State Leadership Conference

When the city of Philadelphia told inpatient psychiatric and other types of hospitals that they would have to reduce patients' recidivism rates if they wanted to receive bonuses, the hospitals weren't happy.

"They told us, ‘We don't have a lot to do with what happens when people leave,'" said Arthur C. Evans Jr., PhD, commissioner of the city's Department of Behavioral Health and disAbility Services. "We said, ‘We think you do.'"

The results bore him out: The hospital at the very bottom of the rankings the first year jumped to the very top the following year.

Providing continuity of care is just one of the elements in the clinical practice guidelines the department has developed as part of its efforts to transform the city's behavioral health system into one emphasizing recovery, Evans told participants at the State Leadership Conference in March. The guidelines have had a big impact, said Evans.

"Our resources have remained flat for three or four years, yet we've increased the number of people seen, and the per person cost has gone down significantly," he said.

Evans and other speakers described how clinical practice guidelines can improve care and cut costs in three kinds of health-care settings:

  • Private third-party payer. "Health plans exist to manage benefits," said Rhonda Robinson Beale, MD, at the time the chief medical officer for external affairs at OptumHealth Behavioral Solutions. Originally designed to cover catastrophic illness, plans now cover what's medically necessary. Making coverage determinations for new "technologies," which include new psychotherapies — and figuring out such details as the frequency and duration of treatment, ease of replication and comparative costs — requires an extensive review of often-inadequate evidence, Robinson Beale said. A clinical technology assessment committee rates evidence, looking for at least three high-quality studies. If there are fewer, said Robinson Beale, Optum has an "emerging" category. "There are a lot of new technologies that are just on the cusp of being successful in terms of satisfying the criteria for ‘proven,'" she said. "We want to highlight those, particularly for our employer groups that are self-funded and can decide for themselves what they cover and don't." Making these decisions isn't easy, said Robinson Beale. Take autism, for example. Lacking practice guidelines, details about what treatment works best for which patient population and information about the expected duration of treatment, Optum brought researchers and providers together to help put together coverage determination guidelines.
  • Managed-care organization. When Kaiser Permanente asked Andrew Bertagnolli, PhD, senior manager for the organization's Integrated Behavioral Health Care Management Institute, to come up with clinical practice guidelines, he balked, arguing that behavioral health was different. Clinicians were opposed, too, worried that the guidelines would be "cookbooks" substituting rules for their own clinical judgment. Now both Bertagnolli and clinicians are supporters. For one thing, the clinical guidelines are flexible. Instead of telling clinicians what to do, the guidelines — and the clinical decision-making tools that support them — give them information they need to make evidence-based decisions in partnership with patients.

"One of the things we hope to achieve by implementing clinical practice guidelines is to reduce unnecessary variation in practice," Bertagnolli explained. "We feel variation is one of the things that leads to decreases in quality and increases in cost."

Because Kaiser can't produce guidelines for all diagnoses, it currently focuses on conditions with high volume or high cost, significant practice variation and areas with multiple treatments, including adult and teen depression, alcohol use and serious mental illness.

Once created, added Bertagnolli, "the guidelines take a tremendous amount of effort and upkeep" to ensure they're up to date.

  • Public health system. For Evans, reducing variation is also a key factor behind the city's practice guidelines. "Payers are under enormous fiscal pressures," he said. "Because of that, what we're trying to do is reduce variability in practice so we're more likely to get the outcomes we want as a payer." That's challenging when you consider the 200 providers that serve the system's 120,000 patients. "Some organizations have highly trained individuals; others have people with high school educations who have clinical responsibility," he said. The guidelines also support the system's shift to a recovery framework. Designed to give clinicians the information they need to make that happen, the guidelines depend on three types of information: empirical data, professional consensus and the perspective of people with "lived experience" of behavioral health problems. The guidelines lay out the system's philosophy of helping people have productive lives in the community; values, such as promoting hope and letting patients and families direct services; goals, such as focusing on strengths and integrating services; and domains, such as recruitment and retention in treatment, practices associated with improved outcomes and connections to the next level of care.

"What we're trying to do is create not an algorithm as much as ‘Here are things you have to pay attention to as a provider,'" said Evans.

Rebecca A. Clay is a journalist in Washington, D.C.