Written by Mark Sasvary, LCSW
Post-traumatic stress disorder (PTSD) has a profoundly negative impact on overall mental health, quality of life, and day-to-day functioning.(1) People with severe mental illness (SMI) in addition to PTSD are even more vulnerable to other serious behavioral health problems such as substance use disorders and depression, medical problems which can be chronic and severe, and have extreme challenges to daily living. (2) Research indicates that over one third of individuals with SMI have PTSD. (3) To better serve some of the most vulnerable people in our population we need to find effective treatments that can be implemented, provided, and sustained through the community-based programs that serve this part of our population. The impact of these treatments needs to be measurable in the domains of mental health, physical health, and quality of life. Providers need to demonstrate that the impact of treatment produces long term improvements, as well as concomitant reductions in the total cost of care. By doing so providers can contract with managed Medicaid and Medicare who are transitioning from paying for volume to value, and units of service to population level outcomes.
There is an increasing consensus that the effects of prolonged stress can have severe medical ramifications and PTSD symptoms are linked to higher medical morbidity and health problems.(4) It has been theorized that structural and functional alterations in the neurobiological and neuroendocrine pathways that occur as a result of prolonged stress can lead to chronic inflammation, insulin resistance, a prothrombotic state, and, ultimately, chronic medical illnesses.(5) So it should not be a surprise that people with PTSD, as compared to the general population, show increased health care service utilization as indexed by physician visits, hospitalizations, and mental health appointments.(6) PTSD-related hospitalizations during a 10-year study period cost an estimated total of $34.9 billion, of which $1.2 billion (3.4%) of that total consisted of costs for hospitalizations with PTSD as the primary diagnosis. Though PTSD-related hospitalization costs are extremely high, the researchers indicated that this barely captures the overall economic burden of PTSD-related conditions.(7) Additional research is needed, but it can be hypothesized that the costs related to medical care, behavioral health and quality of life for people with PTSD and SMI is particularly stark.
The enormous cost of PTSD offers providers a unique opportunity to achieve savings by offering people treatments that work. A growing amount of research has demonstrated significant improvements in physical health problems following successful treatment of PTSD.(7) In fact, research has indicated that PTSD treatment, even without a direct treatment focus on health, can have beneficial effects on self-reported physical health symptoms, even without specific changes in health behavior.(8) Researchers have also begun to demonstrate the potential for PTSD treatments to positively impact a variety of conditions including sleep quality, digestive problems, chronic pain, and depression.(9)
Evidence-based practices (EBPs) like Cognitive Processing Therapy have extensive research demonstrating successful treatment in the general population, for veterans, and for victims of sexual and physical abuse, so this type of treatment may offer the best option for people with SMI and PTSD. Finding a treatment option that fits the needs of clients suffering from PTSD and SMI is crucially important because research shows that people with PTSD tend to avoid treatment and are often unsatisfied with treatment.(10) However, there continues to be a real struggle to promulgate and implement evidence-based practices (EBP) for the treatment of PTSD and despite ample evidence for the need for EBPs at the community level, these treatments often remain unavailable to those most in need of these services.(11)
Behavioral health providers need the resources to implement treatments like Cognitive Processing Therapy to make an impact at the population level. This includes research, education, and training. Providers also need the resources to demonstrate success on measurable outcomes and to demonstrate that their services can improve overall health and the quality of life, thereby reducing the total cost of care. These resources include developing the capacity to track and measure outcomes at a population level. The providers that can effectively demonstrate the impact of their services will benefit from value-based payment arrangements (VBP) with payers, which will be increasingly necessary as the public system transitions to these types of payment arrangements. State and Federal governments are increasingly incorporating VBP into Medicare and Medicaid and see VBP as essential to containing the ever-increasing costs of the Medicaid and Medicare system and essential to their continued sustainability. For services and interventions to be supported in the public system, providers will need to demonstrate improved population health and achieve the potential savings that result from these improvements.
It is crucial for providers to link the effective delivery of EBPs to the evolving funding streams that community-based organizations will increasingly rely on. Providers need to be poised to take advantage of the new opportunities that will be offered by VBP. By doing so we can ensure that treatments like Cognitive Processing Therapy are delivered to the most complex and vulnerable populations in our society, and that the providers who often struggle to stay afloat can be rewarded for successful outcomes. Through the effective treatment of PTSD providers can improve the quality of life and the overall health of people with SMI, thereby reducing the total cost of care. In turn these savings can be reinvested in the community and shared with the community-based providers who provide essential services to the people that need them most.
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