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QUALITY—AT WHAT PRICE?

March 1, 2006
by MICHAEL J. STOIL, PHD, WASHINGTON EDITOR
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Payers will have a harder time affecting service quality as they shift more responsibility for costs onto individuals

Regular readers of this column are familiar with the federal government's recent obsession with defining and improving the quality of behavioral healthcare. Several federal agencies are hosting quality initiatives, in part as a result of congressional demands for improved accountability for federal funds and in part as a by-product of President Bush's New Freedom Commission on Mental Health. Some of these quality initiatives are structured around evidence-based practices and “model programs”; others are centered on tracking outcomes according to a standardized format. Their progress often is described in grandiose terms as innovations that can virtually transform practices in the behavioral healthcare field.

Last year, Professor Richard H. Beinecke, PhD, of Suffolk University in Boston, completed a lengthy study of the evolution of mental health practices in the United Kingdom, concluding that the national healthcare system in England already has made significant progress implementing quality initiatives similar to those trumpeted by the U.S. federal government. One major advantage that the British system enjoys is that the majority of U.K. clinicians receive compensation from a single government-administered insurance system. In contrast, the U.S. federal government directly reimburses relatively few behavioral health clinicians outside of the Medicare-eligible population.




Most adult Americans, in fact, do not receive government assistance to pay for behavioral healthcare. They receive health insurance from an employer, labor union, or professional association, or purchase it themselves. Roughly 50 million adult Americans working in the private sector receive employer-provided healthcare for themselves and/or their families. In comparison, 11 million adult Americans are covered by Medicaid, 6 million under age 65 by Medicare, and slightly fewer than 5 million by TRICARE, the Department of Defense's healthcare system.

If all private-sector employers purchasing healthcare coverage spoke with a single voice, the numbers alone suggest that they would have more leverage than the federal government over mental healthcare coverage and practices. Of course, this principle is weakened somewhat by the fact that some private-sector insurance plans exclude behavioral healthcare treatment. However, even when employer-provided healthcare lacks explicit behavioral health coverage, primary care physicians and pediatricians often step into the gap by attempting to diagnose mental health conditions and prescribing psychotropic medications.

The dream of providing employers with the leverage necessary to affect healthcare quality is the driving force behind the National Business Coalition on Health (NBCH), not to be confused with the National Business Group on Health (see sidebar). NBCH is a nonprofit organization of employer-based healthcare coalitions, representing more than 10,000 U.S. employers. NBCH describes itself as “dedicated to value-based purchasing of health care services through the collective action of public and private purchasers. In developing, identifying and disseminating best practices in value-based purchasing strategies, NBCH seeks to accelerate the nation's progress towards safe, efficient, high quality health care.”

NBCH made headlines in 2005 when it released its first annual report. However, the employer-based healthcare coalitions that comprise NBCH membership have been part of the managed care environment for more than 15 years. One of NBCH's largest members, for example, is the Pacific Business Group on Health, established in 1989, that now consists of 50 California employers providing healthcare coverage for approximately three million workers, retirees, and dependents. Other NBCH members include employer coalitions in the Detroit and Dallas–Fort Worth metropolitan areas, and statewide coalitions in Oregon, Colorado, and New Jersey.

By providing evidence-based scorecards on available healthcare plans, these coalitions have a powerful influence on businesses’ annual selection of potential contracts for their employees’ coverage. NBCH is attempting to establish a single national standard for the most widely desired healthcare services that all of these regional and metropolitan business coalitions will adopt.

NBCH's primary tool to achieve this result in behavioral healthcare is “eValue8,” an electronic survey that captures voluntarily reported data and evaluates the performance of more than 250 health plans nationwide. The eValue8 survey includes questions no one else asks health plans and measures performance for eight domains, including behavioral health, disease management, and health information technology. In 2005, all major national health plans responded to the eValue8 request for information in at least one major service area. Respondents included Aetna, Anthem Blue Cross and Blue Shield, WellPoint Blue Cross and Blue Shield, CIGNA, Humana, Kaiser Permanente, and UnitedHealthcare. Employers such as General Motors and Pitney Bowes may choose to contract with a health plan based on the eValue8 responses or may use the survey data to steer their employees to better performing plans.

Analysis of the behavioral health components of the survey is performed by Ensuring Solutions to Alcohol Problems, a division of The George Washington University Medical Center headed by Eric Goplerud, PhD, former director of the SAMHSA Office of Managed Care. At this time, eValue8 asks for performance data on only two behavioral health conditions: depression and alcohol dependence. According to Dr. Goplerud, addressing this past December's meeting of the American Public Health Association, it is an uphill struggle to convince the business community sponsors to expand quality indicators to other behavioral health conditions with less widespread impact on employee productivity and healthcare expenses.

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