The Challenge of Measuring Quality in Behavioral Health

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Despite recommendations and the passage of legislation, there is little evidence that the quality of behavioral health has improved significantly over the last 10 years in the United States.

Ten years ago the Institute of Medicine (IOM) issued a report that made bold recommendations to improve the quality of behavioral health care in the United States, but few of them have been implemented.

According to a recently published overview in the June 2016 issue of Health Affairs, even with the enactment of the Affordable Care Act (ACA), the passage of legislation in 2008 requiring parity of insurance coverage for behavioral and physical health, and greater recognition of the effect behavioral health disorders have on the population’s health, there is little evidence that the quality of behavioral health has improved significantly over the last 10 years. This is the case even though reforms have brought expanded resources and requirements for assessing quality, and provided an increased number of state and nongovernmental organizations charged with focusing on developing and implementing quality measures for behavioral health.


Harold Alan Pincus, MD, of the Department of Psychiatry, College of Physicians and Surgeons at Columbia University in New York City, and colleagues provided an overview of the current state of quality measurement in behavioral health, and make recommendations as to how to develop a set of measures for behavioral health quality that are as robust as those for general medical conditions.

For example, the authors wrote, the average performance on 4 behavioral health measures among commercial plans reported in 2014 was 48% compared with an average of 72% for 6 cardiovascular and diabetes measures. These findings meant that, on average, people with mental health or substance use needs get recommended care half the time, while recommended care occurs about two-thirds of the time for people with diabetes or hypertension. The patterns were the same in Medicare and Medicaid, research suggested.

The authors highlight the following 5 key priorities that need to be addressed:

  1. Expansion of outcomes measurement: an increasing emphasis on engaging patients and families in evaluating health care and prioritizing the development of quality measures incorporating patient-reported outcomes.
  2. Structural approaches that focus on enhancing the capacity of organizations and providers to provide effective care likely to achieve favorable outcomes, including accreditation or recognition programs such as patient-centered medical homes.
  3. Integrate care by taking steps to avoid the current fragmentation of care that leads to a costly, “siloed” system that ignores interfaces between mental and physical disorders and conditions.
  4. Implement psychosocial interventions: interpersonal or informational activities, techniques, or strategies that target biological, behavioral, cognitive, emotional, interpersonal, social, or environmental factors with the aim of reducing symptoms and improving functioning or well-being.
  5. Make treatment of substance use disorders a priority, using reliable and validated ways to assess care for substance use conditions including drug and alcohol use disorders. Few people with these disorders receive even minimally adequate treatment, the authors wrote, and this lack of treatment and the recent rapid rise of opioid abuse suggest that developing new measures for substance use disorders should be a high priority. Although the ACA is expanding coverage and access to care for substance use problems, there are large gaps in the availability of measures demonstrating successful treatment approaches.

The authors concluded that in order to move from measurement to improvement of behavioral healthcare, there must be national leadership and coordination in terms of what entities are responsible for supporting and funding the science of developing quality measurement and improvement strategies.

Stronger collaboration between funding agencies is needed. Data sources must be linked, including better adoption of electronic health records, which has lagged in behavioral health settings. Finally, a well-prepared workforce must be trained and held accountable for improving quality and outcomes for individuals with behavioral health conditions.