Harvard professor Michael Porter, in his strategic paper on “Value-Based Mental Health Care Delivery“, explained that value is the only goal that can unite the interests of all healthcare stakeholders. He also writes about the need to overcome the three myths of mental healthcare delivery, namely:
- Mental illness is different from physical illness and needs to be cared for separately
- Mental health outcomes are too variable and subjective to be measured
- Mental health should be reimbursed separately to control costs
The challenges facing effective mental healthcare, widely regarded as a subset of behavioral health, cannot be underestimated. In their paper, “Value-Based Financially Sustainable Behavioral Health Components in Patient-Centered Medical Homes”, physicians Kathol, deGruy and Rollman explain how in the United States, behavioral comorbidity, especially in patients with chronic and complex medical conditions, is associated with an estimated $350 billion per year spent on unnecessary medical and surgical services. Despite that cost, behavioral conditions remain ineffectively treated. Two-thirds of patients with significant behavioral conditions receive no treatment at all—and of those who do, most receive their care in the medical and not the behavioral care sector. Both papers lead to the need for better frameworks to measure outcomes in mental health.
CMS’ CPC+ program is addressing
Launched in the spring of 2016 – and included within MACRA as an advanced-alternative payment model – the Comprehensive Primary Care Plus (CPC+) value-based care program does require Track 2 practices to account for a patient’s social, behavioral and psychosocial status. This is to begin in 2019, year three for practices who began participating this year as the first performance year.
To follow suit and establish health IT structures for this data, vendors are to be required to certify for its intake and management as part of the comprehensive nature of the program, also by Jan. 1, 2019. This is an extended part of the ONC 2015 Edition of certification vendors must have initially in place by Jan 1, 2018 to cover a broad set of criteria.
As CMS defines the approach, “In Track 2, the practices will heighten their focus on caring for patients with complex medical, behavioral, and psychosocial needs. Thus, Track 2 practices will increase the breadth and depth of services offered, as well as inventory resources and supports necessary to meet their psychosocial needs, as appropriate. Because comprehensive primary care requires advanced health information technology (health IT) support for its population-health focus and team-based structure, CMS will require Track 2 practices to engage directly with vendors about model goals and requirements.”
Currently, Philips Wellcentive is supporting a multitude of practices participating in CPC+ Tracks 1 and 2 across five of the original participating multi-payer regions, and will pursue all related certifications.
Examining performance measures
The current ways in which behavioral health performance is measured makes it hard to incentivize stakeholders to change. These measures include:
- Control of core symptoms of psychiatric illnesses
- Engagement and retention in care
- Establishment of family/community supports
- Access to recovery-oriented services
- Personal and public safety
These measures, however, really address the quality of care for medical co-morbidities—such as diabetes and cardiovascular disease or medical readmissions—instead of focusing solely on individuals dealing with behavioral health issues. This makes it difficult to design shared savings programs based on them, or measure quality and understand when patients are suffering from substandard care.
There must be more focus on the acceptance of evidence-based practices. For example, standards for management of depression in primary care settings already exist. A great example is the PHQ-9 questionnaire that takes from two to five minutes to complete and can provide an accurate summary of depression severity. While this is a great start, there are three key tactics that can help improve the way mental healthcare is delivered:
1.Focusing on key treatment process rather than outcomes. When behavioral health problems lead to personal or public violence, or substance abuse, the patient must be engaged and retained in care for longer periods. During that time, the patient’s response and engagement levels hold greater value until more specific outcomes can be measured.
2.Apply better monitoring of acute care utilization for behavioral health cases. The 3M measure of potentially preventable readmissionsis a great starting point: it includes behavioral health readmissions within 30 days as well as readmissions in which either the first or subsequent admission is to a behavioral health setting. Using such a measure can help prevent readmission and assess the impact of inpatient behavioral health interventions. There are also measures which focus on seven and 30- day follow ups in mental health cases. Value-based payment arrangements can use these to incentivize better participation from hospital and community based providers.
3.Make use of social determinant and functional outcomes. While claims data doesn’t offer insight into such measures, there has been strong support to include such information within patient records. Incentivizing providers to include such information with systems would be a step in the right direction to gaining reliable data that plays a vital role in the overall health assessment of patients.
State-based collaborations underway
There is some good news, as certain states and cities are already applying improvements to how mental health is cared for. Oregon’s Alternative Payment Methodology (APM) pilot is aiming to align payment with a holistic care approach using PCMHs and behavioral health professionals within primary care settings to provide referrals and counseling. In Kansas City, behavioral healthcare providers have entered pay-for-performance agreements with New Directions Behavioral Health, a managed care carve out and employee assistance program. While providers are apprehensive to take more risk on, gathering data and building business cases can set the foundation to achieve the dual success of better outcomes at lower costs.
Some payers are also helping to drive progress. Cigna worked with the American Society of Addiction Medicine to come up with an evidence-based approach to substance abuse treatment tied to value based payments. Cigna has also agreed to share data that can help gauge the impact of prescribed medication on the substance abuse disorders which is useful data that can be leveraged by other mental health providers.
While some stakeholders have taken the right steps in the transition to value-based care, mental and behavioral health should not be left behind. As these are a pressing issue that has drained financial and physician resources, stakeholders must act immediately to develop better performance measures, experiment with programs and adopt a holistic approach to patient care to achieve better behavioral health outcomes.