By Priyanka Dayal McCluskey
December 8, 2015
New methods of paying for health care, designed to improve care while controlling costs, have failed to help a big segment of the population — those grappling with mental illness — a Harvard Medical School study says.
Published Monday in the journal Health Affairs, it said the Alternative Quality Contract, a payment system run by Blue Cross Blue Shield of Massachusetts, is not improving care or saving money for the mentally ill.
The contract works by paying doctors based on how well they meet a set of quality measures and stick to a certain budget. It differs from traditional fee-for-service payments, which compensate doctors based on the number of services and procedures.
While the new model has shown some success in slowing health care spending and improving care, that has not yet reached people with anxiety, depression, bipolar disorder, schizophrenia, and other mental illnesses, according to the study. Instead, doctors have spent more time and resources managing care for physical diseases like diabetes.
“Folks with mental illness, their care is plagued by fragmentation,” said Haiden Huskamp, a professor of health care policy at Harvard Medical School and an author of the study.
Huskamp and her coauthors examined claims data for the first three years of the Blue Cross contract and interviewed several Massachusetts health care providers. They found that providers were not initially focused on coordinating services for mental health patients. But that is changing.
“They are now experimenting with different approaches,” Huskamp said. “There’s still more work to do. I think we’re at an early phase of fully integrating mental health.”
Alternative Quality pays doctors bonuses for achieving high scores on 64 quality measures. Only two relate to mental health.
Alternative payments have grown over the past several years, promoted by state and federal officials to rein in rising health care costs. About 38 percent of people with commercial health insurance in Massachusetts are covered by such payment models. Thousands more are covered under similar models run by Medicare, the government insurance program for seniors.
Dana Gelb Safran, senior vice president at Blue Cross, said the insurer is adding new measures in 2016 that encourage better mental health care — for example, giving patients a questionnaire to screen for depression.
Safran acknowledged the insurer and health care providers were not focused on mental health at first because they were getting used to an entirely new method of payment.
“It would have been ideal to come out of the gate and find even from day 1 behavioral health is getting better. The reality is that [medical] groups prioritized things a little bit at a time,” Safran said.
Mental illness affects tens of millions of people nationwide, but only about half get treatment, according to federal statistics.
One challenge for doctors trying to manage mental health care under new payment models is that the mental health field has been slow to adopt objective metrics.
“It is hard to really capture behavioral health symptoms objectively,” said Dr. Jacob Kagan, director of behavioral health at Atrius Health, the state’s largest independent doctors group. “Historically it has not been as numbers driven.”
Atrius is one of several providers working to improve mental health care. In a pilot program in Chelmsford, Atrius is partnering with other providers to help patients be seen more quickly, triaging them so those with the most serious issues are seen by in-house doctors within two days. Patients with less urgent issues are sent to other providers and are seen within two weeks. It’s an improvement over the three or four months patients typically wait, Kagan said.
Many providers have added social workers and case managers to primary care clinics to give patients better access to help.
Laurie Martinelli, of the Massachusetts chapter of the National Alliance on Mental Illness, said it’s good to see such efforts, but “no one ever said this is going to be easy.”