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
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 lowmedical—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
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
P4P initiatives are less common in behavioral healthcare administration, presumably partly the result of the lack of clearly defined clinical end points associated with mental health conditions. In fact, one set of measures that provides an ideal starting point for depression-related P4P programs, NCQA's HEDIS AMM measures, is among the least targeted among MCOs.6 Rosenthal et al reported that only 37.2% of commercial HMO P4P programs focused on the management of antidepressant medication as a clinical indicator, compared with more than 60% of programs for diabetes care, mammography, asthma medication, and cholesterol management (Figure 2).6
Despite their limited use in P4P initiatives, the HEDIS AMM measures present promise as metrics for granting incentives to physicians providing quality depression care. Bonuses may be awarded to physicians whose patients achieve specific levels of medication adherence at the 3-month (acute) and 6-month (continuation) follow-up periods as well as physicians whose patients meet the criteria for 3 follow-up visits in the 12-week acute treatment phase. These bonuses may also be stratified for greater incentives depending on varying rates of measure achievement, such as 50%, 75%, and 90% of patients reaching goal.
In addition to performance in the HEDIS AMM measures, incentives may also be granted for the use of clinically proven depression screening tools, modeled after P4P programs measuring screening for such conditions as diabetes (A1C screening) and cervical cancer (Papanicolaou tests).1 For depression screening, rates for screening may be measured in patients presenting with depressive symptoms who have experienced a previous episode of depression to target quality care in high-risk populations. In particular, the Patient Health Questionnaire (PHQ)-9 has demonstrated promise for use in P4P initiatives as an ideal tool for screening potentially depressed patients.7 The PHQ-9 is a “depression moduleâ€ that scores the 9 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria as 0 (“not at all”) to 3 (“nearly every day”) and provides an index of the number of symptoms and a total depression severity score. Alternatively, a shorter, 2-item version of the PHQ (PHQ-2) has also demonstrated significant sensitivity and selectivity in diagnosing depression.8 This depression “screenerâ€ uses 2 items from the PHQ that inquire about the frequency of depressed mood and anhedonia during the past 2 weeks, scoring each as 0 (“not at all”) to 3 (“nearly every day”).8 Utilization of either of these 2 screening devices may be employed as a metric to gauge performance in depression care, with PHQ-2 use serving as a less aggressive goal for certain MCOs.
Patients taking antidepressant medication are about as likely to receive appropriate care today as they were in 1999. Similarly, patients hospitalized for mental illness are only marginally more likely to receive appropriate follow-up care. Given the huge economic and societal toll of untreated or inadequately treated mental illness, new approaches must be developed to bring mental healthcare quality to the level of clinical effectiveness that evidence shows to be possible. The use of HEDIS AMM measures has clearly focused the attention of payers and consumers on the importance of quality in healthcare delivery. A first step in improving HEDIS scores is for plans to ensure that clinics and clinicians are held accountable for improving depression care by following accepted guidelines for treatment. Physician-level incentives tied to the delivery of quality care may be the impetus for improving the clinical and cost effectiveness of depression treatment. These incentives are currently being granted to top providers through the implementation of performance-based initiatives in MCOs across the nation. However, while P4P programs are more common in other disease states, such as diabetes and cardiovascular conditions, behavioral health initiatives are still in their infant stages. Importantly, the incorporation of the HEDIS AMM measures and PHQ-9—based measures has demonstrated promise in improving performance in behavioral healthcare delivery.
Address correspondence to: Bill Anderson, PharmD, Health First Health Plans, 6450 US Highway 1, Rockledge, FL 32955. E-mail: Bill.Anderson@health-first.org.1. National Committee for Quality Assurance. The state of health care quality: 2006. Antidepressant Medication Management. Available at: http://www.ncqa.org/communications/SOHC2006/SOHC_2006.pdf. Accessed April 6, 2007.
3. Bull SA, Hu XH, Hunkeler EM, Lee JY, Ming EE, Markson LE. Discontinuation of use and switching of antidepressants: influence of patient-physician communication. JAMA. 2002;288:1403-1409.
5. Dunn JD. Pharmacy management approach: how do we align all the incentives? J Manag Care Pharm. 2007;13(2 suppl B):S16-S19.
7. Spitzer RL, Kroenke K, Williams JBW. Patient Health Questionnaire (PHQ-9). Adapted from PRIME MD TODAY. Copyright Â© 1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a trademark of Pfizer Inc.