ONC Must End Opposition to Behavioral Health EHRs

Edmund Billings, MDExclusion from federal funding makes no clinical, economic or policy sense

A show of hands: Who believes depression or bipolar disorder have no impact on the severity and treatment of a patient’s diabetes and COPD?

It’s an idea no practicing physician would support. Yet time and again, we act as though mental illness and care can be kept separate from physical ailments.

Take Meaningful Use (MU), for example. The federal government believes healthcare must move into the digital age and is willing to pay hospitals to buy computer systems and electronic health records (EHRs). But the financial rewards of demonstrated MU only extend to acute care hospitals and clinics, not psychiatric facilities, as though human health can be partitioned and compartmentalized.

While treating patients holistically has been accepted clinically for decades, some behavioral health advocates are turning up the pressure now to finally also bring behavioral health IT into the digital age.

Because our policy makers in Washington, DC, wield words as weapons, the Office of the National Coordinator (ONC) for Health IT has categorized behavioral health providers as “post-acute care,” thus excluding them from MU funding that has driven EHR adoption elsewhere. While the ONC has created one reality by lobbing definitions, behavioral health advocates are promoting THE reality of mental illness as acute and costly; as debilitating as any disease or condition, if not more so; and as a major co-morbidity factor exacerbating acute illnesses and driving up health care costs.

In a recent letter to Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner, the Behavioral Health IT (BHIT) Coalition made their case for MU and HIE funding:

We strongly believe that to have an effective interoperable Health Information Exchange (HIE), behavioral health care settings must receive meaningful use payments because they are acute care providers.  Under the HIE standards section, we disagree with the classification of behavioral health settings as post-acute and long-term care.

The BHIT Coalition campaign is a public lobbying manifestation of what clinicians in the trenches have known for decades: Mental illness requires acute care and strongly contributes to overall health status and increases in healthcare costs. Synthesis Project analysis conducted by by the Kaiser Family Foundation and Robert Wood Johnson Foundation uses federal government data for Medicaid Social Security Disability Insurance (SSDI) recipients to show that Americans with mental disorders have a high incidence of other serious illnesses:

• 76.2 percent of disabled Medicaid recipients with asthma and/or COPD also have severe mental disorders and comorbid addiction disorders.
• 73.7 percent of disabled Medicaid recipients with coronary heart disease also have severe mental illnesses and comorbid addiction disorders.
• 67.9 percent of disabled Medicaid recipients with diabetes also have serious mental and substance use disorders.

Citing a a study in the CDC publication “Preventing Chronic Disease” that found people with severe mental illness die 25 years sooner on average than other Americans while experiencing elevated levels of morbidity, the BHIT Coalition said only analogous comparisons help us understand how dire the situation is for the mentally ill.

It is important to put these studies in context: There are very few patient populations served by any federal health program that experience such poor overall health. In fact, the available data suggests that people with mental illnesses like schizophrenia and bipolar in the United States have average life expectancy similar to the citizens of poor Sub-Saharan African nations (who lack access to clean water and vaccinations against preventable communicable diseases).

Organizationally, the Coalition is making the case for IT funding to connect behavioral health providers into health information exchanges. To appropriately care for patients with severe mental illness and co-morbidities, they assert, there must be tight care coordination and communication between the behavioral health provider, primary care provider and medical specialists to keep the patient from cycling in and out of intensive care. Behavioral health providers are as critical, if not more so, to a “healthy exchange” and “safety network” as any of the other organizations receiving funding.

Indeed, the BHIT Coalition’s referenced data and anecdotal information strongly support the argument that the majority of behavioral health patients suffer from “acute mental illnesses, substance use disorders and life threatening comorbid medical/surgical chronic diseases.” When these patients severely exacerbate any illnesses, they need acute and even intensive care to prevent the serious and costly escalation of co-morbidities.

“How in the world can cost savings happen,” asked Coalition member Tob Doub of the Nashville-based Centerstone Research Institute, “when the one group responsible for 60 percent of health care costs is excluded?”

Doub’s question is rhetorical, clearly, but begs an answer.

They can’t. Cost savings cannot happen without acute and behavioral health care integration.

Legislation that incorporates psychiatric care into the acute-care spectrum and extends EHR incentives to behavioral health facilities has been proposed for going on five years now. Action by Congress and the ONC, however tardy it may be, is a promising first step toward healthcare that treats the whole patient.