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and BURT HUBBARD
Rocky Mountain PBS I-News
Call them frequent flyers. Or superutilizers. Or loyal customers.
In hospitals across the country, they’re known to doctors and nurses as the people who come back time and again for care.
A very small percentage of patients, they rack up an inordinate share of medical expenses, often preventable. Among Colorado Medicaid enrollees, they spend an average of around eight times as much as their peers.
And many of them — nearly three-quarters by an Aurora study’s recent count — have a mental illness.
It makes intuitive sense, and research confirms it: A troubled mind can take a toll on the body, and vice versa.
This simple fact is leading medical professionals and health officials in Colorado to rethink how to curb high costs in the health care system. What they have found is that it’s impossible to treat the most expensive customers of emergency rooms and other hospital services without addressing mental health.
“You can’t improve the overall health if you’re not treating the whole person,” said Dr. Angela Green, who co-directs an Aurora-based project called Bridges to Care.
Health care costs, many of them preventable, rank among the highest indirect impacts of mental illness, an analysis by Rocky Mountain PBS I-News has found.
Medical expenses associated with mental illness reached an estimated $2 billion in Colorado in 2013, according to 2005 figures from the federal Substance Abuse and Mental Health Services Administration, updated for growth and inflation.
Lost wages cost even more. Workers with mental disorders earn $16,000 less per person, according to a 2008 study published in the American Journal of Psychiatry. I-News estimates Colorado’s share of these lost wages at $2.9 billion.
The costs keep piling up: $425 million for disability pay in 2012, according to the Social Security Administration; $62 million in state education spending for children with emotional disorders in 2012; $44.7 million to hold inmates with mental illnesses in seven county jails, according to a 2010 City of Denver survey of the metro Denver counties; $28 million budgeted this year to treat state prison inmates.
“We’re spending a lot of money on mental health, but in all the wrong places,” says Moe Keller, a former state legislator and advocate with Mental Health America of Colorado. “We’re spending an inordinate amount of money in jails because we’re not treating mental health as a physical health issue, in courts because we’re not treating mental health as a physical health issue, in emergency rooms, in prisons.”
Keller believes the money would be more wisely directed to the front end, to screening for depression in primary care offices and treating people for mental and physical health problems in the same place.
Around the state, health officials and hospital administrators are coming to the same conclusion. And they’re starting with the frequent flyers.
Treating the whole person
Christina Jackson seemed to sleep only an hour at a time after her sister died in March 2013. Her daughter had to coax her to eat. She cried a lot. And then, in July of last year, chest pains punctuated a crying jag. Jackson was having a heart attack.
One thing led to another. The heart attack was followed by a stroke that left Jackson, 47, blind in one eye. Her hopelessness and anxiety deepened.
By last fall, Jackson had visited the emergency room at University of Colorado Hospital in Aurora three times in a span of six months — the tipping point that alerted Bridges to Care to intervene.
Bridges to Care, which is run out of Metro Community Provider Network safety-net clinics in Aurora, launched its frequent-flyer program last year. The program, funded by a federal grant, is part of a national movement aimed at stemming health care costs by improving the way care is given to the most costly consumers in the medical system.
In Colorado, this idea is gaining ground in scattershot efforts launched by state Medicaid administrators and hospitals including Denver Health.
These efforts diverge in how they flag frequent flyers and facilitate care. But they share a philosophy of coordinating services and giving personalized attention to help people navigate a complex health care system more efficiently.
Relationships are key. It’s these relationships — between care coordinators and the patients — that can help turn up the undiagnosed and untreated mental illness beneath the surface of a medical crisis.
Along with getting a care coordinator, each person who enrolls in Bridges to Care receives a home visit from a therapist and a psychiatric nurse practitioner.
The Aurora project has collected detailed profiles of 57 people who have graduated from its two-month program. Around 72 percent of them were diagnosed with one or more mental illnesses. About a quarter of them had depression, 20 percent had anxiety disorder, and 11 percent had bipolar disorder.
Bridges to Care’s findings are in line with what health officials and doctors are seeing across Colorado.
Mental illnesses collectively make up the most prevalent conditions among Medicaid clients who frequent the ER six times or more in a span of 12 months, according to an I-News survey of the state’s seven regional Medicaid administrators tasked with improving care for low-income Coloradans. They’re more common than diabetes, asthma, or any other driver of ER use.
Around 33 percent of these frequent flyers have behavioral health claims, but that’s likely an underestimate of the true disease prevalence, Medicaid administrators say.
“When you look at the claims data, it doesn’t help paint the picture at all,” said Jenny Nate, community strategist for Rocky Mountain Health Plans, which helps administer Medicaid for much of the western half of the state.
“Sometimes behavioral health diagnoses get missed or minimized,” says Nate. “So it’s hard to get the real story.”
On top of that, Medicaid clients get their physical care and their mental health care from separate places, making it harder to track any overlap.
and cutting costs
That’s where care coordinators like Alyssa Murphy come in.
Alyssa Murphy, a former AmeriCorps volunteer, was assigned to guide Christina Jackson to a primary care doctor and make sure she could get an appointment when she needed it.
The two hit it off immediately.
“I really love her,” Jackson beamed at Murphy, who was sitting across the room from her in Jackson’s duplex in east Aurora. Before, she couldn’t seem to get a doctor’s appointment when she needed it and hospital staff didn’t seem to care about her at all. Murphy seemed genuinely interested in her well-being. “She helped me through it.”
Along with arranging transportation to the clinic and helping her apply for food stamps, Murphy introduced Jackson to the clinic’s behavioral health team, who taught her breathing techniques to manage stress.
On the sofa at home, Jackson demonstrated her breathing exercises. She inhaled, one-two-three, and exhaled. Immediately, her face looked less drawn; she smiled and sat up straighter.
Jackson graduated from the two-month program at the end of January, without going to the hospital once during that time. While her depression hasn’t lifted, Jackson has found that its burden was eased by the personal attention and a sense of empowerment about her health.
As time-consuming and resource-intensive it is to provide care this way, it’s actually expected to cut medical costs, says Green. Six months after graduating from the program, 79 percent of the patients were either visiting the emergency room less frequently or not at all.
With an eye toward reducing Medicaid expenses, state government recently launched pilot programs to do similar work in regions with the highest concentration of what they call superutilizers.
The state’s intervention targets people who visited the emergency room six times or more in a span of 12 months, or used 30 prescriptions — a population that cost $25,187 per patient in 2013, on average. By comparison, the average Medicaid patient costs just $3,000 a year.
Care coordinators — the kind of personal medical assistant that Murphy was to Christina Jackson — will be assigned to these high-cost medical customers in Pueblo and Colorado Springs in order to make their health care more efficient.
Behavioral health will be a key part of the approach, says Patrick Fox, deputy director of the Office of Behavioral Health at the Colorado Department of Human Services.
“Most of these superutilizers have a physical health problem and behavioral health component,” Fox says.
He gives the example of a Medicaid client who was treated for a blood clot in her lung. Afterward, every twinge in her leg or chest would send her, panicked, to the ER. She went every two or three weeks.
“She didn’t understand that her risk of this coming back was nonexistent. Somebody needed to explain it to her,” says Fox. “It was not a severe persistent mental illness, but in a regular primary care office, there’s not time to look for a behavioral health condition. It doesn’t get diagnosed.”
At the same time, it isn’t uncommon for frequent flyers to have a mental illness that’s the main driver of their ER visits. Around 14 percent of the frequent ER users in central Colorado counties, including El Paso, have a primary diagnosis of mental illness, and 18 percent in the state’s southeastern counties, including Pueblo.
They include people like Fruita resident Agnes Shellabarger, who has schizophrenia. Migraines and suicidal thoughts have led her to the hospital repeatedly, and she now works with a care coordinator based at Mind Springs Health, the community mental health center in Grand Junction.
Substance abuse is also a common driver of ER visits.
Robin Bingham was a repeat visitor to the emergency room at St. Mary’s Hospital in Grand Junction, usually for detox from crystal methamphetamine or alcohol. In January, she took an overdose of medication in a suicide attempt, and was referred to a care coordinator at Mind Springs Health who has helped her embark on recovery.
“It’s very difficult to find treatment on your own,” said Bingham in March. “I called every treatment center in town and they didn’t call me back.”
When Denver Health designed its frequent-flyer program, it specifically targeted people with co-occurring mental illnesses. To qualify for an intensive outpatient intervention, patients had to be admitted to the hospital three times in the past six months—or twice, with a mental illness diagnosis.
The reason for this, says Tracy L. Johnson, who directs health care reform initiatives at Denver Health, is the growing body of research on a national level showing the relationship between preventable hospital readmissions and mental illness.
The revolving door is especially likely to ensnare people with mental illness who are non-compliant with medication, who are discharged into unstable care or who have co-occurring substance abuse disorders, according to recent research reviewed by scholars at George Washington University.
Challenge of coordinating care
As big as the financial costs of untreated mental illness can be, the personal ones are much greater. Poor mental health can come hand-in-hand with substance abuse, unemployment, homelessness, high rates of smoking and poor access to medical care.
In part for these reasons, people with severe mental illnesses die an average of 25 years earlier than others, according to a 2008 study by the National Association of State Mental Health Program Directors.
Statistics like this one have convinced many of the benefits of coordinating physical and mental health care. But the mechanics of doing so are often more difficult.
In practice, the two forms of care are in separate silos.
Keller, the mental health advocate, ticks off a list of obstacles that stand in the way of integrating it. Much of it has to do with reimbursement. Physicians can’t bill for anything that doesn’t have its own billing code. And the payment model doesn’t account for the lengthier office visits that a mental-health visit requires.
There are other barriers, too. Nurses, doctors and psychologists are often unaccustomed to working in a team. And broad interpretations of medical privacy laws prevent the sharing of information.
Colorado is applying for a federal grant to integrate its physical and behavioral health care, and Keller believes the Affordable Care Act will go a long way toward reforming payment for mental health.
“There are some good things happening,” says Keller. “We’re not there yet.”