It’s cheaper and more convenient, but we need to invest in it

By Joseph McDonough

THE BEHAVIORAL HEALTH crisis has reached its breaking point in Massachusetts – and across the United States. From severe nursing shortages and long wait times, to rising supply costs and inflation, behavioral health care providers across the state are struggling to accommodate their patients in this unsteady climate.

According to a recent report from the Massachusetts Health & Hospital Association, out of 110 patients seeking long-term psychiatric care, more than one-third waited six months or longer for a bed with one-fourth waiting for nearly a year.

While there are many patients waiting to get into behavioral care treatment, many more are often stranded at many of these in-patient facilities or in hospital settings because they lack options for continuing care in their communities. Even in areas with significant access to hospital-level care, there is still not enough access to after care for patients with behavioral illnesses. In vulnerable communities, already starved of resources, the situation is extremely dire, and the patients suffering the most are disproportionately low-income women and people of color.

Proposed solutions to the current crisis are often short-sighted, focusing narrowly on hospitals instead of communities. Failing to explore more comprehensive, end-to-end solutions only leads to hospitals boarding more behavioral health patients who can’t be discharged, because, frankly, they have nowhere else to go and no services available to support them.

For starters, behavioral health boarding is extremely costly. According to the Massachusetts Health and Hospitals Association, there are an average of 593 behavioral health patients boarded in emergency departments, with a four-week average stay among them. These patients occupy around 20 percent of emergency department beds, but there are some hospitals where that number soars beyond 50 percent. The price tag for a single day is approximately $3,500.

Home healthcare, on the other hand, can be both an upstream and downstream solution across the behavioral health continuum. Investments made in home healthcare would allow hospitals to discharge stabilized patients back into their communities, in a high-touch care environment, and would cut costs. It would also afford patients a better quality of life.

As the CEO and founder of Innovive Health, which is focused on serving some of the Commonwealth’s most vulnerable behavioral health patients, I’ve seen how home healthcare can remove the social barriers to continuing care and reduce unnecessary utilization of high-cost emergency department and hospital visits. Our complex behavioral health patients have at least one severe mental health diagnosis with an average of 10-12 medical comorbidities – they also take up to 10-15 medications and often live in low-income neighborhoods with less access to care.

Historically, this patient population has been expensive for the Commonwealth, regularly cycling in and out of the emergency department, inpatient facilities, and the criminal justice system. But home healthcare has seen consistent success treating these patients in the community, using technology and data as a platform for enhanced clinical decision making. The model basically integrates care for psychiatric conditions and medical issues, facilitating comprehensive treatment and providing optimal outcomes for patients. This keeps costs low, keeping patients out of the emergency department, while moving them toward a more independent lifestyle.

The cost-saving results are undeniable: Complex behavioral health patients are high utilizers of inpatient services, often hospitalized up to a dozen times per year. Based on industry data, the average cost of each hospital stay is $38,000, whereas the approximate annual cost of home health care services is only $25,000. Since multiple studies have shown home health care reduces readmissions to hospitals, we estimate that our services prevent six hospitalizations per year at an approximate savings of up to $200,000 per patient. With proper investment, this model’s value proposition could be implemented on an even wider scale. Unfortunately, home health agencies still do not receive reimbursement that is anywhere near equivalent to the return on investment provided and what limited services that are available are now at risk.

Since the start of the pandemic, labor costs have risen more than 20 percent and supply costs have risen and stabilized around 10 percent over pre-pandemic costs. However, the state’s newly-proposed reimbursement rates for FY24 – MassHealth’s increase of only 2.5 percent above ARPA levels – are inadequate to support this environment.

Current reimbursement rates are not competitive and will continue to reduce the ability of home health agencies to service and staff certain communities – especially urban areas that don’t have equal access to care. Home healthcare agencies are now forced to pick and choose the areas that we can service because we cannot afford to hire and properly pay nurses and clinicians. From a health equity perspective, it is a disaster for disadvantaged communities across Massachusetts where behavioral health patients are literally losing their access to home healthcare. Ironically, this situation is only costing the state more, forcing patients to use the emergency department and hospitals more frequently.

When a behavioral health patient winds up in the hospital, everybody loses: hospitals, insurers, providers, and most certainly the patients. In most cases, hospitalization could be 98 percent preventable with the right infrastructure in place. That’s why it is so encouraging to see Gov. Maura Healey’s appointment of Kate Walsh as secretary of Health and Human Services. She has a proven track record with behavioral health patients in advancing innovative programs that address social determinants to health.

Changing the way we treat behavioral health patients not only makes sense from a human perspective but also a financial one. Home healthcare agencies provide incredible service and value to the entire healthcare ecosystem and we stand ready to take a more central role – working with Healey, Walsh, and the Legislature to examine this population in a novel way. We are invested in delivering excellent care and better outcomes for this patient population, and the state would see a strong return on investment by increasing MassHealth’s reimbursement rates to support the new price and wage levels that would enable home health to remain a driver of quality, equitable outcomes at a cost-efficient rate.

Joseph McDonough is the CEO of Innovive Health.

Read the guest commentary here: Treating behavioral health in the home – CommonWealth Magazine