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One Step At A Time (Or Several At Once): Improving Quality Measurement In Behavioral Health

Background & Purpose
Recent health reforms such as the Affordable Care Act (ACA / PPACA) and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), along with endorsements by health care bodies such as the Institute of Medicine (IOM), have brought increased resources and requirements for measuring and assessing health care quality. Within the field of behavioral health, however, questions remain regarding developing, validating, and using quality measures. In a recent article entitled “Quality Measures For Mental Health And Substance …

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Discussion & Implications

Of the 510 measures identified in one comprehensive review of behavioral health quality measures, only 5% are used in major quality reporting programs and only 10% are endorsed by the National Quality Forum (NQF). The authors noted that many measures are derived from research and may not be generalizable or practical for accountability purposes. In addition, there is insufficient evidence supporting many measures’ utility in predicting and improving health outcomes. Despite the number of existing measures, behavioral health quality measures comprise only five percent of items in the Measures Inventory from the Centers for Medicare and Medicaid Services (CMS), suggesting the topic is underrepresented in CMS programs.

Some of the most widely used behavioral health quality measures exist within the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (NCQA© HEDIS®), and results indicate that performance and rate of improvement in the area of behavioral health is mediocre when compared to that of general medical conditions. For example, in 2014, average performance on four behavioral health measures was 48% compared to 72% for six cardiovascular and diabetes measures. From 2006 to 2014, measures assessing changes in diabetes and hypertension care showed an average improvement of five to seven percentage points, while average quality declined in behavioral health for two out of three payers.

To improve the quality and widespread use of measure development and their utilization in the field of behavioral health, the authors compiled five key priorities for next steps:

Expand Standardized Outcome Measurement:

The nine-item Patient Health Questionnaire (PHQ-9) has been incorporated into two measures endorsed by the NQF that are being proposed for accountable care organization reporting. This use of the PHQ-9 could represent a model for expanding measurement to other behavioral conditions as well as different domains and types of outcomes. In addition, the concept of recovery (i.e., a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential) offers avenues to expand domains of quality measures from clinical symptoms and outcomes to areas such as quality of life and engagement in care.

Implement Structural Changes:

Such approaches to quality measurement focus on increasing the capacity of providers and organizations to provide effective, outcome-improving care. Components of structure associated with high-quality care include systematic, targeted assessment; use of standardized tools on a longitudinal basis; use of a registry to enable follow-up by care managers; and training clinicians to use “stepped care” strategies to intensify treatment when necessary to improve outcomes. These structural approaches are not yet standard in clinical practice, with few recognition programs specifically developed for behavioral health organizations.

Utilize Integrated Care:

It is well-documented that, compared with the general population, individuals with serious mental illness (SMI) often have other chronic conditions leading to shorter life expectancy, and that individuals with chronic medical illnesses often have concomitant behavioral health or substance use conditions. Despite that, few quality measures are in use at the national level to assess the quality of general and behavioral health integration. The authors suggested several strategies for developing such measures: 1. Creation of accreditation or recognition programs focused on integration of behavioral and general medical care systems; 2. Development of measures with focus on access to effective mental health care and access to primary care in behavioral health settings; and 3. Segment analysis of measures for patients with SMI as a “disparity category."

Develop Psychosocial Interventions Measures:There are a variety of evidence-based psychosocial interventions (i.e., interpersonal or informational activities, techniques, or strategies that target biological, behavioral, cognitive, emotional, interpersonal, social, or environmental factors with the aim of reducing symptoms and improving functioning or well-being) for treating behavioral health conditions. However, only two of 31 behavioral health quality measures endorsed by NQF address such interventions, despite their potential role in patient-centered care. The IOM favors use of a structural framework to address training, supervision, and therapist caseload, along with outcome measurement.

Investigate & Implement Sound Measures For Substance Use Disorders:

Recent research indicates that fewer than five percent of patients with past-year alcohol use disorder received treatment for the condition from a health care provider, and excluding tobacco, only five of 651 measures endorsed by NQF are related to substance use. None of the endorsed measures are strongly correlated with clinical outcomes, and they rely on reports of number and timing of visits instead of whether evidence-based treatment was delivered, making substance use an area with significant gaps in the availability quality measures.

The authors also laid out four priorities to  strengthen quality improvement infrastructure in behavioral health:

Investment, Leadership, & Coordination:

The authors recommended an approach that includes representatives from multiple disciplines providing care to patients with behavioral health conditions, consumers, and other stakeholders, with the aim of establishing a set of core measures for use across commercial and government payers in order to reduce variability in measure selection and cost.

Develop Necessary Evidence:

For some disorders and treatments (e.g., psychosocial interventions), clinical guidelines lack specificity, making it difficult to develop quality measures to assess delivery of the best evidence-based care. With more research on the efficacy of interventions, quality measures can be developed to assess what elements reflect fidelity to evidence-based models and key processes of care. The authors also suggested closer collaboration between funding agencies and scientists to fill gaps in measurement.

Improve & Link Data Sources:

Data sources such as electronic health records (EHRs) do not often contain adequate information to measure quality of care, and EHR adoption in behavioral health care settings has lagged behind rates in general medical settings. Enhancing EHR capacity to incorporate specific elements of behavioral health care treatment into structured fields may be one avenue, as is building clinical registries to compile data from multiple electronic sources, as HEDIS depression measures do from EHRs, clinical registries, and case management records. In building these resources, the concerns of behavioral health care providers regarding sharing information (in light of privacy laws) should be addressed.

Build The Capacity Of The Clinical Workforce:

The authors recommended that training in and application of elements of measurement-based care should be key components of behavioral health provider training programs. They also noted the potential importance of shared accountability mechanisms across different silos of care, as well as meaningfully involving consumers in their own care and in the design and improvement of the systems that provide it, perhaps through use of telephone and web applications.

The authors noted that the behavioral health care field has begun to develop a number of quality metrics, but that improving quality of care for behavioral health conditions requires coordinated leadership to build the evidence base and develop integrated data systems.


The full text of “Quality Measures For Mental Health And Substance Use: Gaps, Opportunities, And Challenges” was published online in Health Affairs in June 2016.

This summary has been developed independently of the authors, who disclosed that the work was supported by the Commonwealth Fund and the National Center for Advancing Translational Sciences within the National Institutes of Health. They reported no competing interests.