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Let Us Adopt Measurement-Based Care at Long Last
Churchill is quoted as saying that Americans always do the right thing, only after they have tried everything else. This aphorism will be the perfect sentiment for our field the day measurement-based care (MBC) becomes standard. We have long resisted it, but MBC may emerge as “the right thing” once everyone realizes we are a component of a healthcare system built on measurement.
MBC goes by many names, but it involves measuring the results of a treatment episode while it is in progress. The client is asked to complete questionnaires rating symptoms, functioning, and other clinical indicators. These objective measures of health status are the backbone of clinical research. We determine the effectiveness of psychotropic medicines and psychotherapies using these tools.
Our reluctance to use these tools in everyday practice has often been criticized. The Kennedy Forum produced a definitive statement on MBC in 2015, and they compared this “indefensible clinical practice” with “treating high blood pressure without using a blood pressure cuff.” They encouraged our meeting the standard set by other medical specialties.
The path to MBC adoption may be a long one. The Kennedy Forum notes that only 18% of psychiatrists and 11% of psychologists routinely administer symptom rating scales to monitor treatment response. Concerns about the potential administrative burden of MBC cannot fully explain this. A fear of accountability, a common human foible, probably drives some of it. Yet most have little to fear.
When clinical outcomes are aggregated by clinician, the distribution forms a normal bell curve. No one wants to be in that tail of the curve with roughly 5% of clinicians getting very poor results. Yet our clinicians will find little sympathy for such wariness from a medical community immersed in performance metrics. Clinical performance is a fair question for patients and payers to raise.
The medical community, of which we are rapidly becoming a part, will insist on MBC once the issues are fully understood. However, a more interesting debate about outcomes in our field is now beginning. It stems from stellar clinical results for digital therapeutics. What are the implications of those findings?
A quick review of studies by digital behavioral companies like Silver Cloud, Headspace Health, and Spring Health shows clinical outcomes in the highly effective range. How are these digital platforms getting such good results? We can only speculate until further research clarifies, but the larger point is that we now have the ability to implement a range of valuable services for people needing access to care.
The focus should shift from our long resistance to MBC to new realities. Our field is well along in its business consolidation. We are becoming part of the larger healthcare system, and that system functions on the principle that clinical results are measured whenever possible. Fortunately, new digital products have done this, and we can now design a new behavioral system of care around outcomes.
Our field is at an exciting juncture where MBC can guide care access. Some hopeful signs were previously missed, even by analysts with the Kennedy Forum. They neglected positive real-world psychotherapy studies and chose instead to promote evidence-based prescribing guidelines. However, we are finding that routine therapy services, delivered in several modalities, are getting good results.
The Kennedy Forum is grounded in a psychiatric perspective in which care is based on diagnosis. Yet real world psychotherapy is provided upon request, regardless of diagnosis. Many studies have tracked improvement for groups receiving general psychotherapy. Like recent studies of people using digital tools, real world therapy results are often comparable to those found in academic research studies.
What is the value of MBC for the practicing clinician? It is using data to flag treatment cases at risk for a poor outcome. The vast majority of cases go well, and so MBC is a tool for identifying outliers. At an aggregate level, the value of MBC expands to tracking outcomes at the clinician and clinic levels. Beyond that, we might start to compare outcomes for digital, virtual, and in-person services.
These results can help match people with the right services. Many will improve with digital tools, while others need the interpersonal process of working with a therapist. Complex cases may need modifications, possibly for both therapy and pharmacology. MBC is a way to track progress and know when to make changes, and it facilitates our providing effective services to more people.
Medical leaders will likely promote MBC as best practice as our services increasingly come under their control. We may have legitimate fears about losing autonomy and fitting into the general healthcare system in the coming years. However, objections to MBC will subside without much debate. They have long been spurious. Healthcare relies on measurement whenever possible. We are part of healthcare.
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, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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