Health plan policy

Optimal Behavioral Health Outcomes that Align with Plan Policy

Optimal Behavioral Health Outcomes that Align
with Plan Policy – On-Demand Expertise

by Micah Hoffman, MD, DABPN, FAPA

AllMed Behavioral Health Medical Director

The demand for mental health services in the United States is soaring. In 2018, well before the emergence of Covid-19, nearly six in 10 Americans reported seeking or wanting mental health services for themselves or a loved one.1 Since then, the stresses of the pandemic have only increased the need. Meanwhile, resources—always limited—are becoming scarcer. As of September 2020, there were only nine practicing psychiatrists for every 100,000 people, well short of the nearly 15 per 100,000 that provides good mental health care. The deficit is expected to grow, with demand for psychiatry exceeding supply by as many as 15,600 psychiatrists by 2025.2 To bridge this yawning gap, healthcare organizations have expanded the role of physician extenders, often relying on advanced practice nurses, physician assistants, physician generalists, and prescribing psychologists to meet members’ mental and behavioral health care needs.

Viewed as a strategic necessity, this role expansion can improve access but can result in gaps in training and expert experience that board-certified psychiatrists bring to the table. Forward-thinking health plans are turning to utilization management and independent review organizations such as AllMed for help closing these gaps. Through our behavioral health review services, our board-certified psychiatrists and psychologists can bring insights to your team that lead to better and more cost-effective outcomes.

Expedited Treatment Helps Prevent Escalation

Perhaps the most significant benefit physician extenders provide is expedited treatment. The shortage of psychiatrists and psychologists in the U.S. is a fact. In certain parts of the country, there simply isn’t a psychiatrist at any reasonable distance.3 Aware of this scarcity, many members appreciate the expanded access to treatment and increased provider face time they receive when physician extenders create added capacity. From a health plan perspective, physician extenders—particularly when they collaborate with board-certified specialists—can address members’ issues effectively, before they escalate, minimizing the need for higher-level, costlier care.

Optimal Care Requires Specialized Expertise

That collaboration is key. Managing complex behavioral and mental health needs appropriately often requires specialized knowledge. When physician extenders have reliable access to psychiatrists who can help guide treatment plans, everyone benefits. Members receive the evidence-based treatment that best fits their needs, promptly, and plans can feel confident that the care aligns with plan policy. In our behavioral health reviews, we often encounter situations where such a collaboration would be beneficial.

One scenario that we are seeing with increasing frequency is physician extenders serving as primary providers in cases where members are admitted as inpatients. Many of these members lost access to stabilizing outpatient treatment during the pandemic, and they arrive at the hospital significantly decompensated. Determining the best treatment for them—and avoiding a lengthy inpatient stay—often requires the extensive clinical experience of a sub-specialized, board-certified psychiatrist, yet accessing that expertise can be difficult. As a result, these patients may spend more time at a higher level of care than is appropriate for their condition.

Similarly, we receive reviews involving members who may carry an inaccurate diagnosis. In these situations, the member, provider, and health plan may invest significant time and resources on treatments that are less than optimal or, sometimes, not effective at all. Consulting with a sub-specialized expert with clinical expertise—in, for example, addiction, geriatrics, or treatment-refractory mood disorders—can make a tremendous difference in such cases.

A final example comes from our prior authorizations for branded medications. Often, our reviewers note that no clear evidence exists that the branded version of the medication provides a greater clinical benefit than the generic alternative.

Hidden Costs Can Offset Benefits

As these examples indicate, physician extenders have a valuable role to play in health care, and pairing them with board-certified physicians can result in the most cost-effective, positive clinical outcomes.

These include treating members at the level of care and for the length of time that are appropriate to their condition. Care teams with the expertise to stabilize members as quickly as possible so that they can step down to lower levels of care as soon as is appropriate can deliver not only lower costs but also significantly improved outcomes.

Collaboration can also lead to savings on prescriptions that benefit both members and health plans. At volume, decisions to use branded medication over generics, when not warranted, substantially increase the cost of care. For a sense of the potential scope, consider recent studies concluding that generic and biosimilar medicines generated $2 trillion in savings to the U.S. health care system over the last decade.4

Partnering with AllMed can help you address such considerations effectively, enabling you to maximize the value of working with physician extenders while minimizing the potential downside. Working as an extension of your team, our board-certified psychiatric specialists and sub-specialists can be the knowledgeable intermediaries between physician extenders, members, and health plans, providing guidance on specific, evidence-based treatment likely to be optimal in a given scenario. By leveraging the expertise of our specialists, your team gains ready access to the knowledge they need to ensure appropriate, high-quality care that meets plan policy.