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The Mandate for Measurement: When Will Behavioral Healthcare Fully Embrace Clinical Data Analysis?

March 05, 2019

You should know your blood pressure and your A1C. There are other basic health measures to know, but it is critical that you understand where you are in the domain of chronic clinical conditions that consume half of our country’s healthcare dollars. Chronic means lifetime, expensive and deadly. We have measures that can help you understand whether you are doing better or worse.

You should understand that the planet is changing and that the super-heated earth is going to impact people negatively around the world. We will see more wind, water and heat events than we have ever seen. We are already experiencing this. The endpoint for this is a disaster coming sooner than you thought, based on clear scientific calculations. There are measures we can monitor to see if we are making progress or regressing.

Our moods go up and down. We can be sad one day and anxious the next. Negative moods, classified clinically as major depression or anxiety, are the greatest source of disability and unproductivity at work, and the impact on relationships is never positive. While we have some good treatments for mood disorders, we have no scientific discipline measuring their changes over time.

This seems incredible in the 21st century, but it is true. We measure moods in clinical studies, but most professionals in clinical practice scoff at the idea that they should use measurements to augment their clinical judgment. We may not have precise measures in behavioral healthcare on par with blood pressure and A1C, but we have good measures that are not being used consistently.

The measurement culture

I am a clinical psychologist, and I can tell you that there has never been a measurement culture within the world of clinical treatment. I was trained in empathy far more than statistics. I was focused on clinical models and not clinical measurement. I was exposed to a never-ending series of new treatments, with much hype, and little evidence to support them. I have lived in a clinical environment where the question was what treatment you liked. The question of evidence rarely surfaced.

I may sound like a rabid empiricist in the previous paragraph, but I have a confession to make here. I have read most of Freud’s writing and I loved it. He was a terrific writer. He imagined himself to be a great scientist as well, based on single case studies that he analyzed.

I’m not so enchanted with his work today. Now I wonder if he was not the foremost destructive force for science in our field. His work had nothing to do with science, and yet it held a commanding power over our field for generations.

There is also something sacred about the privacy of the psychotherapy office. Measuring clinical progress in that office, and letting anyone else know those results, seems sacrilegious. I certainly get that argument.

People talk freely and openly with a psychotherapist since they know that everything stays in the room. But then I wonder. Couldn’t numbers on a measurement scale be shared anonymously, if there was a strong scientific ethos, combined with that confidential, healing ethos? In other words, could we not just measure clinical results, and aggregate the findings, without any patient identification information involved? We could then show the effectiveness of the enterprise without disclosing any personal identification.

Failure at the corporate level

I not only worked for many years in clinical practice, but I long served in executive roles within the managed behavioral healthcare industry. These companies had huge financial resources to impact the measurement culture, or rather, the lack thereof. This would have been a big lift, but it should be noted that the history of these companies includes onerous demands placed on clinicians to justify their treatment.

Clinicians were required at the dawn of the managed behavioral healthcare industry to complete long clinical assessment forms to justify ongoing outpatient treatment. There were no clinical measures involved. The process was fundamentally intended to deter ongoing treatment. It is a very sad chapter in our industry. There are a few exceptions, but expecting clinicians to measure the clinical results of their work was rarely a requirement.

When you study the measurement focus of managed care organizations, you find an obsession with the utilization of services and the cost of care. This makes complete sense if you understand that businesses focus on profit and loss. The question of improvement in a patient’s health status is regarded as important. In fact, a fleet of care managers work within these companies to evaluate treatment plans and clinical improvement, but the fundamental success metrics are still the number of inpatient days and sessions used.

It should not be forgotten that managed behavioral healthcare organizations were hired and promoted by large employers. They perceived that health plans did not possess the necessary focus and expertise in mental health and substance use disorders. What have been their expectations regarding measurement? Utilization and cost measurements have reigned supreme since they too care about the business bottom line. There are certainly other measures in the mix, but the rigorous examination of clinical improvement never became an expectation.

The question of convenience

In recent years I have consulted with companies that seek to advance behavioral healthcare improvement on some type of digital technology platform. They build the ongoing measurement of clinical improvement into their platforms. People using the platform don’t object, and clinicians are happy to be informed about the results.

Measurement needs to be convenient. We accept getting our blood pressure measured and blood drawn during our annual physical. The early years of the blood draw process were probably contentious, but I don’t have a memory of that. We need to make the measurement of mental status completely routine. It is already pretty easy since the gold standard at this time is for people to complete brief self-report measures. No blood involved.

The process of educating and scolding clinicians to use behavioral healthcare measures is exhausting. I participated in this process during my days in the managed behavioral healthcare world, and I can attest to the fact that we will never reach our ideal state as long as this is the process.

Establishing a norm

The norm for all specialties of healthcare must be that we identify the best measurement system available and then track how people are progressing clinically as treatment is delivered. In other words, the mandate for measurement must be an overall expectation, rather than a plea to specific clinical specialists. The clinical zeitgeist must be the driver of our norms, not the interests or the preferences of particular clinicians.

I must say without any sense of satisfaction that behavioral healthcare specialists have failed to establish their specialty as a measurement-based practice. Many experts have tried to accomplish this, but the field has been largely unresponsive. We need an overriding set of expectations and protocols that will finally implement robust clinical analytics within the behavioral healthcare field. We need a healthcare template that demands adherence to norms for all specialties.

Let me close by stating how disappointing both governmental regulators and accrediting companies (such as the NCQA) have been in this history. They had the power to say clinical measurement needed to be fundamental in systems of care. They did not do so. Understanding this fact is beyond the scope of this article, but it would be instructive to know more about this failure and how to address similar issues in the future.

I will close by focusing on norms rather than protocols. It is self-defeating to attempt to implement protocols that are contrary to the prevailing norms of an industry. I know this since I participated in that folly during my years at PacifiCare and ValueOptions. I had a dedicated team that accomplished quite a bit in the implementation of measurement-based care. It did not last beyond the corporate mergers that changed each company. The goal should be to change the norm. This is my contribution to that goal.

Ed Jones, PhD

Ed Jones, PhD, is senior vice president of the Institute for Health and Productivity Management.

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