Behavioral health is major issue in N.J.’s low-income communities, study finds

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More than a third of hospitalization costs in 13 low-income New Jersey communities are associated with behavioral health conditions, including mental health disorders and substance use, accounting for $880 million in annual inpatient costs, according to a new Rutgers study.The report by the Rutgers Center for State Health Policy also found that 75 percent of patients classified as “high users” — those with at least four hospital stays between 2008-2011 — were diagnosed with one or more behavioral health conditions, compared with 32 percent of less-frequent users.

In addition to hospitalizations of high users, the study also examined potentially preventable hospital admissions that could have been avoided with high-quality ambulatory care in the community; for example, hospitalizations caused by uncontrolled diabetes. It found that 40 percent of preventable inpatient hospitalizations were associated with behavioral health conditions.

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Sujoy Chakravarty, the report’s lead author and assistant research professor at Rutgers CSHP, noted that the integration of physical and behavioral health services, particularly for the small number of patients who use a disproportionately high level of hospital services, would result in better care for these high-cost patients, decrease avoidable hospitalizations and lead to substantial savings in costs.

“Coordination of behavioral and physical health care in the community setting may promote better health for complex patients, since unmanaged behavioral health problems often lead to poorly managed chronic medical conditions,” Chakravarty said.

Dr. Jeffrey Brenner heads the Camden Coalition of Healthcare Providers, which for more than a decade has been addressing the combination of medical, behavioral health and addiction issues that can send low-income city residents to the ER and hospital beds.

Brenner said the Rutgers report “is a really powerful study and will add a lot to the dialog in New Jersey about where we need to head with our health care system.”

He said the story illustrates “that people are coming to the hospital frequently for a whole variety of reasons, especially around mental health and addiction, and that if we don’t rebalance the health care system and spend less money on acute services and more money on behavioral health and addiction, that we are not going to deliver better care at lower cost.”

Brenner said that, about six years ago, the Camden Coalition was “hit over the head with the degree of the complexity of our patients and the need to grab new skills sets. That this wasn’t just a medical problem but that this was really a holistic challenge that would require new skills set for our staff and new capabilities for our team.”

He said: “There’s a much broader trend going on here, which is our recognizing that it’s not just what’s going on below the neck — what’s going on above the neck is just as important. The American health care system does not do a good job with behavioral health and addiction, and we have to rebalance that. We are medicalizing social problems and we are underspending and underinvesting in services that would really make a difference for these patients.”

Mary Ditri, director of professional practice for the New Jersey Hospital Association, said the Rutgers study is consistent with what NJHA has seen: “A steady increase in patients seeking behavioral health services through the ER or the inpatient setting. No pocket of the state has shown any decrease.”

She said hospitals “are coming together in creative ways to look at how best to meet the needs of their community.” She added that the solutions reflect the cultural nuances of each community: “It really becomes a very local, locally driven design for enhancing services and community outreach.”

Hospitals are partnering with other health care providers to create accountable care organizations, including a Medicaid ACO program that is being launched statewide to provide coordinated care to low-income population. Ditri said hospitals are working to integrate behavioral health services into a comprehensive, coordinated model of patient care.

NJHA data show that, in 2007, New Jersey hospitals reported 289,800 individuals with a behavioral health diagnosis had been treated in the emergency department and, in 2012, that number was 521,000.

NJHA spokesperson Kerry McKean Kelly said the numbers reflect the fact that “patients needed services and they couldn’t access services, so they came to the ED for that care.”

Linda Schwimmer is vice president of the New Jersey Health Care Quality Institute, which is working with the Medicaid ACOs being launched in urban areas throughout the state to improve health care to Medicaid members.

Schwimmer said: “This study confirms what we’ve recognized through our work with the Medicaid ACOs for quite some time — which we as a state and a health care system need to break down the barriers between physical and mental health. Moreover, we need to ensure that health care is a sustainable business in these low-income communities by fairly compensating for appropriate primary and mental health. In short, we need to make sure that patients are able to access the right services in the right places.”

Schwimmer said achieving those goals begins with new payment models — like Medicaid ACOs — that will allow providers the flexibility to invest in services like care coordination that can help guide the most at-risk patients to get the best care. She said the health system as a whole needs to become more integrate and spend smarter, particularly in these 13 communities: “We need to invest in primary care and increase access to behavioral health service.”

She said ideas on what should be done include:

• Support the work of the Medicaid ACOs. They are dealing with this head-on.
• Remove regulatory burdens that make it hard to co-locate behavioral health and physical health services.
• Find innovative ways to move money out of the ER and inpatient setting and into primary care and the community setting — and equip primary care physicians with the most efficient evidence-based approaches to addressing behavioral health needs.
• Ensure that behavioral health providers in these communities are able to be financially sustainable, and that capacity across the state accurately reflects the demand.

Joel Cantor, director of the Rutgers Center for State Health Policy, said the Camden Coalition and the Trenton Health Team have been working on behavioral health issues for a long time. Cantor said the Medicaid ACOs are a key part of the puzzle: “Our data suggest that, if they are to achieve savings by reducing avoidable hospital care, then working to integrate behavioral health and physical health treatment is essential.”

The report, funded by The Nicholson Foundation as part of its ongoing efforts to improve the quality and affordability of health care in New Jersey’s underserved communities, sheds light on the importance of ensuring accessible behavioral health as part of population-based initiatives aimed at improving patient health and reducing avoidable hospitalizations and associated costs. The Foundation is supporting new evidence-based models of care that bring behavioral health expertise into community-based primary care settings.

Rachel Cahill, director of health care improvement and transformation at The Nicholson Foundation, said New Jersey’s vulnerable populations suffer from higher burdens of serious chronic illness and behavioral health disorders than others in the state, and face significant, complex barriers to medical care.

“If we are committed to improving health outcomes for these vulnerable populations, we must increase availability of behavioral health services and the coordination of services by integrating physical and behavioral health care,” Cahill said.

Although the study focused on hospital data in the 13 communities, the data and findings reflect populations throughout the state, including patients with Medicare, Medicaid and commercial insurance, as well as the uninsured. Along with the Medicaid population, behavioral health issues were significantly present among patients with other sources of insurance. Therefore, the findings can guide the efforts of policymakers, insurers, and delivery systems in general, not just those specific to Medicaid, Cahill said.

The findings are based on analysis of New Jersey’s uniform billing hospital discharge data from 2008-2011, available from the state Department of Health. Working with the DOH, researchers created a dataset that enabled them to follow patient utilization over time. The study population included hospitalizations of all adults (age 18 and over) living in one of 13 low-income communities in New Jersey: Asbury Park, Atlantic City, Camden, Elizabeth, Jersey City, New Brunswick, Newark, Paterson, Perth Amboy, Plainfield, Trenton, Union City and Vineland. In some cases, neighboring towns also were included.

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