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We're not ready for P4P: behavioral healthcare has a lot to do before it can be held to pay-for-performance standards.

The healthcare community generally agrees with the vision laid out by the Institute of Medicine (IOM) in its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, which calls for a safe, effective, efficient, patient-centered, timely, and equitable care system. We just cannot agree on what is needed to get us there.

Private and public payers, including Medicare and a number of state Medicaid programs, are focusing increasingly on efforts to measure healthcare quality in order to improve health outcomes. A parallel effort is assessing providers based on these quality assessments. It is intended that consumers will use quality information about providers to make informed decisions on where to seek care, and that private payers and federal and state governments will use it to assess and reimburse providers based on their performance.

The Centers for Medicare and Medicaid Services (CMS) is in the midst of conducting a number of "pay for performance" initiatives to assess the viability of this approach in hospital settings, and is hoping to expand them to nursing homes and to assessing care coordination for persons with chronic illnesses. Perhaps the sign that this movement is serious is that a new acronym is in vogue among policy wonks--P4P (pay for performance).

A central feature of P4P initiatives is the need to track performance against agreed upon process and outcome measures developed for particular clinical conditions. Participants in these demonstrations that show improvements in patient care as measured by quality indicators will be eligible to receive payment bonuses. At some point, poor performers will receive financial penalties.

There is much disagreement within the healthcare community regarding the objectives and processes used in developing P4P initiatives. Questions include: How are quality indicators chosen? How do collateral contacts within the healthcare system influence patient outcomes? How do you account for heterogeneity within patient populations? It seems unlikely that we will see rapid expansion of P4P initiatives anytime soon.

In fact, there are no large-scale P4P initiatives within behavioral healthcare. Indeed, there are very few agreed upon quality measures for behavioral health conditions in wide use in either the private or public sector. This is probably a good thing considering where we are as a field.

Efforts by SAMHSA to implement a series of National Outcome Measures (NOMs) for all of its formula and discretionary grant programs bear some similarity to this larger P4P effort. A major difference between SAMHSA's efforts with the NOMs and CMS's P4P initiatives, however, is the exclusion of process measures in the NOMs.

The IOM's 2005 follow-up report, Improving the Quality of Health Care for Mental and Substance-Use Conditions, documents widespread practice variation, resulting in only 27% of care for behavioral health conditions adhering to established practice guidelines. Outcomes should be the ultimate measure of success, yet replicable outcomes require standardized practice, which is missing in our field.

Devolution of federal responsibility for community behavioral healthcare in 1981 resulted in hundreds of local and state care systems, each with a unique way of describing, delivering, and financing care. The lack of uniformity presents many practice, policy, and infrastructure challenges to our field.

The implementation of evidence-based practices, or any new approach within our system, has been difficult because of a variety of financial and clinical complications related to these multiple systems. There are no standard service definitions, nomenclature, or billing codes in use within or between states. This variation has hampered efforts to establish uniform reimbursement policy for evidence-based practices, as well as the development and implementation of health information infrastructure. Widespread "uniqueness" results in increased costs due to duplication of data and reporting requirements, and enterprise software and electronic health record systems need to account for hundreds of billing and service definition codes within the same state.

We have neither agreed upon clinical competencies for evidence-based service delivery, nor standardized credentials for delivering this care. Instead we have a system of state and discipline-specific criteria that bear little resemblance to contemporary public-sector best practices. In this complicated environment, individual provider agencies must do their best to recruit, train, and retain competent staff.

Moreover, we have no agreed upon standard of care for most behavioral health conditions. Services delivered to individuals with the same diagnosis, functioning level, and personal goals likely will vary considerably within the same agency, let alone the same state. We need to be able to articulate standards of care for the spectrum of behavioral health disorders.

If we believe that mental health is fundamental to overall health, by extension we believe that behavioral healthcare is part of healthcare. Quality improvement and P4P efforts will continue, and behavioral healthcare needs to be ready to participate. We need to begin getting our house in order before the P4P guests arrive.

Charles Ingoglia, MSW, is Director of Public Policy and Technical Assistance at the National Council for Community Behavioral Healthcare. Linda Rosenberg, MSW, is President and CEO of the National Council. To send comments to the authors and editors, e-mail

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Title Annotation:PERSPECTIVES
Author:Ingoglia, Charles; Rosenberg, Linda
Publication:Behavioral Healthcare
Date:Sep 1, 2006
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