Feature

Pay-for-performance plans--programs designed to reward efficient, high-quality services with financial and other incentives--are mushrooming in the public and private sector.

But while medicine has been greatly affected by these programs for years and has been involved in their development, behavioral health care has barely arrived at the table, said presenters at an APA Annual Convention symposium. In fact, they said psychologists must take swift action to ensure they have a role in these systems, and that these programs are backed by strong science and put patients' interests first.

"It is important that we step up to the plate and be part of this discussion in a way that is fair to providers, fair to payers, and most importantly, that ensures the kind of quality care for our patients that psychologists are known for providing," APA Executive Director for Professional Practice Katherine Nordal, PhD, said at the session.

APA already has taken a significant step in that direction, Nordal said. During the convention, APA's Council of Representatives adopted a policy related to the topic, the Criteria for the Evaluation of Quality Improvement Programs and the Use of Quality Improvement Data. It provides psychologists with detailed, research-based criteria by which to evaluate these programs and make decisions about participation in them, Nordal said. The Criteria also provide a framework for the creation of well-designed programs and provide policy guidance for advocacy efforts in this area. (The document is available at www.apa.org/practice/Criteria-for-Eval-2008.pdf.)

While many practitioners are likely to be skeptical about these plans because of their "Big Brother" feel, it is in their best interests to help shape their direction, Nordal added.

"The day is coming very, very soon when we will all have to be accountable through some kind of measurement paradigm for the kinds of services we provide," she said.

Not the devil

Pay-for-performance plans are not simply crass cost-cutting measures, speakers agreed. Instead, they seek to provide consumers with the best care at the lowest cost by using data on what works and what doesn't--a direction driven as much by employers, the government and other purchasers of health insurance as by insurers, they noted.

"There is increased pressure from purchasers to have a very clear measurement of provider effectiveness," said psychiatrist Rhonda Robinson Beale, MD, chief medical officer for OptumHealth Behavioral Solutions, a major behavioral managed-care entity. "They don't mind paying more, but they want to know what they're paying for."

Purchasers have begun to understand the impact of behavioral health treatment in reducing employee absenteeism, disability and in some cases, medical costs, she noted.

These systems also are interested in allowing consumers to have as much useful information as possible so they can be assured of selecting high-quality providers, Robinson Beale said.

Moreover, pay-for-performance models encourage creative thinking compared with traditional models, said health policy expert Ann Doucette, PhD, of George Washington University. For example, they value integrated-care approaches over care by siloed specialists who rarely confer.

These plans also value strategic, data-based thinking that incorporates cost and quality concerns, said Doucette, who is also a nonvoting member of the American Medical Association's Physician Consortium for Performance Improvement, which makes significant decisions on pay-for-performance measures, including those related to behavioral health.

For instance, while it is standard practice for physicians to check the status of high-cholesterol patients every six months, "we don't have a system where a person with depression comes back for a wellness check six months later," Doucette said. "Perhaps we should. It might mean both better quality care and cost savings."

That said, these systems are still in their relative infancy, especially in the area of mental health care, speakers agreed. For instance, behavioral health measures used to assess performance still focus heavily on inputs--for example, a count of the number of sessions practitioners provide, or the portion of practitioners trained in an evidence-based treatment model--rather than on measures of patient improvement in terms of ability to function, or symptom reduction, they said.

However, many signs point to a growing, lasting trend, Doucette said. For example, the Tax Relief and Health Care Act of 2006 established Medicare's Physician's Quality Reporting Initiative (PQRI), which identified a set of quality measures across physical health-care medical areas. The government provides a small financial incentive for select health-care providers who report on at least three of these measures in 80 percent of the applicable cases. Meanwhile, a significant number of managed behavioral health organizations have published some type of provider profile on their Web sites, Robinson Beale said.

Food for thought

As psychologists consider how to contribute to the scientific and professional quality of these programs, they should keep a number of concerns in mind, presenters agreed.

For one, it's vital that psychologists work both collectively and in collaboration with other mental health professional organizations to avoid working at cross purposes and in isolation, said Robinson Beale.

"Our field is very small and less complex than the medical side," she said. "We have the opportunity to be a more effective care delivery system, starting with developing a consensus on key items across all mental health disciplines."

As an example, it would mean far greater efficiency if all managed behavioral health organizations used the same forms and operating procedures, she noted.

It is also important to hold respectful dialogues with insurers, noted Elena Eisman, EdD, executive director of the Massachusetts Psychological Association. "We won't get far if we assume a malevolent rationale for the changes being proposed," she said.

In a pragmatic sense, psychologists, along with other behavioral health professionals, must consider getting their offices up to speed with technology, in particular with the direct Internet and secure, office-specific e-mail access, said Robinson Beale. "When we looked at behavioral health providers, we were astonished when we found that very few have in-office Internet access," she said.

And getting online could help the mental health professions overcome barriers to accessing electronic health records, she said.

Finally, psychologists also must address how to build plans that protect client confidentiality and that don't unintentionally worsen patient care by creating incentives for practitioners to select healthier patients so their outcomes will look better, for instance, or to avoid sharing the formula of their success in order to maintain their ranking, Doucette said.

"We need to look at measurement feasibility," she said. "If people are spending more time conforming to performance measurement requirements than they are on patient care, we need to step back and look at what we're doing."


This session was sponsored by the APA Board of Professional Affairs.

Tori DeAngelis is a writer in Syracuse, N.Y.