Haiden A. Huskamp and Colleen L. Barry
H. A. Huskamp and C. L. Barry, “Can New Payment and Delivery System Models Achieve High-Value Care for Mental Health and Substance-Use Disorders?” New England Journal of Medicine, published online Nov. 21, 2013.
The accountable care organization (ACO) model is being deployed in Medicare, through the Medicare Shared Savings and Pioneer ACO programs, as well as by state Medicaid programs and private payers. The goal is to improve efficiency and integration of health care services by holding teams of providers accountable for the health outcomes and spending of a defined population of patients. Commonwealth Fund–supported researchers examined the provision of mental health and substance-use disorder (MH/SUD) treatments—typically undertreated in primary care—by ACOs.
With the exception of nicotine-dependence treatment, very few quality-of-care measures related to MH/SUD treatment have been written into ACO contracts. For example, of the Medicare Shared Savings and Pioneer ACO programs’ 33 quality measures, only one—screening for clinical depression and creating a follow-up plan—relates to MH/SUD. Under Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract, only two are related to MH/SUD, both dealing with depression.
The authors note there are good reasons these early ACO models have so few MH/SUD–related measures: payers must limit the number of metrics overall to ensure providers can focus on each one; there are fewer objective quality measures; and the conditions may be less prevalent in particular populations (e.g., schizophrenia among commercial plan enrollees). Several groups, including the National Quality Forum, are working to expand the available set of MH/SUD quality measures.
The Medicare ACO programs and Blue Cross Blue Shield of Massachusetts are well into their initial contracts with providers and will soon be renegotiating, giving them the opportunity to rethink the measures used, including those related to MH/SUD. The authors note that in addition to measures tied to payment, payers should also monitor ACOs on a broader set of indicators that address a wide range of MH/SUD conditions and treatments.