Association of Alternative Payment and Delivery Models With Outcomes for Mental Health and Substance Use Disorders

Carlo, Andrew D.; Benson, Nicole M.; Chu, Frances; Busch, Alisa B.

doi:10.1001/jamanetworkopen.2020.7401

Cited by 30 publications

(10 citation statements)

References 52 publications

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“…Additionally, adjustment for bias at the levels of both individual clinicians and whole teams would preclude possibilities that either cultural differences between providers or “gaming” could attract disproportionate funding. [53] Therefore, adjusting PbR to account for clinician sensitivity/bias may improve efficiency in mental health services.…”

Section: Discussionmentioning

confidence: 99%

Clinicians’ ratings of the Health of the Nation Outcome Scales (HoNOS) show sensitivity/bias that may affect patients’ progress: analyses of routine administrative data

Williams

2020

Preprint

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Objectives(1) To estimate clinician sensitivity/bias in rating the HoNOS. (2) To test if high or low clinician sensitivity determines slower resolution of patients’ problems or earlier inpatient admission.DesignThe primary analysis used many-facet Item Response Theory to construct a multi-level Graded Response Model that teased apart clinician sensitivity/bias from the severity of patients’ problems in routine HoNOS records. Secondary analyses then tested if patients’ outcomes depend on their clinicians’ sensitivity/bias.Outcome measuresThe outcome measures were (1) overall differences in sensitivity/bias between (a) individual clinicians and (b) different Community Mental Health Teams (CMHTs); (2) clinical outcomes, comprising (a) the rate of resolution of patients’ problems and (b) the dependence of the time to inpatient admission on clinician sensitivity/bias.SettingAll archival electronic HoNOS records for all new referrals to all CMHTs providing mental health services in secondary care in a New Zealand District Health Board during 2007-2015.ParticipantsThe initial sample comprised 2170 adults of working age who received 5459 HoNOS assessments from 186 clinicians. From these initial data, I derived an opportunistic, connected, bipartite, longitudinal network, in which (i) every patient received HoNOS ratings from 2 or more clinicians and (ii) every clinician assessed more than 5 patients. The bipartite network comprised 88 clinicians and 778 patients; 112 patients underwent later inpatient admission.ResultsSensitivity/bias differed importantly between individual clinicians and CMHTs. Patients whose clinicians had more extreme sensitivity/bias showed slower resolution of their problems and earlier inpatient admission.ConclusionsRaw HoNOS ratings reflect the sensitivity/bias of clinicians almost as much as the severity of patients’ problems. Additionally, low or high clinician sensitivity can adversely affect patients’ outcomes. Hence, the HoNOS’s main value may be to measure clinician sensitivity. Accounting for clinician sensitivity could enable the HoNOS to fulfil its goal of improving mental health services.Strengths and limitations of the studyThe study derived a connected network of clinicians and patients that approximates a rational design for estimating clinicians’ sensitivity/bias.The opportunistic network sample was atypical, with chronic patients and experienced clinicians – so the study may under-estimate clinician bias.The study’s statistical methods were appropriate to the ordinal nature of HoNOS ratings.The study used earlier estimates of clinician sensitivity/bias to predict later outcomes – so that effects of clinician sensitivity/bias on outcomes may be causalThe study assumed that all HoNOS items tap a single dimension of the severity of patients’ problems.

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Section: Discussionmentioning

confidence: 99%

Clinicians’ ratings of the Health of the Nation Outcome Scales (HoNOS) show sensitivity/bias that may affect patients’ progress: analyses of routine administrative data

Williams

2020

Preprint

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“…Skeptics may argue that multiple large-scale demonstrations have so far not been effective. Evidence for the effectiveness of pay-for-performance and alternative payment arrangements in behavioral health is modest at best (12,13). We believe these large-scale demonstration projects have not worked for at least three reasons.…”

Section: Clarify Incentives and Outcomesmentioning

confidence: 99%

Lessons From Maslow: Prioritizing Funding to Improve the Quality of Community Mental Health and Substance Use Services

Stewart

Mandell

Beidas

2021

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Evidence-based practices (EBPs) are frequently proposed as an approach to close the quality chasm in behavioral health treatment, and many U.S. municipalities are investing in EBPs as a primary way to improve the quality of care delivered to individuals most in need. In this Open Forum, the authors argue that EBPs often cannot be successfully implemented because basic organizational needs are not met in the current fiscal environment. The authors summarize research that supports why EBPs, along with other approaches to improve quality, are likely to fail until there is adequate financing. They also propose a policy and research agenda to ameliorate and address the fiscal challenges inherent in community mental health and substance use services.

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“… 9 To date, VBP models have seen mixed results in reducing overall costs and improving outcomes, which may arise in part because the focus on past-year savings prioritizes short-term cost containment rather than implementation of effective interventions to promote long-term health at scale (such as PPD prevention). 10 , 11 , 12 As most savings from preventing PPD may accrue after the first year, 4 VBP based on 1-year TCOC may miss much of the opportunity to share value and provide strong financial incentives for implementing interventions to prevent PPD.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Estimated Incentives for Preventing Postpartum Depression in Value-Based Payment Models Using the Net Present Value of Care vs Total Cost of Care

et al. 2022

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Key Points Question Do value-based payment (VBP) models that share 50% of the 5-year expected health care savings estimated by reduced postpartum depression incidence offer larger incentives for clinicians to prevent postpartum depression than traditional VBP models that share 100% of 1-year actual savings? Findings In this decision analytical model with a simulated cohort of 1000 pregnant individuals enrolled in Medicaid, sharing estimated savings offered more than double the financial incentives for clinicians to prevent postpartum depression than traditional VBP models, assuming continuous health insurance coverage (ie, no churn). This incentive decreased as rates of annual health insurance churn increased. Meaning These findings suggest that VBP models that share expected future savings may offer greater incentives for implementing interventions that prevent postpartum depression, but additional policy action is needed to address challenges posed by health insurance churn.

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Association of Alternative Payment and Delivery Models With Outcomes for Mental Health and Substance Use Disorders

Cited by 30 publications

References 52 publications

Clinicians’ ratings of the Health of the Nation Outcome Scales (HoNOS) show sensitivity/bias that may affect patients’ progress: analyses of routine administrative data

Clinicians’ ratings of the Health of the Nation Outcome Scales (HoNOS) show sensitivity/bias that may affect patients’ progress: analyses of routine administrative data

Lessons From Maslow: Prioritizing Funding to Improve the Quality of Community Mental Health and Substance Use Services

Comparison of Estimated Incentives for Preventing Postpartum Depression in Value-Based Payment Models Using the Net Present Value of Care vs Total Cost of Care

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