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Measure to improve

Measure to improve strategies assume that the data will be used in real time in an effort to improve the outcome of care and/or allocate resources in a manner to maximize value for the health care dollar. The value of the data extends beyond its worth as a marketing tool. The data is being used to improve the outcomes of care, while assuring medical dollars are used in a manner to maximize benefit to the patient.

The potential return on investment for a successful measure to improve strategy is potentially much larger than the potential return for a simple measure to evaluate strategy.

The measure to improve strategy assumes that the measurement activity will alter the process and/or outcome of care, and this is seen as desirable. Outcomes informed care rests on the assumption that measuring treatment outcomes as the treatment unfolds, and using this information actively, results in a greater likelihood of successful treatment outcome.

For example, research by Michael Lambert and associates at BYU has repeatedly demonstrated that providing therapists feedback on cases, that are not improving as expected, results in a greater likelihood of these at risk cases remaining in treatment and achieving significantly better clinical outcomes.

Similarly, using a measure to improve strategy, a patient might be encouraged to complete a therapeutic alliance measure that would be shared with the therapist. The use of the alliance measure itself fosters more direct communication between the patient and clinician, which may be beneficial. Resources for Living, for example, found that outcomes were significantly better for clients who completed therapeutic alliance measures at the first session, even if the scores on the alliance measure were not high. It appears that the act of asking the patient for feedback is in itself helpful. Also, those who did complete the alliance measure were more likely to have follow-up sessions, and those with poor alliance at the start of therapy tended to report rapid improvement in the alliance. A simple measure to evaluate strategy would not have been able to produce this effect.

Measure to improve strategies have the potential to substantially improve the allocation of resources. Analyses of large datasets from a variety of health plans reveal very little differentiation in the cost of treatment services as a function of the severity of symptoms. Patients entering treatment with relatively mild levels of distress (similar to the general population) utilize almost as many sessions as those with very severe symptoms. The difference is that those with severe symptoms report a substantial reduction in symptoms with continued treatment, while those with relatively mild complaints on average will report little improvement regardless of the length of treatment. If the outcome questionnaires are used by clinicians to inform decisions about the length of treatment, so that those with mild symptoms are more likely to be treated with relatively brief therapy, while assuring that those with severe symptoms remained engaged in treatment until the symptoms improve, the result would be an increase in the overall improvement measured for the population, while the cost of the care would remain unchanged on possibly decline. See Brown et al (2001) and Matsumoto et al (2003) for more information in this subject.

Measure to improve strategies at the level of the individual patient have the potential to deliver direct benefits to patients in terms of a greater likelihood of a successful treatment outcome. There are also direct benefits to the employers and other payers in terms of rational allocation of scarce resources and greater patient benefit per dollar expended. The health plan, however, also has strong reasons to measure outcomes in order to manage the network. Mounting evidence from both clinical trials and real world settings reveals that much of the variance in treatment outcomes resides at the clinician level. Some clinicians achieve better outcomes than others, regardless of the specific treatment method employed.

This means that any strategy designed to help individual clinicians measure and improve their own outcomes is likely to pay dividends across the board. As with any skilled activity, performance feedback is necessary in order to increase the skill level. Unfortunately, behavioral healthcare as currently practiced in the real world, provides clinicians with little opportunity for performance feedback, no way to compare their results to those of other clinicians, and no way to monitor systematically if their outcomes improve as a result of changes in practice patterns, additional training, use of new treatment methods, etc. The extent to which providing performance feedback combined with information of strategies for improving outcomes will have a systematic impact on outcomes across all therapists is unknown. Undoubtedly, some will find the feedback and information more useful than others, and many providers of course achieve excellent results already.

The health plan potentially has a significant financial interest in improving the general effectiveness of providers within their network and to identify those providers who are most effective. Evidence from other health plans indicates wide variance in the effectiveness of providers, and that these differences tend to be relatively stable over time. Highly effective clinicians achieve much superior outcomes while tending to utilize fewer sessions, perhaps because patients tend to experience greater change per session. Any strategy that results in the most effective clinicians receiving a high percentage of referrals from the health plan will have a direct positive impact on both the outcome and cost of care.

A measurement strategy designed to arrive at an estimate of therapist effectiveness that has predictive validity for purposes of future referrals places a high value on obtaining data on as many patients as possible for each therapist, as well as assuring that the frequency of measurement is sufficient to capture most or all of the improvement for each case. If providers wish to use the data as evidence of their effectiveness with the goal of attracting more business, then it is in the providers interest to measure outcomes on as many of their patients as possible using a common measure, rather than have each managed care company assess outcomes on only a fraction of their patients using diverse questionnaires.

Use of the outcome data to manage cost and outcomes through selective channeling of referrals is clearly one of the most effective uses of outcome data for management purposes. PacifiCare Behavioral Health, with their Honors for Outcomes program is the only national managed behavioral healthcare organization that has utilized this approach. Their Lambert Award for clinical excellence, which was given to 100 providers with superior clinical outcomes, included a cash award and was a first step towards pay for performance based on outcomes. PacifiCare's emphasis on outcomes management was instrumental in the expansion of their business, including selection by widely respected Harvard Pilgrim Health Care to manage the behavioral health services for their members.

-- JebBrown - 10 Jan 2007
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