Cost and quality: integrating behavioral and physical health care is the key.

• Author: Hamblin, Allison
• Position: SPECIAL REPORT ON MENTAL HEALTH

Behavioral health issues--mental illnesses and substance use disorders--rarely occur in a vacuum. Many individuals with mental illness or substance use issues also suffer from chronic physical ailments, including diabetes, asthma, and heart disease. All too often, physical needs are ignored due to unresolved and overwhelming behavioral health issues, resulting in costly and frequent emergency department visits and hospital stays. Likewise, many individuals who are hospitalized for acute medical conditions either have or may be at risk for developing a behavioral health condition. Among the highest Medicaid users of hospital care in New Jersey, for example, 80 percent have a behavioral health diagnosis.

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Spending for Medicaid recipients with a behavioral health diagnosis is nearly four times higher than for those without. The average yearly Medicaid costs for someone with diabetes, for instance, are below $10,000 for those with no behavioral health condition but more than $35,000 for those who have a mental illness and substance use issue. As many as one in five Medicaid beneficiaries has a behavioral health diagnosis, and this population accounts for almost half of total Medicaid expenditures.

Historically, the nation's health care safety net has separated treatment of physical and behavioral issues, treating body and mind independently and not providing "whole-person" care. This approach ignores the role of mental illness and substance use as a cause of many medical conditions. In some cases, this may be because behavioral health issues overwhelm an individual's ability to focus on physical health problems; in others, as can happen with substance use disorders, the medical conditions develop as a consequence of untreated behavioral conditions.

Stories of Medicaid beneficiaries are complex and diverse: Jerry, a fifty-two-year-old alcoholic who went on disability after a job-related injury and became addicted to opioids, has visited the emergency department fifteen times over the last year for gastritis and pancreatitis. Sharon, a forty-three-year-old grandmother with severe depression, diabetes, and spinal disc degeneration, became unable to manage her complex health needs and was hospitalized half a dozen times within twelve months. Kevin, a homeless thirty-one-year-old with bipolar disorder, visits the emergency department frequently, and has been in and out of jail eight times in the last three years for disruptive...