In recent years, as the federal government and third-party payers have begun to tie reimbursement rates to patient outcomes, researchers and clinicians have been paying increased attention to the practice of consistently measuring patients’ progress and adjusting treatment plans as needed based on the data.
While the technique goes by many different names, including “outcomes monitoring” and “progress monitoring,” all of them denote essentially the same thing: measurement-based care. And if psychologists aren’t already using it in their practices, they should consider doing so, says clinical psychologist and biomedical informaticist Kari Stephens, PhD, an associate professor of psychiatry and behavioral sciences at the University of Washington.
“For the first time ever in our health-care system, payers are directly connecting the dollars—or reimbursement—with outcome measures,” says Stephens, who studies the use of data in behavioral health care.
Beginning this year, for example, psychologists are eligible to take part in the Centers for Medicare and Medicaid Services’ Merit-Based Incentive Payment System (MIPS). The system rewards providers with larger payments when they track and show patient improvement on process and outcome measures including depression, anxiety and dementia screening scores, as well as pain, sleep and social functioning assessments. The system also penalizes providers who score low in these areas by reducing their payments.
Currently, only a small number of psychologists must participate in MIPS: those who treat more than 200 Medicare beneficiaries, bill Medicare for more than $90,000 in allowed charges and provide more than 200 covered professional services in a year. However, psychologists who meet at least one of these requirements can opt into MIPS, and all psychologists should consider adding measurement-based care into their practices if they haven’t already done so, says Stephens.
“Medicare often sets the stage for all the other private payers, so it’s important for clinicians to pay attention,” she says. Of course, adding outcomes measurements isn’t a simple undertaking for clinicians. Many face logistical, technical and cultural barriers, notes clinical psychologist Zeeshan Butt, PhD, an associate professor at Northwestern University. These include issues related to how to obtain the measurements without disrupting a treatment session, navigating varying electronic health record and outcomes measurement technologies that often don’t interface well together and overcoming the misconception that therapists are able to judge how well a patient is doing in therapy without measuring patient progress.
Still, says Butt, measuring outcomes should be considered an ethical imperative. “In every clinical situation, the patient and the provider are collaborating toward an agreed-upon outcome, and unless you’re measuring it, I’m not sure that you can know whether you’re really moving toward that goal,” he says.
What does the evidence show?
Mounting empirical evidence suggests that when psychologists monitor their patients’ care, patients do better, says Jacqueline B. Persons, PhD, director of the Oakland Cognitive Behavior Therapy Center in California and a member of APA’s Advisory Steering Committee for the Development of Clinical Practice Guidelines.
Two new studies underscore this point. Researchers at the University of Washington School of Medicine and other institutions analyzed 51 randomized controlled trials that examined how frequently providers collected feedback on patient-reported symptoms during medication management and psychotherapy encounters (Fortney, J.C., et al., Psychiatric Services , Vol. 68, No. 2, 2017 opens in new window ). The researchers found that almost all the trials that consistently used measurement-based care showed significantly improved patient outcomes, while one-time screenings and assessing symptoms infrequently were less effective.
A second, more recent narrative review of several meta-analyses and qualitative studies found that not only did measurement-based care outperform usual care; it was also associated with decreased costs and a lower likelihood of patient deterioration while in treatment (Lewis, C.C., et al., JAMA Psychiatry , Vol. 76, No. 3, 2019 opens in new window ).
In fact, simply taking part in frequent assessments seemed to improve outcomes for patients in many studies, regardless of what the providers did with the information. “The act of self-monitoring has been shown to enhance an individual’s ability to quantify their depressive experience, and then, indirectly, that often leads to more self-reflection,” says Cara C. Lewis, PhD, the review’s lead author and an associate investigator at Kaiser Permanente’s Washington Health Research Institute. “That alone adds benefit to the patient outcome experience.”
Lewis also found that when patient scores are reviewed by the clinician and patient—either independently or, ideally, together during the session—that process benefits patient outcomes, in part because it offers a check to the therapist’s clinical judgment and helps ensure that patients agree that their scores reflect their subjective experience.
“These score check-ins also lead to conversations about the patient’s progress, which can be quite rich,” Lewis says. Finally, when the data are used by the clinician to inform treatment planning, they have an even greater positive impact on patient outcomes, according to the study.
However, other studies examining the use of patient-reported outcomes suggest ongoing research is still needed to help clinicians understand the best way to use outcome monitoring and which patients benefit from it most. For example, a 2016 review of 17 randomized clinical trials in which patient-reported outcomes were used raised concerns that the practice was not much more effective than normal care (Kendrick, T., et al., Cochrane Database of Systematic Reviewsopens in new window). The authors noted that many of the individual studies examined were not of the highest quality, due to patient attrition and potential bias in assessments of outcomes, and added that “future research should measure a range of relevant symptom outcomes, as well as possible harmful effects of monitoring, health-related quality of life, social functioning and costs.”
Barriers to tracking outcomes
On a practical level, meanwhile, when a clinician is with a patient and managing competing demands for his or her time and attention, it is easy to let outcomes measurement slide, says Martin Antony, PhD, FRSC, ABPP, a professor of psychology at Ryerson University in Toronto.
“It can be time-consuming, especially if patients are filling out paper questionnaires by hand,” Antony says. “Then they have to be scored, and often clinicians may not know how to do that.”
Even when clinicians have access to technology designed to make collecting, scoring and plotting patient outcomes data easier, they often encounter barriers in terms of data privacy issues, electronic health record systems that don’t interface with the outcome measures and technological complexity that’s often unnecessary, Lewis says.
“Very often when people are developing solutions, they tend to make more complicated versions that have more bells and whistles than you need, and require more clicks than clinicians want to go through,” Lewis says.
Another barrier is that many psychologists have not been trained on outcomes measurement. “A lot of clinicians may not know what outcome measures are appropriate to use or may not have a good understanding of how it can be helpful to use them,” Antony says.
Lewis notes that in addition to some of the logistical and training issues involved with measurement-based care, there’s also a cultural barrier. Mental health providers really value their clinical judgment and capacity to guide treatment, and some don’t believe that tracking patients’ progress toward a goal is necessary.
“Many psychologists enter the profession after years of training and the development of a knowledge base that they value,” Lewis says. “Unfortunately, clinicians are actually quite poor at judging how a patient is doing in treatment, and often overestimate patients’ progress.”
Some clinicians also worry that their patients don’t want this information, or that it will show that the clinician is doing a bad job. Lewis notes, however, that in her observation, none of these things are true. “Patients don’t mind completing outcome measurements if clinicians provide information about why they’re collecting it,” she says. “In fact, you often find that when providers start using outcome monitoring, it breaks down their resistance and shows them the great work that they are doing.”
Butt also says that some clinicians may be concerned that the outcome measurements may not truly capture the progress a patient is making.
“Particularly for those who see the patients with the most problems, it’s important to ensure they are not penalized for the outcomes they are getting,” he says. Insurers, he notes, need to think about how best to adjust scores for providers based on the types of patients they see. Carol D. Goodheart, EdD, APA’s 2010 president, also notes that changes in an individual’s medical status need to be taken into consideration when insurers are examining patient outcomes for reimbursement, particularly for patients with significant medical and mental health conditions. Medication changes made by a patient’s physician may cause significant side effects from a behavioral health perspective, she notes.
“How are these systems going to integrate the psychologist’s data across multiple providers who may not be in the same system, and where are insurers going to attribute the change if a patient is getting better or worse?” asks Goodheart. “Those are legitimate nonhostile questions to be asking, and many of us are tuned in to that.”
Overcoming obstacles
For providers who are just beginning to incorporate outcome monitoring into their practices, a first step is to acknowledge that doing so will require an adjustment period. Practitioners will need to decide which system they want to use (see sidebar), and then invest time and money into learning how to implement the system efficiently and effectively.
Lewis agrees, noting that with outcome monitoring becoming more prevalent, the field is offering more opportunities for hands-on training. For example, PracticeGroundopens in new window is an online community of therapists, trainers and researchers working to improve patient outcomes. The group hosts live and online training programs to help clinicians determine how to incorporate measurement-based care into their practices.
“So, if you’re in a small practice and not sure how to begin, you can join a learning collaborative like this one and begin to try this stuff out,” Lewis notes.
Persons also notes that finding ways to integrate outcome assessment into a practice seamlessly using technology is one of the most important factors in its adoption.
“We need to help clinicians collect outcomes monitoring data quickly and easily in a way that’s convenient for the patient,” she says. “That means having tools that allow the patient to go on his or her phone before the session and answer the questions, and then the data are automatically plotted, and the patient walks in the door and the clinician and patient together can look at the results during the session.”
Having easy access to patient data can be a critical tool leading to more productive conversations with patients who don’t feel like their treatment is really helping them when the monitoring data show otherwise, says APA Practice Director of Research and Special Projects Vaile Wright, PhD. It can also serve to elicit feedback when a patient isn’t showing progress.
“Maybe the clinician isn’t measuring the right thing, but they won’t know that unless they start to collect that data and then have a conversation with the patient,” Wright says.
Overall, Persons says, measurement-based care can provide clinicians with the reassurance that they are doing what they can to help patients meet their goals.
“I have a significant number of patients who have very difficult and challenging clinical problems that I really struggle to understand and treat,” she says. “In those moments where I’m not sure what to do next, it’s reassuring to know that one thing I’m doing that contributes to good outcomes is monitoring progress every session. I’m providing top-quality measurement-based care for my patient.”
