Insurers and Hospitals Can Advance Best Practices in Suicide Care

Suicide reentered the 10 leading causes of death in the United States in 2024, according to the Centers for Disease Control and Prevention. Evidence shows that there are healthcare practices that hospitals can implement to better identify people at risk of suicide and reduce that risk after discharge. These practices include formal safety planning, lethal means counseling, a “warm handoff” (when hospital staff makes a personal introduction between the patient and a mental health outpatient clinician), and follow-up contacts from hospital providers. Yet, when The Pew Charitable Trusts and the Joint Commission conducted a nationally representative survey of accredited hospitals in 2022, they found that only 8% of hospitals had instituted all four protocols.

Courtesy of Richard Frank

In a new paper published by the Brookings Institution and supported by Pew, researchers examined how hospital payment methods can promote evidence-based suicide care services and how private insurance and hospitals can expand adoption of these best practices. Specifically, the paper identified innovative payment arrangements that create financial incentives for suicide care services as a cost-effective model for advancing hospital implementation. 

Pew spoke with the paper’s lead author, Richard Frank, Ph.D., a senior fellow in economic studies at the Brookings Institution and director of its Center on Health Policy. His work focuses on the economics of many healthcare issues, including mental health and substance use care, and he served as assistant secretary for planning and evaluation in the U.S. Department of Health and Human Services from 2014 to 2016.

This interview has been edited for length and clarity.

Why do you think hospitals have been slow to adopt the four recommended practices—safety planning, lethal means counseling, warm handoffs, and follow-up contact—to help reduce suicide risk?

There may be multiple reasons, but one is that hospitals have limited financial incentives to do so. With most other practices and protocols that hospitals provide, they are either paid to do them, often by the health insurer, or it’s a requirement. But in this case, hospitals are being asked to provide care for preventing suicides at a cost to them, yet they do not benefit financially or even break even for delivering these evidence-based services that are expected to result in reduced suicide and suicide attempts and possibly cost savings.  

Is that what the paper describes as “misaligned incentives”? Can you please explain that problem?

If a health system is asked to provide new or additional services but these cost money to set up and deliver and the insurance reimbursement doesn’t cover those costs, then hospitals will not have an economic incentive to adopt the new practices—even if they may save some money down the line and even if hospitals are interested in contributing to reducing the devastating effects of suicide in the community.

For example, following up with a person discharged from the hospital after a suicide attempt can be complicated. A hospital may need to hire specialized staff or devote existing staff to specialized activities and training on new skills. So, even if hospitals are paid for making that 15-minute phone call or having that meeting with a community mental health provider, there are other components of providing the care that are not going to be easily captured by a billing code, making it difficult to get reimbursed for the full cost of the service.  

Your paper suggests that hospitals could be encouraged to adopt these services by tying payment to quality measures. How would that work in practice?

We propose that if a hospital can show that it is pursuing the evidence-based suicide care services with fidelity—that is, it’s adhering to all the recommended steps in the process of providing the care—then it would receive a bonus payment through insurance. That payment should be at least large enough to cover the costs of what it takes to provide the care, and probably a little more so that the organization feels incentivized beyond just covering the cost.

If you think about most activities in our society, whether it’s going to school or getting a raise at work, it is based on performance. So, you get a raise if you did well at work. You get good grades at school if you perform well. This is very much the same thing. In a sense, these financial incentives are grades reflecting how well a hospital implements and provides care that research has shown helps to prevent suicide.

Making bonus payments is justifiable because these evidence-based practices can prevent suicide. Providing sufficient payoffs can motivate hospitals to offer care that is beneficial for society and helpful to the community. You get a good outcome at a reasonable cost.

How can we ensure that this approach is reasonable and equitable for hospitals across the board, understanding that some have fewer resources and some are at an earlier stage of implementing suicide care procedures?

Hospitals don’t have to do it all at once. They have the opportunity to phase in the new care practices and receive bonuses for their steps toward full implementation. For instance, at first, hospitals and health systems can make it a clear win for performing these practices; if a hospital provides these services, then it receives a bonus payment. But if it doesn’t, then it doesn’t suffer a negative consequence. This will give every hospital a chance to bring itself up to a certain level of performance.

The philosophy behind this is we don’t want to tell hospitals how to do their business; we just want to reward them for doing it right.

Your paper recommends that insurers develop this bonus payment model. How feasible do you think that approach is for payers and hospitals?

The research to date has identified four practices—formal safety planning, lethal means counseling, warm handoffs, and follow-up contacts from hospitals—that are shown to reduce the risk of suicide. And there’s a series of steps for hospitals to implement each of them. That becomes the basis for figuring out what it costs the hospitals to start doing these practices. It takes some work between hospitals and insurers to determine how that will work contractually, but I think there’s a pretty clear path to implementation here.

Most hospitals feel it is part of their mission to do things to improve the community’s health. But with suicide prevention, they’re not getting it done because it is relatively new, costly, and not financially rewarding. Our paper proposes a payment approach to make the money work to support hospitals to adopt evidence-based suicide care practices and help save lives.