An Action Research Project

“Our goal is to help enhance the quality of your clinical care.”

What is the TOP?

 

On May 1, 2007, Blue Cross Blue Shield of Massachusetts (BCBSMA), the largest insurer in the state, sent a letter to therapists on its panels saying, “Addressing … gaps (in the quality of (mental health) care delivered) requires the ability to measure the quality of care.” 

 

Working with a company called Behavioral Health Laboratories (BHL), BCBSMA  is adopting a measurement system called the Treatment Outcomes Package (TOP), which they say, “can benefit both you and your provider by helping  you measure your progress and play a more active role in your treatment.  Our goal is to help enhance the quality of your clinical care.”

On the “Registration Page”, to be filled out once, the TOP asks for twelve pieces of information including sex, ethnic group, DOB, living situation, marital status, sexual orientation, employment status, education, income, religion, and number of hospitalizations and therapists.  In the two pages to be filled out every three months, the TOP asks 58 questions about “symptoms, ability-to-function, and quality-of-life”, including questions about drug use and sexual activity.  It attempts to account for external influences on clients’ lives and on their TOP responses by asking another 14 “Psychosocial Stressor” questions about “bad events”, relationship, money, legal, criminal, school, work, or housing problems.  They claim to factor in the 14 questions to be able to distinguish between therapist and life effects on the client.  I do not yet understand how they claim to do this and how it is reflected in the data.  From what I have seen in reports, they simply report on the “Case Mix” replies.  “Use this information to adjust treatment expectations …” (TOP Manual, 2007, p 11).

 

Therapists fax the questionnaires to BHL who then normalize the data by comparing your client to “more than 600,000 other behavioral health clients”.  To BHL, this is a business.  They say, “BHL currently charges $8/member measured for unlimited administrations, real-time lab report generation, and monthly statistical aggregate data analysis. Reimbursing providers at $10-$25 per assessment is reasonable.”

 

By looking at client change over time as measured by the TOP they believe that they can also measure therapist effectiveness as compared to other therapists.   Unlike a math test for which there are, hopefully, correct answers, comparing clients’ results to BHL’s database of results assumes that there are no objective criteria for “mental health”.  Like getting schools to compete over MCAS scores, BHL and BCBSMA seem to believe that therapists and clinics should compete over TOP scores, and the quality of therapy will improve!

 

(I was recently told by a clinician who sees incarcerated clients that, because the TOP does not account for incarceration, data in the database about sexual, drug, and criminal activity might be inaccurate because incidences are reduced due to bars on the doors and windows, not therapy.)  BHL then returns a digested form of the client report to the therapist, suggesting problem areas and sometimes, a diagnosis.  In a cover letter sent with TOP forms, BHL claims “The TOP will never provide a definitive diagnosis, replace your clinical judgment, or prescribe a specific intervention.”

 

In an article sent by BHL with the TOP forms, the authors claim that, with the TOP, “The clinician then has an excellent picture of the patient’s perspective of their troubles…”, “that outcomes management makes us all more effective clinicians…”, that “… TOP results demonstrate to the patient powerful evidence that their work is heading in the right direction …” … that “the TOP can provide very rewarding statistics to help psychotherapists guide their work.”, and that …”We have used this database to identify the proverbial “super shrink,” the ideal psychotherapist who is well above average on everything.”  Reassuring us that “there is no such psychotherapist”, the authors tell us that “A more realistic goal is for all clinicians to monitor their personal strengths and weaknesses by comparing their clinical outcomes with other professionals using a standardized instrument” like the TOP.  There seems to be no mention about BCBSMA also monitoring our TOP identified “personal strengths and weaknesses”.

 

BCBSMA says that “BHL will send us (BCBSMA) a patient-identifiable aggregate score between 1 and 5 indicating the likelihood that the member would benefit from case management or additional resources.”  They say “Providers will be contacted before BCBSMA offers case management services to their patients.” No further details are provided.  BCBSMA also says, “To support evaluation of the impact of behavioral health treatment on medical utilization, we will also receive non-identifiable TOP scores on all members periodically.”  Contradicting that statement, they also say, “BCBSMA will not utilize the responses or domain scores for utilization management purposes.”  The May 1 letter goes on to say “… we anticipate that the outcomes program may ultimately lead to a program of performance-based compensation … “

 

BHL predicts that Outcomes Management (OM) will become universal: “Eventually all payors will require and reimburse for outcomes management.”  If it wasn’t so expensive, BHL would also have employers screen (use the TOP on) everyone. “Whom should you measure? As the 1999 Surgeon General’s report identified, only about a quarter of individuals with a diagnosable behavioral health disorder receive treatment. Untreated behavioral health issues cost employers billions in lost productivity on the job, absenteeism, and higher general medical costs. On the other hand, screening all members for behavioral health issues will increase your behavioral health utilization.”

 

If BCBS is contemplating performance-based compensation, they may be following BHL’s “carrot and stick” approach.  Here is what BHL says: “There is no reason all providers deserve the same rates. Providers that have consistently documented excellent outcomes and are controlling costs within your parameters, cost you less to manage. Reward them with a higher rate. If not today, give them a target date—incentives that drive the entire network towards better outcomes … Excellent providers cost you less because they need little if any management oversight. Until they prove otherwise with declining outcome data, excuse them from tedious requirements like prior authorizations and submission of treatment plans. It will reduce your costs and theirs. For quality providers, you will become their collaborator rather than their overseer. Their satisfaction and yours will improve … Sometimes consumers need incentives too. Consider waiving the first co-payment if a provider agrees to participate. You can provide this incentive whether you require OM data as part of reimbursement or not.”

 

BCBSMA believes that the TOP results will allow them to intervene in the therapist-client relationship in at least two ways (in addition to the invasiveness and disruption of actually administering the test every three months).  They believe that it will allow them to recommend case management (what does that mean?) to clients with the worst scores.  And they believe that it will allow them to distinguish therapists whose clients get the worst scores, allowing BCBSMA to pay those therapists less.  Whatever respect BCBSMA might have for the legal restrictions on client data, they may have none for therapist data.  Maybe they will list therapist scores on their web site.

 

The father of the quality movement, the man whose ideas helped transform Japan from a producer of junk to a producer of quality goods, W. Edwards Deming, had as his first principal for employers, “First drive out fear”.  He knew that goods and services can be improved only by enrolling the help of the people who really know what is going on, the providers and producers themselves.  He also knew that enrollment in a quality improvement effort depended upon providers and producers having no fear, being able to believe that management (in this case BCBSMA) was actually “on the same side” as them, truly trying to improve the product or service.   By introducing a supposed quality improvement program that attempts to impose a methodology that takes power and responsibility away from clients and their therapists, BCBSMA is losing the trust and confidence of those groups.

 

Possible benefits of the TOP

 

To be fair, there must be some benefits associated with the TOP.  In Agency settings, I have been administering the TOP to clients of MBHP for more than two years, because it is mandatory and a condition of employment.  Personally, I have seen almost no benefit, and considerable downside, but I hear that some therapists and agencies value TOP.  I will publish claims of benefits if people send them to me.  There is surprisingly little on the BHL web site.  Here are some things that I have heard, mainly second hand.  I welcome input.

 

· Clients might say things in writing that they might not otherwise say.

· Sometimes issues are exposed by the TOP that might not have otherwise come up.

· It fits with DSMIV views of symptoms, diagnosis, and treatment.

· It gives the more control to the insurers who are trying to contain costs and gain profit.

· The therapist can read a book while the client fills out the form.

· Poor scores over time might expose an agency with poor personnel practices, rapid therapist turnover, and abandoned clients.