Evaluating Behavioral Health Outside Its Own Line Item

Behavioral health symptoms can interfere with the daily work of managing conditions a plan is already paying for, which makes the benefit difficult to assess in isolation.

Behavioral health usually sits in its own contract. Separate vendor, separate reporting package, a PEPM rate judged against utilization and engagement inside that program. There are practical reasons for it. The data lives in different systems, the vendor relationships were built at different times, and behavioral claims carry confidentiality handling that keeps them partitioned.

It makes the benefit easy to price and hard to evaluate, because what a behavioral health program affects is not confined to behavioral health claims. Some of it shows up in how members manage conditions the plan is already paying for.

This is a different argument from the one about untreated distress and the care that never happens. The members described here are already in the system, with a diagnosis and a care plan.

Self-management happens between visits

Type 2 diabetes, hypertension and heart failure are managed mostly by the patient, in ordinary time, between appointments. The medical system supplies the plan. The member carries it out, often for years, without supervision or much immediate feedback.

Depression tends to make that harder. Starting a task that offers nothing back right away takes more effort. Concentration narrows. Fatigue and loss of interest reduce the pull of consequences sitting weeks or months out. None of that is a decision the member is making about their medication. It's the ordinary presentation of the illness landing on a set of daily tasks that happen to be medically important.

A member can be enrolled in a well-run disease management program and still do poorly with it. The program addresses the condition. It usually does not address why the member is struggling to do what it asks. Whether that gap shows up in claims depends on the condition, the member and how long it continues.

Avoidance and access look alike in claims data

Anxiety moves people away from what provokes it, and medical care provides a fair amount. A member who hasn't scheduled the follow-up colonoscopy, the retinopathy screening or the cardiology visit leaves the same gap in the record as a member who couldn't get an appointment.

The record doesn't distinguish them. Outreach programs are generally built for the second case, with calls, texts and help with scheduling. For a member who is avoiding the appointment, that outreach may accomplish less, and nothing in the data indicates which case you have.

Pain and mood

Musculoskeletal care is one of the larger spend categories most employers carry. Recovery from back and joint pain varies widely among patients with similar imaging, and psychological factors are part of what accounts for the variation. Fear of movement and catastrophic interpretation of pain are both associated with slower recovery and with pain that persists past the expected timeline. The association runs in both directions, since persistent pain is itself associated with depressed mood.

Some pain programs assess for these factors. Benefits design generally does not, and a behavioral health vendor operating on a separate contract and a separate reporting schedule usually has no visibility into an active case.

What coaching can address

Wave's model is mechanism-focused, which means a coach works on patterns like avoidance, low activation, emotion dysregulation and rigid thinking rather than on diagnostic categories. Those patterns are also what tends to sit between a member and the daily routine their medical care depends on. Between-session contact matters for the same reason, since self-management happens on the days when nobody is checking.

The limits are worth stating directly. Wave's coaches are National Board Certified, which is a certification and not clinical licensure. A coach does not diagnose, does not treat a medical condition and does not manage a care plan. Coaches work under ongoing supervision and route to licensed care when a presentation calls for it. What a coach can work on is the behavior between a member and a plan their physician has already set.

That is a reasonable path to better self-management. It is not a claim that coaching reduces medical claims, prevents a procedure or produces a particular dollar figure. Whether behavioral support changes medical utilization in a given population is an empirical question, and the answer depends on the population.

Looking at your own data

Most plan sponsors have not run the overlap.

Start with what share of your highest-cost medical members also carry a behavioral health diagnosis, and how many of them have used the behavioral benefit in the past year. That is descriptive. It tells you how much of your high-cost population has a behavioral health component and how little of it the benefit is reaching. It does not establish that addressing one would reduce the other.

From there, ask your behavioral vendor whether they can report outcomes for members who are also flagged in your chronic condition programs, using the same instrument and the same cadence they use for everyone else. Wave measures on a fixed cadence and makes the results auditable, so that cut is available. A vendor who can't produce it is reporting on whoever enrolled.

If the overlap turns out to be large, the behavioral benefit is worth looking at alongside your chronic condition programs rather than only against its own utilization report. At minimum it changes what's worth asking for in reporting.

Wave measures outcomes on a fixed cadence with National Board Certified coaches under ongoing supervision, and reports results that partners can audit.

Want to learn more? Reach out to us at partners@wavelife.io.