Analysis: Behavioral health conditions, risk, and cost during the COVID-19 pandemic

As millions of people found themselves out of work or isolated from loved ones during the COVID-19 pandemic, the added social and economic stress triggered new and exacerbated existing behavioral health conditions. This shift has led payers to look at how they can use data analytics to mitigate behavioral health challenges among the populations they serve. One such payer is Children’s Community Health Plan (CCHP), an HMO serving more than 150,000 members in Wisconsin, the majority of them low-income families.

In a recent analysis, Cotiviti set out to evaluate the current state of behavioral health among CCHP’s population and to identify specific areas of opportunity for monitoring and intervention. The analysis was conducted on incurred claim dates to capture events as they occurred in relation to the lockdowns, policy decisions, and COVID-19 infection trends throughout 2020. Cotiviti’s Medical Intelligence unlocked insights that enabled CCHP to mitigate the growing prevalence and risk of behavioral health conditions. Among the insights, we discovered:

• Innovative opportunities for behavioral health in telehealth
• A trend towards increased risk, decreased cost and prevalence
• Intervention possibilities for opioid dependence and depression related conditions
• Behavioral telehealth visits

Telehealth became critical to the success of continued care of both acute and chronic conditions in the peak pandemic months of 2020. This offered an attractive alternative for the behavioral health population to receive care more conveniently and discreetly than having to physically attend an office visit setting. Members who previously couldn’t afford or manage transportation or felt uncomfortable being seen at a therapist’s office now had access to the same care in the comfort of their homes.

CCHP saw a strong uptick in adoption of telehealth for behavioral health visits, with the number of unique members using telehealth services increasing from more than 200 in 2019 to nearly 8,500 in 2020. However, while more members sought care in 2020, this increase did not entirely mitigate a general decline in overall utilization for telehealth and traditional behavioral health office visits combined, leading to a lower average number of behavioral health office visits per capita.

We expect to see telehealth remain as an essential tool in effective management of behavioral health conditions far beyond the pandemic. With the effective transition to a wide adoption of telemedicine, it is valuable for plans to track outcomes for different groups and speak with providers for best practices and struggles. Plans should be equipped with the right tools to review office and telehealth utilization by category as telehealth increases in prominence. An advanced data analytics solution can help plans to assess behavioral health-specific outcomes and trend utilization, as well as compare these results to other healthcare utilization outcomes and industry norms, and even to drill down to specific members using these services.

“We have begun to use this information to develop a strategic plan for the behavioral health team,” said Lynn Kryfke, MSN, RN, executive director of health plan clinical services at CCHP. “In addition, this data supports the integration of behavioral health with physical medicine to support the needs of our members. The insights provided by Cotiviti analytics will likely be instrumental in making decisions around case management staffing, position development, and training.”

Increased risk, decreased cost and prevalence

Per our analysis across several clients, Cotiviti found that many populations saw a significant decline in behavioral health claims data from 2019 to 2020, which consequently resulted in an observed decline in risk and prevalence outcomes. Unlocking key cost and prevalence drivers of the behavioral health population is critical to targeting the most actionable and effective cohorts for risk mitigation. For CCHP, Cotiviti reviewed key demographics, cost, and prevalence drivers to better profile its behavioral health population for targeted opportunities. CCHP’s behavioral health population showed increasing risk while cost and prevalence decreased slightly.

Using Medical Intelligence, CCHP was able to investigate cost and prevalence drivers, analyzing the specific conditions, procedures, and places of service that drove the observed increases in risk. Condition-specific prevalence is important in identifying actionable opportunities and outliers within the population. Some behavioral health conditions had a decreased impact from 2019 to 2020, which was anticipated due to lower utilization during the pandemic. Unique to CCHP, the analysis found opioid dependence was driving the highest per member per month cost, prompting a deeper analysis into this population.

Opioid dependence and depression present great opportunities for intervention

In analyzing CCHP’s behavioral health population, prospective risk increased by 6.9% between 2019 and 2020—running counter to the trend observed among Cotiviti’s client base generally—indicating the growing presence of costly chronic conditions within its population. Overall, opioid dependence (uncomplicated) and depression-related diagnoses revealed the greatest opportunity for intervention to reduce cost and prevent more severe stages of disease.

Opioid dependence

The COVID-19 pandemic appears to have significantly exacerbated the opioid epidemic in the United States, with the provisional drug overdose counts published by the Centers for Disease Control and Prevention (CDC) showing a 28.5% increase in the number of drug overdose deaths between April 2020 and April 2021.

Opioid dependence (uncomplicated) is the largest contributor to CCHP’s behavioral health plan spend as the top behavioral health diagnosis by cost. It is not only the highest paid among other behavioral health related diagnosis codes in 2020, but among all other code types as well. Within the opioid population, the top five chronic conditions amongst patients with opioid dependence (uncomplicated) as a co-occurring condition were bipolar disorder, hypertension, asthma, osteoarthritis, and hyperlipidemia. The average cost of a member with any of these five conditions was between 1.5 and 3.9 times greater for a patient with an opioid dependence diagnosis as one without.

The most accessible and lowest cost method in identifying potential substance abuse is through routine screening by a primary care physician (PCP). Cotiviti’s analysis found that nearly 24% of unique members with an opioid diagnosis code did not have a PCP attributed to them. Ultimately, if the condition is detected early and the patient does not require inpatient acute stabilization due to withdrawal, then less costly outpatient treatment such as partial hospitalization programs or intensive outpatient programs can be utilized.

Depression

Depression has long been one of the most prevalent behavioral health conditions in the world, impacting approximately 16 million adults in the United States each year. With increased uncertainty and isolation brought on by the COVID-19 pandemic, the importance of screening, monitoring, and treating depression is paramount.

Member demographics of the depression cohort were an impactful discovery and a key point for future consideration when designing mitigation tactics for this condition. Similar to global trends, most members suffering from depression in the CCHP population are women. Knowing the prevalence of the disease within the female population, it is important to have a network of treatment options available.

The top five chronic conditions among patients with depression as a co-occurring condition were asthma, hypertension, osteoarthritis, congenital anomalies, and hyperlipidemia. The average cost of a member within any of these five conditions was between 1.3 to 5.5 times greater for a patient with a depression diagnosis as one without. Proper treatment of behavioral health conditions can positively influence the inherently high prospective risk score for this population. The cost to treat these chronic conditions increases significantly when the patient also has a behavioral health diagnosis.

“The information provided was a real eye-opener,” said Kryfke. “It became a motivator for us to focus our case management efforts more heavily on members with depression and substance use issues. Something as simple as focusing on matching members with primary care physicians and supporting that relationship can pay dividends for the member as well as the plan.

Learning from the CCHP behavioral health population analysis

Data analytics has become a crucial part in identifying and mitigating behavioral health challenges. With the help of detailed claim trends analysis performed through Medical Intelligence, CCHP’s behavioral health population study netted several important insights, uncovering the true value of telehealth services; verifying the true values of risk, cost, and prevalence; and identifying key areas ripe for improvement.

With these insights, Cotiviti provided CCHP recommendations to optimize use of Medical Intelligence and has partnered with CCHP to implement these recommendations, including reviewing existing and establishing new behavioral health specific programs, integrating social determinants of health in their dataset, and incorporating routine monitoring of behavioral health specific utilization for the population.