TAMING THE HEALTH COST BEAST: Integrating mental health and primary care cuts costs
FARGO - Kay Cameron summoned an iron resolve to lose weight on the day her doctor told her she has diabetes. The diagnosis wasn’t a complete shock. Her father’s family had a history of the illness, and she experienced classic symptoms, including a hard-to-quench thirst, before getting tested.By: Patrick Springer, INFORUM
- Kay Cameron in June 2008
- Kay Cameron and her grandson, Julian
- This robot fills most prescriptions at Sanford Medical Center
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FARGO - Kay Cameron summoned an iron resolve to lose weight on the day her doctor told her she has diabetes.
The diagnosis wasn’t a complete shock. Her father’s family had a history of the illness, and she experienced classic symptoms, including a hard-to-quench thirst, before getting tested.
Cameron, 43, had struggled with her weight all her life. But an invisible switch flipped on the day of her diagnosis 2½ years ago. Since then, through diet and exercise, she has lost 75 pounds.
“The idea of going on a diet Monday doesn’t exist anymore,” she said, “because every day is a Monday if you’re a diabetic.”
Cameron succeeded in avoiding insulin shots altogether – she hates needles – and even has been able to wean herself from her diabetes medication.
In retrospect, she realizes she turned to food as an unhealthy form of self-medication for depression. In the course of her diabetes treatment, Cameron felt strong enough to begin therapy for her depression.
In fact, diabetes and many other chronic diseases often coexist with depression, itself commonly a chronic disease. Depression actually is the leading complication for diabetes.
Unless the depression is effectively treated, it can undermine efforts to treat the other disease, since patients are less likely to follow through with their treatment steps if they are depressed.
Most mental health conditions are treated by primary care doctors, often with poor results. Yet patients frequently resist efforts to refer them to clinical psychologists or psychiatrists.
To address that problem – and ultimately to reduce costs through better outcomes – some health providers are combining mental health and traditional primary care.
So, while visiting an internal medicine or family medicine doctor, a patient exhibiting depression can be referred to a mental health specialist down the hall, instead of at a specialty clinic, where statistics indicate half of referred patients fail to show up.
“What we’re trying to do is have more integration,” said Jon Ulven, a clinical psychologist at Sanford Health. “Over time it can dramatically reduce health costs.”
On average, diabetes patients in a study group who were treated for depression in primary care clinics saved $580 a year.
Over two years, the average cost of treating diabetes and depression was $8,000. After four years, study results show, the average cost can be reduced to less than $3,300.
“That’s a huge savings,” Ulven said.
The results come from implementing a treatment model that originated at the University of Washington that
has been adopted at 16 sites around the country involving 1,800 patients.
In a normal primary care clinic, there is a one- in-five-chance treatment will result in a decrease of depression symptoms. Ulven calls that “abysmal.”
But embedding mental health professionals in primary care settings has yielded far better results, with a decrease of symptoms in half the cases on average, and 57 percent among the Sanford study group, which doesn’t include Cameron.
“So almost triple the outcomes,” Ulven said. “It’s a home run.”
Another hallmark of the new approach involves team treatment, with a psychiatrist consulting with a large group of patients seen by a primary care doctor, with much of the more routine work handled by nurse care managers or “health coaches.”
The psychiatric consultant meets weekly with care managers to review cases, make medication recommendations and develop a therapy plan.
Patients are monitored using a questionnaire that provides more precise information to help keep them on track. Also, every patient has a relapse prevention plan.
That’s because depression carries a high risk of relapse. Someone who has had one episode of depression has a 60-percent chance of another; the risk rises to 90 percent for someone who has had three episodes.
Sanford has used the integrated approach for treating diabetes and depression for almost a year. The results are encouraging, and in line with those found nationally.
“We’re learning from each other in this setting,” Ulven said. “We team treat depression here, and that is really a huge change.”
Steps increase efficiency
The marriage of primary care and behavioral health care to treat diabetes and other chronic disease is just one of the ways medicine is being redesigned for better outcomes and cost savings.
Hospitals and clinics are embracing the so-called “lean process” that originated with the automotive industry.
At root, the initiative is about eliminating waste by working in ways that are smarter and more efficient. That boosts productivity, which allows a hospital or clinic to do more with the same resources.
Another example involves interventional radiology, where doctors perform procedures such as treatment of aneurysms guided by sophisticated scanning images.
At Sanford, preparation time for interventional radiology procedures has been reduced by an average of 10½ minutes.
That might not sound like much. But it means staff can handle 28 patients a day instead of 22, an increase in capacity of 27 percent while maintaining the same quality.
“By adding these six procedures, you’re really expanding access,” said Andrew Richburg, an executive vice president of Sanford Health who is involved in the lean initiative.
Better access can help patients avoid complications, which can result if patients can’t get in quickly for an appointment.
“We’re really talking about cost avoidance,” he said. “Somewhere in the system you’re carrying that cost burden.”
For angioplasties, a procedure to unblock coronary arteries, preparation has been trimmed by 14 percent, or almost 25 minutes. That saves more than 4,000 hours at Sanford Medical Center Fargo over a year.
In another example, the co-location of internal medicine and psychiatric care has helped avoid the necessity of having an ambulance bring a psychiatric patient to the emergency room.
As a result, ambulance transports of psychiatric patients are down 44 percent, with transports to the ER down 27 percent. Eliminating an ambulance trip to the emergency room can save $1,600 a case.
Health professionals now routinely work with industrial engineers to make delivery of health care more efficient and effective.
Small examples, invisible to patients, involve improved central supply systems and using a robot to dispense prescriptions in the hospital.
Checklists in the operating room help to ensure, for example, that gauze pads aren’t left behind in a patient’s body. Outlining the place where surgical instruments are hung helps to ensure they are where the surgeon expects them to be, and that they’re returned to the right place.
Small steps, but cumulatively they make a big difference, Richburg said. In internal medicine clinic, patient wait times have been reduced using the lean process.
Last year, time savings for Sanford patients added up to the equivalent of 1,487 days. Staff saved the equivalent of almost 10,000 40-minute appointments.
Also, use of electronic medical records help to flag updated vaccinations, for example, or follow-up appointments. The internal medicine team huddles every morning or every afternoon for a rundown on patients, with a quick review of status, and whether anything should be done that day.
“We feel we’re not missing as many things,” said Dr. Judi Blehm, a senior internal medicine doctor at Sanford who has helped lead the initiative in her department. “We’ve been pretty surprised by some of the benefits.”
Process a 'life-changer'
Kay Cameron has been surprised at how much better she feels as a result of her diet and exercise regimen.
“It’s really been a life-changer,” she said. “I feel like I’m 25 again instead of 43.”
When she started exercising, she could only walk for five minutes at a time. Now she can spend three hours in the gym, exercising on cardio machines, strength machines and swimming laps.
“My husband calls me the Energizer bunny,” she said.
“It’s been a long road. We can do anything we have to.”
Readers can reach Forum reporter Patrick Springer at (701) 241-5522
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