Pay for performance in primary and specialty behavioral health care: Two "concept" proposals.

Abstract

Incipient pay-for-performance (P4P) plans offer to improve the quality of general medical care, but they have not yet begun to influence clinical outcomes in the behavioral health care arena. Following a brief review of the quality chasm in behavioral health care and some initial applications of P4P programs, this article presents 2 bird's-eye view proposals with which the primary and behavioral specialty care sectors of the American health care system can begin to design and implement P4P incentives. Discussion of the value of behavioral health care, the Provider Quality Index, P4P implementation issues, implications for practicing psychologists, and some cautionary notes conclude the article.

Quality Improvement in Behavioral Health

“…However, psychology must be prepared to address the demands of QI systems as payors want providers to demonstrate increasing accountability for treatment outcomes (Bachman, 2006 ;Nordal, 2012 ). These changes will affect all of health care, including psychological practice.…”

Pay for Performance: Can It Help Improve Nursing Home Quality?

“…baseline data and thus raising suspicions of underpayment among providers (Bokhour et al 2006;Korda and Eldridge 2011;Young et al 2005), paying for outcomes not worth their cost (Bachman 2006;Bokhour et al 2009;Briesacher et al 2009;Christianson, Leatherman, and Sutherland 2008;Rosenthal et al 2007), permitting free-riders to participate that are not paying bonuses even though their patients benefi t from improved provider performance (Rosenthal et al 2004), or weak study design leading to ambiguous results (Briesacher et al 2009;Christianson, Leatherman, and Sutherland 2008;Teleki et al 2006). • Implementation failures, including inadequate training and monitoring (Beaulieu and Horrigan 2005;Bonis 2005;Egol et al 2009;Felt-Lisk, Grimm, and Petersen 2006;Greenberg, Dudley, and Ferris 2010;Kurtzman et al 2011;Teleki et al 2006).…”

“…• Th e slippery slope, including demands for "risk compensation" for hard-to-achieve outcomes (Christianson, Knutson, and Mazze 2006;Nicholson et al 2008), paying for conditions not quite meeting bonus criteria (Weissert and Musliner 1992;Weissert et al 1983), meaningless but easy-to-measure outcomes (Christianson, Knutson, and Mazze 2006;Rosenthal et al 2004), paying for good outcomes that do not represent real change from baseline performance (McNamara 2006), or better record-keeping without real improvement in outcomes (Bell and Levinson 2007;Epstein 2007;Khanduja, Scales, and Adhikari 2009) • Th e "distortion eff ect" of care being pulled away from nonbonus patients (Beaulieu and Horrigan 2005;Christianson, Knutson, and Mazze 2006;de Bruin, Baan, and Struijs 2011;Mehrotra, Sorbero, and Damberg 2010) • Cream skimming as facilities become selective in the patients they choose to treat in order to win bonuses (Bachman 2006;Nicholson et al 2008;Petersen et al 2006;Rosenthal et al 2004;Teleki et al 2006;Young et al 2005) • Design failures such as bonuses tied to so many outcomes that staff are unable to keep track of everything or feel overwhelmed (Christianson, Knutson, and Mazze 2006;Harbaugh 2009;Smoldt and Cortese 2007), bonus targets outside provider control (Harbaugh 2009;Nicholson et al 2008;Young et al 2005), puny bonuses that do not motivate providers (Fagan et al 2010;Felt-Lisk, Grimm, and Petersen 2007;Nicholson et al 2008;Petersen et al 2006;Rosenthal et al 2004), competitive payments that only already excellent facilities can win…”

A Measurement Feedback System (MFS) Is Necessary to Improve Mental Health Outcomes

“…However, it also may result in less effective services and a disincentive for improving services. Although pay for performance (P4P) schemes are growing in popularity in the general health sector, they are rare in MH 14. However, P4P should not be undertaken unless a mature measurement system with high integrity and security is in place.…”

“…For example, Ohio has spent more than a decade developing and implementing a measurement system that is now required state-wide. Massachusetts has also instituted measurement systems 14. Lambert and Burlingame, pioneers in the field of real-time outcome measurement, have collaborated with the state of Utah to implement a very brief concurrent measurement system in which data are entered on PDAs and are immediately available to the clinician 41.…”