Despite the expenditure of tens of millions of dollars and scores of outcomes initiatives over the last 20 years, there are few viable outcomes programs in operation.

Most have failed. Some examples from the private insurance market:

–Aetna/HAI’s ambitious nationwide outcomes initiative implemented in the 1990s
–VRIs multistate initiative also implemented in the 1990s.
–Pacificare Behavioral Health’s nationwide program which was terminated around 2004
–Humana’s behavioral health internet based outcomes and behavioral disease management project ended after a year in 2001
–Massachusetts BCBS statewide outcomes program terminated around 2007

A variety of states also initiated ambitious outcomes projects, such as the states of Washington and Oregon, only to jettison them after a few years operation.

JCAHO made outcomes mandatory nationwide in 2000 with its ORYX project. It was ended barely two years after it began.

Companies set up to develop and implement outcomes have also collapsed. Compass, Inc had millions in investment funding in the mid 90s and developed an outcomes system based on the well regarded work of Ken Howard. The company failed after a few years of operation. A number of other outcomes companies collapsed, as well. The few that are remaining have been drastically downsized. The business model of these companies was akin to those of medical laboratories: to sell a “lab test” of mental health functioning to health plans that would enable the plans to determine the necessity and effectiveness of treatment. They reckoned that health plans would buy these services rather than build them themselves.

The outcomes projects in operation now are implemented by true believers; they are mainly financed by providers. For instance Miller and Duncan developed a feedback informed treatment system based on the Outcomes Rating Scale (ORS). It is software based and used by clinicians mainly in the US and Northern Europe. See http://www.centerforclinicalexcellence.com/ICCE. Jeb Brown, an early champion of outcomes who spearheaded the Aetna/HAI and Pacificare projects that were insourced, has a site http://www.clinical-informatics.com in which he provides outcomes tools for clinicians. He has a number of pilot projects underway. But outside of the true believers, outcomes have not gained traction in the mental health community. This despite the fact that 1) outcomes are regarded by the American Psychological Association as an evidenced based approach; and 2) controlled studies and naturalistic studies show conclusively that outcomes with feedback to clinicians improves the effectiveness of treatment.

So the question, why have outcomes failed?

I think there are a number of reasons:

1) Most outcomes systems were developed by psychologists who eschew the medical model. Their instruments (OQ 45, ORS) measure measure general distress. The dominant health care culture is simply not interested in general distress. It is interested in diseases such as Major Depression, Bi-Polar illness, Schizophrenia, and the like. Measures that are disease-specific are of interest to the medical community. That interest turns into funding. For example, CMS will now pay PCPs to administer disease specific outcomes measures such as the PHQ 9 for depression. Behavior follows funding. When mental health clinicians do the extra work involved in collecting outcomes data, they, unlike PCPs, receive no payment for that extra work. This makes sustaining outcomes difficult; only the true believers stay with it.

2) Clinicians resistance has been a big factor in torpedoing outcomes initiatives. There are a number of reasons for this. First clinicians resent the paternalism of managed care companies that have the arrogance to attempt to micromanage their clinical practices. No physician would stand for it. Incidentally, all or almost all the outcomes projects that have been implemented, excluded psychiatrists from participating in outcomes. Why? They would not comply. Also, clinicians are rightly suspect of managed care companies. As one senior executive of a managed care company said–a company that touts its committment to outcomes–”we really don’t care about outcomes.” In addition, many outcomes instruments contain questions that constitute a HIPAA violation. Take this question from perhaps the most widely used outcomes instrument in the world, the OQ 45: “I have an unfulfilling sex life.” Aetna, Pacificare, Value Options and other companies for years routinely collected this information as part of their outcomes initiatives. Third, outcomes could be used a health care company to impair the clinician’s ability to make a living. e.g. poor outcomes could lead to loss of referrals and outcomes decision support data could result in treatment being curtailed, further eroding clinician’s income. Willed ignorance on the part of clinician’s about outcomes is then fully justified. As Sinclair Lewis remarked: “It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”

3) Feasibility. Until very recently outcomes projects were expensive and cumbersome to implement–clinicians had to make an extra effort to make sure the client filled out the instrument, then it would have to be faxed to the managed care organization, etc. The lack of any tangible benefit, eg. real time feedback, contributed clinician demoralization. “Empty compliance” has often been the norm for clinicians involved in outcomes initiatives. Another factor is that clinicians involved in these projects deal with many payers. For one payer to use a procedure that is applied to, for instance, only a handful of the patient’s a clinician sees a week is rightly viewed as an unfair imposition.

Outcomes–Quo Vadis?

1.Outcomes with feedback to clinicians improves behavioral health outcomes, but it is unlikely they will be adopted if the measure is one of general distress. Psychologists who develop these measures need to get out of their silo and develop measures that the health care community is interested in. That means disease specific instruments.

2. Outcomes need to be a standard of care. PCPs do a number of routine procedures, e.g. blood pressure monitoring. They don’t do blood pressure monitoring for one health care company but not another. It is unfair to ask behavioral clinicians to use different procedures for different companies.

3. The technology still has a ways to go–outcomes ought not to burden the clinician and should be fully automated; alerts to the patient for followup assessments should be provided via e.g. email or text message. Clients should be able to complete outcomes measures on the Internet or a smart phone. Reports should include decision support and be provided instantly to the clinician. Also, outcomes must be integrated into electronic health records. Separate outcomes systems which provide e.g. monthly reports are expensive and inefficient. Naturalistic research via Practice Research Networks would be dramatically enhanced if outcomes data and a robust set of clinical data resided in the same database.

4. While outcomes data should be available to health care companies to insure that care is medically necessary, that data should not violate HIPAA, nor should it be used punitively against the clinician.

5. Clinicians need to be rewarded for providing outcomes informed care; reimbursement rates need to go up to defray the cost of implementing these systems.

6. Effective therapists should be rewarded by higher rates of reimbursement. (h/t Ed Wise, Ph.D.)

7. Less than average therapists should be offered state of the art evidence based treatment workshops. (h/t Ed Wise, Ph.D.)

VIDEO 1

VIDEO 2

But behavioral clinicians do not participate in Meaningful Use–which is the bonus system for clinicians who use an ONC certified application. This as I will show not all bad. Indeed, not being part of the Meaningful Use program might be an unexpected godsend for behavioral clinicians–true, they don’t get the bonus payments (which most behavioral clinicians don’t qualify for anyway), but they don’t get the hassles either.

Consider the testimonial of this physician, Michael Koriwchak, MD, an ENT specialist who is also an IT specialist:

“Well, sorry, it’s still that bad (Meaningful Use certification). It took about 150 man-hours of work to complete this project. And our EMR use, our quality of patient care and our practice efficiency is for the most part no better. In some ways it is worse. As a result of MU:

We now take blood pressures on children. This is almost never medically relevant in an ENT practice. We can’t exempt ourselves from this requirement because of our adult patients, in whom blood pressure is often relevant.
We waste volumes of paper printing clinical visit summaries that no one reads. While the concept of a visit summary is OK, the document itself must include so much extra data it is useless. Our web portal, which we are in the process of replacing, does not support this requirement so we have to use paper visit summaries for now.
Patient waiting time is increased while we process data on pneumovax status, smoking status and body mass index on every patient. In our practice these data are medically relevant for many patients, but not everyone. Doing it for everybody is a waste.

To be fair, a couple of good things did happen:

Use of EMR-based prescriptions and true e-prescribing (e-Rx) improved with those physicians that were still hanging on to paper scripts and/or were not using e-Rx.
We were not maintaining true ICD-coded problem lists in the EMR before MU. We had problem lists and diagnoses of course, and we were using ICD codes for billing. But we had never combined the two processes before.

The entire process is complicated, confusing, and intimidating. Not only are the guidelines themselves a mess, but also there is a surprising amount of inaccurate and misleading information out there. Even the CMS publication Attestation User Guide is missing a page compared to the actual attestation web site. After reading the User Guide I lost an entire night’s sleep thinking that the “children with pharyngitis” quality measure had been deleted because it is missing from that document. I have 17 years of medical practice experience and 37 years of IT experience. If I can’t figure this out there is something wrong.”

The view from the top of the MU Mountain looking down is no better than the view from the bottom looking up. Meaningful Use remains an expensive distraction that forces the true benefits of EMR to be overlooked in favor of regulatory compliance. MU also creates an unhealthy alliance between government and the health IT community. The government wants to own health IT just like it wants to own the rest of health care. Don’t fall for it.

Here are the developments:

First, Medicare now routinely reimburses H & B codes nationally, with the exception of Illinois and Wisconsin. However, the number of units allowed is often restricted.

Second, private payers are following Medicare’s lead and are also now reimbursing for H & B Codes. However, most payers, with the exception of United HealthCare, pay only for face-to-face treatment, not for chart review, report writing, etc.

Third, it is often difficult to get many private payers to authorize treatment for H & B services.  Mental health is often carved out by health plans and the contractual boundary between mental health and physical health is often not clear cut. The mental health carve out company, for instance, may not authorize care for treatment of a medical condition or diagnosis, and the medical insurer may not authorize care by non-medical providers. Thus, behavioral clinicians seeking reimbursement for these services are often are left having to petition the plan.

The good news is that progress toward care integration is advancing due to new technologies and reimbursement policies. The bad news is that America’s healthcare bureaucracy seems designed to make that advance as slow and difficult as possible.

One change already taking place is the phase in of parity. Medicare is lowering the 50% co-payment for outpatient mental health services (that has been program policy since 1965) to a 20% co-pay by 2014. Most other outpatient services covered by Medicare have a 20% co-pay.

A second change, reported in American Medical News, is that Medicare will now pay physicians for the early detection of depression and substance abuse. The CMS website lists 8 depression measures, including Hamilton Depression Rating Scale, the Beck Depression Inventory and the Zung Self-Assessment Depression Scale. (The Hamilton Depression Scale is in the public domain). Because parity removes the disincentive to treat depression, the door is open for potential medication and counseling options.

While the focus of Medicare’s efforts is on incentivizing physicians to treat depression and substance abuse, the opportunity for non-medical mental health clinicians to benefit from these changes is significant. CMS requires PCPs to utilize comprehensive care supports, including case management working with the primary care physician; and planned collaborative care between the primary care provider and mental health clinicians. Both of these services–care management and collorative care–can be provided by mental health clinicians. The guidelines also (implicitly) caution against medication monotherapy and require that PCPs pay attention to patient preferences regarding counseling, medications, and referral to mental health professionals.

Clinicians who use an ONC certified behavioral EMR that shares clinical summaries with medical EMRs will be able coordinate care with PCPs and provide the counseling and progress tracking services that busy PCPs are unable to provide.

Update on Recommended Measures

Hamilton Depression Rating Scale (HAM-D)

This 20-item instrument is widely used in a 17-item version in clinical trials to measure remission and treatment response. The scale’s length limits clinical utility, but versions of varying length are available. The HAM-D is not suited to assess patients affected by cognitive impairment and requires administration by trained personnel.

Beck Depression Inventory (BDI)

This 21-question self-report was developed to quantitatively measure depression severity over time. The 1996 revision (BDI-II) occurred when the DSM-IV changed diagnostic criteria for major depressive disorder (MDD). The length of this tool limits its utility for screening; but because patients must choose a level of gravity (corresponding to a distinct definition of the patient’s condition, with reference to the previous week), the BDI lends itself to monitoring of variations in the intensity of depression over time.

Zung Self-Assessment Depression Scale (SDS)

This 20-item measure of depression severity for those already diagnosed with depression is now also used in primary care as a screening tool. The SDS is available in a number of languages and can be completed by most persons in 5 minutes.17 Disadvantages include that it does not cover symptoms of atypical depression, and that it may be less sensitive to change that other scales. Although devised to identify depression in adults in general, the SDS is also used to study depression and cognitive symptoms/disturbances in the elderly.

Center for Epidemiological Studies Depression Screen (CES-D)

This 20-item self-administered screening test, a hybrid of the Zung SDS, the BDI and the Minnesota Multiphasic Personality Inventory Depression Scale (MMPI-D), was designed to assess depression and gravity of depressive symptoms in normal elderly people.18 A concise 10-item version, whose sensitivity has proved to be only slightly lower than that of the original version, is also available.

Geriatric Depression Scale (GDS and GDS-SF)

This 30-item self-reported tool for assessment of depression in the elderly requires yes or no answers describing patients’ feelings on the day of completion.19 There is a 15-item short form version (GDS-SF) where a score >5 may indicate depression warranting follow-up and >10 usually indicates depression.

General Health Questionnaire (GHQ)

This 60-item test is an assessment of psychological well-being to detect those likely to have or be at risk for developing psychiatric disorders. It is a measure of the common mental health problems or domains of depression, anxiety, somatic symptoms and social withdrawal. Developed in the 1970s, the GHQ comes in 38 languages.20 A 28-item version is most often used.

Patient Health Questionnaire (PHQ-2 and PHQ-9)

The purpose of the 2-item Patient Health Questionnaire (PHQ-2) is not to establish a final diagnosis or to monitor depression severity, but to screen for depression in a first step approach. Patients who screen positive on the PHQ-2 require further testing and can be evaluated with the PHQ-9, a self-reported 9-question version of the Primary Care Evaluation of Mental Disorders (PRIME-MD). The PHQ-9 is a more detailed test with a scoring system based on duration/severity of particular symptoms.

Cornell Scale for Depression in Dementia (CSDD)

This 19-item scale has the best sensitivity (93%) and specificity (97%) for identifying depression in a demented population.22 In patients with severe cognitive impairments who cannot reliably answer the PHQ-9, the scale can be completed by a caregiver.

Humana several years ago did the same thing and contracted with Lifesynch to carve out its mental health service.

What gives?

25 years ago managed care carve outs were the rage This was mainly because specialty behavioral health companies had special” know-how” to reduce costly inpatient stays. Over time the industry recognized that this “know how” was easily reproducible. A set of utilization guidelines in the hands of an experienced mental health clinician could achieve lower utilization and cost without resorting to a separate company with the attendant duplication of administrative costs. As a result big companies like Cigna, Aetna and United Health Care brought mental health services in-house, saving the administrative cost of running a carve out.

But now carve outs are back? Why?

The answer I suspect is an accounting gimmick. By outsourcing mental health on a capitated basis companies like BCBS FL and Humana may be able to count the full capitation as “medical loss, “ that is, as health care costs. Accounting rules may allow the full cost of a carve out–including the administrative costs (which can run up to 50%)–to count as actual health care service costs!

The new Obamacare health care law sets a base medical loss ratio that companies must meet (I think 85%) in order to participate in the program. By outsourcing mental health a FL BCBS or a Humana can recoup as much as 1% from administration to medical loss. The arithmetic goes like this: mental health services cost 4% of total health care expenses. If administrative costs are, say, 25% of that 4%, then by carving out mental health, 1% is potentially transferred from administrative side of the ledger to to health care side.

The case of Humana and LifeSynch is arguably even more perverse than that of Fl BCBS and New Directions. LifeSynch is one of the few national companies that does not accept electronic claims! They process only paper claims. The cost of processing paper claims is much more expensive that electronic claims. Also, paper claims result in more errors and more claims rejected or unprocessed. Also, providers who contract with LifeSynch get paid more slowly due to the longer turn around time caused by mail service, etc. The net result is that even more of the premium dollar goes to administration and less to actual health care service.

So who benefits from carve outs? If I am correct that the accounting rules allow the full carve out premium to be used as health care service costs, then healthcare companies are the big winners because they increase the medical loss ratio by counting administrative costs as health care costs.

Who loses? Beneficiaries who receive less care and higher premiums.

Nursing homes collected $2.1 billion in added Medicare payments in the first half of this year, an unintended side effect to a rule change that aimed to clamp down on overbilling, according to a government report.

The federal health care program for the elderly and disabled blocked companies in January from assigning therapists to treat groups of patients simultaneously and billing each individually for the total time of the session.

Operators responded by reclassifying patients in smaller group settings and still billed the government as if therapy was provided on a one-on-one basis, according to the unpublished report by the Department of Health and Human Services inspector general.

The report didn’t single out companies, but recommended the federal government block further overpayments.

Nursing homes “have a financial incentive to choose group therapy,” according to the report, a copy of which was obtained by Bloomberg. It recommended Medicare “take immediate action.”

Medicare pays $430 to $699 a day for nursing home patients, depending on the amount of therapy.

Circumventing the rule change lets operators bill more patients at the highest rate, the report said.

Leading for-profit nursing home chains include Kindred of Louisville, Ky.; Skilled Healthcare of Foothill Ranch, Calif.; Carlyle Group’s HCR ManorCare Inc. in Toledo, Ohio; and Sun Healthcare, based in Irvine, Calif.

Federal officials should close a loophole that’s enabling publicly traded companies to profit and may make the industry a target for broader federal reimbursement cuts, say representatives of nonprofit nursing homes.

Nursing home overpayments have been cited as a concern before by the Medicare Payment Advisory Commission that advises Congress, Medicare administrators, and federal investigators.

The January rule change was designed to slow long-term spending on therapy services.

Medicare administrators restricted the way nursing homes bill for concurrent therapy, in which workers simultaneously treat 10 or more patients recovering from strokes or hip replacement surgeries.

The health program didn’t make a similar change to billing for group therapy sessions involving as many as four patients at a time, or one-on-one therapy.

Outpatient electronic prescribing systems don’t cut out common mistakes

Errors associated with outpatient computerized prescribing systems

Outpatient electronic prescribing systems don’t cut out the common mistakes made in manual systems, suggests research published online in the Journal of the American Medical Informatics Association (JAMIA).

And not all systems are the same: some perform worse than others, the study shows.

The rapid adoption of electronic prescribing systems has in part been fuelled by the belief that they would reduce the sorts of errors commonly made in manual prescribing systems, the authors say.

The authors base their findings on an analysis of just under 4,000 computer generated prescriptions received by a commercial pharmacy chain in three different US states over a period of four weeks in 2008.

They looked at the number of mistakes made and their potential to cause harm, as well as the frequency of particular mistakes and whether these were associated with one type of system.

Of the 3,850 prescriptions assessed, more than one in 10 (452; just under 12%) contained a total of 466 errors.

Of these, a third (163; 35%) were deemed to be potentially harmful.

Mistakes were classified as: “significant,” but posing little serious threat to life, such as rash, headache, or diarrhoea; serious but not life threatening, such as low blood sugar (hypoglycaemia), reduced heart rate (bradycardia), and fainting (syncope); and life threatening if not treated, such as heart attack and respiratory failure.

Among the 163 potentially harmful errors, over half (58%) were significant and the remainder (42%) were serious.

None was life threatening.

Four out of 10 medication errors involved anti-inflammatory drugs and antibiotics (anti-infectives), and the most common types of drugs associated with errors were nervous system drugs (27%), cardiovascular drugs (13.5%), and anti-inflammatories/antibiotics (12.3%).

The prevalence of prescribing errors varied considerably, depending on the system used, ranging from 5% to 37% among the 13 systems analysed. The frequency of certain types of errors was also associated with particular systems.

For example, in system A, omitting to specify length of treatment and dose were common, and “miscellaneous” errors accounted for more than one in four mistakes (27%).

And while system B’s error rate was less than that of system G, system B incurred substantially more potentially harmful errors.

Around 60% of errors related to missing information, which the authors suggest should be relatively easy to eliminate by some judicious tweaking or providing better training for the users.

Options might include “forcing functions” which would not allow a prescription to be completed if certain information were missing; decision support systems, such as maximum dose checks; and calculators, they say.

“Providers appear to be rapidly adopting electronic health records and computerized prescribing, and one of the major anticipated benefits is expected to be through medication-error reduction,” they write.

But they warn: “Implementing a computerized prescribing system without comprehensive functionality and processes in place to ensure meaningful use of the system does not decrease medication errors.”

The adoption rate of EHR in medical practices is expected to accelerate in this country as the government begins providing financial incentives for adoption. But psychologists and social workers are not eligible for these incentives, so can’t they just continue with paper documentation? For most psychologists and clinical social workers, the short answer is no. The answer is no because EHRs are becoming the way providers communicate with each other to coordinate care and refer. The government incentives come with standards for EHRs that facilitate the exchange of clinical information that will become the preferred way of making referrals.

Some background. The last few years has witnessed a dramatic increase in the adoption and implementation ofElectronic Health Records (EHRs) by America’s medical practitioners. It is believed that within the next five years EHRs will be as common in medicine as the stethoscope, the blood pressure monitor, the MRI and other core tools. This rapid adoption of EHRs is being spurred on by the Hitech Act of 2009 which incentivizes practitioners through bonus payments (and later penalties) to adopt federally certified EHRs. The federal certification is called ONC (Office of the National Coordinator for Health Information Technology) of the US Department of of Health and Human Services. ONC certification insures that EHRs are in compliance with the standards and certification criteria of Centers for Medicare and Medicaid Services (CMS.)

Eligible providers (MDs including psychiatrists, nurse practitioners in some states) can receive bonus money from medicaid and medicare by using a certified EHR. They can also avoid a penalty that for non-use which will kick in in 2015 for medicare reimbursement.

Psychologists and other non-medical mental health providers have not been designated by the Hitech act as eligible professionals and so are not eligible for bonus payments. Even so, psychologists, according to Maureen Testoni, JD of the American Psychological Association, “will be impacted by the shift in general record keeping practices across the healthcare industry,” … (and)… “at some point in the future… will be compelled to demonstrate similar progress in order to do business with physicians and hospitals.”

It should be pointed out that most psychologists and clinical social workers, even had the Hitech Act included them as EPs, would only benefit if their practices include a substantial number of medicaid and/or medicare patients.

ONC implementation specifications and certification criteria assure that “certified EHRs” have core features covering interoperability, functionality, utility, and security of health IT. The feature that is most critical to practitioners is interoperability– that is, the ability to share clinical information automatically and in real time. Initially, ONC calls for EHRs to share clinical summaries that include problem lists (diagnoses), medications, and lab test results. It is expected that the amount of information shared will increase over time.

EHRs, then, create the medical equivalent of a grid or network over which clinical information is shared with other users. Being on the grid puts the clinician on the virtual health care team. Any medical referral source–Primary Care Physician, Pediatrician, or Specialist is unlikely to refer to a clinician who can not receive clinical summaries and, who can not, in turn, transmit clinical findings to the referring physician in the standard format used by the rest of the industry.

Interoperability will improve mental health patient care by providing an electronic means for the coordination of care. Psychologists who use a certified EHR will have access to problems lists, as well as medication and lab information. This will enable psychologists with psychopharmacology expertise to make medication recommendations and monitor for side effects. The presence of a psychologist on the patient care team will improve the accuracy of diagnoses and the timeliness of care.

EHRs are the way that integrated care will be realized in the 21st century. However, if psychologists and other non-medical mental health professionals do not use them, not only will individual practitioners be hurt, but so too will the field of psychotherapy as a whole. Specifically, it is likely that the mental health field will become increasing driven by psychopharmacologic treatment. It is of interest, for instance, that ONC quality criterion for depression, measures the percent of patients with a new diagnosis of depression who receive psychopharmacologic treatment within 12 weeks of diagnosis. CMS quality initiatives in the past (see PSQR) used a different criterion: either the percent of newly depressed patients on medication or the percent in psychotherapy. Given the evidence for the efficacy of psychotherapy as a first line treatment of depression, dropping psychotherapy from the quality menu could spell a further erosion of the range of treatments available to patients seeking mental health treatment. More ominously, referral patterns will likely be impacted by quality measure criteria: for example, PCPs who use the depression quality measure will be incented to refer to clinicians who prescribe because doing so will enable them to meet the quality standard for depression whereas a referral to a non-prescribing psychologist will not.

The case for EHRs in the age of the Internet is a strong one. Such features as online scheduling, account setup, self-help, bill pay, access to clinical records, etc will enhance the efficiency and convenience of practice. But what is most important for mental health clinicians is that they get on the clinical team. To do that they will need an ONC certified EHR.

“During the decade from 1998 to 2007, the percentage of the general population who used psychotherapy remained stable. Over the same period, however, psychotherapy assumed a less prominent role in outpatient mental health care as a large and increasing proportion of mental health outpatients received psychotropic medication without psychotherapy.”

Use of only psychotherapy declined from 15.9% 1998 to 10.5% in 2007. Use of only psychotropic medication increased from 44.1% to 57.4% in that same time frame. Declines occurred in annual psychotherapy visits per psychotherapy patient from a mean of 9.7 to a mean of 7.9.