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9/07/2009

Psychological Health Care: A prescription for health care cost savings

It has long been recognized that emotional and psychological factors can affect one's health in a variety of ways. What is also known, but not well appreciated is that health plans can actually reduce their costs by providing psychological health care to subscribers.

The fact is that patients who receive psychotherapy tend to reduce their use of other, more expensive medical services. Despite this well documented finding, it is not uncommon for health plans to discourage mental health care usage, at a cost to themselves, to consumers, and to the employers who typically pay for coverage.

National Institute of Mental Health (NIMH) studies reliably estimate that almost 15% of the population will suffer from some type of emotional disorder during the course of any given year. Most of these people are normal and well adjusted and are simply responding to stress or to a crisis in their lives. These individuals are often referred to as the "worried well."

Only about one fifth of these people will actually seek or receive specialized treatment. Most of those remaining will not, however, simply suffer in silence until their symptoms go away.

NIMH researchers have found that the majority will be treated by their primary care physicians in what has been described as the "de facto U.S. mental health system." Health care dollars will be spent, regardless of whether or not specialized care is made available.

That this is the case is not readily apparent. Rather than complaining about psychological distress, patients will complain about physical symptoms which are caused, aggravated or maintained by emotional factors. Many will experience symptoms for which no organic basis exists.

This is not to suggest that the physical distress is not real. It simply means that real physical complaints can result from emotional concerns. While the patient may be complaining about disturbed sleep, headaches, back pain, dizziness, nausea, chest pains, diarrhea, indigestion, shortness of breath or sexual difficulties, the causative factors and curative means are often not strictly medical in nature.

If these sufferers were simply and effectively treated by their physicians, then insurance carriers would have little reason to be concerned about underwriting a de facto mental health system. Concern is warranted, however, because patients suffering from stress tend to use medical services at a disproportionate rate. It is not just that they seek medical care for problems which are actually psychological in nature, but that they use a great deal more care of all types.

Distressed patients use almost twice as many physician office visits, irrespective of their health status. They use more preventive services, more urgent care, and more hospital days, and they suffer more injuries and accidents. Distressed individuals are more likely to receive inconclusive diagnoses, are usually at greater medical risk, and when ill, are more likely to actively seek treatment.

It has been frequently estimated that at least half of all physician office visits are for symptoms that are primarily emotional or psychological in nature.

While obviously a problem, this situation actually represents an opportunity. A leading researcher in this field (and former American Psychological President), Dr. Nicholas Cummings, has argued for years that the systematic use of psychotherapeutic treatment is probably "the most significant untapped source of health care cost savings" available.

It was Dr. Cumming's studies (conducted some 40 years ago in the 1960's) with a population of some 10,000 Kaiser patients which provided the first demonstration of the potential cost savings. The patients were followed for five years. Those using mental health care during that time were matched with a control group.

Cummings found that those who were seen during that time in psychotherapy reduced their use of physician visits and hospital days to an extent sufficient to fully offset the cost of the treatment and to produce a net savings in general medical costs.

I first wrote on this topic more than ten years ago. At that time, there had been at least 58 studies replicating the original findings. Subsequent studies showed reductions in the use of medical care ranging anywhere from 5% to 79%, depending on the design of the service delivery plan.

The conclusion is simple: as part of a health maintenance strategy, outpatient psychotherapy saves money.

Given the above, it would be reasonable to expect that health plan administrators would actively promote the use of psychological health care. It should also be expected that when purchasing plans, employers would demand ready access to psychotherapy and that consumers would demand as much for themselves. In fact, it has remained the case that health plans often discourage the use of mental health benefits and that those who buy their plans give this service little consideration.

In practice, consumers often face a variety of subtle and not-so-subtle disincentives and barriers to obtaining treatment. Large co-payments, benefit limitations and exclusions, understaffed clinics, waiting lists, limited provider pools, complicated referral procedures and treatment review mechanisms all tend to discourage use. In many cases, physicians serve as "gatekeepers," receiving financial incentives for limiting referrals.

"Cost containment" is a legitimate reason to create disincentives. From the research, however, it can be argued that the potential for even greater savings is being wasted.

Even in plans which emphasize "wellness' programs, benefits are generally designed around the fear that once the doors to the therapist's office are opened, endless waves of patients will flow in to spend years on the couch for basically frivolous reasons. Each of these assumptions is wrong.

Do patients seek therapy they really do not need? Rand Corporation health insurance studies have demonstrated what every therapist knows: people seek help because they are in pain and distress, not because they want to contemplate the meaning of life.

Do liberal benefits produce uncontrollable utilization rates? If access to treatment is improved, there are temporary increases, but the rates quickly stabilize.

Do patients remain in therapy forever? Less than 10% of those entering treatment will require and use long term care. The majority respond to short-term methods, and contrary to the fears of the underwriters, they will have no desire to pursue years or even months in therapy. In any case, the fact that some will continue interminably is of little significance given that it is the average number of visits per patient that determines the cost of the service per subscriber. With a handful of patients using long-term care and the vast majority using just a few visits, the averages remain reasonably low, no matter what type of service delivery plan is provided.

What is most important with respect to utilization rates is that they are thoroughly predictable and therefore insurable. The potential direct service costs are not at all unreasonable. And again, if the treatment is not accessible, the dollars will be spent anyway on even more costly forms of care.

What are the implications of the above?

First, it means that if the Nation is in anyway intent on achieving health care reform and saving the money necessary to make it happen, psychological health care should be at the forefront, and not on the back burner.

During the 2009 health care debate, the Mayo Clinic has repeatedly been cited as a model for progressive care and as a cost saving model. A study released this year by the Mayo Clinic noted that over a four year period of time, the total cost of care provided to patients with major mood disturbances (i.e., bipolar disorder), exceeded the cost for patients with chronic conditions such as coronary artery disease and diabetes. And it wasn't the cost of their psychiatric treatments that made them the most expensive to treat. It was the fact that they used all manner of specialty care. The only group of patients that created greater expenses for the system were those who suffered from both coronary artery disease and diabetes.

Second, it means that rather than being viewed as a form of specialty care, psychological health care should be viewed as an essential component of the primary health care treatment system. While much is being said about the critical role of the primary care physician in guiding patients towards wellness and thereby reducing costs, there should be just as much attention paid to insuring that psychological and emotional concerns are attended to routinely and proactively.

A first step in this direction is to insure that physicians are following the recommendation of the U.S. Preventive Health Service for the routine administration of screening devices for depression and emotional well being.

Health care plans have a role to play in this effort. Insurance companies have the ability to shape practice by the way in which they set reimbursement policies. If it were known that psychological screenings will routinely be reimbursed, physicians would be more likely to employ them. When it is known that psychological consultation is regularly available for patients at high risk for emotionally based complications, it is more likely that physicians will include this service in their regular treatment plans.

Rather than assuming that the use of psychotherapy needs to be controlled, health plans should promote its use as part of a marketing strategy and in a spirit of enlightened self-interest.

Third, there is a role to be played by the employers who most typically pay for health insurance coverage. Employers paying for health care coverage should keep in mind that psychological well-being affects the bottom line. When choosing plans for their employees, they should keep in mind not just the cost of the plan, but the cost of stress related problems such as lost productivity, absenteeism, accidents, sick leave usage, disability claims and employee turnover. Those paying for the health plan need to shop on the basis of whether or not psychological health care is a priority.

Rather than viewing psychological assessment and psychotherapy as an unwarranted and unpredictable drain on resources, health plans would benefit from viewing psychological health care as a central component of a health maintenance strategy which seeks to reduce costs by promoting wellness.


Copyright, Paul G. Mattiuzzi, Ph.D.