Why outcome measurement is critical to value-based care in mental health.

Value-based payment models and other forms of value-based care have been expanding across healthcare. The rough definition of this concept involves a healthcare system adjusting payments, funding or its allocation of resources based on the clinical outcomes achieved by providers. This shift is centred around the goal of creating a new incentive system for providers in order to increase quality of care and reduce overall costs.

For certain verticals and funding streams, this trend is more pronounced. Over 50% of Medicaid beneficiaries in the United States receive care through a managed care organization (“MCOs”), presenting an opportunity for states to negotiate value-based payment requirements into MCO contracts – accelerating widespread adoption. In addition, the US Department of Health and Human Services has been working to expand the share of providers in a value-based alternative payment model, which crossed 34% in 2017.

It is not always appreciated, but the ability to measure clinical outcomes is crucial to the success of value-based care. When adjusting payments based on the outcomes achieved, the accuracy of our outcome measurement will directly affect the fairness of the payment model.

Outcome Measurement in Mental Health

For outpatient mental health treatment, the trend towards value-based care has lagged behind other healthcare verticals. While part of the cause might be the continued lack of focus and funding paid to the sector, there is also a unique challenge that exists: how to effectively measure the outcomes achieved by providers?

This is the sum of two issues.

First, there is a common misconception that mental health is not measurable. The argument proceeds as follows: In a value-based care model, the core goal is to map payments to outcomes. But what if the outcomes from mental health treatment are not as measurable or clear as treating a broken arm or pneumonia?

This is a flawed statement of logic. There are in fact clear and measurable methods to track patient mental health symptoms, progress and outcomes from treatment. It is through the use of Patient-Reported Outcome Measures (“PROMS”) – and like measuring blood pressure or glucose levels – it is empirically validated through research with an acceptable margin for error. This is becoming more widely accepted and understood, but has a long way to go.

In Canada, the Canadian Psychological Association called the routine measurement of clinical outcomes a standard of evidence-based practice and a requirement to comply with college ethical obligations. However in the same report, the CPA stated that just 12% of psychologists currently use any form of measurement.

The second issue is that it is not simple or easy to implement an effective model for measurement. It involves the consistent completion of assessments that are customized to the presenting issues of a client (such as completing the PHQ9 every 2 weeks for clients presenting with depression). Shifting to a model of measurement-based care requires significant change management and increased administrative time for providers.

As well, organizations often approach measurement from a lens of data collection (as opposed to being a core component of clinical care). This might involve the completion of a pre-treatment and post-treatment assessment. This approach leads to a poor quality of data (with 30% or more of patients not completing treatment – and thus not completing the post-treatment measure) and limited clinical buy-in (since the this model doesn’t add any real value for the clinician or client).

The end result is that the quality of measurement in mental health (not the ability to measure) is lagging behind other healthcare verticals. This becomes an important concern when shifting to a model for value-based care – where payment is being linked to measurable outcomes.

The State of Value-Based Care in Mental Health

Let’s revisit the statement from above: the accuracy of our outcome measurement [within VBP] will directly affect the fairness of the payment model.

Without widespread implementation of outcome measurement in mental health, there is often a reliance on other metrics when shifting to a value-based care model. We commonly see the use of an ‘Outpatient Scorecard’ by MCOs. These scorecards will rely on metrics such as wait times, readmission rates and the number of sessions provided. The metrics relate indirectly to the outcomes that a provider achieves, but might be more accurately referred to as ‘outputs’.

It is important to recognize that buy-in from providers is a key challenge that systems face when shifting to value-based care. There is often the belief that an Outpatient Scorecard is easiest for a provider to implement, and therefore the right approach. However, if the goal is to ultimately adjust the payments made to providers, there is likely to be significant pushback if providers don’t believe the adjustments accurately reflect their outcomes.

As a result, healthcare systems will need to carefully consider their approach to value-based care in outpatient mental health treatment. We would argue that the implementation of effective outcome measurement is the best place to start.


About Greenspace:

Greenspace Mental Health is a technology platform that supports healthcare systems and individual mental health organizations with measurement-based care. Greenspace reduces the effort required to successfully implement this evidence-based practice; and helps to drive improved client outcomes.

The team at Greenspace is passionate about improving the quality of mental healthcare, and has worked with systems to successfully implement value-based care models.

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