As I pointed out in a previous post, the Substance Abuse and Mental Health Services Administration (SAMHSA) a branch of the U.S. Department of Health and Human Services is currently working with the managed care industry. They are also the object of criticism by E. Fuller Torrey in his recent editorial and upcoming book for promoting non evidence based care of people with severe mental illnesses and in fact at many levels dismantling existing care. With that kind of a backdrop, their e-mail to me this morning suggesting that I should review the National Behavioral Health Quality Framework (NBHQF) and provide comments as an interested member of the public should not have been very surprising. I thought I would put that commentary here rather than letting it be buried on a government website that nobody would read.
To set the appropriate tone for my comments, the introduction section of this document identifies the major entity that the government is working with here as the managed care industry. I consider the NCQA (or NQF) to be a proxy for the managed care industry. That is their history as I recall it and I am not aware of any physician professional group that says otherwise. In fact, I cannot find the American Psychiatric Association as a member of the NQF, but I am fairly certain that they used to be a member of NCQA..
Getting back to the document - six goals are identified with a page each dedicated to currently available measures and a second page that is described as "future targeted measures that are deemed important to advancing the behavioral health quality measurement." An example of what that involves is illustrated in "NBHQF Goal 1: Effective - Promote the most effective prevention, treatment, and recovery practices for behavioral health disorders." Not to be too much of a stickler here, but I don't really know what a "behavioral health disorder" is. The most precise definition would be "whatever mental or psychiatric disorder that a managed care company has decided that they will pay for". Behavioral health is basically a business term with no medical or psychological meaning. As far as I can tell, it was designed to disenfranchise psychiatrists and other mental health providers and yet the rationale for denying treatment was always proprietary "medical necessity" criteria. Moving beyond that we basically see a number of screening interventions for "Provider/Practitioners", a number of completely unproven interventions and quality markers, and at least 30% of the cells in the matrix are left "intentionally blank". What exactly is there to comment on? In the second page "payers using payment incentives to increase the use of EBP (evidence based practices)" is actually considered a quality marker. That is a conflict of interest much greater than any pharmaceutical company scandal. To translate, that means that managed care companies nation wide have another way to deny payment and save money based on what they consider to be an "evidence based practice." but they are rationalizing it as a quality marker.
Let me suggest how the depression assessment and screening should be done in this matrix. First of all the screening test in this case the PHQ-9 does need to be validated as a diagnostic and outcome measure in populations. The current literature is extremely limited and there is no evidence that population screening for depression accomplished anything other than exposing a lot of people to antidepressants that the FDA has identified as potentially arrhythmogenic. The cost of prescribing SSRIs to a large population as well as the electrocardiogram abnormalities is unknown.
I will briefly comment on the additional goals. "Goal 2: Person-Centered Care". As previously explained, this is the goal of every physician who has ever been trained in medical school. It appears here basically as rhetoric that is designed to disenfranchise professionals and make it seem like managed care companies invented individualized care. "Goal 3: Encourage effective coordination within behavioral health". What jumps out of the page at me under this sparsely populated matrix is "Ratio of detox to outpatient admissions". It is well known that managed care tactics have essentially destroyed the availability of medical detox in most communities. I can recall being told that medical detox was not "medically necessary" by managed care reviewers. I guess the hope was that the cost of detox could be transferred from managed care companies to non-medical county facilities. Quality care for addictions means that there needs to be a spectrum of care. I don't know what ratio is implied by this quality marker but I can assure you that it will favor managed care companies.
"Goal 5: SAFE - make behavioral health care safer." Suicide, injury and death, treatment for overdoses after hospitalization, and discharges on multiple antipsychotic drugs are suggested as quality markers. There is no evidence of what it takes to make the assessment and treatment. To capture any problems in these areas you need a quality process, not a piecemeal check box that can be gamed so that it appears that you are providing quality care. Measuring these variables in the absence of defining a quality process is meaningless.
"Goal 6: Affordable/Accessible: Foster affordable high quality behavioral health care...". This continues to be an absurd priority of the partnership between the government and the managed care system. There is no more "cost effective" approach than what passes for behavioral health care. Mental health treatment in the US has been decimated by 20 years of managed care to the point it is practically non-existent. During that same time there has been an addition of trillions of dollars in Cardiology, Intensive Care, and Oncology infrastructure. Even if that were not true, what is the evidence that cost effectiveness has to do with quality? It is certainly not reflected in the previous specialties that I just listed.
Are there problems with this approach? It turns out there are major problems and here are just a couple:
1. Administrative data - administrators have significant biases that seem to impact on so called quality markers across the board. They don't seem to understand their biases and the major biases include not really knowing anything about medical quality, thinking that medical quality can be derived from what is basically administrative data (length of stay, readmissions, etc.) and at this point in time having so much political leverage from government backing that they don't really have to pay attention to the considerable number of people out there who know a lot more about quality. As I have documented on this blog this is a thirty year trend and all of that is captured in the NBHQF. Any who has followed quality markers over the last two decades will probably have made the observation that business heavy entities like managed care systems are information averse. By that - I mean that they collect a large amount of data but it is really not enough data or the right data. Great examples are HEDIS data and PHQ-9 scores. Is it really possible to collapse medical quality in to what are really simplified demographic parameters? No more than knowing that 50% of 85 year old men have coronary artery disease.
2. Business practices trumping medical practice - on this blog I have also reviewed these practices and will focus on one this glares in this report - "person-centered care". For years HMOs and their administrators were focused on "population based care". They scoffed at the notion that people or patients needed to be treated on an individual basis. This was at the peak time when they were deciding that everyone with a certain condition should be hospitalized for a the same number of days and it was a "quality problem" if the length of stay in the hospital was too long. Nobody ever complained if the length of stay was too short. Many of the thought leaders in managed care go to that position by basically promoting these ideas. Why is the managed care industry suddenly behind "person centered care". You won't see the history recorded anywhere but a lot of it goes back to the primary care physician as gatekeeper. If you assume that you can managed populations of people with the same interventions, you can tell your subscribers that they have to get "referrals" from their primary care physician for any tests or consultations that are viewed outside of the population norm. This was happening on a large scale in the 1980s and 1990s but subscribers rebelled against it. After all they were paying good money for insurance coverage and not seeing it back in what they were interested in for health care. The gatekeeper function disappeared and suddenly even managed care subscribers could directly seek consultations and referrals that they were interested in. Patient centered care from the managed care industry was basically determined by the market and the failed theory of their thought leaders about managing populations rather than treating individual people.
Physicians have always been taught that patient care is highly individualized. The question is will they continue to let the government, business entities, and non-evidence based practices masquerade as quality. Looking at the quality of physician commentary in the media, in journals, and on blogs is not very hopeful. It is clear that physicians would prefer to blame themselves or one up one another rather than look at the true problems with the health care system and what bureaucrats and businessmen are calling quality.
George Dawson, MD, DFAPA
SAMHSA. National Behavioral Health Quality Framework (NBHQF)