by Michael Shepherd, MD, CPA, MBA

March 2023 – Since the beginning of the COVID-19 pandemic, rates of patients experiencing anxiety or depression symptoms have increased 25%, behavioral health care providers have seen increasing requests for behavioral health services exacerbating pre-covid access issues and, emergency rooms have seen an increasing number of pediatric patients seeking treatment for behavioral health issues.  Concomitantly, across the nation, payors have seen a marked rise in outpatient behavioral health services utilization.  Part of the rise in outpatient behavioral health service utilization is directly attributable to the pandemic-related increase in mental health and stress-related symptoms. Another component of the increased utilization is a meta-phenomenon due to lower “no show” rates, with the vast shift from in-office to virtual mental health visits that accompanied the pandemic.

While some payors might be concerned or lament the rise in demand for, and utilization of, outpatient behavioral health services, which has become the new normal, the resultant trend may represent instead an opportunity for those payors and providers who can leverage the increased utilization and engagement in mental health services.   Payors and providers have historically hoped that increased engagement in outpatient care will provide opportunities to avert symptom exacerbation or avoid crises before patients need higher levels of care or show up in the emergency room.   Angst over the rise in outpatient utilization seems paradoxical to this premise and the underlying paradigm of right care, right time, right place.

In addition, patients with behavioral health diagnoses or those treated with behavioral health medications tend to have an overall total cost of care at least twice that of members without behavioral health conditions.   This differential in total cost of care is not a function of behavioral health service utilization but rather is largely driven by physical health service (including inpatient admission) and emergency room utilization for issues related to chronic medical conditions.  As the universe of all patients increasingly overlaps or merges with the universe of patients using behavioral health services, the persisting trend in behavioral health outpatient utilization presents a point of departure for actively and innovatively addressing the holistic treatment of a broader set of patients.

While healthcare systems, payors, and vendors appropriately focus on identification of patients with mental health comorbidities as a first step in the total health improvement journey, the accompanying and overly simplified narrative usually goes something like this:  “If patients have depression or anxiety, this may keep them from taking their high blood pressure medicine and, therefore, if patients are referred to a behavioral health provider and treated, they will take their medications, their high blood pressure will normalize and repeat visits to the emergency room for palpitations or migraines will dissipate, and total cost of care will spontaneously decrease.”   However, this unitary, A to Z narrative can often feel aspirational rather than tangible. It ignores the reality there are also many patients with chronic medical conditions who are not depressed or anxious but who do not adhere to their medications or treatment plans.  Second, the narrative at times conflates identification of behavioral health co-morbidity as the end of the journey rather than the beginning.  Third with the rising trend in behavioral health outpatient utilization, more patients are spontaneously seeking mental health care and are self-identifying.  Finally, and most salient, realizing the promise of truly integrated care is not merely an issue of identification, structure or process, but it necessitates a cultural shift in which primary care, physical health and behavioral health specialists are empowered, facilitated, and incentivized to view themselves as co-managers and real time partners in a patient’s total health.

In the song 11 0’Clock Tick Tock, the band U2 sing “we thought that we had the answers, it was the questions we had wrong.”  Will outpatient behavioral health utilization trends return to pre-pandemic levels and how to best identify those with behavioral health co-morbidities, may be the easier but incorrect questions.  The harder questions are how do we not waste the opportunity of increased behavioral health engagement for those with chronic physical health conditions? How do we create the conditions for behavioral and physical health providers to actively partner with each other? How do we enable and incentivize truly integrated care in action? And how do we innovatively position patients with chronic medical conditions and behavioral health comorbidities to be active investors in their overall health rather than bystanders in the value-based equation?

About the Author

Dr. Shepherd has worked as a psychiatrist in the academic, private, public and payor healthcare sectors.

The views expressed in this column are solely those of the author and do not represent nor are intended to represent the views of any other organizations or entities including past or present employers.