Pay for performance has begun to take hold in the mental health and addiction treatment fields, and the early indications are that it has some ability to improve quality. However, the effectiveness of the incentive-based approach is dependent on the way it is implemented and how it fits among other reimbursement systems.

The first nationwide examination of pay-for-performance (P4P) programs in mental health found that the rapidly expanding reimbursement approach is" not a magic bullet" to improve quality and control costs, as its proponents have promised, but that the approach has potential to help reach those goals.

For P4P to reach its full potential in mental health care, according to the authors of a study published in the December 2008 Psychiatric Services, its proponents will have to develop an improved quality infrastructure, including the development of valid and practical quality measures in mental health and substance use care.

"Many programs struggled with the ability to obtain accurate and valid data on performance because of the combination of a lack of validated performance measures in behavioral health as well as the difficulty of data collection on behavioral health outcomes," wrote Harold Pincus, M.D., vice chair of the Department of Psychiatry at Columbia University, and colleagues.

The study, titled "Pay for Performance in Behavioral Health," described 24 P4P programs for mental health, including substance abuse, across the country. Among the clinicians and other health care workers whose care was targeted by the quality-improvement programs were providers specializing in mental health, substance abuse, and primary care.

The researchers found that depression was the most common mental health condition targeted by P4P programs.

The focus on depression care follows from that diagnosis having the best-developed quality of care guidelines, said Meredith Rosenthal, Ph.D., associate professor of Health Economics and Policy at the Harvard School of Public Health.

Unfortunately, guidelines on depression care are "rarely followed," said Rosenthal, who has studied performance measures in mental health care. Better adherence to quality guidelines—where they exist in mental health care—may improve patient care.

Another finding of the recent study was that financial incentives offered in mental health P4P programs often were small. Also limiting the programs' abilities to reach their goals was difficulty obtaining accurate and valid data from clinicians on quality and outcomes of care.

"Only after the measurement conundrum is resolved can we begin to examine the potential for performance incentives to affect the quality of behavioral health care," Pincus and colleagues noted.

The few and poorly tested quality measures in mental health care do present challenges to using incentive-based approaches in that field, said Benjamin Druss, M.D., M.P.H., the Rosalynn Carter Chair in Mental Health at Emory University, in an interview with Psychiatric News.

The field lags behind much of the rest of health care, he said, in developing these standards because its funding comes from so many more sources—including numerous state-level public-sector programs and patients who pay out of pocket—than does funding for general health care. That divergence among payers also is likely to limit the impact of any P4P systems that attempt to compare outcomes in the mental health field.

"In theory, pay for performance with good indicators makes a lot of sense," Druss said. "Potentially it is a way of incentivizing good practices and promoting good care."

Among the dangers to avoid, Druss said, is the creation of "perverse incentives," in which clinicians improve care in areas tracked by indicators but make few improvement efforts in areas that are not tracked. Incentive systems also must avoid creating incentives for clinicians to" cherry pick" patients who are more likely to have better outcomes, while turning away more complex clients.

These challenges should not dissuade clinicians and professional organizations, especially psychiatrists and APA, from participating in the development of future quality measures in mental health and substance use care, said Richard Hermann, a member of APA's Committee on Quality Indicators, in an interview with Psychiatric News. That participation will determine the strength and accuracy of future quality indicators.

"We're at the midpoint in the evolution of a process that still needs to mature," Hermann said about the development of quality indicators in mental health.

The study authors offered several recommendations to avoid further problems as P4P develops in mental health care.

Among their suggested improvements were that general health care P4P programs raise the profile of the mental health component of their plans. Most incentive programs include mental health outcomes as a subset of other general medical care outcomes, which takes the focus off of mental health and limits the incentives that could lead to enhanced clinician" performance."

"Intensive efforts aimed at strengthening the quality infrastructure in behavioral health will be a prerequisite for ensuring the implementation of more robust programs," Pincus and colleagues wrote.

Another key to future P4P efforts is for planners developing P4P systems to avoid assuming that "one size fits all" when designing programs. Instead, "tailored" approaches are needed for substance abuse treatment providers, mental health centers, psychiatric hospitals, and outpatient psychotherapists, for example.

The need for an individual approach also was emphasized by Anita Everett, M.D., chair of APA's Council on Healthcare Systems and Financing, in an interview with Psychiatric News. Mental health care is very different from other areas of medicine that were early adopters of P4P approaches, such as cardiology. "Our field has much more variability in it," Everett noted.

Her experience with a Maryland state P4P program that rewarded evidence-based mental health programs had good results, including the collection of better patient data and more focus on the patients' goals for improvement. But the experience reinforced her perception that P4P works best when it is designed as one of several payment structures under which mental health specialists are reimbursed for services.

Future P4P programs also might benefit from changing their approach from concentrating on outcome measures to gauging if patients meet the treatment goals that they set at the start of care. This approach would better fit serious mental illnesses, in which recapturing levels of functioning that existed prior to the worsening of illness is often the goal, as opposed to complete eradication of all signs of illness.

"Pay for Performance in Behavioral Health" is posted at<http://ps.psychiatryonline.org/cgi/content/full/59/12/1419>.▪