Achieving Quality in Behavioral Health Care

Shared accountability between providers and care settings is a critical element of quality in behavioral health care.

Overcoming a fragmented system is the key to effectively measuring the efficacy of behavioral health care, a healthcare quality expert says.

Eric Schneider, MD, MSc, is executive vice president of the Quality Measurement and Research Group at the National Committee for Quality Assurance (NCQA). Before joining the NCQA staff in January, he worked at The Commonwealth Fund as senior vice president for policy and research focusing on quality measurement. Prior to his tenure at The Commonwealth Fund, he was principal researcher at the RAND Corporation. As a professor at the T.H. Chan Harvard School of Public Health and Harvard Medical School in Boston, Schneider taught health policy. He began his career as a primary care physician and practiced primary care internal medicine for 25 years.

HealthLeaders recently talked with Schneider about a range of issues related to achieving quality in behavioral health care, including the role of quality data in promoting health equity and behavioral health care, the importance of achieving shared accountability in behavioral health, and the value of using standard quality measures in behavioral health. The following transcript of that conversation has been edited for clarity and brevity.

HealthLeaders: What are the primary challenges of measuring the efficacy of behavioral health care?

Eric Schneider: The biggest challenge is the fragmentation of behavioral health care across the United States. Primary care does a large amount of behavioral health care, but primary care physicians do not have the capability to manage all behavioral health problems. The behavioral health professional sector has been chronically underfunded, so the availability of practitioners is also a challenge. When it comes to the measuring of efficacy, in a fragmented system it is difficult to have the data systems in place that enable the collection of data on performance—particularly measures that can be reported by all of the settings and providers that contribute to behavioral health care.

Data availability is a primary challenge, but it is driven by the fragmentation of the existing system. The fragmentation means there is not a consistent set of data systems across the providers and settings to report on services for behavioral health.

HL: Why is quality data vital to promoting health equity and behavioral health care?

Schneider: One of the things we know about behavioral health—and it is true of primary care services for other chronic diseases as well—is that care is paid for by three major payers: commercial payers, Medicare, and Medicaid. Those payers are not equally generous in paying for behavioral health services. The inequities that result from that situation include lack of access to meet the demand, especially for people living in poor communities and people of color. Without sufficient funding, there is even more fragmentation of the data.

The way we can understand the lack of access and understand how needs are not being met is to do quality measurement at the payer level. So, Medicaid, Medicare, and commercial health plans all have something to contribute in terms of understanding whether people have access to behavioral health services and whether provider networks are adequate to provide services. Without shining light on where access is better or worse, it is difficult to figure out how to intervene to improve health equity.

HL: Why is shared accountability a problem in behavioral health care?

Schneider: The shared accountability model is important because without the sense of shared accountability, providers tend to just operate in their silos and manage their piece of the puzzle without being able to support the other providers in their recommendations and treatment plans.

HL: Define shared accountability in behavioral health.

Schneider: In behavioral health, it can be voluntary shared accountability to optimize the treatment plan of the patient, but that is difficult to do without either a management infrastructure or direct financing of that shared accountability. So, value-based contracting is a mechanism for trying to create shared accountability—if each of the providers who are participating are getting paid based on whether they are participating in shared accountability, that tends to be a strong incentive.

Shared accountability can also be accomplished by creating management systems such as business process management systems that specify how providers in one part of a system communicate with providers in another part of the system. It is a set of expectations or protocols. If a patient is seen in an emergency room, the primary care provider is notified and the behavioral health professional responsible for that patient is notified. If a person is in crisis and appears in a community health center, other providers will be notified. That's the kind of shared accountability that can be created by management systems that groups such as accountable care organizations or payers or care managers can provide.

HL: Why is it important to have consistent use of standard quality measures in behavioral health care to increase shared accountability and promote quality improvement efforts?

Schneider: Without a shared understanding of what represents a good outcome, it is difficult for the providers to navigate to a good outcome or help the patient navigate to a good outcome. There are several standard quality measures, and they are a mechanism for helping providers to share accountability—they can all see the metrics, preferably on a dashboard. Then they can adjust their approach over time for the populations they are seeing—they can adjust their approach to improve quality.

We think about standard measures in two categories. First, there are measures on the outcome side such as symptom reduction and functional improvement, whether patients can attain their goals, social outcomes in terms of school and employment, and family outcomes. Second, there are several measures on the process side such as whether behavioral health is being well integrated, whether goals are being set effectively, and whether there is an evidence-based care plan.

HL: How can you establish and use health information systems to capture patient-reported behavioral health outcomes?

Schneider: This is a game changer. This type of data collection for patient-reported outcomes has traditionally been done through paper-based surveys, but we are moving to a digital world. People are used to receiving surveys on their smartphones. That technology is enabling us to do much better real-time collection of data from people who are experiencing behavioral health problems. You can capture their current symptomatic state, then share and analyze the data to understand whether a patient is improving or getting worse.

After surgery for hip replacement, we would want to measure how many steps a patient can go day-by-day. If someone has a behavioral health crisis, we want to measure or understand through a standardized tool how they are doing at the time of the crisis and how they are doing after treatment is initiated. Health information systems enable much more efficient capture and analysis of that data.

There is a huge opportunity here. We still do not have digital standardization, but that is something NCQA is working on. There are also several companies that are creating electronic health records or other platforms that can enable the collection, storage, and analysis of patient-reported outcome data. Once we have the protocols in place to share that data and we have behavioral health quality frameworks to align clinical treatment settings, payers, and state and federal regulators, then we will have a much better chance of understanding a patient's journey with their behavioral health issues.