Health Affairs

Health Affairs, 25, no. 3 (2006): 681-693 doi: 10.1377/hlthaff.25.3.681 © 2006 by Project HOPE	New Online   Getting Health Reform Done   After the State of the Union   Incremental Reform   E-Health in Developing World   Most-Read Articles in 2009

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Quality & Access

What Is Necessary To Transform The Quality Of Mental Health Care

Kavita K. Patel, Brittany Butler and Kenneth B. Wells

Abstract

 
Improving the quality of care is a national priority in the United States; however, it is not clear how to accelerate progress for mental health care. We recommend advances in three capacities: (1) developing quality improvement resources applicable to a diverse set of mental health disorders, clients, and service settings; (2) improving the infrastructure for providing evidence-based psychotherapy and psychosocial interventions; and (3) promoting innovation in financial incentives for quality improvement in mental health care. We also discuss the need to develop leadership among health care stakeholders and community engagement to promote public commitment to high-quality care in mental health.

Despite this, major barriers to improving the quality of mental health care remain. In a recent report on the state of quality measurement in medical practice, only 4 of 179 quality indicators were related to mental health care.³ Efforts to include mental health in broader quality improvement initiatives face such barriers as condition- and treatment-related social stigma and regulations concerning privacy. These barriers are often exacerbated by system factors specific to mental health, such as the broad array of provider specialty types and agencies providing services, and characteristics of the market, such as financing limitations.

To address these deficits, a recent Institute of Medicine (IOM) report suggests that the IOM’s aims, rules, and strategies for redesigning general health care be applied to mental health care. The report emphasizes the importance of a client-centered approach that includes a focus on recovery and self-management, of developing and applying explicit standards for safety and effectiveness and valid quality measures, of innovations in financing, and of development of the professional workforce.⁴ Although these are important steps, we suggest that to transform mental health care quality across diverse community settings, three additional reforms are necessary; we discuss these reforms below.

Developing Quality Improvement Resources

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The first of our reforms, developing quality improvement resources, is fundamental to improving mental health care, and such tools must be reasonably comprehensive to broadly stimulate change. Quality improvement programs are practice and system strategies that support efficiency, appropriate care, and acceptable health outcomes. Comprehensive approaches that support client and provider education; encourage consumers to take a more active role in their recovery; and make use of support structures, such as case management to coordinate care, have been shown to improve quality, in terms of both processes and outcomes of care.⁵ Nevertheless, these strategies have important limitations, particularly in their lack of applicability to community settings. This is because such programs are typically developed for clients having a particular condition within a specific care setting and in a particular age group. Further, most documented evaluations of such programs in mental health have been conducted as part of research demonstrations, rather than in community practice settings.⁶ Finally, developing such programs is often highly resource-intensive and requires knowledge, skills, and financing that are not widely available in community practices. We focus on more comprehensive approaches to quality improvement, derived from the disease management literature, because the activities that community practices often use in quality improvement efforts, such as screening, provider feedback, and reminder systems, have not demonstrably improved outcomes in mental health care.⁷

Importance of generalizability. We suggest that to support communitywide quality improvement for mental health care, such programs need to be made more widely generalizable. This can be done by expanding implementation of quality improvement programs across a range of psychiatric disorders; tailoring them to diverse age and sociocultural groups; and adapting them for a spectrum of settings, particularly those outside of traditional research environments. Doing this will likely increase community and public health systems’ confidence to integrate quality improvement initiatives into their own care delivery contexts. This also has the potential to reduce fragmentation in the mental health system. Flexible tools that fit the infrastructure and systems of practice thus have practical as well as clinical value to community settings.⁸

Milestones in quality improvement. The greatest development of comprehensive quality improvement programs in the published literature has been in the field of depression in primary care, where evidence-based programs exist across age groups and are effective in some underserved minority groups and for both men and women (Exhibit 1).⁹ Such programs have been shown to be cost-effective in the range of widely used medical treatments and to improve societal economic indicators such as employment status. Yet most of these demonstrations relied on well-established, organized care settings, and further development is needed if they are to be useful in most current practice settings, which are struggling to overcome problems related to fragmentation.¹⁰

Filling in the gaps. An important next step for the quality improvement field is increasing the range of disorders and age and sociocultural groups for which effective programs exist and adapting them for diverse service settings. For example, quality improvement programs for attention deficit hyperactivity disorder (ADHD) in children are needed to support providers in primary care, specialty care, schools, juvenile justice, foster care, and other agencies serving children. For such challenges, interagency approaches are needed to reduce fragmentation.¹³

Another gap is that existing quality improvement programs in mental health primarily address the quality domains of appropriateness or effectiveness of care. Less focus has been placed on other domains, such as safety, timeliness, efficiency, client-centeredness, and equity.¹⁴ For example, although medication safety indicators were included in a recent comprehensive study of quality of care for children with psychiatric disorders, they remain largely unaddressed in quality improvement initiatives, apart from a few indicators such as avoidance of long-term use of benzodiazepines in depressed elderly people.¹⁵ Timeliness of care has been largely unaddressed, but a recent national study noted long lag times between illness onset and treatment.¹⁶ Equity has recently been addressed in some quality improvement programs but certainly does not receive the same prominence in quality debates that effectiveness does.¹⁷

Cooperation and training of stakeholders. Developing more-comprehensive quality improvement resources and tools will require the cooperation of diverse stakeholders, including the training of researchers with skills in quality-of-care methods as well as a commitment from appropriate funders to complete the necessary work. Once these resources are developed and integrated into a comprehensive improvement initiative, they must be adopted by practitioners at the point of service delivery. We have chosen to illustrate the challenges of delivering high-quality mental health services by focusing on delivery of evidence-based psychotherapy.

Developing Infrastructure For Evidence-Based Psychotherapy And Psychosocial Treatments

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To realize gains from the use of quality improvement resources, systems must have the necessary infrastructure to deliver the care that the tools potentially support. Serious infrastructure gaps, such as lack of accountability mechanisms to assure provision of evidence-based psychotherapy, can undermine quality improvement efforts even when the best tools are made available.

Psychotherapy is one of the primary treatment modalities for mental health conditions. But there is a substantial gap between the state of evidence for effectiveness of particular models of structured psychotherapy and what we know about the content or effectiveness of psychotherapy as delivered. For example, psychotherapy is as effective as antidepressant medication for most patients with major depressive disorder, and combined psychotherapy and medication is the most effective option for chronic forms of depression.¹⁸ In addition, even for disorders for which psychotropic medication may be necessary, such as schizophrenia and bipolar disorder, outcomes are improved by psychosocial interventions, such as family psychoeducation.¹⁹

Despite these potential benefits, the infrastructure for assuring the availability and delivery of evidence-based psychosocial treatments in the United States remains one of the most serious infrastructure problems in mental health services delivery, in stark contrast to the delivery of medications. Medications are generally available through pharmacies, and for-profit industries promote their development and use. Barring practice errors and adherence problems, they can be administered in a uniform and reliable fashion. Although evidence-based psychosocial treatments such as cognitive behavioral therapy (CBT) and interpersonal psychotherapy exist, there are no training, licensure, or certification requirements obligating providers to have competence in such therapies and no easy way for consumers or providers to identify practitioners who deliver the treatments.

Improve practice regulation through market forces. One means for addressing these problems is to improve practice regulation through market forces. Most private-sector mental health care is managed through managed behavioral health care "carve-out" companies that typically contract with fee-for-service behavioral health care providers. Because of their broad geographic reach, these carve-outs could exercise more leverage to standardize market regulation of psychotherapy, a strategy that has not yet been realized. Incentives such as bonuses for voluntary acquisition of training might be one way to approach this infrastructure improvement goal at the provider level while retaining existing provider panels. Such incentives have been demonstrated to be a strong influence on providers’ behavior in other health sectors such as primary care diabetes management.²⁰ However, this could be a weak intervention in mental health services because any one behavioral health care company manages only some of a provider’s clients. Further, different managed behavioral health care firms compete for enrollment of the same providers in many market areas, so unusual management requirements from any one company could lead to a loss of provider enrollment. Thus, if these companies’ potential to shift the market toward evidence-based psychotherapy is to be attained, an unusual degree of cooperation among competing for-profit firms in collaboration with local specialty societies would likely be needed.

Need for professional leadership. Leadership, especially at the level of professional organizations and training institutions, is central to achieving widespread use of evidence-based psychotherapies. Professional organizations can play a role by developing resources available to members to support evidence-based psychotherapies and providing training during annual national and regional meetings. Academic training programs similarly can lay a foundation by routinely exposing trainees to a variety of evidence-based psychotherapies and requiring competency in at least one form of evidence-based therapy, while learning how to evaluate the evidence for that therapy.

We nevertheless think that meaningful strides are possible through feasible, straightforward training approaches. In the Partners in Care study summarized in Exhibit 1, local therapists affiliated with community-based, managed primary care practices were trained in an evidence-based form of psychotherapy; consumers received an incentive (reduced copayments) to use those therapists but could opt (under regular copayments) for any therapist. Availability of trained therapists was advertised by educating primary care clinicians in lectures and through coordination of care managers. The intervention including these features led to long-lasting outcome improvements and reduced health outcome disparities for minorities relative to whites. The tiered approach (that is, national experts training local experts who trained local therapists) might have been a salient feature of the intervention, which suggests that finding incentives for some providers to become experts and others to rely on them might be key to progress. Successful client outcomes could serve as one reinforcer for the value of such options.

Innovation In Financing

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Financial incentives hold the potential to influence adoption and implementation of quality improvement programs, but effective financing tools for this purpose have not yet been fully developed in mental health. A key feature of the U.S. mental health care system is its division into public and private systems, with a disproportionate share of people with moderate-to-severe mental illnesses largely being treated in the public system. Additionally, diverse streams of funding finance the mental health system. Innovations in financing should acknowledge this complexity while supporting a responsible infrastructure in which access to, efficiency of, and quality of services delivered are fundamental values.

Managed mental health care. Although a majority of payments for mental health services are made by public insurance (Medicaid and Medicare), most people’s mental health care is financed through private insurance. Both the private and public sectors enlist managed behavioral health carve-out programs that contract with plans, purchasers, or provider groups. The carve-out programs use provider networks with established reimbursement rates and a common goal of managing the affordable implementation of mental health services. To date, reform efforts in managed care have largely addressed cost containment, general accountability, and efficiency concerns rather than quality improvement. Carve-out programs have also been employed as a means of ensuring mental health parity in both the public and private sectors. Several states such as Vermont introduced managed care carve-out contracts with an eye toward spending control and improved benefits. In most cases, this has produced only modest changes in spending, with higher utilization rates of outpatient mental health services.²¹

Parity in coverage. The attention to parity stems from a long history of restrictions in mental health insurance coverage in comparison to coverage of general health services. Over the past decade, several bills have been introduced in Congress and in state legislative agencies that would require parity in benefit design for these services. Opponents of parity legislation have argued that mandating parity would result in higher use of mental health services and in turn increase the costs of benefits. Prior research has suggested that such claims for a former federal parity initiative were largely unfounded.²² Recent evaluations of a mandated parity benefit for the Federal Employees Health Benefits (FEHB) Program suggest that this initiative did not lead to increased costs and did protect some consumers from high out-of-pocket costs—a key goal of parity initiatives.²³ These findings, however, do not inform the debate on how to improve quality of care, and a combination of parity and quality improvement program initiatives could be required. Such a program would have uncertain cost implications. Similarly, a host of prior policy studies in mental health have suggested that financing variations affect services use and costs but typically not quality of care.²⁴ More generally, financial incentives that can achieve cost containment goals while supporting quality improvement goals have been difficult to identify.²⁵

Public mental health care. Another area of opportunity lies in the fact that a disproportionate share of consumers with severe mental illnesses and psychotic disorders use public services. The ability to deliver high-quality care for this vulnerable population is contingent on the availability of funding as well as a matrix of accountability. The Government Performance and Results Act (GPRA) of 1993 helped establish a set of expected outcomes as part of block-grant funding of public agencies. Some states have seized the opportunity to implement outcome management systems, but given the potential for state Medicaid funding cuts, policymakers and providers are often faced with balancing the need to maintain a system of care, prioritizing which clients receive services, and adjusting the scope of services to the available budget. Further, resources to meaningfully track outcomes or to address critical methods problems (such as tracking no-shows) are often very limited. A number of states, with support from the Substance Abuse and Mental Health Services Administration (SAMHSA), have been initiating programs to improve quality of services for people with severe and persistent mental illnesses, and it will be important to determine how these programs implement accountability mechanisms.²⁶ Given sparse resources for public agencies to initiate new management infrastructure, such as health information technology (HIT) to support disease management systems, support from private companies with appropriate infrastructures could hold promise and might be feasible through expanding contracts to managed care programs that are already providing services to those public-sector agencies.

Performance-based incentives. Another promising approach across public and private mental health systems might be performance-based incentives. These include providing salary bonuses or withholds based on quality indicators such as client satisfaction, improvement in health indices, or meeting process-of-care standards, such as providing psychotherapy or appropriate antidepressant medication for the majority of patients with depressive disorders. To explore this approach in mental health, initial work could focus on psychiatric conditions, age groups, and various provider settings and types for which there is strong evidence for process-outcome relationships. Initially, such indicators might be feasible to assess only through primary data collection efforts, given limited data in claims and medical records. Once effectiveness of performance-based incentives is demonstrated in this context, wider use could be achieved through development of a more comprehensive and generalizable set of validated process and outcome indicators.

A challenge to linking quality measurement to financial incentives is the possibility that pay-for-performance (P4P) initiatives will bias providers to focus only on measured quality domains. Achieving the conditions for wide-scale quality improvement would thus require considerable research, followed by the coordinated effort of policymakers, consumer groups, professional organizations, and purchasers. Such efforts would in turn need to be supported by leadership development, education, and engagement of stakeholders.

A variant of P4P that could have particular relevance to mental health is the realignment of financial incentives to reflect patients’ preferences for treatments and outcomes. This strategy has been adopted by some health plans and consumer advocacy groups but has not yet been extensively described in the literature or formally evaluated. Developing a better understanding of patients’ preferences could inform risk-adjustment models by explaining additional sources in variance around mental health spending.²⁷

Implications And Future Directions

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Investing in comprehensive, high-quality care is one way of improving public mental health, given the paucity of proven primary prevention strategies in this field. Since mental health issues are not necessarily the first priority for most stakeholders, it has been difficult to develop support for improved mental health services. The recent California experience with implementing Proposition 63 (the Mental Health Services Act) is a noted exception and was based on consumer organization leadership, but it remains to be determined whether and how such initiatives achieve quality-of-care goals. Despite the relative lack of similar public reforms, there have been recent federal calls to action spanning Republican and Democratic administrations to improve the quality of care across diverse populations groups, disorders, and service settings.²⁸ But the necessary research and development to deliver comprehensive resources to support quality improvement in mental health services have not yet been completed, nor has it been determined how to integrate such resources into a whole package for diverse systems—for example, using advanced information systems. Increased commitment of funders across federal and private sectors is needed to complete this important work.

Ongoing clinical training. Even with these resources, key infrastructure problems must be solved to support dissemination of best practices, particularly in the area of evidence-based psychotherapy. We have emphasized the need to promote clinical training and to instill commitment to ongoing learning of new approaches, and developing accountability structures and incentives to promote the use of evidence-based therapy practice, goals that will require cooperation among private plans and behavioral health management companies and professional societies. Lack of public familiarity with specific therapy processes and standards suggests a key role for information transfer and public engagement.

Incentives for adoption of quality standards. Improved public-sector contracts and private-sector reimbursement systems that provide incentives for adoption of quality standards as well as quality improvement programs are needed. More consistent implementation of mechanisms to handle selection issues and more consistent implementation of equivalent benefits and management strategies for mental and physical disorders might help make higher-quality care affordable to more people. Innovations in financing strategies and more consistent evaluation of policy innovations are needed to help this field contribute to achieving effectiveness and appropriateness as well as efficiency goals.

Need for leadership. We build on the perspectives of Joseph Newhouse and others in the field when we say that leadership development and public engagement across a diverse group of stakeholders are critical to achieving a commitment to quality improvement goals.²⁹ Having diverse stakeholders is necessary for overcoming system problems, resolving conflicting quality goals, and achieving practice changes across a variety of often uncoordinated service agencies serving people with mental disorders (Exhibit 2). However, new programs might be needed to generate such leaders, particularly in underserved communities, and to foster team-based approaches across stakeholders—for example, to arrive at a consensus on quality indicators or feasible incentives. The public and private health care sectors, professional agencies, consumer groups, foundations, and public funders can all play a role in prioritizing development of leaders for high-quality mental health care as well as for a better-informed public. Focused commitment across these sectors and stakeholders can help the mental health care system achieve higher-quality services and ongoing quality improvement, based on evidence and experience.

Editor's Notes

 
Kavita Patel (kpatel{at}rand.org) is an associate natural scientist at RAND in Santa Monica, California. Brittany Butler is a research associate at the UCLA Semel Institute for Neuroscience and Human Behavior Health Services Research Center in Los Angeles, California. Kenneth Wells is director of the Health Services Research Center and a senior natural scientist at RAND.

Support for this project was provided by the UCLA/RAND/NIMH Center for Research on Quality in Managed Care (Grant no. P30 MH068639), NIMH Partners in Care (Grant no. R01MH061570), and the RAND Health Program. The authors thank Basit Chaudhry and Michael Schoenbaum for their insightful comments as well as Donald Metz and the anonymous reviewers who offered valuable feedback on earlier drafts.

NOTES

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