Measurement-based care (MBC) is increasingly a primary point of focus in behavioral health and healthcare in general. It's also considered a standard of care for mental health providers. Despite this attention and recognition, MBC remains underutilized, and its importance in behavioral health is often underappreciated. Let's take a closer look at why this is the case.
What is Measurement-Based Care?
Measurement-based care is, in its simplest form, measuring an outcome secondary to an intervention. That intervention could be in a physical health realm, such as a surgical procedure or prescribed medication.
It could also be any number of interventions in the world of behavioral health, such as transcranial magnetic stimulation (TMS), medication, or therapy. Whatever the intervention is, MBC is designed to look at the outcome.
How Measurement-Based Care Is Used in Behavioral Health
When we leverage measurement-based care in behavioral health, we are following an entire process of care starting with a behavioral health screening, followed by a diagnostic interview, a diagnostic decision, a treatment decision, and finally a series of monitoring events to assess outcomes of the treatment. Each of those steps is part of an MBC process.
Following the patient through treatment is an essential part of the process regardless of the treatment(s) delivered. For example, the treatment could be a short intervention, such as SBIRT (screening, brief intervention, and referral to treatment). That's where you perform an assessment and see that a patient has an issue, such as with smoking or alcohol use. Then there's a 15-minute intervention. Then we follow up and see how that intervention did with helping the patient reduce their smoking or their alcohol use. Or the treatment may be more involved, such as a prescribing a medication and a series of online cognitive behavioral therapy (CBT) modules and self-study content. In each case, MBC should be used to assure a target outcome is achieved.
Why Measurement-Based Care Is Essential to Supporting Patients
Measurement-based care plays a vital role in supporting patients. The reason: We want patients to get better. That's the whole intent of the therapeutic process. In working with patients, having accurate information about their status (i.e., Is what I'm doing for or what's being done to this patient improving their status?) and measuring that change in status over a defined period becomes imperative.
The way we as behavioral health providers characteristically measured progress in the past was we put somebody on a medication, the patient would come back in a few weeks, and we'd ask how they were feeling. And the patient might say, "I think I'm better." Our response would be to repeat the process for four more weeks and see how the patient was doing then. Consider the opposite response, where a patient comes in and says, "I don't think I'm doing any better." Our response might be to double the medication dose and see how the patient was doing in four weeks.
That was the level of sophistication that we had. Our hope — and hope is a poor care plan — was this patient would be better if we doubled their medication. The problem here is that if the patient came back in four weeks but were not any better, there was no way to truly measure this outcome.
With MBC, we can track and measure a patient’s improvement over time, which is also part of the therapeutic process. For patients to be able to measure their outcome and then see themselves getting better is in of itself therapeutic.
Shortcomings With How Providers Are Using Measurement-Based Care
Unfortunately, there are multiple shortcomings concerning the usage of measurement-based care by healthcare providers, one of which is its failure to be used. We recognize that MBC is used in other areas of medicine, but in behavioral health, it's not been as conscientiously applied. To some extent, the reason for this lack of uniform application is that the sequencing for behavioral health is a bit different than what occurs with physical health.
Let's say that in the physical realm, I'm treating somebody for hypertension. I give them a medication. I then measure their blood pressure over time. I may measure the heart rate, heart rate variation, or other vital signs, but ultimately what I'm doing is following metrics over time to tell me if the medication I chose had the outcome that I wanted. For hypertension, that would be a reduction of blood pressure.
As physicians, we are used to taking that approach in the physical realm. In behavioral health, we're less used to it because that approach has not been part and parcel of the behavioral health process over time. The complexity of the situation in behavioral health lends itself to MBC but is often not used because of said complexity.
What do I mean by this? Let's take, for example, a patient with depression and anxiety, which are frequently identified together. Herein lies the complexity: Am I measuring one? Am I measuring both? How am I measuring them? What do I consider improvement?
Then there's some nuance around my expectations for treatment. For example, if I put somebody on an antidepressant, what should my expectation be for their status going forward? This is often unknown. If I measure the patient and then see the patient again in a week and the measurement this time does not indicate an improvement, is that acceptable? Is it unacceptable? Is it within the range of norm? Some of that information and the complexity of each individual patient's response isn't known. But we do know, for example, that if we don't see some improvement within six weeks, then some other intervention is needed.
Complexity is a problem. But it's not a problem if you're not measuring care. That's a catch-22 which has created some of the challenges around MBC.
How Providers Can Strengthen Their Incorporation of Measurement-Based Care
The good news is that there are ample opportunities for improvement around measurement-based care in behavioral health. I think the way providers can do better with MBC is to take the same approach as they would with nearly any other process improvement. Once you integrate something into your normal workflow, it becomes easier. Things that we become habituated to — whether because it's the right thing to do, what other people are doing, or some other motivating factor — are more likely to get done, get done consistently, and get done correctly.
In physical health, regulatory bodies have driven a lot of the usage of measurement-based outcomes. Now we are also seeing that happen in behavioral health. Let's look at one of the simplest of measurements for behavioral health: screening. Regulatory bodies require behavioral health providers to provide a screening and follow-up on that screening with a patient over time. Medicare is requiring the screening process model in the accountable care organization (ACO) world.
We are also beginning to see a movement toward the Joint Commission requiring measurement-based outcomes for accreditation of hospitals that provide behavioral health services. If a patient has depression and a provider at the hospital identifies it and initiates treatment, that treatment will need to be measured. Then, when the hospital discharges that patient, the hospital will need the ability to demonstrate that they discharged the patient with some outcomes achieved. All that is being driven by this need to have data and measurement. In other words, I must be able to show that I did something and it imparted an outcome.
Another reason providers should look more closely at incorporating MBC for behavioral health is the fact that we, as a medical community, are still moving toward value-based payment. For value-based payment to become the norm in the land, if you will, outcomes must be measured. Why? If I'm a payer reimbursing somebody for a perceived outcome, I must be able to measure that outcome.
For example, let's look at depression. Let's say the payer requires me to show improvement using a depression outcome measurement scoring tool. That means no matter the treatment, whether it be ketamine-induced therapy, psilocybin-induced therapy, TMS, medication, therapy alone, or cognitive behavioral therapy, I need to measure the outcome for that patient. With depression, an acceptable outcome may be improvement at 12 weeks and sustained improvement up to a year.
Under a value-based model, If I'm going to make that the stake in the ground for what's considered a valuable treatment for depression and expect a payer to pay for the care, I must see that the patient got better in 12 weeks. And then I must subsequently see that the patient maintains this improvement for up to 12 months. The ability for people to do that is through measurement-based outcomes.
The reality is MBC benefits the provider — the physician, nurse practitioner, therapist, whomever it may be — in making better-informed decisions. MBC helps the patient understand their condition. And MBC provides for a value-based payment model and the ability for payers to make decisions about choices of therapy and the people they may put in their network.
Final Thoughts on the Future of Measurement-Based Care
Globally, measurement-based care improves the health system because it helps the provider, it helps the patient, and it helps the payer. MBC is here after being delayed because value-based payment got derailed by the pandemic right as it was advancing. COVID-19 essentially pushed back the value-based payment process by two to three years. Now we know value-based payment is back on track and expanding, and for this, you need measurement-based care.