Okay folks, take a deep breath and think quality. With the high-pitched buzz about increased access to services with the advent of health care reform, let’s not get too far ahead of ourselves. The jewel in the crown known as “quality of service” is quietly sitting in the corner of the room. If we are not careful, quality runs a high risk of not getting invited to the decision-making table.

Harsh, right? Well, actually not, and thanks to Network faithful who are keen on us backing up what we say with data, let’s look at a few tasty morsels that will make you cringe:

• Nearly 90 percent of medical payments are based on quantity, not quality, according to a new scorecard released by Catalyst for Payment Reform, a nonprofit employer coalition working for payment reforms. They found that about 11 percent of payments to doctors and hospitals are tied to how well they deliver care, but the vast majority of payments continue to be based on the number of tests and services they perform. Traditional fee-for-service (FFS), bundled, capitated and partially capitated payments without quality incentives, make up the remaining 89.1%.  The scorecard reveals that we make the vast majority of payments for health care on a fee-for-service basis without any rewards for quality and efficiency,” CPR Executive Director Suzanne Delbanco said. The CPR report emphasized that there’s still a long way to go.
• Granted, the Catalyst report deals more with bones, tissue and blood, but make no mistake – the troubling findings carry over to the world of providing services for children with emotional challenges as well so don’t think we are off the hook. Consider this – In a story from Kaiser Health News, they report that we can expect to see a big jump in workers being provided through staffing companies. Now, the article focuses on the way many companies will get around providing health insurance to employees (hence the focus on staffing companies), but what is giving me a rash is what is not being talked about in this article – quality of service. For example, from the article, Jeffrey Silber, who follows staffing company stocks for BMO Capital Markets, is quoted as saying, “when Massachusetts implemented its own requirement that companies provide health coverage to full-time workers, temp jobs increased six times faster than in the country as a whole.” So we see a big jump in temp services providing staff. It seems to me we are likely to see something similar from agencies that provide services to youth and families. Where are the accompanying statistics on quality of care? Consider this quote from the same article when talking with a school official about the benefits of utilizing staffing services to fill positions that deal directly with students in a learning environment:
  • The people running Dothan schools see a double benefit. By hiring substitutes through Kelly they’ll avoid possible medical costs and at the same time dodge the complexities of how the health act affects subs, said personnel director Goodwin.

    Sometimes subs work more than 30 hours and sometimes they don’t, she said, and keeping track of who would be owed health coverage “would just be a continuing accounting nightmare.”

Jeeze, someone give me a bromoseltzer… So it’s great for accounting, great for cutting cost, but is it great for quality of services provided? Is it great for the end user? I don’t think so and I sure don’t see the issue of quality for the end user of services being discussed in this article or many articles like it – only cost containment.

Okay, still not convinced that quality is getting overlooked, are ya? Well, how about this little tidbit to further upset your stomach:

• In a recently published article by Garland, et al titled Improving Community-Based Mental Health Care for Children: Translating Knowledge into Action some sobering statistics emerged regarding quality in traditional mental health services. Garland, et al. shines a bright light into the dark corners of traditional mental health delivery. They note that 68% of the care in the studies reviewed was clinic based. A sobering reminder of how fragile our current mental health services are is the finding that “a third of the directors with site-specific budget data indicated that their agency ran at a budget deficit.” This is so important for advocates to understand. For us, “what works” goes far beyond usual care. It involves the active participation of community groups and families and initially may cost more. Yet, a third of Clinic Systems Project (CSP) cited in the article ran at a deficit and the largest funding source was Medicaid, which has what I consider to be narrowly fundable criteria, i.e., “usual care.” Are you starting to get the picture? If we allow policy makers to just fund what we do now, (i.e., usual care) in the spirit of saving money without doing rigorous quality checks, then we are doomed to a mediocre at best mental health service delivery system.  We need a system that evaluates and supports services beyond usual care if we are going to make significant improvements.

  The synthesis of current knowledge about specialty outpatient children’s mental health care in this article provides a sobering reminder that we have effectively been “asleep at the wheel” when it comes to comprehensive evaluation of the quality of mental health services being provided to children and families. In this new age of health care reform, this is a travesty that cannot stand. We cannot be complacent and be steamrolled into accepting anything less than the rigorous evaluation of what is being provided to youth and families in mental health care settings.

  The authors also point out a troubling finding that indicates big gaps between identified evidence-based practice and common usual care practice. All 50 states in the U.S. reportedly “promote, require, or support” the use of EB practices in children’s mental health service delivery in some way, but only eight states have explicitly mandated their mental health care systems to “promote, support, or require” specific EB practices (Cooper et al., 2008). This fits a common concern I hear from colleagues around the country who complain about practitioners providing usual care but calling it an evidence based practice – not because they are trying to be deceitful but because they might have gone to a training or seminar and feel that they are effectively applying what they learned in their practice. Where is the quality control in that? As evidence of this, the article cites that in one study they “found that approximately half of the patients’ charts did not meet basic treatment quality indicators based primarily on EB “best practices.” And how do we expect this to get better in these fiscally tight times with increasing client loads and clinicians not able to access quality training and coaching?

Combine the results identified in the examples above with the efforts to farm out responsibilities happening across the country and cutting costs and consolidating functions without actively considering how to maintain high standards for quality of care… Looks like  ”Quality” is gonna remain in the corner of the room… unless we collectively raise a ruckus.

Scott Bryant-Comstock, President & CEO
Children’s Mental Health Network