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Psychology contemplates
‘pay for performance’
(June
2007 Issue)
By Nan Shnitzler
"Pay for performance" (P4P) programs in their various guises
link quality of care to provider pay via incentives. P4P has been
widely adopted in medicine, and behavioral health is now testing
the waters.
The Tax Relief and Health Care Act put P4P into Medicare and Medicaid
by asking non-physicians, including psychologists and social workers,
to report on outcomes, but without the benefit of associated quality
measures which have yet to be determined.
"It's an incremental approach," says Ann Doucette, Ph.D., of the
research faculty at George Washington University Medical Center,
who is working with the APA on P4P guidelines. "The handwriting
is on the wall; the government is unwilling to pay providers that
don't demonstrate outcomes."
Private payers feel the same. MHN, the behavioral health subsidiary
of Health Net, is finalizing plans to launch later this year a P4P
pilot for psychiatrists at a medical independent practice association
in Connecticut, says medical director Ian Shaffer, M.D., MMM.
Without revealing details, Shaffer says MHN does not plan to lower
current fees but to reward clinicians based on performance metrics
from such organizations as the National Committee for Quality Assurance.
"If a national organization recognized throughout the country says
this is quality care, then that's the place I think you start,"
Shaffer says.
Shaffer thinks the P4P foray into psychiatry could be a springboard
to psychology, though determining metrics for psychotherapy won't
be easy, he says. With help from the provider community, he thinks
they could define metrics that demonstrate efficiency and effectiveness
of service, quality of care and value to consumers.
To psychologists who think P4P is just another way for insurers
to shortchange them, Shaffer counters that providers should be using
evidence-based treatment (EBT) and aligning their practices to national
standards.
"When I walk into a provider's office, I want the provider to work
with me to figure out what's wrong with me, then tell me the treatment
options, what the literature says is most likely to help and the
risks," Shaffer says. "We can do that for a lot of behavioral care
at this point."
He knows providers are not fond of what they perceive as "cookbook
medicine" and treatments they were not trained to do. He realizes
it's important to provide equal opportunity for all providers to
participate in P4P, even those who used an open-ended therapy approach.
"But at the end of the day, we can't be incenting two different
treatments for the same disorder if the evidence-based literature
says this is the treatment," Shaffer says.
Doucette says the problem with incenting EBT is how do you know
the provider is executing the protocol as prescribed? The client-clinician
alliance accounts for a much greater proportion of the therapeutic
outcome than the modality used.
"You can train people in EBT protocol, but without the ability
to form a relationship with a client, EBT is relatively useless,"
Doucette says.
APA policy counts EBT in a broader definition that includes clinical
judgment and patient preference, says Sanford Portnoy, Ph.D., Massachusetts
representative to APA.
"The concern is that EBT not become a way for insurers to define
treatment so that it limits choices for consumers or acts in arbitrary
ways to limit services," Portnoy says.
He says the APA Practice Directorate is watching P4P closely and
has two concerns - that P4P be used to enhance treatment and not
limit access and to guard against incursions into confidentiality.
Doucette says it's up to psychologists to provide evidence to insurers
and employers that the treatments they use are effective.
"APA is making sure psychology has a voice at the table to shape
performance metrics that demonstrate effectiveness and determine
what the benchmarks are going to be," Doucette says. The stakes
are high for psychology, she says if it hopes to swing the reduction
in reimbursement rates in the opposite direction.
In another scenario, if a client is neither showing for appointments
nor taking prescribed medications, Doucette says, P4P programs should
not hold the treatment team responsible. But they could incent consumers
to participate in their own care with, say, lower co-pays.
Another focus is developing outcome measures for serious illness
like bipolar disorder; research shows that adding psychotherapy
to medication is beneficial.
"I think we're beginning to see integration of psychotherapy in
the care of chronic disease," Doucette says.
It's seen not just in chronic brain disease but also chronic medical
conditions, says Rodger Kessler, Ph.D., A.B.P.P., of Berlin Family
Health, Fletcher Allen Health Care, a primary care practice in Montpelier,
Vt.
He thinks trying to incent behavioral health in and of itself is
misguided because outcomes are not monitored, because surveys show
psychologists have little confidence in EBT and because managed
care has wrung behavioral health dry.
Yet compelling data show the efficacy of psychological care for
depression and anxiety in chronic medical conditions like diabetes,
asthma and cardiac disease. Ignoring such comorbidities is a huge
cost driver, he says.
"If you track the cost of medical care for diabetic patients who
are not depressed with patients who are depressed but not treated,
the cost is 50 to 70 percent higher on the medical side. What we
need to do is integrate the behavioral health expense target as
an element in P4P for improved medical care. That's where the richness
is for pay for performance," Kessler says.
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