How Do We Make Decisions On Where To Go For Help When There Is No Reliable Data? OUTCOMES!

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I read an article over the weekend which focused on helping the consumer find the right provider for mental health services when they may need it.  Given the myriad of treatment options out there today, the unethical behavior by a few, the immense amount of marketing dollars spent on appealing to a sometimes naïve and desperate consumer with pictures of swimming pools and mountains, I found the article to be refreshing and very insightful. It was clearly written by someone who has been around long enough to understand the pitfalls one can easily fall in to when faced with a mental health crisis and someone who clearly cares about patients and their families.  The author lists the following criteria that one should ask a provider when seeking or considering treatment options. Many of these are good to know, a few (I think) are not overly helpful and many probably mean a lot more to professionals than to a consumer. The last one, however, is critical to all of us. It is written as, “How does the treatment provider measure success?” and it deserves recognition and further conversation.

· How is your program licensed? (Residential, IOP/ PHP or ?)

· What is the length of the program?

· What do you do for detox if needed?

· Where are your services provided?

· What is a typical day in your program?

· What is your relapse policy?

· What is your maximum patient capacity?

· How do you work with co-occurring issues?

· How many on your treatment team have Masters Level or above educations?

· Are there medical personnel on-site 24/7?

· What does insurance cover?

· What is your cash pay cost?

· If a client leaves treatment early, is there a refund for unused amount

· What age group/gender do you serve?

· How many one-on-one sessions does a client have with Master’s Level or above clinician per week?

· Is the client expected to prepare their own meals (sober living level) while in treatment?

· How often do you drug test?

· Are phones and computers allowed?

· Is there a family program? If so, please explain.

· Do you have an MFT on staff (Marriage and Family Therapist)

· Is there an aftercare program?

· How does the treatment provider measure “success”?

As with any purchase, the right choice for a buyer is subjective. People make decisions based on what matters to them and what value they may place on something (referred to sometimes as a consumer’s “reservation price”). Some place price above all else whereas others include additional criteria such as quality, convenience, turnaround and durability in their decision making process. Some people buy from a brand or a particular company regardless of cost whereas others shop around and compare products as they make their decision. What is common is that most rational people who are spending their own money like to have some reliable and relevant information on the products or services they intend to purchase prior to making their decision. In most cases people tend to use that information to compare products and services across multiple sellers; for example- if I can buy an 8 ½ x 11 piece of white paper for 2 pennies from a seller 5 minutes away and I can buy the exact same piece of paper for 1 penny from another seller 5 minutes away (the other way), all other things equal I am going to buy from the 1 penny seller. If my intention is to print on that piece of paper I would want to know that the print-ability of the two papers is comparable. 

In this simple example if I am unable to ascertain whether or not the two papers are of similar quality, it would be very difficult for me to make a rational decision on which paper to purchase. In fact, I probably wouldn’t buy either! It could be that the 1 penny paper is completely ragged and will not run through my printer. If my goal is to run the paper through my printer for a wedding invitation, this paper could cost nothing and I still wouldn’t want it. Looking at it another way and assuming now that the 2 penny paper is a much nicer shade of white than the 1 penny paper, if I can afford the 2 penny paper and a nice shade is something that matters to me, then I would likely buy the 2 penny paper. 

Having this information is not only helpful as we make an assessment on who to buy from but it is also helpful for both sides (the buyer and the seller) as to what the agreed price is and in exchange for that price what the buyer should expect to receive in return (the bargain). For instance, if I agree to buy a sheet of paper from either seller which is supposed to measure 8 1/2 x 11 yet when it arrives at my office it measures 8 ½ x 5 ½, then I know I have not received what I bargained for. Maybe the seller made a mistake, maybe there was a problem in production or maybe I ordered the wrong size. Assuming I did not make the mistake, having had this information up front enables me to hold the seller accountable for what she agreed to sell me in the first place. In this instance I have the option of sending the wrong size back or possibly I bargain for a reduction in cost given the smaller size of the paper I received. If it was unclear what size I was going to receive when I agreed to make the purchase, I would have an impossible time holding the seller accountable for what to me is nothing short of an error.  

The point is we need information in order to make decisions and yet in healthcare, particularly in mental health, this information does not readily exist for the consumer. This makes the decision on who to see, where to go and when to go nearly impossible.  In mental health we currently rely on word of mouth, referrals and marketing materials.  This works for some but not optimally for many. Fortunately, this is changing as the focus is turning to having reliable and relevant data from providers which measure outcomes (results) and value, just as we had in my simple example of the paper. That said, the reason we are living in the dark ages at the moment is not necessarily because providers are inherently not interested in providing data for consumers. Rather, it is because there is currently very little in terms of universally accepted outcome measurements that the field agrees are relevant, it is extremely difficult to measure these outcomes with our patient population and it is even more difficult to risk adjust- which is critical if we are to use outcomes to make decisions.

Some providers are tracking functional outcomes such as follow up visits made and medication adherence. Some are tracking re-admissions and relapses. Others are tracking using tools such as Beck Depression Index, PHQ-9 and the Addiction Severity Index. While all of these measurements provide valuable data for both patient and provider, unless we all agree on universally standardized outcome measurements for the diseases we are treating, we simply cannot compare one provider to the next. Esteemed groups such as ICHOM have recently established a standard set of measurements for depression that the world is being encouraged to use. However, to date there is nothing for substance use disorder nor eating disorders, and this is troubling.

To make matters more complicated, risk adjusting our patient population is extremely difficult to do and yet it is a critical piece of data one must have when evaluating outcomes. For instance, if you have two providers who treat eating disorders and one sees only patients who have been hospitalized at least three times whereas the other sees patients who have never been hospitalized and whose disease is generally caught early, looking at an outcome such as readmission rates in a comparison between these two providers will tell us nothing. Of course the provider who sees the higher risk patients is likely to have a significantly higher relapse rate that the provider who sees the lower risk patients. Does that mean the former is not as good of a provider? Absolutely not. Only once risk adjusted do outcomes in this field mean anything when comparing providers.

When one is measuring a patient reported outcome measurement such as level of happiness or self- content on a given day, in this field we all know our patient population’s answer can sometimes be subject to the effects of the very illness we are trying to treat. Relying on an important outcome such as this can therefore be potentially misleading.  Yet this is the type of outcome that matters most to our patients and capturing the accurate answer when we want to know it can be incredibly powerful.

Comparing results across multiple providers is what is ultimately most important to a consumer as they attempt to make a rational decision for themselves and their healthcare, given their specific situation. In mental health we want to know what a provider is particularly good at, and what they may not be so good at. If our goal is to truly live free from the disease of addiction, then we probably do not want to work with an eating disorder provider who focuses mostly if not exclusively on achieving a certain weight for a patient. It would be similar to going to Burger King for a 5 dollar meal if what you really wanted was a 50 dollar steak from Morton’s. Yet we know not to go to Burger King for a really good steak because we have visibility in to what each provider really specializes in.

If our goal is to get back to work and live free from our active addiction, and we are able to compare three providers against one another and all three show relevant outcomes that are more or less comparable and yet one is 10% less expensive, then we want to know that. If a provider advertises that they are experts in treating co-occurring disorders, then we want to be able to see what happens 3 and 5 years out for their discharged patients…. How do we know if a provider is truly an expert in treating the more complex co-occurring cases? We would know if that provider and others who claim to do the same are tracking and measuring relevant outcomes that matter to the patient who suffers from a co-occurring illness. If someone says they specialize in co-occurring disorders and yet the data shows that the majority of their patients post treatment over a 5 year period re-admit to different specialists in eating disorders and anxiety, then maybe that provider really doesn’t specialize in treating co-occurring cases but rather what they really do well is treat people with less complex substance use disorder cases. 

Once we have outcomes and results available to consumers, we can begin to rely on those results as we make decisions and we can hold our providers accountable for delivering those results to me. Let’s say in a perfect world (the future) I am a consumer and I present with a risk adjusted case of substance abuse category “A”. I am able to pull up data on three providers who specialize in treating what I have. The reported outcomes that matter to me are all essentially the same. However, two of the three quote a price of 20 and estimate the time I will be in treatment and away from work at 5 days. The third provider quotes a price of 30 but estimates the time I will be in treatment and away from work at 3 days. If I have the means and if getting back to work is very important to me, I may choose the third provider. Granted I am paying a little more but in exchange I am getting something that is of value to me. Let’s say, however, that for reasons that don’t have to do with me interfering with my treatment (KEY AND NOT SIMPLE), I choose the third provider and yet after all is said and done I am in treatment for 6 days. First of all, having had the information I had before making my decision on where to go I am in a much better position to hold my provider accountable for the extra 3 days I was in treatment. In other words, when they come to me and ask for another 30 because of the extra 3 days, I don’t fork over the money without a thorough analysis of what went “wrong” and who should be held accountable for the extra 3 days’ worth of treatment….. There is a measure of accountability that comes with having data prior to making a decision. Patients can hold their providers accountable for their side of the bargain. One may think this is horrible for providers, yet it is not at all. This type of risk sharing inherently incentivizes providers to be more efficient and effective with everything they do from diagnosis to treatment to follow up. And it goes both ways. In this example if I chose the 30-dollar provider and they treated me in 2 days, conceivably there is a savings of 10. If the provider gets to share in that savings, there is incentive, motivation and an inherent alignment of goals. Risk sharing can’t go just one way. That’s not fair to providers and it will never work.

If we are all measuring ourselves against one another using standardized outcomes, then we know what we are good at and we know what we may not be so good at. With this information, we can choose to focus on improving where we need to and can improve or possibly get out of the business of what we may not do so well and focus on what we do exceptionally well. This would be good for all providers and all patients. We can’t all be good at everything, yet what we are really good at is where we should be focusing our time and energy. This makes good business sense, and it is good for patients.

The outcomes that we are measuring must be standardized and relevant, and they must be results that matter to patients. Without this, a consumer can look at the best data in the world and have no basis with which to compare providers against one another in an effort to find what works for them. This is how markets work. It is normal, and this is where healthcare is headed. Getting there with mental health is anything but easy.  However, as providers and payers work together to establish mutually agreeable standardized outcome measurements, we will get there. And when we do, our patients will be ecstatic as the quality of care will naturally increase and no longer will patients be forced to live in the dark ages as they make decisions at an incredibly vulnerable time in their lives.