In the United States, approximately 5.5 percent of the population, or more than one of 20 individuals, experiences serious mental illness (SMI). SMI can be defined as a mental illness that “interferes with a person’s life and ability to function,” and includes diagnoses like schizophrenia-spectrum, bipolar, and major depressive disorders. But the measures that health care payers (including both private insurance companies and the government) use to pay providers who treat SMI are primarily behavioral health outcome measures that do not capture the true value of the services and supports provided to people with SMI. These measures often rely on standardized process metrics (e.g., follow-up after hospitalization) that may not reflect the nuances of SMI care and the direct needs of patients in recovery. Instead, we need payment measures that capture meaningful outcomes: lives improved, acute events avoided, and successful recovery and rehabilitation.
What Gets Measured and What Matters Most
Currently, there are validated, patient-reported outcome measures available to assess aspects of SMI recovery, including quality of life, social support, problem-solving, and general health. The International Consortium of Health Outcomes Measurement includes many of these in its measurement framework for psychotic disorders with domains of symptoms, recovery, functioning, and treatment. In contrast, those most commonly used for payment programs are primarily limited to National Committee for Quality Assurance clinical process measures, such as whether people get timely follow-up after psychiatric hospitalization, which captures only a small portion of the quality picture. When we talk to people with lived experience with SMI, they often tell us that they want to improve their quality of life and reduce loneliness. Pregnant and perinatal people, those with multiple health conditions, and people involved with the criminal justice system could benefit from improved focus on social drivers of health, as these measurements have been found to promote greater health equity for marginalized populations.
The Measures that Matter Project, led by Fountain House, aims to reshape approaches to measuring recovery for people with SMI and lay the groundwork for adopting measures that reflect their recovery needs. The goal is to identify the most important behavioral health measures, as identified by people with SMI and other key stakeholders, determine how they can be integrated into payment and reimbursement programs, and develop a roadmap for moving forward.
Several public and private sector organizations have demonstrated their commitment to improving quality through measurement as well as testing out value-based payment (VBP) systems in mental health care, including the Centers for Medicare and Medicaid Services (CMS), the Center for Medicare and Medicaid Innovation (CMMI), the National Committee for Quality Assurance (NCQA), the U.S. Department of Health and Human Services (HHS), and the U.S. Department of Veterans Affairs. It is important that these organizations employ recovery measures that people with lived experience of SMI deem most important and impactful. These often include measures that focus on recovery, quality of life, loneliness, and addressing social needs.
Through engaging these VBP stakeholders as well as people with lived experience, the Measures that Matter roadmap will address how measurement-based care can be integrated into certified community behavioral health clinics, pay-for-performance programs, VBP models, CMMI innovation models, state Medicaid waivers, and other federal initiatives, including those from the Substance Abuse and Mental Health Services Administration. It is often said that “what gets measured gets done.” When payers and purchasers tie measures to economic incentives through VBP and other reimbursement programs, measurement assumes increased influence. Incorporating this approach into payment models has the potential to drive significant improvements in how individuals with serious mental illness receive support and treatment and can lead to substantial personal, social, and societal benefits.
The Measures that Matter project is funded by the Commonwealth Fund, Arnold Ventures, the Mental Health Strategic Impact Initiative, and the California Health Care Foundation.
