Quality Care Measurement, Other Managed Care Notes from Psych Congress

Measuring quality in psychiatric care and using mindfulness-based stress reduction techniques for better pain management were some of the ideas of interest to managed care professionals at the 27^th US Psychiatric and Mental Health Congress, which opened Saturday in Orlando, Florida.

Coverage of the Congress from The American Journal of Managed Care from the Rosen Shingle Creek Hotel appears on AJMC.com.

Psychiatrists who don’t actively measure their effectiveness don’t know they’re failing patients until it’s too late, Mark Zimmerman, MD, of Rhode Island Hospital and Brown University, said in Saturday’s session on quality care measurement.

“No one tells me why they’re leaving. They just don’t come back,” said Dr Zimmerman. Improving over time means measuring everything from the quality of the initial patient contact to the cleanliness of the waiting room. Good outcomes measurement follows key principles:

• It must be clinically meaningful and quantifiable
• Data collection cannot interfere with work flow
• Information gathered must be used to improve service delivery
• When possible, measures must be supported by existing empirical evidence, to demonstrate their validity.

The basic reasons to measure quality are to grow professionally and to improve patient outcomes, Dr Zimmerman said. But as his talk progressed, he also warned that if the mental health field doesn’t embrace quality measurement on its own, it will become “the victim” of measurements imposed by government agencies or insurers, on behalf of taxpayers and employers who are paying for care. Dr Zimmerman, for his part, doesn’t fear a reimbursement model based on quality instead of fee-for-service.

“I look forward to the day when we get paid for outcomes,” he said. “I embrace pay for performance.”

Some stumbling blocks remain to a performance-based model remain, he said; in particular, such a model would have to recognize variations in case mix severity — in other words, some psychiatrists handle more patients with complex or hard-to-treat diagnoses, while other patients with mild depression are treated by their primary care physician.

Cognitive Behavior Therapy. Building trust, or a “therapeutic alliance,” between the therapist and a patient with personality disorder is needed to help the patient work through core beliefs of worthlessness that affect behavior, according to Judith S. Beck, PhD, who was the featured speaker Saturday.

Dr Beck, the current president of the Beck Institute, in Bala Cynwyd, Pennsylvania, has taken over as the standard bearer of cognitive behavior therapy, the movement founded by her father, Aaron T. Beck, MD. The senior Dr Beck, now 93, is still active but no longer travels, his daughter said.

Techniques of cognitive behavior therapy emerged as a way to quickly understand how underlying thought patterns affected behavior; by setting goals and homework at each session, the therapist and patient could work quickly to modify behavior. Not only did the patient feel better, but the cost of therapy could also be held in check. Dr Judith Beck said this has sometimes led to confusion to those untrained in the techniques about the depth of the relationship between patient and therapist; in fact, she said, a strong alliance is key.

A common element in many of these disorders is the feeling of worthlessness; the patient feels on a deep level that he or she is flawed or “bad.” Before real progress can occur, Dr Beck said, it takes time to build trust; patients cannot be compassionate toward others until the first learn to be compassionate toward themselves.

“All patients, but particularly those with personality disorders, come to treatment feeling extremely vulnerable,” Dr Beck said. “It is my responsibility to make them feel safe.”

A person with obsessive/compulsive disorder, for example, has overcompensated in systemization and is underdeveloped in the ability to be spontaneous or impulsive. A patient with schizoid personality disorder has been repeatedly rejected and thus overcompensates by retreating from the world. This person has a hard time with intimacy.

Mindfulness-Based Stress Reduction (MBSR). Steven Hickman, PsyD, of the University of California at San Diego, presented an 8-week program on bringing mindfulness techniques to patients with chronic conditions, which can offer an alternative to managing pain with drugs alone.

The techniques, based on 2000-year-old Eastern philosophy, and can be done anywhere and involve breathing exercises, a “body scan,” which requires the participant to recline and focus on individual parts of the body, and taking a daily check of pleasant experience with a record of one’s mood and thoughts at the time.

“If a person has chronic pain, there is the sensation of the pain, and there the relationship the person has with the pain,” Dr Hickman said. These two “parts” of pain — the sensation and the stress — must be understood, he said. Seeking treatment for the sensation is not the same as seeking judgment, which “just contributes to the suffering.”

A core concept in MBSR is understanding the difference between a “reaction,” and a “response;” the latter teaches patients to notice pain but be with it in a different way. Instead of activating the sympathetic nervous system — the “fight or flight” response — techniques that involve breathing and being consciously aware of different parts of the body allow patients to experience pain differently.