Notes From Our Uncertain Future: Good News About "Outcomes Management"

Arthur L. Kovacs, Ph.D.

I am on my way home from the first meeting of the APA Committee for the Advancement of Professional Psychology's Outcomes Work Group. I want to take some time and space in our publication to alert our members and other readers to what I consider to be extremely important developments in our field. In order to understand these changes, we must first remind ourselves of recent developments in the financing and delivery of psychological care.

The very, very good news I bring to your from our meeting is that the managed care movement appears to have begun to implode and to self-destruct even sooner than I would have predicted. The profitability of managed care organizations (MCOs) appears to be entering a period of marked decline. As you are aware, MCOs have been in a furious battle for market share over the interval. Bankruptcies, mergers, and acquisitions have been the order of the day. The primary tool used by MCOs to seize market share has been the constant cutting of capitation rates charged to large employers to cover their employees. We all know how the cutting has been achieved. Care has been denied and limited, and reimbursement rates paid to professionals have steadily declined.

Capitation rates are now so far down, however, that there is little more that can be cut. In addition, the MCOs now face increasing media exposure focused on their enormous profits and questioning the morality and consequences of their behavior. Both federal and state legislatures are increasingly willing to place limits on egregious MCO practices, and courts are beginning to hold MCOs accountable for the quality and consequences of the care they deliver, rather than treating them simply as contractual business arrangements. Employers are also becoming more sophisticated and are asking pressing questions about the quality and accessibility of the healthcare they are purchasing. The MCO model of expanding market share through the denial of care and the cutting of reimbursement rates will not continue to support ongoing corporate growth.

MCOs are working hard to reposition themselves in the market in order to restimulate profitability and lessen risk exposure. As part of a strategy calculated to defend against increasing media scrutiny and the concerns of health care purchasers, MCOs are now trumpeting their ability to deliver "quality" as well as dollar savings. There is a frenzy of design effort in the marketplace being carried out by the MCOs themselves, provider groups, consulting firms, and individuals all racing to create and to implement measurement technologies that purport to serve as demonstrations that a given care system provides "quality" care. (A recent issue of The Independent Practitioner contained an article by Michael Brickey surveying some of the existing "quality assessment" tools.)

APA Practice Directorate staff and the Committee for the Advancement of Professional Practice (CAPP) have been tracking these unfolding developments for the past few years. The matter of quality assessment with regard to psychological care is a particularly compelling one for psychologists. What discipline is superior to ours in having the training, the mind sets, and the tools to carry out program evaluation and outcomes assessment? A review of the technologies currently being promulgated in the marketplace reveals that a large number of the products being touted by MCOs as indices of quality are trivial client satisfaction self-reports or contaminated ratings of symptom reduction.

Given these facts, CAPP came to the wise conclusion that the possibility of APA identifying or developing a well reasoned, scientifically valid technology for evaluating the effectiveness of psychological care that was capable of encompassing a wide range of treatment orientations could be a highly desirable project for the Association. If psychology is to influence these developments, however, we must act quickly before other technologies, some of dubious quality, get written into a variety of regulations and set a poor standard. NCQA, the "accrediting" organization created and sponsored by MCOs, has begun requiring demonstrations of "quality" (largely defined by MCOs themselves) from its participating members. JCAHO, which is also driven by large healthcare organizations, is on the verge of listing a set of defined technologies it finds acceptable and requiring the nation's hospitals, clinics, and other healthcare structures to make use of one or the other of these in order to renew accreditation.

In 1995, CAPP decided to pursue the feasibility of what was then called the "data base project." CAPP undertook a review of existing "products" to assess whether any existing measurement system met our needs, or was modifiable to do so. The hope was that a partnership could be formed with an external vendor. CAPP appointed a Work Group to review the results of this search and to recommend to CAPP whether or not the possibility of forming such a strategic alliance was either possible or desirable. I was appointed as a member of this Work Group to advocate for and to safeguard the interests of the members of Division 42.

Our efforts to determine whether there was an existing product that met our standards and our needs led to the reluctant conclusion that there was not. During the search and evaluation period, however, fate intervened in what has turned out to be a marvelous fashion. Congress, in its usual cost-cutting mood, has been becoming increasingly alarmed at what it believes to be the high cost of providing medical and psychological care to the military and at what some have characterized as waste and duplication of effort. A mandate was given to the uniformed services: find ways to integrate, end duplication, cut costs, and become lean and mean or the privilege of providing care for the military is going to be taken away from the armed services and is going to be outsourced and put up for bids to the MCOs.

The military in the greater Washington, DC area responded to this challenge by creating the National Capital Area Mental Health Alliance (NCAMHA). The military has traditionally run three completely separate healthcare systems in this area, one system each administered by the Army, the Navy, and the Air Force. This included three separate and prestigious hospitals, along with their training and residency programs, located within a few miles of each other, as well as a variety of clinics and outpatient settings. In contrast to MCOs, the armed services' responsibility for providing care for its enrollees is not limited to a 1-year period at a time. A large portion of the military in the National Capital Area are career personnel. The military are responsible for providing continuing care to these individuals and their dependents for 20 to 30 years of active duty, and in many cases after they retire as well. The military is therefore keenly interested in such questions as: (1) what care ought to be provided now so that confronting ever worsening and debilitating conditions some years later can be avoided; and (2) what efforts at prevention ought to be implemented and paid for to preserve wellness.

Mental health professionals at the Department of Defense (DoD) contacted APA staff with a series of exploratory questions that eventually led to a request to provide consultation about integrating their mental health services in the National Capital area and their desire to build what they described as an "outcomes management technology" into the system. On recommendation from our Task Force on the Data Base Project, CAPP agreed to consult with the NCAMHA in collaboration with National Computer Systems Assessments (NCS). (Some of you will recognize NCS as the corporation that publishes and distributes the MMPI and the Millon. Its personnel have considerable expertise in the development of data management systems as well as in the design and development of psychological assessments.) CAPP felt, quite correctly I believe, that participating in the NCAMHA project would teach us a lot about the challenge of creating outcomes technology, that the consulting contract would provide funding for otherwise expensive early-phase efforts we were interested in undertaking, and that if a successful military system could be designed, portions of it might be applicable to the assessment of civilians seeking psychological care.

Developing an outcomes management system that would accommodate military needs turned out to be an even more ambitious project than was first anticipated. The outcomes management system envisioned was for more encompassing than simply developing a technology to demonstrate quality of care. The latter is retrospective. Care givers give care. When they are finished giving the care, some quality assessment technology is employed to issue a scorecard about how good that care had been. This is true whether the scorecard is for an individual provider, for a unit, or for an entire system.

Outcomes management, on the other hand, not only renders a retrospective conclusion, but also tracks care while it is still in progress, provides feedback at specifiable points, and permits patterns of care to be altered or modified as care is proceeding. Its aim is to build a kind of continuing feedback loop that will make possible the ongoing improvement of the quality of care. Outcomes management technologies can also be directed at studying the performance of an organization (e.g., a clinic), a component of an organization (e.g., the effectiveness of a family therapy program for substance abusing adolescents), or of some aspect of the care given by an individual psychologist (e.g., Dr. Wiseperson's work with troubled couples).

Let us make no bones about a critical issue. It is the latter prospect - being subject to an individual evaluation of our own performance - that sends chills through all of us. The health care field is moving inexorably towards the design of data collection and data analysis systems that will have the potential to issue a scorecard on how well each of us may in fact be doing what we say we are attempting to do. There is a tremendous amount of well-justified anxiety about how much even carefully crafted outcomes management systems will be able to capture what we consider to be the important ingredients of change and the deeper, more lasting, and highly individual outcomes of psychological treatment. I believe that the design of the NCAMHA project should provide at least a modicum of comfort to all of us.

In my view, the designers of the NCAMHA system have fashioned something that is wise, robust, practitioner friendly, and, as it begins to generate data, of tremendous potential value in demonstrating the worth of liberal access to psychological services of all kinds. Let me review some critical aspects of the NCAMHA system as it has been proposed:

The system has been designed and will be implemented by the very professionals who provide psychological services. The system is practitioner friendly and designed to provide clinically meaningful information of value to practitioners. It is not a structure imposed by managers, bean counters, avaricious MBAs, or any others whose primary motivation is to cut costs while generating cosmetic data to hide damage being done to consumers.

Yes, the system will require the inputting of certain data about patients and certain data generated by those rendering service. The military, however, know how to encrypt and protect the privacy of data better than almost anyone. I am persuaded that sensitive and critical material about care episodes will be much better protected from breaches of confidentiality in the NCAMHA system than are the materials most of you share with MCOs.

The NCAMHA has defined the goal of the system as putting the best information in the hands of professionals so that they can make decisions on behalf of their patients. Each professional can begin to study the types of patients or patient issues that he or she works with most effectively.

The primary focus of study for the NCAMHA will be data regarding units within the NCAMHA and regarding specialized tracks within units. This will enable the examination of issues such as the what types of planned interventions appear to work most effectively with what kinds of conditions.

APA and NCS staff asked the DoD representatives over and over again, in a set of successive iterations, to define what the purposes of psychological care in the military might be. What was the overarching goal that interventions should be designed to achieve? The initial and continuing answer from the representatives of the military was that both they were committed to safeguarding preparedness and returning personnel not presently prepared to a state of military readiness. Many of us groaned at this description. What kind of strange system would have to be designed to assess whether the goal of securing military readiness had been achieved? What on earth could be the possible adaptability to civilian care systems of a system promoting military readiness? But as the military began to clarify for themselves and for our consultants what they meant by the concept of "military readiness," I began to be thrilled.

What the NCAMHA understands by "readiness" turns out to be contained in such concepts as resiliency, robustness, a capacity to endure sudden and marked life disruptions and very threatening and awful life circumstances-- often without adequate social support-- and nonetheless to be resistant to personality decompensation or to markedly impaired functioning. In some ways, Maslow and members of the human potential movement would be very happy with the kinds of formulations the military generated for the aims of their system. I certainly believe that such a conceptualization would be wonderfully apt for a civilian system as well. What, after all, are we describing by these concepts if it is not helping humans to achieve the best use of their potential that they are able? And is that not what we professionals in civilian life aim to achieve as well?

With readiness as the outcome variable to be assessed, the military then went on to develop a conceptual map of what antecedent variables would either support or tend to impair a given uniformed person's readiness. With extensive questioning from APA and NCS consultants, the military at last identified two antecedent variable sets. On the one hand, they postulated a personal, intrapsychic variable set that includes certain kinds of enduring and handicapping personality traits, thought and mood disorders, and intelligence, among other variables of importance. They have also described a contextual variable set that includes such other matters as occupational maladjustment, family problems, financial problems, physical health, and other life stressors. In the final analysis, they have simply succeeded in operationalizing the classic formula, B = (f) P, E. What is lovely about this structure is that the military is committed-- for as long as might prove necessary-- to working on and to treating any or all of the antecedent variables in either of the variable sets so long as progress is being made towards the end objective of restoring readiness. Remember, the DoD, in contrast to MCOs, views uniformed personnel and their families as precious assets and will make quite long-term investments in them to keep them functioning in a highly effective fashion.

Related to the above, the NCAMHA employs the services of a very large cadre of mental health personnel. It also delivers a rich array of services to members of the military and their dependents: inpatient, partial hospitalization, and outpatient services. In those settings, almost the entire diversity of group, individual, and family therapies characterizing our field are practiced, including long term psychoanalytic care, cognitive behavioral treatments, the systemic psychotherapies, and problem focused counseling. The conceptual structure adopted by NCAMHA for a wide range of treatment approaches, encouraging professionals and clinics to conceptualize and describe the relationship of these treatment approaches to different individual and contextual antecedents as a way to begin addressing the match between patient and treatment.

The consultants have spent the past few months helping NCAMHA personnel to select instruments that can be given both to patients and to therapists to measure both the antecedent and outcome variables. Once the lengthy and difficult process of articulating the clinical framework, goals of treatment and prevention, and determinants of dysfunction had been accomplished, selection of specific measures to capture different aspects of this conceptualization was relatively easy. Instruments were chosen (1) because they represented what appeared to be the best scientifically validated choices, and (2) at the same time were not onerous for the parties to fill out.

I believe I have reasonably well conveyed the significant challenges and possibilities posed by the Tri-Care project. Before closing this article, however, there are a few more matters of note that I want to bring to your attention:

As part of the integration of the NCAMHA delivery system that has now been effected, the importance of professional labels and designations has been obliterated. The directors of large programs and of subunits have been chosen for capability and seniority, and not for reasons of turf. This means that for the first time psychologists and social workers in the military have been invested with a variety of high level managerial assignments.

Word is now out everywhere in the health care industry about the project and about the consulting roles of NCS and APA. Many are looking to NCAMHA as a model for what the civilian care system might come to look like. The telephone is ringing often now in the Practice Directorate with various organizations and corporations calling to begin explorations of the possibility that APA might be of help to them. What we have designed is not an outcomes assessment "product." That is, we do not have a uniform, one-size-fits-all set of instruments to copyright and to sell to others. What we have developed, instead, is a very sophisticated consulting technology. It goes something like this: you want us, we are going to enter into a dialogue with you forcing you to sharpen your understanding of what the goals and purposes of your care system are and what benefits you want those who receive care to derive from it. Then you are going to have to define how you understand impairment and what genotypical variables produce it. Next, you will have to tell us for the persons you treat which of these variables you are willing to pursue, and how intensively. Then we will help you to identify measuring instruments and set up data collection and data analysis procedures that will allow you to study and to manage your own identified outcomes." It may in fact become commonplace for any health care plan to have available statements of care philosophy, statements of what kinds of care for what purposes will be given, statements of how the need and intensity of care to be provided is conceptualized, and statements about how effectiveness will be measured. What a scorecard that would be! Both employer/purchasers of care and subscribers would at last have the data necessary to make informed choices among care systems.

There remains a dark side to these developments. Practitioners who want to continue to access third party payments are slowly going to have to go on line with computers and modems to be eligible to participate. Each plan will require the collection of data from patients and some from treating professionals which will have to be input into central storage. Feedback will be available about the entire system's care experiences as well as individualized data for each participant. I cannot, however, promise that the encryption rituals of the MCOs will be as rigorous and protective as are those of the military. Nor can I promise that the MCOs will not use data you generate to dump you out of the system.

Jeff McKee
Saturday, April 25, 1998