Medscape Medical News: Psychiatryby Alicia AultFebruary 25, 2016Starting in 2017, the Joint Commission will require the 2300 behavioral healthcare organizations it accredits to initiate standardized measurement of interventions designed to improve patients’ mental health outcomes. "We’re going to put in place a measurement-based care requirement," said Margaret VanAmringe, the Joint Commission’s executive vice president for public policy and government relations, at a meeting sponsored by the Kennedy Forum and the Satcher Health Leadership Institute’s Kennedy Center for Mental Health Policy and Research.
Attendees from government agencies, patient and mental health advocacy groups, philanthropic organizations, and academic institutions applauded the announcement. Systematically tracking and reporting outcomes could help build an evidence base of best interventions and practices. In turn, the data could be used to reduce coverage exclusions, which are still common despite laws that require benefit parity for medical and mental health services, such as the Mental Health Parity and Addiction Equity Act of 2008.
According to the State of Parity report released at the February 26 meeting by the Kennedy Forum, founded by former congressman Patrick Kennedy in 2013 and the Scattergood Foundation, "insurers still circumvent the [Parity] law’s requirements." Samuel Nussbaum, MD, executive vice president and chief medical officer for Anthem, Inc, said that insurers are often stymied when trying to apply both the letter and the spirit of parity, in part because of a lack of evidence. "How do we determine what works?" Dr Nussbaum asked.
The Joint Commission hopes to help answer that question with its new requirement, VanAmringe told Medscape Medical News. The current standard for the 2300 behavioral healthcare organizations it accredits requires outcomes assessments, but there is no requirement to use standardized measurement tools or to aggregate patient data, she added. The new policy will require a standardized method of measurement that is sensitive enough to show that an intervention improved a patient’s outcome. Organizations will also be required to assess outcomes on a population-wide basis and to use the information for continuous quality improvement, VanAmringe said.
That kind of data collection can "make your organization more valuable" to insurers, she said, "because you show that you are improving outcomes." The data can also be used to show that mental health care services work, she said. "Too often, people don’t think that they are that effective," said VanAmringe. A Joint Commission committee will review the proposed requirement in March. The requirement will then be made available for comment by accredited organizations, and it will be reviewed by the Joint Commission’s board. It is hoped that the new standard will be announced in July, VanAmringe told Medscape Medical News.
Use of the new standard would not be required until January 2017 — about the time that the Centers for Medicare and Medicaid Services will start payment for its collaborative care model, which was made final in the 2016 Medicare fee schedule rule. The model, developed at the University of Washington, creates a team involving a primary care physician, a care manager, and a psychiatric consultant. It is still not clear what that model will look like or how physicians will be reimbursed. The CMS will "propose the details of that methodology" this year, said Patrick Conway, MD, the agency’s acting principal deputy administrator, at the meeting.
It’s 1980 again, or maybe still – the same rhetoric. The only place that this really fit was in the medical modeling of certain physical diseases, so that’s the direction things took. Known diseases, diagnosed with clear criteria, treatable with defined treatments [time limited] – something like psychic pneumonia. We built a diagnostic system based on that model [and even messed up the places where it fit eg depression], and set out to prove drug efficacy based on clinical trials of treatments aiming towards creating guidelines that could then be generalized to those diagnostic groupings. Medications were approved based on the specific diagnoses. Since we had no markers or lab tests, the clinical scales or their derivatives from the clinical trials became the proxies. So the whole system became modeled on the Randomized Controlled Trial [RCT]. Now, the whole system will actually become a Randomized Controlled Trial [RCT] with outcome variables.
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There’s no provision for the actual mental illnesses that come closest to fitting their model – Schizophrenia, Manic Depressive Illness, Melancholia [or whatever you choose to call them]. Are the PCP’s to treat them too?
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Practically speaking, the only available treatment to recommend will be medications, or some different medication, and right now we’re at the end of that road rather than the beginning like we were in 1980. This system is based on the fantasy that a psychiatrist can help a primary care physician use medications better, yet we are in a time when the limitations of symptomatic medication alone are staring us in the face. How will this make anything better?.
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Candidly, this is backwards, "Samuel Nussbaum, MD, executive vice president and chief medical officer for Anthem, Inc, said that insurers are often stymied when trying to apply both the letter and the spirit of parity, in part because of a lack of evidence. ‘How do we determine what works?’ Dr Nussbaum asked." A better version might be, "How are we to determine that insurers are actually interested in the treatment of their client’s mental illnesses [speaking of a lack of evidence]?"
The Joint Commission should reflect carefully on the results of the pain initiative they initiated in the year 2000. This seems like the same administrative speak -flowery rhetoric with nothing to back it up. The only difference of course is that it will give managed care companies even more leverage in rationing care and trying to intimidate physicians.
“The new policy will require a standardized method of measurement…”
This will be a method that will serve the administrators in large organizations. Not the patients. Not the clinicians. So disheartening.
I don’t object to documenting patients’ progress with rating scales. After all, I committed the HAM-D scale to memory during my residency training. But scales supplement the clinical narrative – they don’t substitute for it. The über-managers in health systems and insurance corporations don’t have clinical backgrounds, so they have no awareness of how unprogrammable clinical work can be. That’s why they frame clinical problems as algorithms and why they cast clinicians as cyborgs. Problem is, our patients didn’t get that memo and they are now mad as hell because their face time with physicians no longer allows the depth of human interaction it once did. It is ironic that we succeeded mostly in keeping the FDA from muscling in to regulate the practice of medicine, yet the Joint Commission and CMMS and insurance companies throw their weight around with impunity. He who pays the piper calls the tune.
“But scales supplement the clinical narrative – they don’t substitute for it.”
Metrics are trampling relationship & narrative. Algorithms are trampling the un-programmable. This war is being lost, in both healthcare and education. Perhaps in healthcare the war is largely over. When public and private insurance stops covering prescriptions and lab requests from out of network providers it may largely eliminate most of the independent solo practitioners in psychiatry too.
1boringyoungman,
I remember thinking thoughts like that 30 years ago when I left Academia. But on the other side of the coin, it was a time of Managed Care, and having someone else telling either me or my patients what to do was no good for what I saw as the task at hand. I didn’t use insurance for my own treatment even though I had it for the same reason. So I guess I was a “free-range” doctor on the “open market.” I charged modest fees and had no overhead other than a place to work. I was never on a “panel” or a “provider.” I taught whenever asked and didn’t charge for that. My friends said I was naive to believe that my notion that if what you did was effective and delivered with integrity, things would work out. My models were the doctors who took care of me when I was a sick kid and a line from the movie “Field of Dreams.” I didn’t write that many prescriptions and didn’t need any lab work.
I was right. Things worked out quite well. I recommend naivety…
1bom, thank you.
Great post and comments. All I would add is that another factor to consider in using metrics judiciously, and I would add sparingly, is that rating scales and outcome measurements have risks that beyond those we experience in the consulting room.
I am on an insurance panel, and I’m getting on a few more, and I am grateful that insurance carriers are reimbursing for psychotherapy. And I do not have to have a laptop open for every session. (Though I do for intake and it definitely gets in the way, in some cases way more than others.)
But the time lost outside of the consulting room is a huge hidden cost as well. I consulted with a few of my colleagues today, and we all have been so bogged down by forms and paperwork that we were like starving animals fighting over a kill— all talking over each other, desperate for human feedback and interaction.
The idea of another vast data collection and analysis effort will fill me with dread if I surrender to my… er, automatic thoughts on the subject. There is a terrible feeling of despair that comes from spending time filling out checkboxes and forms that could be spent doing literature review or consulting with people you trust.
When will some government agency decide that NBA players will be more skilled if they document their shots on an electronic record in the middle of games?