The growing impact of clinical practice guidelines
By Rebecca A. Clay
When clinicians hear the word "guidelines," what they often think they're hearing is the word "cookbook," says Andrew Bertagnolli, PhD, senior manager for the Integrated Behavioral Health Care Management Institute at Kaiser Permanente. "They think, 'You're going to tell me to do this, do this, do this,'" he says.
Psychologists and other behavioral health providers can find the prospect of clinical practice guidelines especially troubling, says Bertagnolli. When Kaiser Permanente's leadership told Bertagnolli that behavioral health needed to start developing clinical practice guidelines, for instance, he was staunchly opposed. Behavioral health, he argued, was different from other clinical areas and couldn't possibly impose guidelines on its practitioners. But that was the same story Kaiser's leaders had heard from clinicians in primary care, oncology, emergency and every other department.
Now Bertagnolli has become a big supporter of clinical practice guidelines, even for behavioral health. And he's not alone. Faced with intensifying fiscal pressures, health plans, managed care organizations and even entire behavioral health systems have introduced guidelines for behavioral health providers. No matter where they're implemented, however, guidelines share the same goal: reducing variations in care as a way of making the most of limited resources.
Managing health plan benefits
Take private payers, for example. "Health plans exist to manage benefits," says Rhonda Robinson Beale, MD, former chief medical officer for external affairs at OptumHealth Behavioral Solutions. "We have unsustainable increasing costs in health care," says Robinson Beale. "There is a great need to try to shape what is paid for by insurance."
Originally meant to cover only catastrophic illness, insurance has broadened its mandate since the 1960s and 1970s to cover at the minimum anything deemed "medically necessary." Noting that a controversial Kaiser Permanente settlement in 2004 brought health plans and payers to a common definition of "medically necessary," Robinson Beale said that medically necessary services are those provided to diagnose or treat illness or injury by providers exercising "prudent clinical judgment."
"Prudent clinical judgment is not just what you think," Robinson Beale said, explaining that judgment must be based on diagnostic codes and evidence-based guidelines. In the absence of such guidelines, services must be in accordance with generally accepted standards of practice — standards outlined in peer-reviewed articles, consensus panels or specialty society recommendations, for example. Things get even stickier when you move beyond clinical appropriateness and try to determine medical necessity when it comes to such factors as frequency and duration of treatment, Robinson Beale added.
At Optum, a clinical technology assessment committee assesses the evidence behind any new technology — which includes new psychotherapies — the company is considering covering. Two reviewers use a scientific merit rating scale to independently examine research Optum has identified; if their scores are in line with each other, the company does a more thorough review according to certain criteria, such as at least three high-quality studies. (If there are fewer, the technology falls into an "emerging" category.) The company also examines such factors as the technology's safety, how easy it is to implement with fidelity and its comparative cost value. "It doesn't help if a therapy is effective, but costs so much that it's prohibitive in terms of being able to offer it generally," says Robinson Beale.
The problem comes when there's just not evidence to make a decision, says Robinson Beale. Some states have mandated coverage for autism, even though there aren't widely accepted practice guidelines showing what works for which patient population or information about how long treatment should take. "All of these things are a black hole," says Robinson Beale. To come up with coverage determination guidelines, Optum brought together researchers and providers to assess which therapies have the most evidence.
Reducing variations in care
At Kaiser Permanente, clinical practice guidelines are helping behavioral health providers reduce unnecessary variations in the care they provide and thus meet the Institute for Healthcare Improvement’s triple aim of improving care, improving population health and reducing per capita health care costs. "We feel that variations in practice are one of the things that lead to decreases in quality care and increases in cost," says Bertagnolli. Other goals include preventing errors, increasing clinicians' accountability and improving resource utilization.
The guidelines Kaiser Permanente is developing go beyond the guidelines most mental health practitioners are accustomed to, which focus on things like familiarizing yourself with the laws in your state or knowing what to write in charts. Instead, says Bertagnolli, the guidelines are systematically developed statements to help practitioners make appropriate decisions in a variety of circumstances.
Kaiser Permanente hasn't produced guidelines for all 300 diagnoses in the DSM-5. Instead, it has targeted four clinical areas — adult and teen depression, alcohol misuse and serious and persistent mental illness, especially suicide — that are both prevalent and costly. These areas also have multiple treatment options — with uncertainty about which one is most efficient — and significant variation in practice.
Kaiser Permanente either adopts guidelines from external organizations or creates its own. In addition to ensuring that the process used to create recommendations meets a certain level of rigor and is free of bias, Kaiser Permanente looks for recommendations that are "actionable." "A medication recommendation that says, 'All antidepressant medications are equal; just pick one,' is not a terribly actionable recommendation," says Bertagnolli. "If they're all equal, we often look at what medication is the least expensive, because we want to use our membership dollars in the most efficient way."
Once a guideline is adopted, Kaiser Permanente looks for ways to support its use. The electronic health record system includes clinical "decision support" tools, for instance. "If a diagnosis comes up, it says, 'Consider x, y and z,'" says Bertagnolli. The guidelines don't tell clinicians what to do, however. Designed to allow flexibility, the guidelines simply tell clinicians what they need to know to make good decisions in partnership with their patients. Guidelines also inform patient education materials, both on Kaiser Permanente's website and in the written instructions patients receive during visits.
Once Kaiser Permanente has a guideline, the process isn't finished. "There's a huge maintenance component of guidelines," says Bertagnolli. "They take a tremendous amount of effort and upkeep." Accreditation by the National Committee for Quality Assurance requires a review of guidelines every two years, for example.
Transforming a system
The Philadelphia Department of Behavioral Health and Intellectual disAbility Services is using clinical practice guidelines for an even more ambitious purpose — supporting the effort to transform the entire system from one that focuses on managing patients' symptoms to one that facilitates adults' recovery and children's resilience.
"Payers are under enormous fiscal pressures," says psychologist Arthur C. Evans, PhD, the department's commissioner. "Because of that, what we're trying to do is reduce variability in practice so we're more likely to get the outcomes we want as a payer." Reducing variation and ensuring a commitment to the recovery framework are especially challenging given that the 200 provider agencies that serve the system's 120,000 patients range from highly trained clinicians to those with just high school educations, says Evans.
To help ensure that shift, the department has developed guidelines based on scientific data in the form of randomized clinical trials, meta-analyses and even program evaluations; professional consensus and the perspective of people with "lived experience" of behavioral health issues. The resulting guidelines lay out the system's values and goals in several domains. The 10 values include hope, community inclusion, patient and family involvement, and cultural competence, for example. Goals include integrating services and creating an atmosphere of strength instead of just focusing on patients' challenges.
The guidelines also outline various domains providers need to pay attention to, including finding ways to engage and retain people in treatment, using practices associated with improved outcomes making sure patients get connected to the next level of care after they're discharged and having connections to and building the capacity of community resources like Alcoholics Anonymous meetings.
Like Kaiser Permanente's guidelines, Philadelphia's behavioral health guidelines allow flexibility, giving information to supplement clinicians' own judgment. The guidelines aren’t intended to be an algorithm, explains Evans, but rather they draw on the literature, clinical consensus and input from behavioral health professionals to outline things that providers should pay attention to.
To be a provider in Philadelphia's system, clinicians must show they know the guidelines. The guidelines also form the basis of Philadelphia's pay-for-performance system. So far, says Evans, the guidelines are having an impact. "Our resources have remained flat for the last three or four years," says Evans. "Yet we've increased the number of people seen, and the per-person cost has gone down significantly. I am happy that this has been accomplished by improving clinical outcomes."
Note: This article is based on a workshop presented during the March 2014 State Leadership Conference in Washington, D.C., sponsored by the APA Practice Organization and APA.