The Impact of Designated Behavioral Health Services on Resource Utilization and Quality of Care in Patients Requiring Constant Observation in a General Hospital Setting: A Quality Improvement Project

Constant observation (CO) is a common economic burden on general hospitals. A quality improvement (QI) project focusing on behavioral health (BH) management of this population was piloted using a novel BH protocol for the proactive assessment and management of all patients requiring CO. The impact on CO-cost and length of stay (LOS) was assessed. Data on demographics, diagnoses, psychopharmacologic treatment, complications and clinical setting were collected and analyzed for all CO-patients over a 6-month period. Cost and LOS data were compared with a similar sequential group prior to project implementation. Out of the 533 patients requiring CO during the study period, 491 underwent the protocol. This QI-project resulted in a significant reduction in the average monthly CO-cost by 33.06% and a 15% reduction in LOS without any increase in complications.

Measuring Efficiency at the Interface of Behavioral and Physical Health Care

BACKGROUND

Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both).

AIMS OF THE STUDY

To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development.

METHODS

We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included.

RESULTS

85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31).

DISCUSSION

Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes.

LIMITATIONS

We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified.

IMPLICATION FOR HEALTH CARE PROVISION AND USE

Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care.

IMPLICATIONS FOR HEALTH POLICIES

Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts.

IMPLICATIONS FOR FURTHER RESEARCH

There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

Towards a Global Health Contribution for Critical Health Psychology

The ability of critical health psychology to deliver on its implicit promise to link social and biological processes is compromised by: (1) a morally superior stance of being critical of rather than being critical for other disciplines; (2) insufficient pluralism in its concepts and methods; and (3) unwillingness to engage with more ‘distant’ disciplines that are salient to its goals; particularly economics, management and law. The global health movement offers critical health psychology an avenue to develop its project, especially in low-income countries, where a pragmatic approach to the interconnectedness of poor health and inequality is needed.

Advocating an agentic and potentialist view to health psychology

The article covers the notions of agency and potentials, social cognitive theory (SCT), their definition and importance for the health. These two notions are crucial for reorienting psychological investigations and interventions in accordance with new findings about human personality and the new demands of society. The notion of agency points to the fact that people may actively contribute to the full expression of their natural and social endowments, the notion of potentials highlights the fact that much of human strengths derive from people discovering and nurturing their capacities while acknowledging environmental opportunities. A basic goal of agentic and potentialist views is to shed light on the psychological systems that enable people to regulate their experiences and actions and thus to contribute to the development of their potentials. In this regard a large body of research attest to the merits of social cognitive theory (SCT) in providing a firm basis for guiding research and designing psychosocial interventions aimed at maximizing individuals' functioning and well being. SCT focuses on the unique properties of human agency that allow people to reflect on their capabilities for action and to accord their conduct to the pursuit of outcomes they value, and points to structures and processes which enable people to guide behaviour purposively and to chart the course of their life. Social cognitive theory and practice provide unique directions to identify the strategies more suitable to promote individual flourishing by enabling people to make choices and to engage in pursuits that mostly serve to their growth, health and well-being.

Using behavioral economics to promote physical activity

Behavioral economics is a relatively new field of economics that uses experimental techniques to produce insights about human decision-making. One of its key findings is that people's preferences for actions are not absolute, but rather relative to some anchor point, and can therefore be influenced by changing the anchor. Anchor points can be social norms, habits acquired in childhood, or a cultural frame-whether physical activity is presented as fun or as drudgery. Physical activity promotion can benefit by intervening on these anchors, but doing so is most effective when it is undertaken for society as a whole. Behavioral economics accordingly suggests that physical activity promotion should incorporate attempts at a cultural shift to support individual health-promotion efforts.

Behavioral modification. With the historic enactment of mental health parity legislation, providers may see themselves freed from treatment limitations

The huge financial bailout passed in Washington last week also brought relief for another sector: behavioral health. When it becomes effective Jan. 1, 2009, the mental health parity legislation is expected to give more than 100 million people access to coverage and will free providers from treatment limitations. "This is long overdue to cover these illnesses," says Mark Covall, left.

Billing effectively with the new health and behavior current procedural terminology codes in primary care and specialty clinics

The health and behavior current procedural terminology (CPT) codes introduced in 2003 have gained nationwide acceptance through Medicare and limited acceptance through third party payers. The codes facilitate accurate description and quantification of behavioral medicine services within a primary care or specialty clinic setting. The author reviews their appropriate utilization to enhance reimbursement and facilitate development of self-sustaining behavioral medicine programs. Information is provided on increased use and reimbursement of codes within psychology. Future directions for continued advocacy, increased acceptance, training, and research are discussed.

Behavioral health service use and costs among children in foster care

This article compares behavioral health service use and cost for foster care versus nonfoster care children; children before, during, and after foster care placement; and successfully reunified versus nonsuccessfully reunified foster care children. Behavioral health service costs for children in foster care were higher than for children not in foster care. Children in foster care used more services during their foster care placement than before placement and after discharge. Nonsuccessfully reunified children received a significantly larger quantity of services than those successfully reunified.

Reversal of fortune. After years of scaling back beds because of low occupancy rates, behavioral health facilities are beginning to make a comeback

For decades states have been cutting behavioral health beds because of low occupancy. But a recent survey showed occupancy rates at these hospitals at record highs, and analysts expect more consolidation as larger providers expand. A change in federal payment methods favors free-standing facilities. "The free-standing units will do better as a group," says the National Association of Psychiatric Health Systems' Mark Covall.

Behavioral economics and health policy: understanding Medicaid's failure

This Article employs a behavioral economic analysis to understand why Medicaid has failed to improve the health outcomes of its beneficiaries. It begins with a formal economic model of health care consumption and then systematically incorporates a survey of psychosocial variables to formulate explanations for persistent health disparities. This methodology suggests that consulting the literature in health psychology and intertemporal decision theory--empirical sources generally excluded from orthodox economic analysis--provides valuable material to explain certain findings in health econometrics. More significantly, the lessons from this behavioral economic approach generate useful policy considerations for Medicaid policymakers, who largely have neglected psychosocial variables in implementing a health insurance program that rests chiefly on orthodox economic assumptions. The Article's chief contributions include an expansion of the behavioral economic approach to include a host of variables in health psychology, a behavioral refinement of empirical health economics, a behavioral critique of Medicaid policy, and a menu of suggested Medicaid reforms.

General medical and pharmacy claims expenditures in users of behavioral health services

OBJECTIVE

To quantify the magnitude of general medical and/or pharmacy claims expenditures for individuals who use behavioral health services and to assess future claims when behavioral service use persists.

DESIGN

Retrospective cost trends and 24-month cohort analyses.

SETTING

A Midwest health plan.

PARTICIPANTS

Over 250,000 health plan enrollees during 2000 and 2001.

MEASUREMENTS

Claims expenditures for behavioral health services, general medical services, and prescription medications.

MAIN RESULTS

Just over one tenth of enrollees (10.7%) in 2001 had at least 1 behavioral health claim and accounted for 21.4% of total general medical, behavioral health, and pharmacy claims expenditures. Costs for enrollees who used behavioral health services were double that for enrollees who did not use such services. Almost 80% of health care costs were for general medical services and medications, two thirds of which were not psychotropics. Total claims expenditures in enrollees with claims for both substance use and mental disorders in 2000 were 4 times that of those with general medical and/or pharmacy claims only. These expenditures returned to within 15% of nonbehavioral health service user levels in 2001 when clinical need for behavioral health services was no longer required but increased by another 37% between 2000 and 2001 when both chemical dependence and mental health service needs persisted.

CONCLUSIONS

The majority of total claims expenditures in patients who utilize behavioral health services are for medical, not behavioral, health benefits. Continued service use is associated with persistently elevated total general medical and pharmacy care costs. These findings call for studies that better delineate: 1) the interaction of general medical, pharmacy, and behavioral health service use and 2) clinical and/or administrative approaches that reverse the high use of general medical resources in behavioral health patients.

Evolution of the biopsychosocial model: prospects and challenges for health psychology

Although advances have been made in specifying connections between biological, psychological, and social processes, the full potential of the biopsychosocial model for health psychology remains untapped. In this article, 4 areas that need to be addressed to ensure the continued evolution of the biopsychosocial model are identified and a series of recommendations concerning initiatives directed at research, training, practice and intervention, and policy are delineated. These recommendations emphasize the need to better understand and utilize linkages among biological, psychological, social, and macrocultural variables. Activities that facilitate the adoption of a multisystem, multilevel, and multivariate orientation among scientists, practitioners, and policymakers will most effectively lead to the kinds of transdisciplinary contributions envisioned by the biopsychosocial perspective.

Health services and health care economics: the health psychology marketplace

In an effort toward cost containment, the health care system in the United States has undergone radical changes in the last decade. These changes have influenced the delivery of clinical health psychology services. This article reviews several economic and marketing factors salient to the clinical health psychology marketplace. For example, these economic changes have placed greater emphasis on the need for cost-effectiveness and accountability in the health psychology field. Implications for education and training, collaboration with other health care specialties, new practice initiatives, and public relations are reviewed. Future challenges and opportunities for clinical health psychology are discussed.

Financing results and value in behavioral health services

Current changes require that behavioral health care leaders understand how public and private financing mechanisms interact and how, now more than ever, behavioral health care leadership must span multiple systems and financing streams. Understanding how financing mechanisms work, what they create, and what they cause is essential if we are to make the most of increasingly limited and increasingly complex resource streams in today's health care market. This article explores a different paradigm of what adds value to publicly funded behavioral health care systems, and provides the framework for the American College of Mental Health Administration's call to behavioral health care administrators to take a new approach to the considerations behind funding decisions and payment mechanisms.