NCQA: Early Intervention, Quality Follow-Up Care to Combat High Cost of Mental Health Care: Page 2 of 3

June 30, 2016

Root of the Problem

Despite the worrisome results of the study, O’Connor acknowledged the encouraging findings as well. “A positive finding is that treatment is initiated for the majority of adolescents,” she said, noting that nearly two-thirds of those with newly identified depression symptoms did receive some sort of treatment. “And most included psychotherapy, which is often considered one of the best components of treatment for adolescent depression.”

She also pointed out some of the uncertainties that need to be taken into account. “An important point about this study is that we can only see what is in the electronic health record, so we can speculate about why some of the follow-up care didn’t occur but we can’t test it in this study because we didn’t see it,” she said. “There are a lot of variables we’re not aware of that could contribute to this lack of follow-up.”

Perhaps the adolescent didn’t want to return for treatment, maybe the family chose not to pursue treatment, or maybe a long wait to see a specialist pushed the follow-up visit beyond the 3-month period analyzed in the study, O’Connor put forth as examples. There is also a small percentage of adolescents whose symptoms alleviate without any follow-up care, eliminating the need to seek further treatment. 

Dig even deeper, though, and there could be other issues contributing to the current level of care, such as the stigma that continues to surround mental health, a lack of resources needed to ensure appropriate follow-up, or even the cost structure and how care is paid for. 

Cost of care is less of a concern now because of recent legislation regarding mental health parity that requires health insurance plans to provide the same benefits for mental care services as for medical services, explained Sarah Hudson Scholle, the study’s principal investigator and vice president, Research and Analysis, NCQA. But sometimes the real issue boils down to availability within a plan network. Services may be offered, but they may not be readily available if long wait times delay appointments and treatment. 

Payment arrangements can play into this as well. Coordination between the primary care provider and the behavioral health provider includes follow-up with patients, and those are the kinds of services that aren’t paid by traditional fee-for-service arrangements, she pointed out. Private doctors’ offices, for example, aren’t compensated for the time spent interacting with the behavioral health provider and coordinating related care. 

Some alternative arrangements are beginning to emerge, however. “We see this in patient-centered medical homes,” Scholle said. “Some health plans and other kinds of payers are actually providing primary care practices with essentially a care management fee to recognize their role in coordinating care and following up with patients to make sure they’re getting the care they need.”

The Affordable Care Act (ACA) has supported a number of delivery system reforms, particularly with advanced primary care for patients in a medical home, she added, so there are a number of initiatives across the country to encourage practices to organize the infrastructure needed to manage their patient population and monitor the quality of care. It’s also embedded in the Medicare Access and CHIP Reauthorization ACT of 2015 (MACRA), which reinforces the shift of Medicare spending into value-based payment models.