Assessing and Improving Quality of Care Programs Under Managed Care

While managed care generally has limited inpatient care and contained short-term costs for mental health and substance abuse services, significant questions remain about how these changes in health care delivery affect the quality of care patients receive.

Some answers are emerging in quality assessment and quality improvement studies described in a recently released government report, Parity in Financing Mental Health Services: Managed Care Effects on Cost, Access & Quality, prepared by the National Advisory Mental Health Council (NAMHC) and the National Institute of Mental Health (NIMH). (See also parity story in PT, November.)

Traditionally, quality of care has been assessed on three dimensions: the structure of the health care organization or system, the process of the delivery of health services, and the outcomes for the consumers of those services. Such outcomes might be clinical (e.g., symptoms, course or relapse), functional (e.g., social and occupational functioning, ability to participate in activities of daily living), and attitudinal (e.g., patient satisfaction).

Quality of care can be enhanced or diminished under managed care, according to the report.

"Case management, utilization review and implementation of standardized criteria may reduce services that are unnecessary, overly intensive, and neither goal-directed nor demonstrably effective," the report said. As an example, the report cited the study by Frank et al. (in press), which found that not only is adherence to professional consensus treatment guidelines enhanced in managed behavioral health carveout plans, but that adherence to such guidelines has a positive effect on patient outcomes (Katon et al., 1997).

However, in some cases, the introduction of managed care has limited access to mental health services, resulting in "decreased work performance, increased absenteeism and greater use of medical services."

A study at Yale (Rosenheck et al., unpublished data), for instance, examined the effects of managed care over time on employees of a large national corporation. The study compared three-year trends in the use and cost of specialty mental health and general mental health services as well as trends in employees' absenteeism and work performance. Use of specialty mental health services decreased by 41% in outpatient settings and 4% in inpatient settings during the study period, resulting in a 44% decrease in mental health care costs. But there were hidden costs.

"Compared with other employees, users of specialty mental health services showed significantly reduced work performance over time (down by 5.1%), increased absenteeism (sick leave up by 21.9%) and increased general health services costs (up by 36.6%). These trends offset any savings in mental health specialty costs and resulted in no net economic benefit or loss to the company," the report said. "These findings raise concerns that in the three-year shift to increased use of general health care services for mental health care, employees may have received less appropriate and less effective treatment, resulting in a decline in work function."

To improve outcomes, experts have sought to build consultative relationships between mental health specialists and primary care physicians (PCP) and to more fully educate PCPs about mental health issues. Wellsand colleagues (in press) reported on the development of a systematic consultation arrangement between PCP practitioners and psychiatrists that has resulted in markedimprovements in depression treatment inprimary care settings.

In another instance, MCC Behavioral Health Care is collaborating with academic health scientists on the Large National Airline Carrier Study. The study's goal is to improve primary care practitioners' recognition of major depression and the appropriate use of treatment intervention guidelines for patients with major depressive disorder; the guidelines were developed by the U.S. Agency for Health Care Policy and Research.

The study compares the effect of traditional primary care detection and treatment practices for major depression with the effect of integrating psychiatric specialists in the primary care setting, combined with case management and mental health care training for PCPs. Outcome measures include changes in depression, life activities, work performance, disability and medical care costs. In addition to providing longitudinal assessment of clinical outcomes, the study should permit evaluation of the economic impact of this intervention on the health system (including claims costs as well as medical and pharmacy utilization) and on the workplace (including job performance, productivity and absenteeism).

Analysis of quality of care issues has been hampered by several factors, according to the report. These include a competitive environment emphasizing price, the developmental and operational costs of outcome data systems, and the lack of standardized methodology for collecting and reporting outcome data.

"Within the managed care industry, current incentives generally do not encourage an emphasis on quality of care and its assessment. Consolidation...has created intense pressure for competition based almost exclusively on price," the report said. "It has also created disincentives for capital investment to develop comprehensive quality information systems that would allow competition on the basis of quality."

Most quality reporting systems in managed behavioral health systems are based on administrative data rather than on clinical outcome data. Comprehensive clinical quality information systems are more expensive and complicated than administrative data systems, but "have much greater potential for evaluating the actual impact of programs and practices on patient outcomes."

With the help of NIMH, one managed behavioral health care organization implemented a clinical quality system. They found that the initial development costs for the system was less than one cent per member per month (Kane et al., 1998).

Some companies, such as MCC Behavioral Care, are currently testing the feasibility of implementing systemwide collection of clinical outcome data, according to the report.

Among the core features of MCC Behavioral Care's system are the following: 1) structured collection of baseline data is integrated into documentation of the initial clinical assessment of every patient; 2) longitudinal assessment occurs at six and 12 months with telephone follow-up of outcomes and satisfaction; 3) patients are assessed along multiple domains of function; and 4) clinical outcomes data can be linked to and analyzed with existing data on costs and utilization of services, as well as characteristics of providers, patients and benefits.

Already, the system has enabled MCC to identify significant predictors of treatment engagement, such as copayments less than $20 and special assistance for patients having difficulty getting to treatment appointments. It also has demonstrated the benefits of some substance abuse treatment programs on mental health, medical and functional outcomes.

Another quality information system was introduced by United Behavioral Health (Goldman, 1997; Goldman et al., 1998). The Goal-Focused Treatment and Patient Outcome system is a case management system for quality improvement through collaborative goal setting and focusing of treatment between clinicians and patients in psychotherapy.

Since 1994, data have been collected on general and individualized treatment goals at the beginning of all modalities of psychotherapy in adult members of the managed care system. Treatment and evaluation has been completed by 10,544 members (66%). Outcome is evaluated from global improvement ratings by providers and from patient satisfaction ratings from a mail survey.Ratings showed improvement at termination of treatment by 87% of the psychotherapy patients. Predictors of improvement included the absence of co-occurring disorders,participation in a higher number of treatment sessions (?12) and termination aftercompletion of treatment goals (versus discontinuation).

The lack of agreement on outcomes measures and strategies, the report said, prompted the American College of Mental Health Administrators to invite industry, advocacy, professional, regulatory and government organizations to a summit in 1997. The purpose of the meeting was to develop a "consensus on core performance measures and strategies in mental health and substance abuse care."

The result was the specification of key outcome indicators that included mental and general health, housing, working, social and legal dimensions of function (American College of Mental Health Administrators, 1997).

References:

References

1.

American College of Mental Health Administrators (1997), Santa Fe Summit Summary Report.

2.

Frank RG, Berndt ER, Busche SH (in press), Price indexes for the treatment of depression. In: Measuring the Prices of Medical Treatments, Triplett J, ed. Washington, D.C.: Brookings Institute.

3.

Goldman W (1997), Goal-Focused Treatment Planning and Outcomes. United Behavioral Health.

4.

Goldman W, McCulloch J, Sturm R (1998), Cost and utilization of mental health services before and after managed care. Health Aff (Millwood) 17(2):40-52.

5.

Kane RL, Barlett J, Potthoff S (1995), Building an empirically based outcomes information system for managed mental health care. Psychiatr Serv 46(5):459-461.

6.

Kane R, Beyer Z, Potthoff S (1998), The future of outcomes monitoring in managed behavioral health care: report to NIMH from MCC Behavioral Health Care and University of Minnesota School of Public Health, Clinical Outcomes Research Center, Minneapolis, Minn.

7.

Katon W, Von Korff M, Lin E et al. (1997), Population-based care of depression: effective disease management strategies to decrease prevalence. Gen Hosp Psychiatry 19(3):169-178.

8.

Wells K (in press), the design of "Partners in Care": evaluating the cost-effectiveness of improving care for depression in primary care. Social Psychiatry and Psychiatric Epidemiology.