High-need adults — defined as those with three or more chronic conditions and a functional limitation — who have a diagnosed behavioral health condition among their multiple chronic conditions make greater use of some health care services than their counterparts without a behavioral health condition. They are also more likely to have high costs that persist over time, according to our recent analysis of nationally representative data from the 2009–2011 Medical Expenditure Panel Survey. More than half of high-need adults (56%), or about 6.7 million people, have a diagnosed behavioral health condition such as depression, anxiety, alcohol- or substance-related disorders, or a severe mental illness such as schizophrenia, as one of their three or more chronic conditions.

In previously published analyses, we found that the U.S. health care system is not adequately meeting the needs of the 12 million sickest adults — those with three or more chronic diseases as well as a functional limitation that hinders their daily activities. Despite much higher health-care spending compared to other adults, these high-need adults more often struggle to get needed care and report worse experiences with patient services. We now find this situation is exacerbated for high-need adults with a behavioral health condition.

Compared to high-need adults without diagnosed behavioral health conditions, those with such conditions made 27 percent more visits to hospital emergency departments and used, on average, 35 percent more paid home health care days. And one-third of adults with a behavioral health condition (34%) remained in the top 10 percent of spending over two years compared to less than a quarter of those without a behavioral health condition (23%). (Behavioral health conditions often go undiagnosed or untreated, however, which limits our ability to fully distinguish their effects on health care use and spending.)

High-need adults with behavioral health conditions also more often reported an unmet medical need than those without them. And they less often reported they had easy access to specialists or that they had “good” communication with their health care provider — meaning that their provider always spent enough time, showed respect, listened carefully, and explained things in a way that was easy to understand.

However, equal shares (46%) of high-need adults with and without a behavioral health condition reported having a usual source of care that provides comprehensive, accessible, and responsive care — three key components of the patient-centered “medical home.” (Among the total adult population, the share was 36 percent.)

High-need adults with diagnosed behavioral health conditions have some unique characteristics that may influence how they experience care. For example, they are relatively younger; more than half are ages 18 to 64, while only about a third of their counterparts without a behavioral health condition are in this age range. They are also more likely to be insured by Medicaid, either alone or in combination with Medicare.

These findings point to the need for tailored approaches that optimize the care of high-need adults with behavioral health conditions. Prior research by The Commonwealth Fund found that U.S. adults with mental health issues may benefit from the enhanced access to care and service coordination that patient-centered medical homes provide. The medical home also offers a foundation on which to integrate mental health services and primary care. Health care payers, including Medicaid — the nation’s largest payer for behavioral health services — can play an important role in promoting such integration. For example, as of September 2016, 19 states and the District of Columbia have supported the creation of “health homes” for adult Medicaid enrollees with multiple chronic conditions that include a behavioral health condition.

But behavioral health integration is about more than integrating behavioral health and primary care. Experts say behavioral health should be addressed across the continuum of care — from the emergency department to home-based care settings — to fully realize the triple aim of better care and better health at lower cost. Hospitals and other providers can play a critical role by stepping up efforts to screen patients for behavioral health conditions and offer appropriate treatment and referral for services.

It is encouraging to see a growing recognition among payers and providers that high-need adults with behavioral health conditions have unique characteristics that must be taken into account when designing programs to improve care and reduce costs for the high-need population.



The authors thank Benjamin Miller, Psy.D., director of the Eugene S. Farley, Jr. Health Policy Center and associate professor, Department of Family Medicine, at the University of Colorado School of Medicine, for generously sharing insights regarding the implications of these findings. Analysis of MEPS data conducted by Claudia Salzberg, Ph.D., M.S.E., under a grant to Johns Hopkins University.