The National Committee for Quality Assurance has developed a Behavioral Health Quality Framework to help align behavioral health quality efforts within health systems by focusing on setting population health goals and using sets of aligned and coordinated quality measures to measure progress toward achieving those goals.
During a recent webinar, state government, managed care and clinical executives discussed the potential of the framework with NCQA officials.
“Behavioral health has always been a neglected part of our healthcare system, but I think the pandemic has really brought to our attention just how terrible the situation is, in a time when the needs are much greater than they ever have been. Behavioral health is also particularly challenging to measure,” said Peggy O’Kane, president of NCQA. “Part of the challenge with measuring behavioral health, is it's very hard to figure out an accountability model that doesn't leave out many parts of the system that really do contribute either positively or negatively.”
“We know behavioral health conditions are a leading cause of disease burden, and that this burden is unevenly distributed across populations,” noted Serene Olin, Ph.D., NCQA’s assistant vice president of research and analysis. “People with behavioral health conditions account for over half of all healthcare spending. And yet, behavioral health services account for only about 4 percent of this cost. National efforts are evolving to pay for value rather than volume, and we urgently need effective performance measures to guide payment models that drive high-quality and equitable behavioral healthcare.”
With support from the California Health Care Foundation, NCQA conducted an environmental scan looking at 39 active federal programs’ reporting requirements and counted more than 1,400 measures and metrics.
They found only 35 unique standard behavioral health measures used for reporting, and they tend to be narrowly focused on diagnoses such as depression and specific care processes such as screening. They rely on administrative claims data, which is useful for accountability, but limited for improving care delivery Olin added.
Among programs that focused on integrating behavioral health and physical services, homegrown measures were particularly common, she explained. “Standard quality measures did not include key aspects of behavioral healthcare integration, such as integrated care processes, care coordination, cost of care, patient experience, or health outcomes. The lack of consistently used measures in important areas of behavioral healthcare point to a big challenge in shifting to paying for value.”
In conversations with stakeholders, NCQA heard that behavioral healthcare is paid for via complex assortment of funding streams. “There's a lot of piecemeal funding to cover important aspects of care and social needs that influence health outcomes, and each funding stream comes with its own reporting criteria, which are often rudimentary and not typically very helpful for improving care delivery,” Olin said. “The enormous reporting burden drains resources for innovation and for measuring what matters. Additionally, we heard very clearly that behavioral health integration is viewed as key to combating stigma and improving care access, but there was actually very little agreement on who should be held accountable for behavioral health integration or how to measure what successful behavioral health integration would look like. And the perennial problem of behavioral health data infrastructure and data sharing issues were also raised as key barriers to using quality measures to drive career improvement.”
To drive improvements in behavioral health quality and promote joint accountability across entities responsible for serving individuals with behavioral health needs, NCQA is proposing a Behavioral Health Quality Framework adapted from the Applegate Alignment Model created by Mary Applegate, M.D., the Medicaid medical director in Ohio. This framework prioritizes alignment and use of meaningful sets of quality measures, uniquely targeted to each level of the health care system, that coordinate and assess progress towards population-level goals. Bundles of measures and metrics are transparently defined, measured, and coordinated, and data use is based on each entity’s position and relationship with respect to goals and populations served.
Switching from fee for service
Applegate was among the webinar discussants of the framework. “At the state level, we do use a framework like this and measures to monitor the utilization of services and quality of care,” she said, “but most importantly, this is about switching from fee-for-service payment to managing the care of the population entrusted to us. In that regard, it is about aligning physical and behavioral health systems and social systems, for example, by designing quality improvement efforts to continuously improve, always hearing the voice of our patients and our members in everything that we do. This allows us to test what works and what doesn't, and sets the stage for value-based contracting, so that we can take care of large swaths of people.”
Gail Edelsohn, M.D., is senior medical director of Community Care Behavioral Health Organization, which covers more than a million Medicaid members in Pennsylvania. She said the framework aligns very well with Community Care, which has a seven-pillar infrastructure and three of those pillars are population health, health equity, and quality performance. “It aligns with our identification of population goals and prioritizing populations,” she said. “Two examples would be decreasing suicide rates in members and decreasing overdose deaths. The framework is very successful in facilitating and creating bundles of evidence-based measures and metrics. It certainly aligns with our behavioral health financing in terms of value-based contracting, and it supports the standardization of measures.”
Tammy Allen is a licensed clinical social worker in behavioral health at Hill Country Health and Wellness Center, a federally qualified health center in far northern California. She said integrated care and a whole-person perspective are essential to the FCHC's mission.
“Our most helpful and ambitious efforts have been highly dependent upon grants, short-term contracts, and various partnerships of different kinds,” she said. We've also done a lot of pilots and demos to get the services established. Some days It feels like we're neck deep in quality measures.”
Innovation and expansion of services require both motivation and money, and there are many hurdles for providers and clinics and facilities along the way, Allen added. Many have to do with quality measures and accountability. “When it comes to program evaluation and measurement, every funding source has their own desired outcomes, preferred measuring strategies, reporting requirements, and typically in integrated care and behavioral health this involves program-specific metrics and non-standardized measures, that don't transfer well to other programs,” she said. “Beyond that, the outcomes are rarely shared beyond the program stakeholders, even when the outcomes are outstanding, and that's a major shortcoming. Standardized measures that are meaningful and friendly to both the funder and the providers are greatly needed. We look forward to that day.”