Evidence for Mental Health Contributions to Medical Care in Diabetes Management: Economic and Professional Considerations

Abstract

Purpose of Review

This paper considers the potential contributions of behavioral health providers to interprofessional, collaborative treatment for diabetes. We have the following objectives: (1) review the behavioral health complications, risks, burdens, and costs associated with diabetes management and consider the role of behavioral health providers in treating mental health concerns specific to diabetes; (2) highlight two frameworks for incorporating behavioral health into diabetes treatment, and review the empirical support for each; and (3) consider the financial feasibility of integrating behavioral health services into diabetes medical care settings.

Recent Findings

The healthcare field is still in the nascent stages of integrating behavioral health services in endocrinology clinics, but there is growing evidence that integrated behavioral healthcare has the potential to improve disease management and psychological functioning for individuals with chronic medical conditions. Furthermore, as a result of recent changes to the billing structure for behavioral health services in a medical setting, reimbursement rates for behavioral health providers in this capacity have improved considerably.

Summary

If delivered by qualified behavioral health providers using evidence-based guidelines, behavioral health integration has the potential to optimize health outcomes, improve quality of life, and decrease fragmentation of care for patients with diabetes. Future research should focus on developing a financially feasible, empirically supported model of integrated behavioral health and disseminating the model to medical providers treating patients with diabetes.

Introduction

Diabetes currently affects more than 30.3 million Americans, among whom 90–95% have type 2 diabetes (T2D) [1]. Diabetes-related complications contribute substantially to morbidity and mortality. Diabetes management is very challenging, requiring patients to take multiple medications and master complex daily behaviors including blood glucose monitoring, monitoring dietary intake, and exercise. More than 50% of patients with T2D fail to consistently achieve the recommended glycemic target of HbA1c <7%, which increases the risk of developing serious complications, including death [2]. The self-management tasks associated with diabetes can be daunting and overwhelming, particularly when complicated by obesity and other psychosocial stressors.

In addition to the complex demands individuals with diabetes face, there is also a significant financial burden to society. The global economic burden of diabetes has been estimated at $1.3 trillion, and projected to increase to $2.2 trillion by 2030 [3]. The American Diabetes Association (ADA) estimated that the total cost of diabetes in the USA alone is $327 billion, with $237 billion in direct medical costs and $90 billion in reduced productivity [4].

The incidence, impact, and complications associated with diabetes can be mitigated considerably, but there is a clear need to expand and improve current treatment approaches. A more comprehensive interdisciplinary approach targeting the modifiable risk factors associated with diabetes, if implemented on a widespread basis, has the potential to substantially mitigate this burden and reduce the healthcare costs associated with diabetes [5]. A very promising strategy, for which there has been an increased interest in and support for, is behavioral health integration, which shifts care from a traditional, physician-centered model of care to a more interdisciplinary model [6, 7].

Behavioral Health Comorbidities Associated with Diabetes

Diabetes is highly comorbid with behavioral health disorders, which can have a significant impact on diabetes management. Such comorbidity has been associated with worse treatment outcomes, including reduced treatment compliance, lower adherence to self-care behaviors, worse glycemic control, complications, worse quality of life, increased emergency room visits, high cost of care, and mortality [2]. There is increasing recognition of the mental health complications associated with diabetes and need for behavioral healthcare to be integrated into diabetes treatment. In 2018, for example, the American Diabetes Association (ADA) issued a report recommending that mental health screening and treatment should be incorporated into routine diabetes treatment [8].

Of the behavioral health disorders associated with diabetes, depression is the most widely recognized; estimates suggest that 1 in 4 adults with type 1 or type 2 diabetes exhibit significant depressive symptoms, with 10–15% meeting criteria for a formal diagnosis of depression [9, 10]. The combination of depression and diabetes has been associated with impaired diabetes self-management and reduced life expectancy [9, 10]. Patients with comorbid depression and diabetes also have an increased risk of vascular complications and dementia, which has been linked to a decrease in quality-adjusted life-years (QALYs), a summary health measure that combines life expectancy with quality of life and attempts to quantify disease burden [6, 8].

A related but distinct phenomenon is diabetes-related distress (DRD), which describes the negative emotional reactions, including worry and rumination, specific to managing diabetes [11]. Common worries include fear of hypoglycemia, guilt or shame (particularly in relation to lifestyle or obesity), inadequate support, emotional burden, and access to care. DRD is common, affecting over a third of patients with T2D [12]. DRD is a stronger predictor of diabetes self-care than depression, with direct links to glycemic control [2]. Reductions in DRD have been associated with clinically significant reductions in HbA1c levels [11, 12]. There are a number of validated screeners to identify DRD [11]. Once identified, DRD can be targeted and monitored as part of a psychological intervention within a medical clinic.

Psychological Treatment of Diabetes-Related Behavioral Health Comorbidities in Medical Settings

There is growing evidence that psychological interventions are more effective when they are specifically tailored to people with diabetes (PWD). Studies have shown that treating behavioral health disorders, particularly depression, in PWD is necessary but not sufficient to improve diabetes outcomes (e.g., glycemic control) [10]. It is critical, therefore, for behavioral health providers treating PWD to identify modifiable behavioral targets associated with diabetes management, rather than provide more general psychotherapy. Specific modifiable behavioral targets for behavioral health providers treating PWD include glycemic control, adherence, depression, motivational status, and lifestyle modifications [13]. Psychological interventions can target these outcomes through a number of interventions, including behavioral management and reinforcement, guided problem-solving, supporting patients in setting realistic and attainable goals, and teaching relaxation strategies for managing diabetes-related stressors [13]. In order to provide effective care, behavioral health providers should have an understanding of the distinctive issues associated with diabetes. Doctoral-level clinical health psychologists are arguably best-positioned to deliver this care, given their advanced training in evidence-based behavioral medicine; at a minimum, however, a behavioral health specialist should be licensed and trained in evidence-based treatments specific to diabetes [14].

Several psychological interventions have modified cognitive behavior therapy (CBT), widely considered one of the most effective and well-researched treatment methods for behavioral health disorders, to target the specific behavioral health needs associated with diabetes [14]. One study delivered emotion-focused CBT through a skills training program to patients in an endocrinology clinic in an urban academic medical center. Patients who participated in the program improved glycemic control, used more effective coping skills, and reduced anxiety and emotional burnout [15, 16]. This evidence suggests that interventions that specifically target emotional regulation may help PWD optimize diabetes outcomes by improving adherence and glycemic management [2]. Another randomized controlled trial (RCT) study utilized CBT for Adherence and Depression to treat patients with uncontrolled T2D [10]. Participants who underwent treatment demonstrated clinically significant improvements in diabetes self-management, glycemic control, and adherence—and gains were maintained at 8-month follow-up. Results suggest that integrating adherence counseling into depression treatment (compared with treating depression alone) improved diabetes outcomes.

Psychological Screenings

Early and frequent screening is necessary to intervene and maximize long-term health outcomes. The ADA recommends routine psychological screenings for diabetes-related topics, including health-related quality of life, depression, anxiety, diabetes-specific emotional distress, and fear of hyperglycemia and hypoglycemia [8]. Routine psychological screenings should be conducted at the initial visit and on a periodic basis going forward, even if no clinical concerns were identified in the initial screening.

In addition to behavioral health disorders and diabetes-related distress, there are a number of other psychosocial factors impacting diabetes self-care. Further complicating factors include health literacy and numeracy, low socioeconomic status, lack of psychosocial support, and low diabetes knowledge [17]. These should all be considered during screenings so that problems can be identified early and further deterioration prevented. Routine screenings and assessment for these issues should be part of every medical visit as part of comprehensive treatment. When warranted, patients should be referred to a qualified behavioral health provider for more formal diagnostic assessments [18].

The increased focus on behavioral health integration has come interest in measurement-based care, a data-driven approach to behavioral health integration [19]. In the course of such measurement-based care, patients are given validated symptom rating scales, which are then reviewed by clinicians during the encounter. This helps to inform clinical decision-making, giving providers the ability to determine the efficacy of a given treatment and direct the course of referrals, consultations, or modifications as needed. The US Preventative Services Task Force (USPSTF) recommends depression screening for the general adult population, regardless of risk factors [20]. Given the elevated risk of mental health complications for PWD, this recommendation is particularly important for this population.

Behavioral Health Integration Frameworks

Given the complex mental health and psychosocial needs of this population, there has been a trend away from the traditional physician-centered medical treatment mode toward a more integrated approach [21]. Two primary frameworks have emerged as part of the trend toward interdisciplinary diabetes care: (1) the collaborative care model and (2) the co-location model (i.e., embedding a behavioral health provider within a medical clinic or practice) [22]. Both frameworks are described below.

Collaborative Care Management

Collaborative care management (CCM) is a structured, multicomponent approach that involves consultation and shared decision-making between behavioral health providers and primary and/or specialty care providers [23]. Key services include care management support for patients receiving behavioral health treatment and regular psychiatric inter-specialty consultation. The CCM team consists of at least three individuals: a behavioral healthcare manager, a psychiatric consultant, and the treating physician. Treatment plans are developed and modified based on symptom severity and outcomes. Core components of the CCM intervention include evidence-based protocols for treatment initiation and adjustment and specific strategies for engaging patients in goal setting, medication adherence, self-management, care management and interdisciplinary collaboration, systematic follow-up, patient education, and counseling to promote engagement and adherence [22]. Importantly, providers in a collaborative care setting are not only co-located within a setting; primary care providers and mental health specialists actively collaborate on treatment plans.

There is growing evidence that the CCM model can improve mental and physical health in people with chronic physical conditions [7, 18, 22]. There are some diabetes-specific findings, with studies showing that CCM interventions have demonstrated efficacy in diabetes self-management and psychosocial functioning [11]. One notable example is the TEAMcare health services model, a 12-month intervention aimed to improve disease control for patients with chronic illness [24]. The TEAMcare intervention, which integrates collaborative depression care with systematic chronic illness care and disease-specific treatment recommendations, has been showed to improve disease control and reduce depressive symptoms [6, 25].

Co-located Model

In a co-located care model, a behavioral health provider is embedded within a medical clinic or practice. Patients are typically screened through formal measures or based on clinical observation, and referred to the behavioral health provider by the physician for more comprehensive evaluation and treatment, if deemed necessary. There is some shared treatment planning between the two providers, but the amount of collaboration between non-psychiatric physicians and behavioral health providers varies based on the setting. Co-located care can include occasional warm hand-offs (i.e., a system in which a physician introduces a patient to behavioral health provider during a clinic visit), but barriers such as distance and limited availability of behavioral health providers are often cited as limiting factors [26]. The majority of research on co-located care has been conducted in primary care or other specialty medical clinics, but recent studies have applied this research to endocrinology clinics [27]. Co-located behavioral health services have improved initial engagement for patients with comorbid depression and diabetes, and access to services and equipment for chronic disease management [1, 26].

Insurance Reimbursement for Behavioral Health Integration

Limited insurance reimbursement has traditionally been a significant barrier to behavioral health integration. A survey of 56 sites with integrated behavioral healthcare, for example, demonstrated that revenue from insurance billing and patient payments covered only 21% of the costs of their services, with over three quarters (78%) of the sites relying on grant funding to sustain the presence of behavioral health providers in their clinics. The participating sites identified several major obstacles to sustainability, including same-day billing restrictions, the need for grant funding, and the inability to bill health and behavior codes [28].

As healthcare moves from a fee-for-service, volume-based model toward a total-cost-of-care payment reimbursement, there have been significant changes to the billing structure for behavioral health services in a medical setting [29, 30•]. In the USA, licensed behavioral health providers in a specialty, medical clinic have traditionally used Health and Behavior CPT codes, which were established in 2002 to reimburse psychologists for helping patients manage physical health problems [31]. These codes were revised in January 2020 and replaced with Health Behavior Assessment and Intervention (HBAI) services, which include health-focused clinical interviews, behavioral observation, evaluation of patient’s response to illness, coping strategies, motivation, and treatment adherence. Health behavior interventions include “promotion of functional improvement, minimization of psychological and/or psychosocial barriers to recovery, and management of and improved coping with medical conditions.” Effective January 1, 2020, clinicians were advised to use these new CPT codes to report HBAI services when billing all third-party payers, including both federal and private insurance carriers. The codes have increased in value and are more consistent with Medicare reimbursement for psychotherapy, meaning that psychologists receive higher payments for providing treatment to Medicare patients with a physical health condition [31].

There are important distinctions between HBAI services and psychotherapy [29]. HBAI services must relate to a physical health diagnosis and cannot be billed using psychotherapy codes. HBAI services require an ICD-10 diagnosis as the primary diagnosis (rather than a DSM-5 diagnosis, which is used for mental health disorders) and apply to psychological interventions utilized in the treatment of patients with physical health problems, such as treatment adherence counseling, pain/symptom management, health-promoting behaviors, and adjustment to physical illness.

The implementation of the new HBAI code set has promising implications for improving the financial feasibility of integrating behavioral health providers into medical settings; however, we do not yet have data on the impact of this new billing structure. It may take some time for medical clinics to adapt to this approach and determine whether it has resulted in better financial sustainability.

There has been some controversy over limits to same-day billing for multiple behavioral health integration services. In January 2020, Medicare Part B issued a statement that it would pay for “reasonable and necessary integrated health care services when furnished on the same day, to the same patient, by the same or different professionals whether the professionals are in the same or different locations.” [32] They further clarified that while they will pay for “multiple mental health services furnished to the same patient on the same day,” they will not pay for “inappropriate and/or duplicate services on the same day.” [29]

Financial Feasibility

There are a limited number of studies that have specifically addressed the financial feasibility of integrating behavioral health into diabetes care. Most of the existing studies have been conducted in other disciplines (e.g., primary care or other specialty medical clinics) [33]. There is some research suggesting that a behavioral health model can be financially sustainable over a longer period of time using a traditional billing services model, but certain conditions must be met [27]. One study considered the financial feasibility of co-located mental health services within a pediatric endocrinology clinic, analyzing the revenue generated over an 18-month period. The clinic, which was open for a half-day each week, ultimately posted a net gain of nearly $4000 over the course of the 18-month period after an initial period of breaking even or losing money in the first few months following start-up [27]. The study utilized a break-even analysis, a measure that has been used to compare the variable and fixed costs and revenues of psychological services in a medical clinic setting and designed to determine the point at which costs and revenues of psychological services are equal, beyond which the services began generating a profit [34]. They estimated that when a supervising doctoral-level licensed psychologist is paid at market rate (roughly $100 an hour) and masters-level (i.e., non-reimbursed) psychology trainees provide the services, they would need to see six appointments per half-day in order for the clinic to make a profit. Another RCT found that a collaborative treatment program for patients with comorbid depression and uncontrolled diabetes demonstrated significant cost-effectiveness, reducing outpatient costs by $594 (compared with usual care) [35]. The intervention also resulted in in a significant reduction in depression-free days and quality-adjusted life-years (QALYs). Using an incremental cost-effectiveness ratio, they found a mean cost-savings of $1773 per QALY.

Some research has suggested that patient revenues will eventually offset the initial costs of hiring a psychologist to be part of a medical clinic. One study budgeted psychologists’ salaries upfront, with patient revenues offsetting these costs [33]. After budgeting psychologists’ salaries, patient revenue covered 57% and 76% of the upfront costs in the first 2 years of the program. Over the 7 years of continued behavioral health integration, nearly all of the initially budgeted costs (98%) were recovered through revenue of the clinical services provided by the psychologists and their trainees.

Future Directions

This review has considered the importance of psychological expertise in the delivery of evidence-based diabetes lifestyle and disease management interventions, in addition to delivery of mental health treatment for PWD. The approaches described in this article demonstrate that it is possible to successfully target and modify aspects of diabetes care through behavioral health interventions, improving the care and outcomes associated with standard treatment. The healthcare field is still in the nascent stages of integrating behavioral health services in endocrinology clinics, but there is growing evidence that integrated behavioral healthcare has the potential to improve psychological functioning in and disease management for individuals with chronic medical conditions. Below are a few recommendations drawn from analysis of these BHI efforts.

1. Given the considerable variability among and even within sites, it will be important to evaluate existing integrated care sites—both primary care and endocrinology, in hospitals, community mental health facilities, and private practices—that treat PWD to determine the cost-effectiveness of real-world BHI. Future studies should specifically address the cost-savings associated with their interventions using formal measures such as break-even analyses.

2. Behavioral health providers should identify clear, realistic, and modifiable targets for successful behavioral health integration. If a medical clinic is focused on immediate profit, a behavioral health integration model is unlikely to succeed, at least in the short-term. Evidence suggests that these clinics can take several years to break-even or generate a profit, and even then certain conditions need to be in place for a BHI clinic model to generate a profit (e.g., meeting a minimum number of appointments). We recommend identifying alternative targets, in line with population health and value-based care. The literature supports depression-free days [9], quality-adjusted life-years, reduced outpatient costs [9], decreased diabetes-related distress [11, 15], improved adherence behaviors [13], and glycemic control [16]. Additional possible targets might include decreased hospital admissions, fewer episodes of diabetic ketoacidosis (DKA), reduced insulin waste, and improved attendance to medical appointments. If significantly impacted, all of these targets have the potential to lower healthcare costs.

3. There is substantial interest in and recognition of the need to extend the reach of these interventions to more vulnerable, underserved, and disproportionately affected individuals. This is particularly important given that racial minorities are disproportionately affected by diabetes [36]. The evidence-based interventions with the strongest support are time- and resource-intensive, which limits their reach and efficacy. This means that populations that might benefit most from these interventions—the disadvantaged, impoverished, and/or racial and ethnic minorities—who are on public assistance and most likely to be treated in community mental health settings may not be getting them. When scaling up interventions, future studies should consider how best to reach these vulnerable individuals.

4. Within the sub-specialty of health psychology, there has been a push to adopt some of the standardized methods for conducting cost-effectiveness and cost-utility analyses that are already widely used in medicine and public health [37]. Future studies should consider how to balance quality control and treatment integrity with flexible adaptation across a range of medical settings. Such studies should also focus on the economic costs associated with the behavioral health integration efforts. In addition, it will also be critical to utilize meta-analyses of rigorous, large-scale RCTs to collect and analyze long-term clinical and cost-effectiveness data of these integrated models.

Conclusion

If delivered by qualified behavioral health providers using evidence-based guidelines, BHI has the potential to optimize health outcomes, improve quality of life, and decrease fragmentation of care for PWD. However, more information is needed to scale up existing frameworks to meet a larger need. Our review underscores the need for clinical trials that can offer additional guidance for narrowing this knowledge gap. Future research should focus on developing a financially feasible, empirically supported model of integrated behavioral health and disseminating the model to medical providers treating PWD. A successful model will include allow for flexible adaptation, with fidelity to the key elements of the framework.