Reimbursements and the problems that arise while negotiating with payers.
Clinical burnout that leads to turnover.
Turnover that leads to staffing shortages. .
Patients re-entering treatments at rates of 30% or higher year over year.
These are common pain points across the behavioral health and addiction treatment field. While discussed often, solutions have been few and far between. But, there is light on the horizon, and organizations can adapt and incorporate evidence-based solutions to not only address these obstacles but enhance their levels of care, become a differentiator in a saturated market, and thrive as a forward-thinking, data-driven, life-saving business.
In this 3-part series, we’ll look at the future of clinical care in behavioral health. This week, we start with measurement-based care (MBC), which needs to be on every provider’s list of top priorities.
Relieving the Pain With Evidence-Based, Measured Care
Before jumping MBC, let’s take a step back and talk about Evidence-based practices (EBP) in general. Backed by research and clinical trials across populations, EBPs are the gold standard in behavioral health treatment. And it's easy to understand why; it is beneficial for providers and payers (more on this later) that the treatment modalities are as efficacious as possible. Furthermore, patients find comfort in knowing their treatment is grounded in science and that comparable treatments have helped those with similar conditions in the past.
But there are two issues plaguing the successful implementation of EBPs across organizations: training and data collection.
Yeah, But We’re Already Implementing EBPs…
When examining the dissemination of EBPs across the behavioral health field, the late Dr. Kathleen Caroll of the Yale University Department of Psychiatry found some startling results:
"Multiple lines of evidence also indicate that EBPs are far from universally available and competently implemented. For example, a recent national survey in the United States indicated that most treatment programs do not offer training or supervision in EBPs, nor do they require their newly hired clinicians to have training in EBPs [8]. In our own work, we evaluated 'treatment as usual' as practiced in 20 sites across the United States in a recent Clinical Trials Network study of motivational approaches. Prior to implementation of the study, clinicians reported that they made extensive use of EBPs such as CBT and 12-Step facilitation (TSF) [9] However, when more than 700 audio-taped 'treatment as usual' sessions were evaluated by independent raters, interventions associated with those and other EVTs were virtually undetectable [10–12]. In fact, therapist-initiated discussion of issues clearly unrelated to any patient problem or issue (e.g. 'chat') was seen more frequently than any EBP" [13,14] (Carroll, 2012).
In summary, clinicians believe they are providing EBPs effectively, but they are not because they have not been trained to do it properly.
When we talk to clinicians about EBPs, we’ll often ask them if they are implementing them in their practice. Invariably, the answer is yes. We then follow up with, “What EBPs do you use?” and they’ll respond with the usual CBT, DBT, MI, etc. Our next question is, “What about those modalities produces better outcomes? What specific elements help your patients the most?” This is where clinicians get stuck. And that’s OK, because graduate and licensing programs rarely provide training on these elements. They’re told what modalities are evidence-based, but not what about those modalities works. And therein lies the rub, only a handful of studies have been conducted trying to tease that out, all with small sample sizes and little predictive power.
With several EBPs at a clinician's disposal (Cognitive-Behavioral Therapy (CBT), Interpersonal Psychotherapy, Dialectical-Behavior Therapy (DBT), Motivational Interviewing (MI), Twelve-Step Facilitation, etc.), there are a variety of paths accessible for clinicians and patients. Still, these modalities will only reach their full potential if delivered correctly. Once clinicians have been properly trained, there is another obstacle to overcome; every patient is different, and some might respond better to one form of treatment than another.
How can we know for sure which type of treatment is the most effective for a particular patient?
There is only one answer: measurement.
Enter Measurement-based Care (MBC)
Measurement-based care, also known as routine outcomes monitoring, is a systematic process that monitors patient progress through observation, self-reporting, and assessment to inform clinical decision-making and the best course of treatment for an individual patient. It differs from the standard view of outcomes tracking, of which results are routinely viewed every 90 days or more, because the data is used in real-time to provide better-informed care.
Without data, we cannot know if a particular intervention is effective for that patient. Our field is full of anecdotal stories, that one patient that did really well after X intervention. Anecdotes are not enough. We need to know if an intervention helps most patients. Just as importantly, as Dr. William Miller found, some interventions can even harm patients (Miller & Moyers, 2021). , so it is of critical importance that we’re tracking the effects of particular interventions for specific patients.
MBC is the future of behavioral health, but recent statistics show that only about 20% of providers have integrated measurement and outcomes tracking into their programs. Barriers to integration include concerns over confidentiality and HIPAA compliance, a lack of understanding on how MBC will benefit organizations, a reported lack of resources (funding) for training and implementation, and a belief, usually on an individual level, that a practitioner knows better than the data (Lewis et al., 2018).
The remaining barriers simply must be overcome if an organization expects to survive going forward; the writing is on the wall.
It Matters to the Payers, So It Needs to Matter to Providers
Like it or not, agree with it or not, the payers want MBC and programs not implementing it are going to be closed in 5 years or less. Talking to many providers big and small, we’ve heard numerous cases of payers, Optum in particular, denying to contract with a provider because their outcomes weren’t good enough.
How can you improve outcomes if you aren’t measuring them? The answer is, you can’t.
For obvious reasons, the payers prefer to work with larger providers that get good outcomes for their members. If you were a payer, would you want to contract with 15 little treatment programs, most without outcomes tracking. Or would you want to contract with 1 or 2 large providers clearly demonstrating efficacy across their continuum?
We all know the answer to that question. The writing is on the wall and eventually the bigger providers, at least the ones implementing MBC, will be the ones with all the contracts and the little guys will fade into oblivion.
Right now, providers are lucky. Since MBC isn’t being implemented hardly anywhere, providers big and small have the opportunity to start demonstrating outcomes and contracting with payers. 5 years from now, the big players will be established and these opportunities won’t exist, but if you can start MBC now, you can survive.
The other side of the payer coin is that they want to invest in quality programs. If they see a small provider implementing MBC, they’re going to want to help that provider grow. We’ve heard that several times straight from the horse's mouth. What this doesn’t mean, is that the provider tells the payer they’re using EBPs. That’s not enough. The payers don’t know about the general research. They’re not interested in anecdotes. They want to know, do you implement EBPs in a way that is actually effective for patients. This means they want to see your data and your patients’ actual outcomes, not just the fact that you say you’re implementing intervention X, Y, or Z.
Executives know that MBC is the future, they often just don’t know what steps to take or how to implement correctly in a way that their teams find most helpful. That’s where the Institute comes in. We train clinical teams on how to implement evidence-based treatment, then we teach them how to implement measurement-based care. Of course, you need patient outcomes tracking in place before we can train the team on using it, which is why we’ve partnered with one of the industry leaders in outcomes tracking - ERPHealth. In addition to training, we then provide ongoing auditing, feedback, and support to help clinical teams effectively implement MBC so they get better and better over time.
References:
Carroll, K. (2012), Dissemination of evidence-based practices: how far we've come, and how much further we've got to go. Addiction, 107: 1031-1033. https://doi.org/10.1111/j.1360-0443.2011.03755.x
Jensen-Doss, A., Douglas, S., Phillips, D. A., Gencdur, O., Zalman, A., & Gomez, N. E. (2020). Measurement-based care as a practice improvement tool: Clinical and organizational applications in youth mental health. Evidence-based practice in child and adolescent mental health, 5(3), 233–250. https://doi.org/10.1080/23794925.2020.1784062
Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglas, S., Simon, G., & Kroenke, K. (2019). Implementing Measurement-Based Care in Behavioral Health: A Review. JAMA psychiatry, 76(3), 324–335. https://doi.org/10.1001/jamapsychiatry.2018.3329
Miller, W. & Moyers, T. (2021) Effective psychotherapists: Clinical skills that improve client outcomes. Guilford press. ISBN 9781462546893