by the APA Practice Organization

March 27, 2008 — Pay-for-performance programs and other quality improvement efforts are already widespread in medical settings. Increasingly, government agencies and health insurers are applying these programs to mental health services delivery.

How do such programs affect practicing psychologists? Experts at the APA Practice Organization's 2008 State Leadership Conference explored the issues.

Proliferating programs

The number of organizations now developing and promoting the use of quality measures is huge, said Ann Doucette, PhD, a research professor of health policy at George Washington University Medical Center's School of Public Health. And the array of organizations participating in quality improvement efforts is quite diverse.

For example, in the private sector, the American Medical Association (AMA) has formed a consortium of more than 100 medical specialties, the Physician Consortium for Performance Improvement, to develop evidence-based performance measures for physical health. The Ambulatory Care Quality Alliance (AQA) has formed a partnership with the American College of Physicians, America's Health Insurance Plans (AHIP) and the Agency for Healthcare Research and Quality (AHRQ) to address quality issues for ambulatory care. The National Committee for Quality Assurance (NCQA) and the Joint Commission are also examples of accrediting entities with dedicated quality improvement programs.

Federal initiatives include the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI) and the Hospital Quality Initiative. In addition, there are public/private consortiums like the National Quality Forum (NQF). NQF acts as a clearinghouse, reviewing the integrity of performance measures and endorsing their application. Many quality improvement initiatives look to NQF for what measures to select in improving care outcomes.

Professional organization and federal efforts to improve care have been supported and extended by purchasers (employers) and commercial health plans. Humana, Aetna, United Behavioral Health and other insurers are developing their own approach to assessing the quality of the care they provide to insured populations. Other organizations like Bridges to Excellence, a consortium of employers, providers, researchers and industry experts, have moved beyond measuring quality to rewarding health care providers who deliver high-quality care.

According to Doucette, while all of these efforts initially targeted physical health care, they are now moving toward including behavioral health care in performance measurement development, quality improvement efforts and pay-for-performance initiatives.

She noted that there are many approaches to pay-for-performance. Examples from programs that have been implemented include higher capitation rates, increased reimbursement rates and bonuses to provider networks that meet or exceed performance standards. Some provider groups have chosen to reinvest financial rewards to subsidize quality improvement infrastructure.

Pay-for-performance is also directed toward consumers. Some health plans offer individuals reduced premiums, lower co-payments and deductibles for selecting practitioners who meet quality standards.

For many psychologists, said Doucette, the idea of pay-for-performance programs is "like fingernails on a chalkboard." She outlined several concerns. Practitioners may focus on earning an incentive rather than providing good care. Emphasis on meeting program criteria may obscure other areas that contribute to good outcomes. To make themselves look good, programs also may select patients who are likely to do well in treatment.

In addition, said Doucette, there may be sustainability issues. As performance improves and more providers become eligible, it may become harder to continue paying incentives.

She encouraged practitioners to be part of the pay-for-performance dialogue to ensure that performance measurement efforts are aligned with sound clinical practice, to engage in the systematic collection of outcome data as evidence of quality care they provide and to identify practitioner issues and concerns regarding safeguards against the misuse of performance data.

In the public sector

One of the most notable pay-for-performance efforts was implemented in 2007 in the public sector: Medicare's Physician Quality Reporting Initiative (PQRI) initiative.

"It's actually pay for reporting," explained Diane Pedulla, JD, director of regulatory affairs for APA's Practice Directorate. "At this stage, it's not measuring performance or quality. It rewards independent practitioners for reporting data on a selected series of measures."

The number of measures that psychologists can use has already increased dramatically, said Pedulla. When the program began, there was only one mental health measure, which involved the use of antidepressant medications for patients with major depression.

Now there are six measures that relate to mental health services delivery. In addition to medication assessment, these include developing a treatment plan with a patient, screening for cognitive impairment, screening for depression, performing a diagnostic evaluation and assessing suicide risk. Two more measures were designed for use by physicians but could also be used by psychologists: assessing pain and verifying current medications.

The program is more expansive than you might think, said Pedulla. "While the bonus isn't extremely high, it isn't limited to the measure you're reporting on," she explained. "It's applied to all of your Medicare claims." One thing to keep in mind is that to receive the bonus, a practitioner must report on 80 percent of possible cases in each category.

Privacy concerns

Pay-for-performance and similar programs that rely on collecting outcome data directly from patients present confidentiality challenges, warned Alan Nessman, JD, special counsel for legal and regulatory affairs in the Practice Directorate.

To illustrate those concerns, Nessman presented a hypothetical scenario. Say you're a patient in therapy, he proposed, and one day your psychologist hands you a questionnaire from your health insurer. The company's information sheet says it will enhance treatment, and its Web site promises to protect your confidentiality. Reassured, you reveal bisexuality and occasional drug use.

"Now fast forward in time," said Nessman. "You're involved in a custody dispute with your spouse, and the conservative judge doesn't trust bisexual parents. And you're denied a security clearance because of your drug use." Then you discover that the psychologist had a financial incentive to get you to complete the questionnaire. The result? Among other things, your relationship with your therapist is ruined.

Nessman noted that in scenarios like this one, by collecting data directly from the patient instead of asking the psychologist about the patient, a company can undercut three critical privacy protections. First, the psychotherapist-patient privilege would not apply because the patient's filling out a company questionnaire clearly does not constitute a patient-therapist communication. Second, the questionnaire would not qualify for psychotherapy notes protection under the Health Insurance Portability and Accountability Act. Finally, it undercuts the psychologist's discretion to determine the appropriate level of detail in recording sensitive information, in light of potential record disclosures.

"Real informed consent of patients might be one solution," said Nessman. "If patients understand the real privacy risks, they can make informed choices about whether to answer the questionnaires." Another solution might be to enact legislation preventing disclosure of outcomes data.

One state's experience

Privacy issues aren't the only concern, said Elena Eisman, EdD, director of professional affairs and executive director of the Massachusetts Psychological Association.

Implementing protocols used in general medical settings to behavioral health settings doesn't work for several reasons. "It's harder to measure behavioral health outcomes than somatic factors," she said.

"We also work with the door closed," she added, noting that practitioners can say they use evidence-based practices even when they don't. Further, psychologists typically have small patient loads with many different insurers-each of which may have its own measurement system. This situation prevents a practitioner from gaining the necessary volume with any one program to participate effectively in these programs.

In Massachusetts, psychologists suddenly found themselves facing a plethora of outcome measurement programs with some problems.

Eisman noted that one insurer incentivized a pay-for- participation in an outcomes process through promised "financial incentives" for measuring outcomes. In reality, for many psychologists with primarily assessment or psychotherapy practices, the incentive turned out to be "less of a decrease" rather than an increase. According to Eisman, other insurance company programs feature survey instruments and analyses with significant validity and methodological problems.

To effectively monitor and improve these programs, said Eisman, psychologists need to get involved in advocacy:

• Use the medical community as an early warning system. "What happens to them is going to happen to you," she said.

• Work in coalition with other behavioral health and consumer groups.

• Use a professional tone and collaborative approach so they see you as having solutions to offer, not just criticism.

• "Come with data, not just kvetching," she recommended.

• Use your psychological training to evaluate and when appropriate to challenge the validity of outcome measures and data analyses and how they are used in setting policy.

• Explain the differences between experimental and research-based data and real-life results.

• Work with consumers to use the press to get important messages across.

• Suggest alternatives and work with companies.

"We need to stop being reactive," said Eisman. "We need to get ahead of the curve and advocate before the policies are designed and set in stone."