There’s a big problem with measurement-based care in behavioral health that few are talking about: the fact that many clinicians are highly skeptical of payers.
While most therapists use clinical assessments to care for patients, many are concerned about privacy and how health plans will use the data that’s shared with them.
These attitudes come amid a growing push by operators and payers to use measurement-based care metrics, which often include clinical assessments, to demonstrate a behavioral health intervention is working. Behavioral health company Alma examined the topic as part of a newly published survey-report.
Alma is a digital behavioral health company that helps providers streamline their business and work with insurers. Last year, the company closed a $130 million Series D funding round, bringing its total raise to more than $220 million.
There is broad adoption of clinical assessments among behavioral health providers, with 87% of therapists reporting using clinical assessments in some capacity, according to Alma’s new survey, which included feedback from 224 therapists. Still, only 40% of therapists said that the assessments were useful in tracking their patient’s progress over time.
Alma’s CEO Dr. Harry Ritter noted that clinical assessments are variable and likened it to a primary care doctor checking a patient’s blood sugar. It’s a snapshot in time.
“You take a PHQ-9 right after you talk to your boss, and it might be a different answer than if you’ve just played with your baby,” Ritter said.
The most common reason therapists use clinical assessments is to establish a baseline with clients at the start of care. Just over half of therapists use assessments to track client progress throughout treatment.
“I think for many clinicians, these metrics are very nonspecific and change a lot, day to day, hour to hour,” Ritter said. “What folks will often tell us is that it’s beneficial at the beginning, on an individual client basis, and it’s really helpful at a population level. … But if you simply pick two moments in time, you might get a very misleading clinical insight.”
Many provider organizations tout the benefits of using measurement-based care metrics to help guide treatment and show progress. Educating providers on the importance of measurement-based care and demonstrating the value for patients is a large part of getting buy-in from clinicians.
“I remind our clinicians at orientation that measurement-based care has been shown in multiple studies and meta-analyses to be superior to care as usual, even with the same clinicians,” Dr. Ravi Shah, chief medical officer at Geode Health, told BHB in an email. “The great thing about these studies is that they used the same clinicians. That means that data-informed clinicians provide better care than the same clinicians who don’t have data. I usually see a lot of head nodding when I share this.”
Geode Health was founded in 2021 by global investment firm KKR. The Chicago-based startup provides in-person and virtual outpatient treatment across the country.
Questions on data use
But trust is a major obstacle in sharing clinical assessment data.
Many therapists are skeptical about how payers will use a client’s clinical assessment data. Nearly three-quarters of therapists that participated in Alma’s survey-report said they aren’t confident they understand how payers will use the clinical assessment data.
“We have a belief that when providers have the support and tools they need, the system gets better for everyone, but you have to have trust to do that,” Ritter said. “What you’re finding in the data is a clear indication that there’s some serious work to be done to build trust with providers. … The providers [need to] feel that this data will be used to advance access and reimbursement policy, and make it more equitable and a better ecosystem for providers. But I think there’s scar tissue.”
Roughly 77% of therapists surveyed in the Alma report said they think insurance companies will use the data from patient’s clinical assessments to reduce or restrict the length of care their patients will be covered for. Nearly half said they think payers will use the data to unfairly draw conclusions about the effectiveness of their care.
But there may be some hope for the future as payers evolve in their approach. One of the ways that health plans could get more buy-in from providers is by working with therapists and clinicians on creating measurement-based care metrics together.
“It is absolutely all about developing trust between us as the health plan providers out there in the community,” Dr. Douglas Nemecek, chief medical officer of behavioral health at Evernorth, told BHB. “It’s really important that we not pick metrics that are just important to us as a health plan, but also metrics that are important to the providers.”
Evernorth is the health service division of the national health plan Cigna Group (Nasdaq: CI).
Nemecek noted that it’s important for clinicians to know that the data being collected is being used for patient care and not to lower reimbursement rates or kick someone out of the network.
Clinical assessments are just one part of the total patient picture. Providers are prioritizing for more holistic care metrics.
More than half of providers in Alma’s survey-report said one of the most important factors in assessing therapy is improving client functioning. Another 42% said that the strength of the client relationship is one of the most important factors, and 42% said a reduction in clients symptoms. A client’s sense of self and alignment around client goals were also important to providers.
“It’s really important that we can work together with providers, and that they can see the benefits of collecting those metrics,” Nemecek said.
But building trust between the clinician and the health plan is only one component of adoption. Many providers are also concerned about keeping their patient’s data private, especially when using third-party tech platforms.
Only one-fifth of therapists surveyed said they are confident they understand how their clients’ clinical data is used by tech platforms. But Shah notes that many providers are already using technology, and collecting data points will be done on the same systems.
“With respect to privacy, clinical scales/assessment should have the same privacy protection as PHI (patient health information) in the medical record,” Shah said. “If clinicians trust their organization or EMR with PHI, they should feel comfortable with the scales. However, if there are privacy concerns with the EMR/PHI, then those same concerns should be considered for the scales.”
While health plans and technology partners have a long way to go in building trust with behavioral health providers, it’s unlikely the push for measurement-based care is going away anytime soon.
And there could be some positive implications for patients and providers.
“I don’t think anyone knows for sure why MBC works. My hypothesis is that for patients who are getting 10% or 20% better but reporting they feel the same, it helps the clinician feel confident that the treatment is working and stick to the plan,” Shah said. “For patients who are not getting better, I think the numbers really prompt the clinician to consider a change of treatment style, medication, or considering a consultation to try to get the patient moving in a better direction. The good news is that even though we don’t know exactly why, empirically we definitely know that data-informed clinicians deliver better outcomes than clinicians who do not have that same data.”
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