dennis served as Chief Medical Officer of ValueOptions’ Commercial Division, then the nation’s largest independent behavioral healthcare company. Throughout his career Dr. Dennis has also served as a Consulting Psychiatrist at Skilled Nursing Facilities. He continues to practice as an Emergency Psychiatry Attending in the North Shore LIJ Health System in NY. In 2013, Dr. Dennis chaired NCQA’s Managed Behavioral Healthcare Advisory Committee, and is an active member of their Standards Committee. Board certified in Psychiatry, with an MBA in Healthcare Administration, Dr. Dennis is a Fellow of the American Psychiatric Association, a member of the American Medical Association, has been elected to membership in ACMHA: The College for Behavioral Health Leadership, and completed his residency through the Albert Einstein College of Medicine.

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