Chapter 1. Defining and Measuring Value

In 2010, the World Health Organization (WHO) estimated that mental health and substance use disorders accounted for a loss of 183.9 million disability-adjusted life years (DALYs), or 7.4% of all DALYs worldwide (Whiteford et al. 2013). Despite a relatively low contribution to overall years of life lost, mental health and substance use disorders are the leading cause of years lost to disability worldwide, with over 75% stemming from depression, anxiety, and illicit drug and alcohol use. Notably, the burden of mental health and substance use disorders increased by 37.6% between 1990 and 2010, an increase that was largely attributable to population growth and aging (Whiteford et al. 2013). These estimates are likely conservative; because of a variety of factors (including the exclusion of personality disorders from disease burden calculations), the burden of mental illness may be underestimated by almost one-third (Vigo et al. 2016).

In the United States, health spending is expected to grow at an average rate of 5.5% per year between 2017 and 2026, approximately 1% faster than the average expected growth in the gross domestic product (GDP). As a result, health spending as a percentage of GDP is expected to rise from 17.9% in 2016 to 19.7% in 2026, reaching $5.7 trillion annually (Centers for Medicare and Medicaid Services 2018b). The United States spends the most on health care from a per capita basis than any other nation in the Organisation for Economic Co-operation and Development (OECD), at almost 2.5 times the average among the 35 member countries, and 25% higher than the next highest spending country, Switzerland (Organisation for Economic Co-operation and Development 2017). Despite the higher level of spending, the people of the United States, on average, do not appear to enjoy improved access or quality on several metrics. For instance, the United States has the second highest rate of patients skipping physician consultation because of cost (22.3%) and by far the highest rate of patients forgoing prescription medication because of cost (18%), although wait times are less of a concern compared with some other OECD countries. From a quality metric perspective, the performance for the United States is mixed, with some metrics, such as 30-day mortality after acute myocardial infarction, being middle of the pack, and others, such as number of admissions to hospital for an exacerbation of congestive heart failure, trending toward the higher end. Even with high rates of spending, the United States does not have the best outcomes. Despite the prevalence and growing availability of evidence-based psychiatric treatments for mental illnesses, stigma at the individual and system levels plays a complex role in creating barriers to care at multiple levels (Corrigan et al. 2014). In addition to the direct costs of care provision, it is likely that many costs associated with mental disorders are indirect, including costs incurred from reduced labor supply and earnings, public income support payments, and consequences such as homelessness and incarceration (Insel 2008). With an emerging focus on mental health and concerted efforts to destigmatize mental illness, it is time for patients and providers to develop quality frameworks and demand value in mental health care.

The health care industry is facing many challenges in the United States. With increasing expenditures as compared with other high-income nations, there is no bigger challenge than reducing costs of services (Anderson et al. 2003). One way to reduce costs is to provide accountable or value-based care. As mental health providers adapt to these challenges, they have to face the daunting task of coming up with ways to measure quality, cost, and benefits, and thus defining value in mental health care provided to consumers.

Health care costs in the United States are driven in large part by the high costs of services in acute care facilities, expensive pharmaceuticals, and administrative costs, primarily in medical settings (Papanicolas et al. 2018). A 2015 report on utilization of Medicaid recipients noted that about 20% of the members have a behavioral health diagnosis but that this cohort accounted for 50% of total Medicaid expenditures (Medicaid and CHIP Payment and Access Commission 2015). Thus, when defining the value of mental health services, providers and policy makers need to assess the value of services in the interface between physical health and mental health. Mental health can cause significant effects on recovery from somatic illnesses; this has been widely studied in relation to access to care, compliance with treatment, and response to treatment. Patients with moderate to severe mental illness have a higher prevalence of physical comorbidities (Parks et al. 2006). Mental illness and substance use comorbidities are also related to higher total cost of care. These findings are not unique to the United States. In the United Kingdom, the National Health Services has studied and confirmed high costs related to mental health comorbidities in patients with chronic medical illnesses (Naylor et al. 2016). A landmark U.S. report commissioned by the American Psychiatric Association (Melek et al. 2018) highlights an opportunity for significant savings if comorbid psychiatric conditions are effectively treated in individuals suffering from chronic medical conditions. Using data from insurance claims, the authors reported on total health care costs of individuals suffering from chronic conditions in cohorts with and without comorbid mental health and substance use conditions. Individuals identified as having comorbid conditions were noted to have significantly higher costs. Furthermore, it was noted that the increased costs were related to expenditures for treating physical illnesses.

There is growing acknowledgment of social determinants of health and their effect on health care outcomes and costs. WHO’s Commission on Social Determinants of Health has defined social determinants of health as “the conditions in which people are born, grow, live, work and age” (www.who.int/social_determinants/en). According to a national study on the modifiable factors that can affect health outcomes, such as life expectancy and quality of life, clinical care accounted for only 16% of the outcomes (Anderson et al. 2003). Other factors, such as socioeconomic status and health behaviors, are deemed much more influential in affecting the health of communities (Hood et al. 2016). As the awareness of social determinants of health grows, multiple stakeholders are starting to address them and at times are coming together to improve conditions in our communities to promote healthy behaviors and quality of life.

As part of New York State’s Delivery System Reform Incentive Payment program, large health systems and community-based organizations collaborated to develop programs to address unstable housing and food insecurity (Feliciano and Romanelli 2017). Medicaid plans have introduced initiatives to screen for social determinants and reimburse for some social interventions (Bachrach et al. 2018). With regard to seeking value in these efforts, an emerging theme is to how to leverage improvements in social determinants of health and align them in value purchasing arrangements. This can be both a welcome change and a challenge for mental health delivery service organizations. Although the increasing focus on social determinants of health is relatively new to both payers and large health systems, many mental health service delivery organizations have been contributing to this work for decades. The challenge lies in measuring work and effort in nontraditional sectors and quantifying its value; this will require investment in a robust infrastructure around use of data analytics to capture and properly attribute the benefits of the work done outside the traditional health care delivery model. Social determinants of health are considered in greater detail in Chapter 4, “Social Determinants of Health.”

The broad trend of consolidation in the health care industry has increased our ability to invest in large-scale programs. Growth of technology has been another catalyst in bringing change to traditional ways of providing mental health care. Some of the new initiatives in this regard have been in areas of integration of mental health services with primary care, as well as wider implementation of electronic health records, digital therapy tools, and telepsychiatry. These new offerings bring with them challenges of developing models for reimbursement in the existing fee-for-service payment methodology. Hopefully, the move toward value-based payments will align incentives with models for innovative solutions that promote accessible and high-quality mental health care.

There are multiple established value-based strategies that seek to maximize outcomes and reduce associated costs. To better understand these varied approaches, one needs first to consider the stakeholders within the health system who have an interest in these outcomes and associated costs (Allen et al. 2017):

Although the interests and desired outcomes for each stakeholder group may overlap, at times they might stand in opposition to one another. Established value strategies attempt, in various ways, to address the needs of each stakeholder. We explore some formal value strategies—value-based insurance design (V-BID), cost-effective analysis (CEA), value-driven population health (VDPH), and the Triple (or Quadruple) Aim—to broaden the understanding of value in mental health services.

The scientific approach to quality improvement (QI) in medicine can be traced as far back as Florence Nightingale’s groundbreaking statistical analysis of the relationship between hygiene and mortality among soldiers wounded in the Crimean War in the 1850s (Kudzma 2006). However, the importance of QI did not come to the full attention of the U.S. health care industry until a series of landmark reports published in 2000–2001 by the Institute of Medicine (IOM), since renamed the National Academy of Medicine. To Err Is Human: Building a Safer Health System (Institute of Medicine 2000) exposed the troubling state of American health care, specifically the 45,000–100,000 annual deaths linked to preventable medical errors. A follow-up report, Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of Medicine 2001), concluded that health care lagged other industries in terms of quality and safety by at least a decade and called for a fundamental redesign of the entire health system rather than incremental or piecemeal attempts at addressing the problem. Together, these works heralded a national call to action and laid out a framework for health care to systematically approach quality and safety as a priority.

The Institute of Medicine (1990) has defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (p. 21), and defined safety as “freedom from accidental injury” when interacting in any way with the health care system (Institute of Medicine 2000, p. 4). It identified six aims to guide health care organizations in their improvement efforts (Table 1–2).

Building on this work, the Institute for Healthcare Improvement (IHI) introduced the concept of the Triple Aim in 2008 (Berwick et al. 2008), and a fourth aim, focused on improving the work life of clinicians and staff, was added in 2014 (Bodenheimer and Sinsky 2014) (see Table 1–1). Subsequent work by the IOM, IHI, and other key organizations, such as the Centers for Medicare and Medicaid Services (CMS), the Joint Commission, and CARF International, has further advanced the field of QI in health care. All have recognized a need to learn from and adapt advances in QI from other high-reliability fields such as manufacturing and aviation. A detailed discussion of applied QI methods (e.g., Plan-Do-Study-Act, Lean Six Sigma) is beyond the scope of this chapter, but these methods are considered further in Chapter 2, “Evolution of Funding and Quality Control in Health Care.” For the purposes of this discussion, suffice it to say that a fundamental first step for any QI endeavor is the development of measures that reflect the quality of care being delivered. As Sir William Thomson, better known as Lord Kelvin, famously said, “If you cannot measure it, you cannot improve it.”

Many frameworks exist to inform the selection and implementation of individual quality measures. A simple and straightforward approach, described by Hermann and Palmer (2003), requires that measures are meaningful, feasible, and actionable. The following list provides some key considerations regarding each of these requirements.

Behavioral health has lagged behind the rest of the medical field in terms of quality measurement. Behavioral health systems have long existed in a silo apart from the rest of the house of medicine, partly due to financing structures. Many behavioral health services are financed by Medicaid and various locally administered funds and are thus beholden to local regulation as much as nationwide federal standards. In both public and private sectors, managed care organizations often “carve out” behavioral health services into a separate managing entity, further leading to fragmentation and silos. Even federally funded behavioral health systems such as Medicare often exclude behavioral health when developing their measurement systems. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a patient satisfaction survey required by CMS for all hospital inpatients, excludes psychiatric inpatients (Centers for Medicare and Medicaid Services 2018a). Similarly, the Health Information Technology for Economic and Clinical Health (HITECH) Act provided financial incentives for health care organizations to demonstrate “meaningful use” of electronic health records to improve quality outcomes but did not include psychiatric facilities (Cohen 2015).

Currently, the most widely used behavioral health measures focus on inpatient psychiatric services, substance use screening, and outpatient depression care. The Hospital Based Inpatient Psychiatric Services core measure set was developed by the Joint Commission on Accreditation of Healthcare Organizations and adopted by CMS for its Inpatient Psychiatric Facility Quality Reporting program (Joint Commission 2019). The measure set includes metrics related to seclusion and restraint use, substance use screening, antipsychotic polypharmacy, and care coordination. The CMS Merit-based Incentive Payment System for physicians includes several measures related to depression screening, metabolic monitoring for patients taking antipsychotics, and coordination of follow-up care (Centers for Medicare and Medicaid Services 2019).

Fortunately, there is increasing momentum to develop additional standards and measures for behavioral health. The Interdepartmental Serious Mental Illness Coordinating Committee, an advisory committee created by the 21st Century Cures Act, recommended that federal quality and measurement initiatives include behavioral health in its initial report (Interdepartmental Serious Mental Illness Coordinating Committee 2017). The American Psychiatric Association is supporting measure development via the PsychPRO registry (American Psychiatric Association 2020) and has recently received grant funding from CMS to develop additional behavioral health measures for the Quality Payment Program (American Psychiatric Association 2018).

The opportunity to guide our own measure development is a pivotal moment for psychiatry. Via the selection and endorsement of measures, professional organizations and regulatory agencies can incentivize improvement in strategic areas of behavioral health care delivery. For example, the increasing focus on the 25-year mortality gap (Parks et al. 2006) between individuals with serious mental illness and the general population has increased emphasis on the value of whole-person health. This has led to the adoption of measures related to physical health and behavioral health integration. Physical health screening and disease management measures have become increasingly employed in behavioral health settings, and the Certified Community Behavioral Health Clinics demonstration program includes multiple measures related to preventive care and screening for diabetes and smoking cessation (Substance Abuse and Mental Health Services Administration 2010). Conversely, measures related to depression and substance use screening are increasingly common in primary care settings, which support the adoption of integrated/collaborative care models and measurement-based care.

An important challenge will be to develop measures supporting the delivery of recovery-oriented care. The Substance Abuse and Mental Health Services Administration (2012) defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” Thus, recovery is both a process and an outcome, a fact that does not fit neatly into the frameworks described earlier in this chapter. However, application of the Critical-to-Quality approach (see earlier subsection “Aligning Metrics With Values”) would focus on the key attributes included in the above definition of recovery to inform the development of more specific metrics. Improved health, wellness, and reaching one’s full potential can be captured in quality-of-life measures. Self-direction is more complex, but a promising place to start is with measures of consumer satisfaction and shared decision making, both of which have been correlated with better treatment engagement and outcomes (Joosten et al. 2009; Lanfredi et al. 2014). Measuring recovery in this way reflects a more holistic concept of value that includes not only what care we as psychiatrists deliver, but also how we do so.

As the personal and economic burden of mental illness increases, there is a clear need to understand value in the context of mental health services. As a profession, psychiatry must participate in discussions and decision making surrounding the question of value. Value can be broadly defined as outcomes divided by costs, but the negotiations surrounding which outcomes are most important and how much should be spent are complex and challenging to navigate. There are multiple facets to value in mental health beyond the quality over cost equation in delivery of services. Mental health conditions are often unrecognized and undertreated in our communities (Kessler et al. 2005). Improving access—and beyond that, focusing on preventive care—is a new frontier for demonstrating the value of mental health services in our communities.

As noted earlier in this chapter (see “The Cost of Mental Illness and Substance Use”), costs for care are high for patients with mental health conditions because of the high prevalence of physical comorbidities. Thus, as new payment models develop that focus on shared savings programs, we see a great opportunity for increasing value by expanding access and improving the mental health care delivery models. Another area of value that needs further exploration is the interface of social services and health care delivery. Mental health service providers are well suited to guide this work because they have the most experience in working with the biopsychosocial model and have been working collaboratively with social service agencies for decades.

No discussion on improving value is complete without addressing the waste and inefficiencies that exist in the current system. It is estimated that in the United States, about 30% of health care costs are attributed to waste in the system (Berwick and Hackbarth 2012). Our field needs to analyze the true costs of our practices and invest in the comparative research of effectiveness of various treatment modalities. Among the various areas of waste that have been identified in health care, improving preventive care, enhancing care coordination, and reducing fragmented care are significant areas of opportunity in mental health services.

As experts in mental health, psychiatrists can play a unique role in defining value by working to bridge differences in perspectives between the various stakeholders involved in mental health care. Psychiatrists are often poised at the interface of the major stakeholder groups—providers, purchasers, suppliers, payers, and patients/consumers—and can link the evidence and clinical perspectives to the broader systems organization. The various stakeholder groups may have differing opinions on the outcomes that are most important and what they are worth. Psychiatrists have an opportunity to lead educational initiatives and foster a shared understanding of the biopsychosocial approach to managing patients appropriately. It is critical that psychiatrists remain engaged in administrative processes and focused on leading system change. One must be involved in order to influence, and we psychiatrists can use our collective voice to advocate for systems that deliver high-value care for all.