Improving Quality Measurement For Behavioral Healthcare

Physical medicine has had many years' head start over behavioral medicine in adopting quality performance measures and data-driven quality improvement (QI), as well as value-based payment arrangements and incentives. The longstanding, divided nature of how mental and physical health is organized, paid for, and regulated has had an untoward effect on behavioral health. It's resulted in fragmented and inequitable care that's less accessible than physical healthcare and produces more varied efficacy of outcomes.

Behavioral health quality must improve

Behavioral health conditions (including mental health and substance use disorders) are a leading cause of death and disability in the US, with drug use disorders now the number one cause.

Nearly 20% of adults and children experience a mental health disorder each year, with mental illness-induced suicide as the second cause of death among people 15-29. Yet, the care quality for behavioral health has not increased at the same level as care for physical conditions. People living with behavioral health conditions receive suboptimal care and suffer poorer health outcomes, including complicating comorbidities that cause premature death.

Behavioral health needs standardized, validated quality measures

Quality measurement for behavioral health has become a priority as healthcare providers, payers, and digital mental health service organizations work to address the growing mental health crisis. While it's estimated that there are hundreds of behavioral health measures, few are standardized, scientifically validated, or used consistently.

A 2019 review found that less than 20% of behavioral health practitioners have integrated measurement-based care (MBC) into their practices. This is despite evidence that patients who receive MBC are 2.5 times more likely to reach remission at half the treatment timespan.

A 2021 white paper published research by the National Committee for Quality Assurance (NCQA) from their review of 39 active federal programs and 1,400 quality measures found that “federal programs, especially those focused on behavioral health care, rely heavily on metrics and non-standardized quality measures, limiting use for benchmarking and value-based payment models."

Their research highlighted the disjointed nature of measurement:

• Only four behavioral health measures were used most frequently across all programs.
• Standardized behavioral health quality measures focus on narrowly-specified conditions or processes.
• Measures are misaligned and used variably across programs.

As the largest payer for behavioral health services in the US, how CMS (federal and state programs) approaches behavioral health quality measures has a cascading effect across all behavioral healthcare. In response to these issues, industry experts, including the NCQA and the Kennedy Forum, are calling for quality measurements that “can guide and hold entities jointly accountable for improving care access and outcomes."

Behavioral health performance measurement and payment

The types of performance measures that are voluntarily or required from behavioral health providers depend on the payment model. The behavioral health profession is made up primarily of independent fee-for-service practitioners. This contributes to disjointed quality care. However, for individual or larger practices, their desire to solidify contracts and receive higher reimbursement is moving more providers into health plan networks. For payers—government and commercial—the need to address care shortages, increase access, and control all healthcare costs (as behavioral health greatly compounds physical health costs), is beginning to move more care from fee-for-service to value-based.

Government programs rely upon established behavioral health measures like the Core Set for Medicaid and CHIP, and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) introduced the Quality Payment Program (QPP) with two tracks—the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Through these programs, clinicians who provide high-value, high-quality care are rewarded through Medicare payment increases. Those not meeting performance standards receive reduced Medicare payments. As of 2023, the MIPS quality measures comprise 30% of the total MIPS score. Among Veterans Health Administration (VHA) facilities, 75% use a specialized process for collecting their own set of quality-related measures for behavioral health.

Barriers to implementing MBC in behavioral health

MBC for behavioral health relies on the ability to systematically capture and share outcome data with health plans. This is where many providers lag behind physical health in the use of health technologies like electronic health records. Again, because behavioral health was carved out and treated differently from physical health during the 2009 HITECH Act, behavioral health providers were exempt from the subsidies that helped other healthcare providers adopt these tools. These tools are expensive to implement and maintain.

Also, behavioral health facilities are not typically included in state or regional health information exchanges, and they face different privacy regulations than physical health providers, particularly those related to substance use disorder.

Outcomes for behavioral health are more complex to measure than some physical conditions that rely on straightforward clinical measurements like glucose levels, blood pressure, etc.

Patient attribution for behavioral health is more challenging compared to physical health. When a patient with a physical disease also has a behavioral health condition, it is difficult to parse out where improvements made the most impact.

Lastly, behavioral health providers may not want to engage in value-based contracts if they don't perceive their reimbursement to be comparable with physical health.

What's next for quality measurement in behavioral health?

In 2022, CMS launched a new behavioral health strategy, emphasizing equity, access, and high-quality payment models. The strategy includes 5 overarching aims:

• Improving equity and quality in behavioral health care
• Boosting access to substance use disorder programs
• Improving pain treatment and management care
• Expanding access and quality to mental health services
• Using data to guide services

CMS paid particular focus on boosting quality measures in pain management and behavioral health, aligning with their recent announcement of pursuing a Universal Foundation of simplified quality measures across physical and behavioral health for adults and children. Their movement toward adopting data-informed approaches is critical to downstream influence on commercial health plans and value-based contracting.

Commercial health plans are leveraging behavioral health QI measurement

Commercial payers are taking up the mantle to improve health outcomes, control costs, and provide more integrated benefits, particularly regarding behavioral health services, coverage, and network access. They see that standardization and improvement in measurement and accountability is the only way to monitor and reward high-quality care. Highmark Blue Cross Blue Shield of Western NY, for example, partnered with Value Network, a large BH collaborative of providers. Their arrangement includes an alternative payment model of capitated payment with upside risk, following a model often used for primary care practices.

Frequently, payers contract with managed behavioral healthcare organizations, carving out management and reimbursement separately from physical healthcare. Separating reimbursement drives further fragmentation. In part because of efforts by Medicaid to shift to whole-person, integrated care, health plans are beginning to look to performance measures as a way to align incentives.

Moving the needle on mental health parity

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 and the Affordable Care Act (ACA) of 2010 were critical first steps to addressing access barriers, including behavioral health coverage for more people and eliminating restrictive limitations. Beyond legislation, health plans like Blue Cross of North Carolina are changing the dynamic.

Their Blue Premier ACO integrated outcomes measures and provider financial incentives, thereby providing the infrastructure to measure behavioral health outcomes and facilitate provider collaboration. They also integrated person-reported measures.

Since the launch of its basic value-based model in 2020, Blue Cross NC reports seeing a high level of behavioral health provider involvement. This is reinforced by the regular quality reports Blue Cross gives its providers. The organization also surveys clinicians for feedback. The company looks to build a behavioral healthcare delivery system that maximizes accountable care while improving access and quality.

Tackling Behavioral Health Quality Measurement Improvement Collaboratively

Quality measurement is critical to managing clinical processes, outcomes, and patient preferences, and implementing system-wide changes that improve care for all, equitably.

Health plans and behavioral health provider organizations don't have to climb the quality measurement hill alone.

RTI Health Advance has the expertise and experience to support all aspects of quality measurement—from behavioral health assessments, capturing measures, integrating into workflow, compliance and oversight reporting, as well as technology to support the program. Contact us.