The mental health industry has long lagged behind traditional healthcare in identifying what high-quality, high-value care should look like. This is in part due to the fact that each individual’s mental health journey is incredibly personal. Unlike a knee replacement, mental health treatment plans are unique to an individual’s needs. What works for one person – whether that be a specific treatment modality, format or care plan – may not work for another. This is why measuring value in mental health requires a holistic approach and a comprehensive set of metrics.

Until relatively recently, most mental health services have been delivered via traditional, in-person therapy sessions. Occasionally, providers would do assessments of “moment-in-time” anxiety or depression levels, and then perhaps modestly adjust the member’s care plan. However, we know mental health isn’t just about one episode: rather, there are many episodes, of varying intensity, within that journey during the course of someone’s life span. In order to improve outcomes, a stratified approach to care is needed that addresses both subclinical and clinical needs. Such services combine self-guided care with mental health coaching and clinical services and providers within these systems determine how to navigate between levels of care through ongoing assessment that tracks a member's progress and care needs, ensuring the right level of care is available at the right time. 

This approach is (rightfully so) called measurement-based care (MBC). It’s a continuous and action-oriented tracking of individual outcomes, such as engagement, symptom severity and goal attainment. Simply put, it allows providers to measure and adjust care over time, with options to escalate and deescalate care when needed.

Implementing MBC is not just a trend, but a transformative approach that centers on effective and accountable mental health services. Let's explore how MBC works, its key components, and the barriers that are limiting it from gaining broader adoption.

What is measurement-based care?

Historically, mental health services have lacked a structured approach to when and how assessment measures are utilized. MBC has addressed this gap through a framework where assessments are frequent and consistent. Clinicians utilizing MBC gather baseline data to inform personalized treatment planning and goal setting. As treatment progresses, these measures are administered at regular intervals to check the effectiveness of the treatment plan and to identify where adjustments to the plan need to be made. MBC ensures a treatment experience that is highly intentional, collaborative, and transparent, and serves providers, patients and insurers equitably. 

However, according to a study in JAMA Psychiatry, less than 20% of mental health providers practice MBC. If we’re to get to a place where we’re measuring true impact – to the member’s mental and overall health – providers and health plans must start thinking differently, treating differently, and measuring differently.

The barriers preventing broader MBC adoption have centered around two issues: limited care options (ie: therapy or therapy/psychiatry-led care models, which don’t account for subclinical care needs related to prevention and maintenance), and limited measurement mechanisms to capture improvement milestones in the patient journey and, ultimately, measure outcomes. Outcomes tracking should include access times, functional improvements, member experience and therapeutic alliance. Therapeutic alliance is especially critical as it serves as a proxy in determining if members are receiving culturally responsive and compassionate care, a key indicator of members complying with their treatment plans – and ultimately seeing symptom improvement.

Additionally, traditional outcome measurements for mental health, like the PHQ-9 questionnaire, have typically focused on narrow objectives of symptom improvement. We’ve missed a lot of how recovery from a condition can be assessed, including important social determinants of health (SDOH) measures that impact quality of life and resources needed to achieve health outcomes. That’s made it harder for mental health providers, plans and systems to judge improvement/impact, and, therefore, they’ve been more cautious to engage in value-based care-like payment models.

Key components of measurement-based care

There are three commitments mental healthcare providers can make to move to a measurement-based model:

1. Integrate a layered approach to care. With large-scale, digital-first providers like Headspace, it’s now possible to deliver team-based, culturally responsive care at scale that is centered on SDOH and other health disparities. With a high-touch, stratified care model, we’ve set up an opportunity to capture the state of someone’s mental health at multiple moments in real time, and make adjustments to the level of care needed. There are a number of different layers that can be instituted into the care model, ranging from coaching to therapy to psychiatry. The key is that these providers must work together, and utilize MBC at each level to determine the best approach to care to meet the member where they are, at any given moment.

2. Commit to a more holistic set of measurement and reporting for your plan partners. With a higher, multi-touch model, we can go beyond the traditional and infrequent gold-standard assessments (PHQ-9/GAD-7), and add PHQ-4, PSS and other SDOH impact measurement to inform treatment in real time. These questionnaires were created to assess varying levels of depressive and anxiety symptoms and perceived stress, and technology can help to capture member metrics at scale. For example, automated surveys that come to a member’s attention (vs. relying on in-person delivery via a clipboard), enable data to be collected more systematically, making it more useful for measurement. Because the surveys are delivered in a virtual setting, members and providers can be held accountable for completing them, and in turn, generate more baseline data, which is essential for knowing how people are improving as a result of care.

3. Stand up milestones- and outcome-based payments that reward your value. When a more holistic, measurement-based care model is coupled with an expanded view of outcomes measurement overall, we create the opportunity to stand-up successful outcomes-based payment models. This has been our recent experience with Blue Shield of California, with whom we have an outcomes-based payment model based on member engagement and, most importantly, clinical outcomes:

• 80% of members with moderate to severe depression at intake had improved symptoms.
• 76% of members with moderate to severe anxiety at intake had improved symptoms.

The good news is, digital health companies are rolling out new, more holistic care models and robust outcomes measures regularly. Thinking differently about measuring the impact of mental health – at scale – will push our digital health peers, our health plan partners and traditional providers to start paying and charging for care in a different way. At Headspace, we are focused on continuing to develop integrated care solutions and measurement protocols to assess the true impact of our care model on the member journey and their outcomes. 

But we’re just one player in an expanding market that’s rapidly evolving to meet the ever-growing need for accessible, high-quality mental healthcare. It’s not enough for just one or two nationwide providers to practice MBC and get paid for improved outcomes. It’s time for mental health providers to take the steps necessary to make the combination of therapeutic and financial value a reality. The systemic challenges that previously caused mental healthcare to lag behind the progress of physical healthcare can now be corrected. The tools for outcomes-based care and measurement exist. The framework is there for value-based payment. The solution is right in front of us. You can learn more about the impact Headspace delivers here.