Behavioral Medicine and the Affordable Care Act
By Rick Richert, Graduate Student Troy University
The Society of Behavioral Medicine (2015) describes behavioral medicine as “the interdisciplinary field concerned with the development and integration of behavioral, psychosocial, and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment, and rehabilitation” (Sbm.org, 2015). King (2013) pointed out that the United States (US) was ranked 28th in life expectancy at birth, yet was one of the top health care spenders in the world. In the US, 75% of all health care dollars are spent on individuals suffering from preventable illnesses. 4,000 children smoke for the first time each day, and 26% of them will become addicted to tobacco. Individuals in the US who are over the age of 50 have the highest level of functional disability among the worlds developed nations. At the same time, the number of obese individuals in the US is higher than any other developed country (King, 2013). Behavioral medicine helps to provide tangible improvements in US health care. Tobacco use has been cut in half over the last 50 years. The power of lifestyle changes introduced though behavioral medical care has improved the prevention of diabetes type 2. Behavioral prevention efforts have reduced the incidence of HIV/AIDS by half over the past 15 years. Improved understanding of genetic influences on the expression and impact of stress upon individual behaviors has improved the prediction, identification, and treatments for stress related depression and anxiety. Smoking cessation and physical activity are two of many behavioral medicine interventions that are making huge improvements in the health of millions of individuals (King, 2013). This essay describes the impact of the Affordable Care Act (ACA) of 2010 upon behavioral medicine, and how the ACA envisions implementing behavioral medicine policy so that it is accessible to more individuals. This essay provides a literature review describing the history of behavioral medicine, the successful implementation of behavioral medicine models, and the need for improved behavioral medicine curriculum for graduate mental health care students. Finally, two case studies are described that demonstrate how behavioral medicine can be implemented in the clinical setting.
Background
In 2010 the US Congress passed the Affordable Care Act (ACA) in hopes of improving health care delivery, and controlling rising health care related costs. There are an estimated 3.7 million individuals in the United States suffering from mental health illnesses. The ACA was developed to improve access to behavioral medicine care through the expansion of Medicaid, subsidized private insurance, and requirements for employers to provide health care insurance to employees (Mechanic, 2012).
The ACA prohibits employers, in certain instances, from denying healthcare coverage to their employees. This change should make mental health care available to more individuals since prior to the passage of the ACA individuals with pre-existing mental health issues were often denied healthcare coverage. The ACA also makes behavioral healthcare services available that were not available before. For instance, comprehensive care management, care coordination, social support, transition care, collaborative care, and other evidenced-based interventions are reimbursable due to the passage of the ACA. Mental health care makes up 25% of all healthcare expenditures in the US. Because of the huge amount of money involved with Medicaid, healthcare policy makers and healthcare regulators have new leverage available for directing cost savings measures, and for rewarding efficient practices (Mechanic, 2012).
Perhaps the biggest impact upon behavioral health care delivery by the ACA is the creation of three delivery models for providing health care to individuals. Patient-Centered Medical Homes (PCMH) combine improvements to primary care elements (first contact, comprehensive, and coordinated care) with the “systematic improvement of the health of the practice’s patient population” (Bao, Casalino, & Pincus, 2013, p. 123). Improvements include better patient overall health, implementation of electronic information systems, improved disease management, continuous quality improvement, etc. Since behavioral health conditions are frequently co-morbid with physical illnesses and diseases, they will be co-managed in the PCMH. Medicaid patients who suffer from mild to moderate mental health problems will be best served in the PCMH. Primary care clinics are in the best position to become a PCMH since they are already patient-centered with a whole-person approach. Studies have demonstrated the improved patient outcomes associated with collaboratively managing behavioral and medical conditions (Bao, Casalino, & Pincus, 2013).
The Health Home is the second delivery model put forth by the ACA. The Health Home provision of the ACA provides states with 90% matching funds for the first two years of each Health Homes’ creation. Health Home providers may be a “designated provider”, a “team of healthcare professionals”, or a “health team”. Examples include physicians, clinic group practices, rural health clinics, community health clinics, and home health agencies. Medicaid recipients that have two or more chronic conditions, or one chronic condition while at risk for a second condition, or a serious mental health condition, are eligible for Home Health services. Medicaid patients with serious mental health conditions may be best served by a Health Home. Health Homes focused upon behavioral health will integrate primary care with behavioral health delivery (Bao, Casalino, & Pincus, 2013).
The third ACA health care delivery model is the Accountable Care Organization (ACO). ACO’s manage the entire range of medical and behavioral care, and are accountable for the costs and care of a defined patient population. ACO’s receive fee-for-service payments, and they share in the savings they achieve for efficient delivery. ACO savings opportunities should provide improved collaboration between traditional medicine domains and behavioral medicine/health domains. ACO’s are more mainstream and serve more non-Medicaid clients than PCMH’s or Health Homes. Individuals with mild to moderate mental issues are able to receive services at an ACO. ACO’s will be more apt to provide or have access to intensive and specialized behavioral healthcare specialists (Bao, Casalino, & Pincus, 2013).
Literature Review
Keefe (2011) describes the past, present, and future of behavioral medicine practice. Keefe (2011) stated that the term “Behavioral Medicine” was first used in 1973. In the beginning biofeedback and behavioral therapy for individuals with medical problems played an integral role in behavioral medicine. Research in health psychology and public health revealed the role that behavior contributed to cardiovascular diseases and cancer. Keefe (2011) described present trends in behavioral medicine by discussing how it has affected pain research and treatment practice. Pain has biological components in the brain such as cognition (expectations, beliefs, memories), and affective processes (positive mood, negative mood). Pain has psychological components which can be treated with pain-coping strategies, self-efficacy, pain beliefs, pain catastrophizing, emotional expression, anxiety, fear, acceptance, social support, stress. In the social domain behavioral medicine research learned that race, ethnicity, and SES may affect how pain is treated. In one study it was shown that despite similarity of pain symptoms, African-American patients were less likely to receive pain medication than Caucasian patients. As the Society of Behavioral Medicine (SBM) moves forward, it uses the Translational Behavioral Medicine (TBM) journal to inform and facilitate research, support practitioners, and influence policy. A career working group is working on methods to help members with career development. The SBM Strategic Working Group is developing long-term goals and objectives such as working with the US Department of Veterans Affairs (Keefe, 2011).
Greenwald, Roose, and Williams (2015) write about the history of behavioral medicine and compare and contrast it to the field of applied behavior analysis (ABA). Applied behavior analysis is focused upon assessing and intervening for the purpose of reducing or acquiring sought after behaviors. “Behavioral medicine is a treatment approach that occurs in response to a disturbance of the biological body, but also a disturbance of the physical body’s interaction with the environment that has biological implications for the organism” (Greenwald, Roose, & Williams, 2015, p. 26). A main focus area of public health is non-infectious disease such as cancer and obesity since behavior is a primary contributor to the diseases. ABA and behavioral medicine are able to provide cost-effective treatments (Greenwald, Roose, & Williams 2015).
Shin, Sharac, and Mauery (2013) describe the role of Community Health Centers (CHC) in providing behavioral health care due to the passage of the ACA. Mental health illness is higher among low social economic status (SES) individuals, yet these individuals are unlikely to be able to afford mental health treatment. CHC’s operate in mostly low-income areas of the US. Individuals who seek help at CHC’s with on-site behavioral health capabilities have less difficulty obtaining specialty services than at CHC’s without them since they must be referred out for the services. Since low SES populations are largely impacted by mental health illness and substance abuse disorders, improving behavioral health delivery is a CHC goal. From 2000-2010 behavioral health service at CHC’s have outpaced medical services. Behavioral health for low SES populations was at one time primarily found at community mental health centers (CMHC). However, funding for CMHC’s has been shifted away from federal sources. With the advent of Health Home federal funding by the ACA, behavioral health services for low SES individuals will either shift from CMHC’s to CHC’s, or CMHC’s will begin to offer medical services such as screening for common medical problems (Shin, Sharac, & Mauery, 2013).
Baron, Lattie, Ho, and Mohr (2013) conducted a longitudinal observational study of mental health and behavioral medicine counseling services at primary care clinics. Of 650 returned surveys, 297 individuals (45.7%) reported an interest in counseling services for stress, depression, or anxiety. 58.9% of respondents reported an interest in at least one type of behavioral counseling (health/lifestyle, smoking, pain, etc.). Obese or overweight respondents had the most interest in behavior counseling. Individuals with depression and/or anxiety showed the greatest interest in mental health counseling. Despite the interest, the rates for actually obtaining the services was low, especially for individuals interested in obtaining behavioral health counseling. It was thought that low utilization rates may be due to poor availability or ignorance about how to obtain the services; however, other studies have shown that cost is usually the biggest barrier to individuals obtaining needed counseling services (Baron, Lattie, Ho, & Mohr, 2013).
Cox, Adams, and Loughran (2014) pointed out the need for better training for graduate-level mental health students on primary care (PC) settings and expectations that could be found in a PCMH. The ACA envisioned that PCMH homes would have PC providers acting as team captains, and mental health counselors (MHC’s) would be in the role of team members. Thus the authors believed it to be imperative for MHC’s to learn how to operate in the PC environment. Cox, Adams, and Loughran (2014) advocate for a renewed focus on curriculum and training that stresses the importance of incorporating inter-professional competencies into graduate school MHC curriculum (Cox, Adams, & Loughran, 2014).
Case Studies
The Information-Motivation-Behavioral (IMB) Skills intervention was developed to support coronary artery bypass grafting (CABG) patients. Studies found that CABG patients had poor compliance with post-surgery rehabilitation requirements such as exercise, diet change, smoking cessation, and medication management. The compliance rate was between 25-40%. The information component of IMB provides information about heart disease risk factors, nutrition, exercise, smoking cessation, cardiac rehabilitation, stress management, medication compliance, and compliance with physician guidance. The motivation component uses motivational interviewing counseling techniques to lead patients to identify, verbalize, and reinforce positive attitudes toward overall post-surgery rehabilitation compliance. The behavioral skills component focuses on teaching individuals how to monitor their nutrition, integrating their physical activity into their lifestyle, smoking cessation strategies, stress reduction strategies, and on how to self-administer medications. The study showed that higher levels of information, motivation, and behavior skills resulted in higher levels of post-surgery rehabilitation adherence. The study showed that the single-session on behavior skill acquisition was not enough. Also, the amount of information provided to the participants pre-surgery was overwhelming and hard for them to use during post-surgery since they did not feel well (Zarani, Besharat, Sarami, & Sadeghian, 2012). This study provides the reader with an example of how collaboration between medicine and behavioral medicine can improve patient health outcomes. This particular intervention could be easily adapted for other post-surgery patients such as heart attack, gastric bypass, stroke, etc. This intervention strategy could easily be implemented in the PCMH or ACO setting.
A pilot study of the physiological and behavioral outcomes of physical activity on survivors of cancer showed that cancer survivors experienced significant improvement in aerobic capacity and functional capacity due to physical exercising during cancer treatment. Depression is common in the general population, and the likelihood of depression increases once it is diagnosed. Cancer patients usually experience depression due to fatigue, and an associated reduced level of activity. Physical activity in this study was effective at relieving fatigue related depression (Hatchett & Bellar, 2012). The behavioral health consultant could use this intervention for preparing a similar program for implementation within a primary care clinic, or oncology center by collaborating with the physicians, a health care outlet, and behavioral health/mental health counselors. Patients would need to be assessed to ensure that they are appropriate candidates, motivated for compliance, and are monitored to track compliance, improvement, and for appropriate clinical reporting. As their health condition improves individuals should experience renewed hope, improved self-efficacy, and increased desire to endure cancer treatments.
Conclusion
The ACA of 2010 was envisioned to improve patient outcomes, and to reduce costs (Mechanic, 2012). One of the biggest impacts of the ACA on behavioral medicine is the implementation of three behavioral medicine delivery models. Patient-Centered Medical Homes (PCMH) which most closely correlates to the primary care clinic with a behavioral medicine component. The Health Homes, which are similar to community health centers, integrate medical and behavioral care. Behavioral health clinics will need to incorporate some sort of medical screening capability to qualify as a Health Home. Accountable Care Organizations (ACO) are large health care agencies such as a hospital that can provide specialized care (Bao, Casalino, & Pincus, 2013). Behavioral medicine is not a new treatment modality. It not only looks to improve patient outcomes using evidenced-based therapy, it promotes research to identify racial and ethnic treatment inequality (Keefe, 2011). The mental health counseling profession may benefit if practical behavioral medicine instruction was incorporated into graduate-level curriculum (Cox, Adams, & Loughran, 2014). Evidenced-based interventions such as the Information-Motivation-Behavioral (IMB) skills intervention demonstrate the effectiveness of behavioral medicine approaches to improving patient outcomes (Zarani, Besharat, Sarami, & Sadeghian, 2012). By collaborating with the PC team the mental health counselor/behavioral health consultant can modify and incorporate proven behavioral medicine interventions into the PCMH, Health Home, or ACO setting, and improve patient health (Cox, Adams, & Loughran, 2014).
References
Bao, Y., Casalino, L. P., & Pincus, H. A. (2013). Behavioral health and health care reform models: Patient-centered medical home, health home, and accountable care organization. The Journal of Behavioral Health Services & Research, 40(1), 121-32.
Baron, K. G., Lattie, E., Ho, J., & Mohr, D. C. (2013). Interest and use of mental health and specialty behavioral medicine counseling in US primary care patients. International Journal of Behavioral Medicine, 20(1), 69-76.
Cox, J., Adams, E., & Loughran, M. J. (2014). Behavioral health training is good medicine for counseling trainees: Two curricular experiences in interprofessional collaboration. Journal of Mental Health Counseling, 36(2), 115-129.
Greenwald, A., Roose, K., & Williams, L. (2015). Applied behavior analysis and behavioral medicine: History of the relationship and opportunities for renewed collaboration. Behavior and Social Issues, 24, 23-38.
Hatchett, A., & Bellar, D., (2012). Physiologic and behavioral outcomes of a physical activity intervention designed specifically for survivors of cancer: A pilot study. Integrative Medicine, 11(4), 19-25.
Keefe, F. J. (2011). Behavioral medicine: A voyage to the future. Annals of Behavioral Medicine, 41(2), 141-51.
King, A. C. (2013). Behavioral medicine in the 21st century: Transforming "the road less traveled" into the "American way of life". Annals of Behavioral Medicine, 47(1), 71-8.
Mechanic, D. (2012). Seizing opportunities under the affordable care act for transforming the mental and behavioral health system. Health Affairs, 31(2), 376-82.
Shin, P., Sharac, J., & Mauery, D. R. (2013). The role of community health centers in providing behavioral health care. The Journal of Behavioral Health Services & Research, 40(4), 488-96.
Sbm.org. (2015). About | Society of Behavioral Medicine (SBM). Retrieved 12 September 2015, from http://www.sbm.org/about
Zarani, F., Besharat, M. A., Sarami, G., & Sadeghian, S. (2012). An information-motivation-behavioral skills (IMB) model-based intervention for CABG patients. International Journal of Behavioral Medicine, 19(4), 543-9.