Behavioral health program reduces MCO costs
Program reduces utilization in just six weeks
Case managers with managed care plans know that a small fraction of their members consume a major portion of health care resources each year. In fact, roughly 50% of all primary care visits are for patients with no diagnosable physical disorder.
These patients often complain of headache, fatigue, insomnia, weight gain, weight loss, back pain, or chest pains. A simple, replicable, six-week behavioral health program that uses videos, group sessions, and experiential exercises helps these patients recognize the underlying causes of their physical disorders and offers HMOs a solution for reducing both utilization and costs, says Matthew A. Budd, MD, president of HSC Associates in Cambridge, MA, and former director of behavioral health for Harvard Pilgrim Health Care in Brookline, MA. It was during his time at Harvard Pilgrim that Budd developed the Personal Health Improvement Plan (PHIP).
"Harvard Pilgrim found that patients who went through the program had significantly fewer visits over a six-month period over similar patients who didn’t go through the program," notes Budd. "The program recognizes that patients are whole, not parts, that without treating underlying conditions such as depression or anxiety, we are not treating patients effectually, and they won’t get well," he explains.
Patients with chronic disease such as multiple sclerosis and rheumatoid arthritis, whose moods seem to influence their physical health, also benefit from the program. "In fact, almost any patient who has been assigned a case manager could probably benefit from this course," says Budd.
Other physicians who have tried the program agree that it fills a necessary gap in the traditional HMO model. "This program addresses a population that we haven’t been able to help effectively in a traditional primary care model," notes Patricia Ford, MD, medical director for PHIP at Community Health Plan in Albany, NY. "Even with disease management and demand management efforts, this population is not served. These members get frustrated and doctor shop within the plan. They seek alternative providers outside the plan, and they still don’t get better."
Outpatient costs have dropped
Community Health has been using the program for nearly 12 months, says Ford. "About 130 members have completed the program, and we’ve reduced outpatient costs by about $650 per patient per year for members completing the PHIP program," she notes.
In addition to tracking utilization patterns, Harvard Pilgrim measures mental health status of patients before and after completing the PHIP program, notes Budd. "We administer anxiety, depression, and functional assessments before and after the program, and patients show improvement in all three. The good news is that these improvements seem to persist for up to one year," says Budd, adding that the program also scores high on patient satisfaction measures.
Cue the video
The PHIP program consists of six weekly 90- to 120-minute sessions in a classroom format. A trained facilitator works with a manual to direct groups of 15 to 20 patients though a series of specific exercises and interactive discussions. Facilitators use a video-based curriculum supported by wall charts and participant workbooks to teach patients coping skills, says Budd.
The group format serves two purposes, he notes. "First, patients benefit from learning that others feel similar to themselves. Second, it helps remove any resistance patients may have about participating in a mental health program," Budd explains.
The videos are short five- to 10-minute segments that set up role-playing exercises, note Budd and Ford. "Patients then pair up and work through the exercises and concepts," explains Ford.
"The purpose of the course is to show people how to be more self-sufficient in their living and more trusting in their relationships. Increasing both those elements in their lives leads to increases in well-being. Once they have some coping skills, these patients seem to improve," explains Budd.
"The program uses proven adult learning methods in a strict curriculum so the results are consistent and replicable," adds Ford. "Patients who successfully complete the program undergo a gut change. They learn how to take more responsibility for feeling well and staying well."
One reason the program yields such consistent results is that PHIP facilitators must complete an intense six-day training workshop, ote Budd and Ford. Facilitators must complete the PHIP course themselves and practice each exercise.
Community Health has developed three marketing strategies to target high-cost patients and refer them to the PHIP program, says Ford. "Our first marketing efforts are directed at providers. We send information in our provider newsletters. We’ve also given continuing education presentations for providers.
Talking about sensitive issues
"In fact, the key barrier to offering this program is making it comfortable for providers to approach patients. Behavioral health issues are touchy. Providers don’t easily discuss the mind/body connection with their patients."
The second marketing effort targets patients directly. "If approached correctly, most patients recognize that stress plays a major role in their disease," notes Ford. "We place materials about the PHIP program in all our waiting rooms. We also educate all staff members at our health centers about the program, so that they are ready to answer patients’ questions about PHIP."
The last marketing effort is aimed at Community Health’s employer groups. "We especially target our self-insured employers. They are at risk for health care dollars spent, and they are pretty receptive to any program that promises to reduce utilization," says Ford.
Patients interested in the program can call a toll-free number for more information or registration over the telephone, adds Ford. "A PHIP coordinator answers the toll-free line. These are people who have gone through the program themselves and can screen patients for appropriate referral into the program."
"Patients tend to self-select very well into the program," notes Ford. However, some patients may not be appropriate for PHIP. Those might include:
• patients with severe mental disorders such as uncontrolled panic disorder or severe depression;
• patients who find group learning too difficult.
Community Health has roughly a 20% dropout rate, notes Ford. "This seems to be a typical pattern for managed care plans who offer the course," she notes. "After about the second or third class, patients get a better handle on what we’re trying to do, and they’re not receptive to the approach.
"Sometimes, it’s simply the time commitment that’s the problem. Many of these people are people who are very committed to lots of activities and simply can’t make it to six two-hour sessions," she explains.
"By the end of the six weeks, patients begin to recognize patterns of behavior that they’ve repeated throughout their lives. We give them the tools to break those patterns and design new, healthier patterns of behavior. We teach them to stop and ask what circumstances in their life may be contributing to how they feel physically before they pick up the phone and make an appointment," concludes Budd.
[Editor’s note: Harvard Pilgrim has made the PHIP program available to other managed care plans through an arrangement with Proctor & Gamble Healthcare in Cincinnati. For more information contact Mertech in Braintree, MA. Telephone: (888) 794-7447.]
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