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Editor’s Note: This is the second of four AHRQ Views blog posts written by the Agency’s National Advisory Council members about their discussions on advancing healthcare quality in different care settings. The Council provides advice to AHRQ's director on Agency activities and priorities. This blog does not necessarily represent the views of AHRQ.

Patients, policymakers, and practitioners recognized an acute need for change in the country’s behavioral health systems of care even before the COVID-19 pandemic, fueled by opioid misuse and falling life expectancy due to diseases of despair. The pandemic elevated awareness of this need for behavioral health services, with climbing rates of anxiety and depression, clogged emergency rooms with acute behavioral health crises, and an unprecedented surge in suicidality, particularly in adolescent girls.

Behavioral health touches every healthcare field and presents itself in every setting. We often think of behavioral health conditions as those showing flagrant symptoms of psychosis, mania, suicidality, and substance abuse. Still, more prevalent diseases such as depression, anxiety disorders, and trauma-related conditions continue to drive medical care utilization and increase suffering across large segments of the population. 

The AHRQ National Advisory Council recognizes that the country is at a critical juncture to define and measure the outcomes and quality of behavioral health services, including those targeting mental health and alcohol- and other substance-related conditions. Because of the breadth of behavioral health conditions, it is essential to understand the context of why measurement challenges exist. At least three characteristics of behavioral health challenge clear, consistent, and simple measurement: the existing broad set of diagnoses, variable treatment models, and unclear visibility around conditions and health outcomes.

Behavioral health is incredibly complex, encompassing a broad set of mental health conditions, severe mental illness, alcohol use disorders, and other substance use disorders, which are treated in various care settings. The burden of social needs, trauma, physical disease, social drivers of health, and grief compound the presentation and treatment of these conditions.

While behavioral health conditions are often first diagnosed in primary care, they drive utilization throughout the healthcare system, as evidenced by studies showing the poor health outcomes of those with comorbid behavioral and physical conditions. Workforce issues loom over the field and include an aging and increasingly burnt-out provider workforce and incomplete integration of behavioral health services. Insurance-related carveouts or inadequate coverage, as well as cash-only models of care, also have the potential to limit access. Uncertainty persists about which behavioral healthcare outcomes are patient-centered, clinically relevant, and sensitive to improved accessibility and care processes.

Enormous variability exists in treatment models for behavioral health, ranging from pharmacotherapy and psychotherapy to new, costly technologies such as transcranial magnetic stimulation and vagus nerve implants.

While some evidence-based guidelines exist, there is often disagreement on the approach to treatment. The introduction of mobile health app-based care has further complicated standardized measurement across widely variable settings. Psychotherapy services are typically not subject to external measurement, as they are delivered in a variety of settings by many clinicians, ranging from marriage and family therapists to social workers and Ph.D.-trained psychologists. In addition, these services are sometimes not documented directly within electronic health records, further challenging measurement efforts.

Behavioral health insurance benefits often do not align across distinct market segments for adequately covering beneficiary needs. For instance, specific Medicaid funding streams exist for services not available in a commercial health plan or Medicare benefit. Many veterans obtain behavioral healthcare through Veterans Affairs clinics, while their physical health care is provided through private clinics and hospitals.

Finally, visibility challenges can make behavioral health conditions difficult to recognize. Because there is no reliable biomarker, such as blood pressure or hemoglobin A1c, for common behavioral health conditions, process and outcomes measures of care based on widely accepted standards have been slow to arrive.

It is hard to rely on administrative coded data to identify relevant patient cohorts for several reasons. Contributing factors include continued stigma associated with behavioral health diagnoses, diagnostic uncertainty due to limitations of classification systems and overlapping symptom presentations, the lack of longitudinal/shared information due to confidentiality concerns, and one-time specialty consultations. In addition, privacy standards and limited documentation impede the ability to categorize many therapeutic services that patients receive.

Early efforts at quality measurement in behavioral healthcare have focused on a few screening measures and measures of follow-up after inpatient psychiatric care or starting medications. However, the evidence base supporting specific time frames for follow-up and the “right” way to measure quality remains very limited. Indeed, there are little published data to show that our existing measures make a difference in population health and the overall cost of care.

Though measurement-based care is a current buzzword, where and how this concept moves into standard practice for behavioral healthcare is still being determined, given uncertainty about what magnitude and velocity of quality improvement can be expected. 

AHRQ will be convening a group of experts, including providers, researchers, and consumers, to address the complexity of behavioral health quality measurement. AHRQ recognizes the need to ensure that there is not only harmonization of measures across Federal agencies, but also across medical and psychological societies. The group will look at models of care for specific conditions, review existing quality paradigms, consider areas where more research is needed, prioritize patient-centered outcomes and patient experience of care measurement, and evaluate economic factors related to care delivery. 

Caroline Carney is the President of Magellan Behavioral Health and is the Chief Medical Officer of Magellan Health. Asaf Bitton is the Executive Director of Ariadne Labs, Brigham and Women’s Hospital, and Harvard T.H. Chan School of Public Health. Patrick S. Romano is a Professor of Medicine and Pediatrics at the University of California Davis. 

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