Supplements Trends in Managed Behavioral Healthcare: A Focus on Improving Depression Outcomes
HEDIS Antidepressant Medication Management Measures and Performance-based Measures: An Opportunity for Improvement in Depression Care
Using the Health Plan Employer Data and Information Set (HEDIS), the National Committee for Quality Assurance partners with more than 90% of the nationâ€™s managed care organizations to collect, audit, and report performance on a range of standardized healthcare quality measures. Many HEDIS measures have been useful in promoting population health, such as rate of beta-blocker use after myocardial infarction or rate of cervical cancer screening. Other measures, such as those for Antidepressant Medication Management (AMM), have been less successful. Several trends are occurring within behavioral health management that attempt to improve depression treatment outcomes, including the implementation of performance-based initiatives using the HEDIS AMM measures and the 9-item Patient Health Questionnaire. Ultimately, linking quality measures to clinical strategies is critical for achieving successful depression treatment outcomes.
(Am J Manag Care. 2007;13:S98-S102)The Health Plan Employer Data and Information Set (HEDIS) was developed by the National Committee for Quality Assurance (NCQA) in the early 1990s to provide insight into the performance of managed healthcare plans. HEDIS provides objective clinical performance data measured against a detailed set of criteria. Using these data, HEDIS rates health plans and is the set of quality indicators used most by purchasers in selecting and rating plans. The NCQA selects indicators for HEDIS evaluation based on their scientific soundness, relevance, feasibility, and standardization as measures of healthcare provider performance. In 2005, HEDIS was used by more than 90% of America's managed healthcare plans to measure performance on important dimensions of care and service.1
HEDIS AMM Measures
The HEDIS Antidepressant Medication Management (AMM) measures focus on compliance with medication regimens and appropriate follow-up as the key to improved care for eligible members (ie, patients >18 years of age with depression as of the 120th day of the measured year). The AMM measures consist of 3 components: effective follow-up in the acute and continuation phases of treatment and appropriate practitioner follow-up.1 The acute phase is defined as the 3 months immediately after the diagnosis of a depressive episode. The AMM acute care measure describes the percentage of eligible plan members who were diagnosed with a new episode of depression, treated with antidepressant medication, and remained on an antidepressant drug throughout the 3-month period.1 Effective continuation phase treatment is defined as the percentage of eligible plan members who were diagnosed with a new episode of depression, treated with antidepressant medication, and who remained on an antidepressant drug for at least 6 months.1 The optimal practitioner follow-up measure is defined as the percentage of eligible members with a new diagnosis of depression treated with antidepressant medication who received at least 3 follow-up office visits with a primary care physician (PCP) or mental health provider in the 3-month acute treatment phase. At least 1 of the 3 follow-up contacts must be with a prescribing practitioner (ie, licensed physician, physician assistant, or other practitioner with prescribing privileges).1
Health Plan Performance on the AMM
Performance on HEDIS mental health measures from 2000 to 2005 (the last year data were available) shows mixed results, but have shown little improvement over time.1 Performance on the AMM measures from 2000 to 2005 is illustrated in the Table. For patients enrolled in commercial plans and for those with Medicare, follow-up rates have barely changed in the 6 years between 2000 and 2005 and even less so in the past 3 measurement years (Figure 1).1 Approximately 60% of patients enrolled in a commercial plan received prescriptions during the acute phase of an episode and only about 40% renewed a prescription during the continuation phase of therapy. Barely 20% of patients received at least 3 follow-up office visits during the acute treatment phase. performance on the AMM was worse in the Medicare population.
Performance on HEDIS AMM measures has consistently lagged behind the performance of other chronic conditions. Druss et al compared the performance of commercial plans on the mental health measures (ie, the HEDIS AMM measures plus 2 measures for follow-up after discharge from a hospital for a mental health—related stay) with 9 non—mental-healthcare measures and observed that the mean rate of mental healthcare performance was 48%, compared with 69.2% for non—mentalhealthcare domains.2 Rates of improvement on mental health performance have also been less robust than for improvement on other medical domains.1
Why Do Plans Perform So Poorly? A number of patient, provider, and system-level factors are likely to explain the continuing low scores of HEDIS performance measures. A survey was conducted of patients to better understand the reasons for early discontinuation of selective serotonin reuptake inhibitor medications. This study found lack of communication between physicians and patients regarding duration of therapy and side effects to be the most important causes of premature discontinuation.3 Another study examined plan-level predictors of poor HEDIS mental health performance and observed that poor scores on general medical indices, failure to report findings publicly, and low
medical—loss ratio (proportion of revenues spent on clinical care) all predicted poor performance on the mental health measure.2 A major challenge to understanding and improving mental health performance among health maintenance organizations (HMOs) is the fact that some of these plans carve out their mental healthcare to behavioral health managed care organizations (MCOs).4 Depression care may be provided solely within the HMO, within a carve-out, or in a combination of the two. An important step for plans intent on improving their mental health performance is to understand where care is provided, and then to identify the clinicians or clinics responsible for ensuring that it is delivered appropriately.
Barriers to Quality Improvement in Behavioral Health
The modern healthcare delivery and reimbursement scheme has created several economic barriers that hinder quality improvement in depression treatment. Foremost, provider payment arrangements in capitated or bundled systems affect decision making within medical practices.4 These arrangements create an incentive for providers to deliver fewer services than fee-for-service systems, which reward provision of additional services. In the area of depression care, in which continuous and comprehensive care is paramount, payment arrangements that create an incentive for fewer services provided can be detrimental to patients' mental health. Furthermore, many health systems offer PCPs productivity bonuses based on the total number of visits provided in the course of a week. Because identifying and treating depression often takes more time than treating other conditions, these bonuses provide disincentives for treating depression or at least treating depression effectively.4 Attempting to diagnose and treat depression in 10 to 15 minutes or less leads to counterproductive responses from seriously ill depressed patients.
Similar to the barriers created by payment arrangements, no mechanism exists in current
managed care design for reimbursing PCPs for depression care managers' services or mental health specialty consultations.4 This may discourage PCPs from referring depressed patients to mental health professionals, whose expertise in major depressive disorder could play an invaluable role in effective treatment. The desire to reduce financial risk for patients through insurance also may affect clinician choices and patient honesty, leading to incorrect diagnoses or coding to avoid high premiums associated with behavioral health conditions.4 Furthermore, the relative levels of coverage in health insurance plans drive patients and their physicians, acting as the patients' agents, to favor one type of care over another. For example, given that prescription drugs often carry copayment amounts of $10 to $20, whereas psychotherapy may carry a 50% copayment rate for a service costing $80 to $150, patients will tend to favor pharmacotherapy over psychotherapy, all else being equal.4 All of these issues are exacerbated by the fact that the methods used to organize and pay for healthcare can insulate both providers and patients from the full consequences of their treatment decisions. Ultimately, when the relative prices faced by patients and clinicians do not reflect the relative costs of the services, treatment may be directed away from the most cost-effective forms.4
Pay for Performance
Considering a number of the barriers to quality improvement in depression care are largely financial, a solution employing economic components may serve as a viable answer. One such solution is the implementation of pay-for-performance (P4P) initiatives, a movement that is gaining popularity in MCOs across the nation. P4P initiatives were originally designed to repair the perceived disconnect between rising costs and stagnant quality improvement.5 Considering this inconsistency between increasing expenditures and unsatisfactory care, managed care stakeholders are seeking more effective ways to allocate funding and improve the overall quality of healthcare. As such, P4P initiatives seek to improve the delivery of services in managed care by using evidence-based medicine to drive financial incentives.5
Metrics. At the center of all P4P programs are specific metrics employed to measure performance and determine incentives to be awarded. These measures typically fall under the categories of clinical, efficiency, patient satisfaction, and information technology (IT).5 Clinical metrics focus on targeted intermediate outcomes resulting from adequate care, such as glycosylated hemoglobin (A1C) levels in patients with diabetes or low-density lipoprotein cholesterol levels in patients with cardiovascular conditions. Efficiency metrics look toward performance, such as generic substitution rates, utilization of services (episodes of care), and practice patterns, with apparent financial implications. Surveys or opinion cards are distributed to gather information regarding physician performance in patient satisfaction metrics, which measure the quality-of-care delivery from the patient's perspective. Increasingly incorporating measures of performance, IT metrics recognize the value of employing healthcare technology innovations, such as electronic medical records and e-prescription refills, in managed care.5 These performance-based measures are often established by widely recognized national health organizations such as the NCQA (eg, HEDIS and Bridges to Excellence), National Quality Forum, American Medical Association Consortium, or the Centers for Medicare & Medicaid Services.5