Behavioral Healthcare Market Sector Overview
The providers in Behavioral Healthcare typically have treatment specialties. Three primary categories to consider are:
The National Council on Alcoholism and Drug Dependency estimates over 23 million Americans (age 12 and older) are addicted to alcohol or other drugs. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), just under 11% (2.5 million) received care at an addiction treatment facility. SAMHSA also estimates the market for addiction treatment is about $35 billion per year.The fatality rate from drug overdoses is has surpassed the average of 15 per 100,000 in 2014 from nine per 100,000 in 2003. The trend is now close to the HIV epidemic in the late 1980s and early 1990s, according to Robert Anderson, the C.D.C.’s chief of mortality statistics.
There are about 14,500 behavioral healthcare providers. The largest 50 organizations control less than 20% of the market. Some operate their own freestanding facilities, others manage networks of providers and in some cases, do both to widen their reach and revenue streams. About 40% of substance abuse treatment providers have special care programs for women. There is significant consolidation underway in this highly fragmented sector although it trails the consolidation trends seen in other healthcare sectors like hospital, health systems, long term care, assisted living and surgery centers.
Legal Versus Illegal Substances And Substance Abuse Treatment Issues
Largely, the issues stem from abuse of both legal (Schedule 2 / C-2 / prescription drugs) and illegal (Schedule 1 / C-1 / heroin, crystal methamphetamine, etc. non-prescription drugs) substances. While the manufacture, distribution, prescribing and dispensing of C-2 products has always been closely managed and regulated, further measures of control are necessary to address what is generally referred to as the "opioid crisis". It will involve additional layers of diagnosis and prescribing protocol, categorization of patients, tracking and associated analytics ( both required and voluntary ) across multiple points of care including pharmacy (retail, mailorder, specialty and compounding), physician practice, hospitals, health systems or integrated delivery networks ( IDNs), oncology, surgical centers, ambulatory care clinics, and other patient care venues where pain management therapies are utilized.
There will be more direct dialogue with behavioral healthcare providers involved with substance abuse recovery to more closely assess patients to determine the origin / method of access patients have with obtaining prescription medication for unauthorized use so trends / and solutions can be more quickly identified. These measures will also be reflected in more tightly managing the prescribing of medications like methadone used to help patients wean themselves through the recovery process.
To view a composite list featuring images and descriptions of the top 30 abused prescription and illegal drugs in the United States published by the U.S. Drug Enforcement Agency ( DEA ) please click here.
Behavioral Healthcare Consumer, Patient and Provider Reimbursement Policies
Reimbursement changes/challenges continue based on diagnosis, facility/institution classification and behavioral, medical and pharmacy benefit coverage guidelines. In November, 2013, regulations to fully implement the Mental Health Parity Act of 2008 were issued. Insurers are now required to cover mental health illnesses to the same degree as physical illnesses. The regulations apply to most health plans presently in the nation plus the new ones which will be marketed as part of healthcare reform.
For behavioral healthcare providers, this helps them administer care, obtain reimbursement and align protocols. For consumers / patients, the removal of pre-existing condition clauses and coverage for evaluations and screenings enhances their ability to get coverage for care and access to some of the medications necessary for behavioral healthcare treatment. For insurers, it provides guidance in determining benefit designs and plan coverage. The risk management professionals within the insurance and employer segments continue to be challenged with evaluating the additional cost streams associated with wider coverage --while both clinical and financial stakeholders are assessing care / cost variables leading to positive outcomes.
Competitive, Cost, Risk Management And Compliance Challenges
There are numerous regional and metropolitan providers with further defined specialties across the United States as an estimated 1 in 5 Americans experience a behavioral healthcare issue each year. Based on scale and scope, behavioral healthcare's finances when it comes to paying for patient care and / or the providers and provider organizations involved lacks standardization. This issue is receiving more attention as behavioral healthcare gets more media attention and better recognition from both commercial and government payers.
Ongoing changes encompassing behavioral healthcare insurance coverage is not only a cost and risk management concern for plans. It is a competitive challenge to better engage consumers and employers with attractive behavioral health and wellness benefit plan features that fit within patient and employer cost sharing. The ongoing changes are also critical compliance challenges; insurance plans and employers must be cognizant of what is required based on State, Federal and other regulatory agency policy decisions and account for them in behavioral healthcare counseling, prescription benefits and other treatment coverage options.
Pharmaceutical Innovations Spanning Behavioral Healthcare Needs Continues
For pharmaceutical marketers, the behavioral healthcare marketplace has been a growing opportunity for clinical and commercial development. Therapies used in this sector once only familiar to clinicians, their patients and the pharmacists dispensing their prescriptions, have become as familiar as some consumer brands.
Numerous oral behavioral medications have been developed spanning these and other indications:
Early on, these five behavioral health therapies benefited by effective clinician promotion and targeting as well as consumer / patient word-of-mouth notoriety:
- 1963: Valium ( diazepam ) was introduced by Hoffman-La Roche as an improved formulation of Librium
- 1981: Xanax ( alprazolam ) by Upjohn
- 1987: Prozac ( fluoxetine ) by Eli Lilly
- 1992: Zoloft ( sertraline ) by Pfizer
- 1996: Adderall ( dextroamphetamine and levoamphetamine ) by Shire
Food and Drug Administration Policy Changes Widened Promotional Opportunities And Information Sharing
Behavioral healthcare needs and issues became even more openly discussed between family members, friends, coworkers and clinicians as the FDA made two significant changes in their prescription drug advertising and marketing policies regarding direct-to-consumer advertising ( DTC ). These impacted not only behavioral healthcare products but a wide array of pharmaceutical products depending upon brand and product marketing strategy and budgets:
- 1985: Consumer print advertisements featuring prescription drugs was permitted
- 1997: Consumer television advertisements featuring prescription drugs was permitted
Clinical And Cost Market Access Strategy Value Propositions For Pharmaceutical Manufacturers
Internet, social media and other digital venues offer more options for promotion and information sharing. Regardless of brand recognition and promotional messaging, pharmaceutical manufacturers need to have a robust market access strategy that deploys data supported clinical and economic value propositions. These are essential to engage prescribers and payers including the medical and pharmacy directors of PBMs, MCOs, government-sponsored health plans as well as employer medical directors and employee benefit consultants.
Contracting strategies need to anticipate the variables of formulary tiers, brand and generic competitors as well as clinical / cost decision drivers of MCO and PBM decision makers and their client or partner stakeholders. Behavioral healthcare medications are prescribed by a variety of clinicians, both medical and psychiatric, which need to be part of the care and cost formulas in value propositions that require data support. More than ever, successful patient outcomes are determined based on patient wellness and the clinical and economic outlays necessary to achieve it.