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Business Consolidation Must Not Interfere With Our Field’s Advancement
Whether we like it or not, our field is being acquired and merged into larger healthcare entities. This consolidation should benefit many stakeholders with various types of integrated care. However, the guidance we will get from healthcare’s big payers and health systems will not always be useful. Their solutions will not always be best for us because behavioral health has unique challenges.
Consider the triple aim, the template for improvement widely embraced in healthcare today. Some of its features fit our field, but we have priorities that differ from the rest of healthcare. This is unsurprising given our distinct histories. Our field has struggled with stigma and inadequate funding, while the greater healthcare industry has ascended to being one-fifth of the US economy.
It is important to understand how and why our strategies diverge, and the best way to explore this is through specific examples. Two domains, quality and cost management, epitomize how we need models for improvement that are tailored to our own needs.
Measuring Quality in Behavioral Health
For decades, health plans have invested in the approach to quality of the National Committee for Quality Assurance (NCQA). However, we need to rectify deficits in our field that NCQA has not touched. NCQA’s model seems to miss the mark for a biopsychosocial field like ours.
NCQA was founded in 1991, with accreditation for behavioral health added 6 years later. For a quarter century, NCQA has ignored one of our field’s major failings, the absence of measurement-based care (MBC). While our leadership is responsible, NCQA has quietly accepted measurement-free care.
To be fair, NCQA never mandates processes like MBC. It promotes quality metrics (HEDIS) and recommends conducting QI studies with wide latitude for the focus. NCQA’s quality paradigm may seem universal, but it is rooted in the medical model. This is readily apparent in the medically oriented HEDIS metrics for our field that focus largely on issues like medication and hospitalization.
Such a quality orientation can minimize our field’s psychosocial origins and methods. A medical view of psychotherapy focuses primarily on whether research supports it as an evidence-based practice. If so, quality is assured. It is comparable to offering the right surgery, device, or medication. Yet therapy needs ongoing measurement embedded in it, gauging how therapy is progressing for each client.
MBC is far more than a quality initiative. It is a critical piece of healthcare reform for our field. Improvements like MBC must be internally grown and developed. This particular improvement has roots in the research traditions of psychology. Those roots may not develop in medically dominated institutions (like NCQA or health plans), and this is a problem. We do not want to lose such paradigms.
This problem will get bigger as we merge with healthcare institutions in the payer and provider realms. They operate from a predominantly medical perspective, and so we need effective advocates for psychosocial solutions. Leaders in large medical systems will be responsive to our needs only if we are well represented. Behavioral leaders must rise to this challenge.
Ringing Alarm Bells on Value-Based Care
Payers are experimenting with new cost management strategies under the rubric of value-based care (VBC). Our field needs to articulate its place in VBC since these models have the potential to devalue our services. The problem with VBC is not the concept. It is the execution.
VBC encompasses several ways to replace fee-for-service care with provider risk arrangements and better coordinated services. Behavioral healthcare is often part of this more holistic approach to care. However, VBC is primarily about finding cost efficiencies, and how those efficiencies are achieved is the dilemma.
Health plans could take several unacceptable paths to cost efficiencies. Might digital and virtual services be substituted for in-person care? Might there be 2 tiers of services, one with peer health coaches combined with digital therapeutics and another with licensed therapists? Will therapy be managed more tightly, reserving it for severe issues and eliminating it as discretionary self-improvement?
These provocative questions are presented mainly to ring alarm bells. Outpatient care is our field’s largest aggregate cost, yet access rates are still too low. We should be wary of leaders with limited understanding of our work monitoring our costs. Our own experts will disagree. Some psychiatrists only support diagnostically based, structured therapies, and so a lively debate about therapy is coming.
Preserve a Space for Our Own Innovation
Let us be alert to roadblocks to our continued advancement as we get folded into the larger healthcare enterprise. Our unique needs could easily get missed inside multispecialty health plans and health systems. Our triple aim is different from the rest of healthcare. We must preserve space to pursue our own home-grown solutions. That space will probably not be ceded to us.
Ed Jones, PhD, is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, Addiction Professional, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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