What’s the cost of mental health integration?

Kaiser Permanente Washington shows price may not be a barrier to primary care implementation, Dr. Kai Yeung reports 

Costs do not appear to be a major barrier for health systems to integrate mental health into primary care, according to an analysis of a Kaiser Permanente Washington initiative. The study was led by KPWHRI Assistant Investigator Kai Yeung, PharmD, PhD.

Health care systems are increasingly interested in integrating services for conditions such as depression, alcohol and substance use disorders, and suicidal thoughts into a more comprehensive model of primary care. However, study coauthor Ryan M. Caldeiro, MD, who is Kaiser Permanente Washington assistant medical director of addiction and recovery services and consultative psychiatry, says, “As health care operations leaders, we are faced with not just looking at which are effective programs to implement to improve patient care, but also what are the costs to implement these programs?”

To find out, Dr. Yeung and colleagues used data from Kaiser Permanente Washington’s rollout of behavioral health integration, now called integrated mental health. They examined costs starting in 2014, when many primary care clinics first began screening for common conditions such as depression and unhealthy alcohol use with a goal of helping members get appropriate care.

”We used data from the Kaiser Permanente Washington experience,” Dr. Yeung says, “to provide information to other health system leaders who want to know the costs of incorporating mental health screening, assessment, and patient identification into primary care.”

In an accompanying commentary, Drs. Trina E. Chang and Timothy G. Ferris from Massachusetts General Hospital and Harvard Medical School called the results “an important blueprint for those interested in building a better health care delivery system.”

KPWA’s experience

Kaiser Permanente Washington’s mental health integration rollout implemented annual screening, assessment, and identification in primary care for depression, suicidality, and unhealthy alcohol, cannabis, and substance use. To determine the cost of this effort over 25 sites, Dr. Yeung and coauthors studied 3 evidence-based strategies that supported the transition: 1) practice coaches, 2) clinical decision support in the electronic health record, and 3) performance monitoring and feedback.

The analysis focused on 5 personnel groups involved in integration: project leaders and administrative support, practice coaches, EHR programmers, performance metric programmers, and staff involved in implementation at each site. Using nearly 3 years of data from personnel reports on time and travel, and state labor and other data, the team determined the costs for 1 year of implementing integrated mental health.

“The cost per screened patient was only $5,” Dr. Yeung says. “And the cost to identify someone who had one of the conditions and might benefit from counseling or treatment was $38.” Total implementation costs for integrated mental health at 25 Kaiser Permanente Washington sites, Dr. Yeung says, was more than $1.5 million. But since the program was successful, with 89% of patients with primary care visits screened annually and care team members reporting better patient and provider experiences and care quality, the costs per screen were considered low.

Most of the costs (69%) were for 2 personnel groups: project leaders and practice coaches whose assistance to clinics included designing site-specific workflows, offering clinical knowledge about screening, and training to reduce stigma, for example about alcohol use. Costs declined from the first 3 sites that integrated mental health during a developmental phase to the next 22 sites, suggesting low costs for additional implementation.

Learning from KPWA

In their commentary, Drs. Chang and Ferris say other systems integrating mental health care into primary care may have different experiences and costs. However, they praise the utility of the analysis, saying, “We saw numerous elements that would have helped us on our own journey in behavioral health integration at our health system had we known them at the time. We commend the authors for taking the time to assemble this information in a useful format so that others might benefit.”

For Kaiser Permanente Washington, Dr. Caldeiro notes that the investment in integrated mental health has led to sustained improvements and added value to patient care. “We are currently working to expand this work to the adolescent population,” he says, “and these findings help support our approach — not just around integrated care, but investments in how we go about implementing this program.”

Drs. Yeung and Caldeiro’s coauthors on the study in Health Services Research are, from KPWHRI, Research Associate Julie Richards, PhD, MPH; Research Support Specialist Eric Goemer, BA; Senior Investigator Paula Lozano, MD, MPH; Assistant Investigator Gwen Lapham, PhD, MPH, MSW; Associate Investigator Joe Glass, PhD, MSW; Research Associate Amy Lee, MPH; Carol Actometer, MS, AR, NP; and Senior Investigator Kathy Bradley, MD, MPH. Other coauthors are, from the University of Washington, KPWHRI Affiliate Researcher Emily Williams, PhD, MPH, and from Kaiser Permanente Washington, Integrated Behavioral Health Clinical Consultant and Social Work Manager Rebecca Parrish, LICSW. Funding was from the Agency for Healthcare Quality and Research.

Disclosure: Chris Tachibana, KPWHRI scientific editor, assisted with this story. She is also the senior managing editor of Health Services Research but had no involvement in the Yeung et al. paper.