Reducing emergency room visits and hospitalizations among patients with behavioral health conditions: Lessons learned from California's low income health program

Background: The Low Income Health Program (LIHP) is a county-operated Medicaid Waiver demonstration project, which expands coverage to eligible low-income adults effective July 1, 2011 -- December 31, 2013. Under the Affordable Care Act (ACA), LIHP enrollees will transition to California's Medi-Cal Program or its health benefits exchange, Covered California, in January 2014.

Objective: To assess the impact of offering comprehensive behavioral health services on the utilization of medical care among LIHP enrollees with a behavioral health condition (BHC) and exam whether providing comprehensive services reduces expenditures and improves health outcomes.

Methods: Claims and enrollment data submitted by 13 participating counties and a consortium of 35 rural counties were used. Over 570,000 adults between 19 and 64 years of age who were enrolled in LIHP during the first program year were included. We identified individuals with any mental health or substance abuse diagnosis and assessed utilization patterns of these individuals compared to those without such diagnosis in logistic regression models. Services assessed included emergency room (ER), hospitalization, and evaluation and management (E&M) visits. We assessed difference in patterns of use when comprehensive behavioral health services were offered. We defined comprehensive behavioral health services as substance abuse benefits or integrated medical and behavioral health care.

Results: Of all LIHP enrollees, 13.9% (79,930) were diagnosed with a BHC at some point. Of this group, 64.3% had any E&M visit, over 28.4% any ER visit, and 14.1% had any hospitalizations. The rates of ER visits and hospitalization of these individuals were significantly higher than those without a BHC. After controlling for demographic and chronic conditions, those with any BHC had higher likelihood of hospitalizations and E&M and ER visits. In counties with comprehensive behavioral health services the likelihood of E&M visits was significantly higher for those with any BHC (OR=1.43) than those without (OR=1.14). In contrast, the likelihood of ER visits (0.77 vs. 1.26) and hospitalizations (0.86 vs. 1.43) significantly declined.

Conclusions: The findings provide unique evidence that any mental health and substance abuse diagnosis increase the likelihood of medical care use significantly. There's also preliminary evidence that offering comprehensive behavioral health services, such as substance abuse benefits or integrating medical and behavioral health services, may reduce costly services such as ER visits and hospitalizations and improve primary care delivery. The findings highlight the importance of efforts to integrate and coordinate behavioral and medical care services to improve patient outcomes and reduce costs.