Feature

For the first time, psychologists are using computer technology, medical claims information and patient demographics to show that behavioral interventions--compared with other more expensive treatments such as surgery--provide better health-care outcomes and lower overall health-care costs.

While patient outcomes studies are nothing new for psychologists, these studies are different because they could demonstrate the cost-effectiveness and value of psychological services when integrated into physical health services, say experts.

Several studies are in the works. At Beth Israel Deaconess Hospital in Boston, psychologists are testing whether patients with chronic illnesses--such as cardiovascular disease, cancer and diabetes--who receive behavioral interventions require fewer medical services than patients who receive standard care.

At Duke University Medical Center, psychologists are studying the financial impact and return on investment that may result from integrating psychotherapy services into cardiac patient care. Preliminary results show that cardiac patients who received stress management interventions required fewer hospitalizations and emergency-room visits.

And, recently a national study of patient outcomes conducted by the Health Enhancement Research Organization (HERO) in Birmingham, Ala., a national, nonprofit coalition of corporations, insurers, health-maintenance organizations, hospital systems, consultants and associations, including APA, found that health-care costs rise when stress and depression are left untreated. A second phase of the study will look at how depression affects workplace productivity.

Many psychologists say such studies may help employers and managed-care companies see the value of their services.

"Health-care purchasers are spending a ton of money on health, disability and workers compensation insurance without a whole lot of evidence that their money is well spent," says Ron Z. Goetzel, PhD, vice president of consulting and national practice for The MEDSTAT Group, which provides databases and software to help clients manage the cost, quality and delivery of health-care services and benefits.

"Large employers are beginning to ask providers and health plans to come up with documentation that their money is being spent effectively," he says.

Tracking outcomes

New technology--such as databases that track how health, disability and workers compensation claims affect each other and computers with large storage capacity--have made it possible for psychologists to track patient outcomes, in both the health-care and disability systems. But not enough practitioners are doing this type of work yet, says C. Henry Engleka, APA's assistant executive director for marketing in the Practice Directorate.

Collecting these data can be time consuming and expensive, but the benefits outweigh the drawbacks, because it may lead to better treatments and help physicians see the importance of psychosocial interventions by proving that behavioral interventions enhance clinical outcomes and lower overall health-care costs.

"Being able to tell a managed-care company and employers that for this much money we can provide this much service and these are the outcomes is a very powerful competitive advantage, especially if you can support it with data," says Kirk Strosahl, PhD, formerly research evaluation manager for Group Health of Puget Sound, Wash., who now consults with provider groups that are attempting to collect outcomes data. He is principal and director of research and training for Mountainview Consulting Group in Moxee, Wash.

In 1998, HERO conducted one of the first studies that showed the impact mental health can have on physical health. HERO's study found that health-care costs rise when stress and depression aren't treated.

The survey, based on more than 46,000 workers at several major U.S. companies, found that depression and stress were the primary predictors of total health-care costs. Patients who reported they were unable to control their depression or stress had higher health-care costs, says Goetzel, whose company, The MEDSTAT Group is a HERO member. Costs were 70 percent higher in depressed patients and 46 percent higher in patients who reported being under stress, and their treatments were typically medical rather than psychological, he says.

This is a wake-up call for the medical community, Goetzel says.

"Unless physicians pay attention to psychosocial factors, they may be spending a lot of time, effort and money on medical treatment without getting to the root of the problem."

HERO is now working with Harvard Medical School to study the impact depression has on work productivity. The study will compare patients who are assigned a highly skilled psychiatric case worker to help them get the treatment they need with patients who are left on their own to decide whether to seek mental health treatment. The hypothesis is that people who are clinically depressed and get exemplary care will have higher productivity at work than those who receive standard care, says R. William Whitmer, HERO's president and CEO.

"It's what providers and employers are looking for," says Whitmer, "something solid that says, yes this therapy is expensive, but if productivity goes up one, two or even three times the cost of therapy, then it's economical to do."

Similarly, psychologists at Beth Israel Deaconess Hospital in Boston hope to demonstrate the value of behavioral interventions for patients with chronic illnesses such as cancer, diabetes and cardiovascular disease by collecting patient outcome data as part of an APA demonstration project. They're testing whether patients with chronic illnesses who receive a behavioral intervention require fewer hospital and emergency-room visits than those who receive standard care.

"We hope to show that people who receive a psychological intervention cost insurers less money down the road," says Nick Covino, PhD, director of psychology at Beth Israel.

And at Duke University Medical Center, James Blumenthal, PhD, professor of medical psychology in the department of psychiatry and behavioral science, just completed a five-year outcomes study of 107 cardiac patients. They were assigned either a 16-week cognitive-behavioral therapy program for stress management, a 16-week exercise program or standard medical care without psychotherapy or exercise.

APA's Practice Directorate, in conjunction with PricewaterhouseCoopers and Duke University, has developed an actuarial model based on the study that will project the financial impact and return on investment that results from integrating psychotherapy services into cardiac patient care.

"If we can demonstrate that behavioral interventions are inexpensive and they have good outcomes, they may become an important part of managing and treating patients with cardiac disease," says Blumenthal.

Fears about data collection

Yet, while many psychologists understand the potential benefits of outcomes data, some remain reluctant to begin their own collection, worrying that if patients aren't getting better, managed-care companies will use those results to remove psychologists from provider networks or to limit the types of patients they can treat.

But says Jacqueline B. Persons, PhD, a private practitioner in Oakland, Calif., and San Francisco, psychologists have more to gain than to lose by capturing data.

"We can't afford to be fearful of finding out patients aren't doing well," says Persons, who has been collecting patient outcomes for almost two decades. "How would you feel if your physician was reluctant to really nail down in a clear way that you're making progress? Would you have confidence in that doctor?"

Meanwhile, other psychologists admit they are intimidated by tracking outcomes for psychological interventions, particularly if psychologists' services are held to the same standards as large pharmaceutical trials--those require replication and verification before they're adopted as mainstream practice.

This will be a challenge for psychologists, says Blumenthal. Behavioral interventions are complicated to do, patient recruitment is difficult and most traditional graduate psychology programs don't provide the kind of training needed to do large-scale clinical trials. Traditionally, psychologists have tested their interventions in carefully controlled studies with as few as 20 patients. In comparison, large-scale clinical trials involve thousands of patients--including an adequate number of women and minorities--and multiple sites, he says.

Even so, says Blumenthal, psychologists shouldn't shy away from large-scale clinical trials because outcomes data may shape the practice of psychology. While most employers restrict mental health benefits, Blumenthal says, outcomes data might change that scenario.

"If you can demonstrate that not only is a psychological intervention inexpensive compared to surgery but it also has good outcomes, physicians and policymakers would be willing to pay for it," he says.

But Russ Newman, PhD, JD, APA's executive director for practice, cautions that while gathering outcomes data is important, it's not the only or ultimate solution to ensuring psychologists' interventions are appropriately recognized and reimbursed.

"Currently, managed-care companies don't really look at the outcome of care based on both cost and quality," says Newman. "They look at outcomes based on what's the least costly service they can provide."

Which is why, he says, it's also important to reform the marketplace so that the quality of care is valued at least as much as the cost of service. In today's health-care market most insurance companies carve out mental health services, treating them as specialized care and keeping the reimbursement system segregated from medical/surgical claims data. This prevents employers and managed-care companies from easily seeing any cause-and-effect relationship between the two.

"As long as our health-care system is set up that way, even if physical health-care dollars are to be saved by the expenditure of psychological health-care dollars, you can't account for it," says Newman.

And, he says, proving the value of psychological services to employers might not be enough because employers often don't have the ultimate say in how benefits are provided to employees--the final say often lies with managed-care companies.

"Employers' health plans are often-times altered by the intermediary role of managed-care companies," Newman says.

To tackle that problem, APA's Practice Directorate is pushing for legislative and legal reforms that would hold managed-care companies accountable for the quality of services provided to patients. The directorate is supporting federal legislation that would amend the 1974 Employee Retirement Income Security Act to allow patients to sue managed-care companies for inappropriate denial of treatment or inadequate care. The directorate has also been fighting to set court precedents by legally challenging managed-care companies that are, they charge, interfering with and even inhibiting patient care by placing too much emphasis on cost-cutting measures.

Despite these concerns about managed care, Strosahl of Washington says psychologists will need to work with managed-care executives to help determine what assessment measures should be used and how patient confidentiality can be protected when collecting outcomes data.

"If we can use our training background in assessment, methodology and statistics to move the dialogue forward," Strosahl says, "it would be a tremendous boost to psychology's place in the market."

Data collection 101

Gathering outcomes data doesn't have to be complicated and time consuming, say psychologists who've been capturing such data for years.

For instance, Jacqueline B. Persons, PhD, has been collecting patient outcomes for nearly 20 years. She owns a private practice with locations in Oakland, Calif., and San Francisco. She suggests that psychologists who want to begin data collection begin with one or two patients. They might want to begin a new procedure with a new patient to make the process easier. She also advises that psychologists explain to their patients that as part of their treatment goals they'll be asked to fill out a weekly survey that measures their progress.

"Patients are usually receptive," she says. "The key is for the therapist to be comfortable with it."

Persons routinely uses three measures to track weekly progress: the Beck Depression Inventory, the Burns Anxiety Inventory and the Yale-Brown Obsessive Compulsive Scale. She keeps these three surveys on clipboards in her waiting room and asks her patients to arrive five minutes before their scheduled session to complete the appropriate one.

When the patient gives her the completed survey, she reviews it and enters the score for that week on a graph where she's recorded scores from previous weeks. Any pronounced changes are discussed during the psychotherapy session, she says, and if the scores show the patient isn't getting better they'll discuss whether to change the treatment plan.

Persons says having outcomes data makes it easier to work with managed-care companies.

"When the managed-care company wants to know if the patient is getting better, I can show them their progress with the inventory test scores," she says.

The more psychologists can collect this type of data and compare their treatment outcomes to traditional medical approaches, the more value employers and insurers will place on behavioral interventions, says psychologist Ron Z. Goetzel, PhD, vice president of consulting and national practice for The MEDSTAT Group.

"If psychologists can walk into an employer and say, 'I can provide this form of treatment and it will have these outcomes in terms of health and finances,' you'll have their attention."

--L. RABASCA