Identifying Effective Clinician
Incentives to Improve
Depression Care
A collaboration between researchers and the
managed behavioral healthcare community
Lisa Meredith, Ph.D., RAND
Francisca Azocar, Ph.D., UBH
Academy Health
June 27, 2005
Community Partnership
United Behavioral Health (UBH)
– One of the largest managed behavioral health organization
(MBHO) in the country
• Serving 1,700 customers and approximately 24 million members
nationwide
• Our customers are large and small employers from different
industries, health plans and public sector entities
• Both our Employer Division and Health Plan Division and Public
Sector are served by 7 care management centers in different
regions of the country
• UBH service products include EAP, behavioral health, and
disability services
– A national provider network with over 62,000 clinicians
representing
• Multiple specialties
– 7,500 psychiatrist; 13,400 psychologists;24,400 master’s level
counselors; 530 psychiatric nurses
• 2,500 facilities with locations in every state
Collaborators and Funding
United Behavioral Health (UBH)
• Francisca Azocar, Ph.D.
• Joyce McCulloch, M.S.
• Robert Branstrom, Ph.D.
RAND Corporation (RAND)
• Lisa S. Meredith, Ph.D
• Michael Schoenbaum, Ph.D.
University of California, Los Angeles (UCLA)
• Susan Ettner, Ph.D.
• Mindy Morefield, M.A.
Supported by NIMH grant #P30 MH 068639 to Dr.
Kenneth B. Wells
Can incentives influence evidence-based
care for depression in a MBHO?
• Gap between evidence-based practice and health
care as typically practiced in the real world (“Quality
Chasm” report: IOM, 2001)
• Changing the behaviors/practices of clinicians can
increase evidence-based care
• Little is known about efficient and generalizable
strategies for motivating clinicians to adopt evidencebased care
• No work on use of incentives with mental health
specialists – only primary care (RWJF)
• This project builds on and complements primary care
incentive demonstrations
Clinician Incentives Pilot Development Plan
Task
Goals
1. Identify potential (modifiable) clinician behaviors.
2. Understand how each behavior will improve care
for depression (potential impact of change, pros
and cons, sustainability for behavior change).
Round #1
Interviews
Timing
Dec 04/Mar 05
(Research team picks 5 behaviors with most potential)
1. Identify incentives to clinician behavior change
(pros and cons, impact, and sustainability).
2. Query experiences with the incentive structures
including consequences to implementation.
Round #2
Interviews
May/June
2005
(Research team generates list of provider/incentive packages)
Administrator
Interviews
1. Assess real-time feasibility of packages.
2. Explore ability of databases to support intervention.
3. Determine if reliable quality indicators can be
constructed from existing claims and drug data.
June and Nov
2005
(Research team conducts analysis to assess tracking capability)
Consensus
Panel
1. Present top 5 options and elicit feedback.
2. Engage group in discussion of behavior/incentive
pairs to pick most viable option.
Pilot Study to determine feasibility
Sep/Oct 2005
Stakeholder Characteristics (N=14)
Characteristic
Type
UBH Administrator*
Other Administrator#
Psychiatrist
Psychologist
Masters-level therapist
Gender
Male
Female
N
4
3
1
2
4
6
8
*Includes 1 administrator, 2 quality/clinical education specialists, and 1 medical director
#Includes 2 benefits consultants, and 1 benefits manager
Top 5 Behaviors for Targeting Change
Combination Therapy
Patient Education
Antidepressant Treatment
Rapid Access to Care
Clinician Education
Coordination of Care
Longer Treatment
Family Involvement
Employee-EAP Linkage
Psychotherapy
0
2
4
6
Summed Rankings
8
10
12
Results: Types of Incentives
Money
“more money, … to
attract more
psychiatrists”
“Everyone wants to be
paid more.”
“You could also give
clinicians a bonus if…”
Resources
“There is a resource
issue because of the
national shortage of
psychiatrists”
“Provide educational
materials to therapists
free of charge”
Opportunity
“Provide opportunities
for clinicians to talk
with each other.”
“Give the clinician
more empowerment”
“CEUs—When people
feel more informed,
then they feel more
competent.”
Incentives by Behaviors
Incentive
Combo
Therapy
Pt
Educ
AD Tx
Rapid
Access
1
4
Clin
Educ
Financial (Money)
Increase amount of reimbursement
1
Create new billing code
1
1
Bonus pay for meeting target
Pay more for psychiatrists to increase access
2
1
1
CEU-based education (online, face-to-face), training
1
2
Plan provide access to a preferred physician that will do
coordinated treatment
1
1
Provide readily available information (free) through plan
1
Non- Financial (Resources and Opportunity)
2
2
1
1
1
Provide feedback on patient outcomes
2
3
1
Reduce patient copay
1
Recognize through an extra credential/autonomy
1
Increase amount of approved sessions
1
Remove authorization requirement
1
Make participation in network contingent on practice
1
1
1
1
Anticipated Challenges
• What behavior to incentivize will in part be
determined by the clinician’s specialty, how
the incentive is structured, measured, and
risk adjusted –
• Main challenges:
– What to incentivize
– How to measure it
– How to reward the incentive
– Sustainability
Issues
• Large provider panel
–
–
–
–
62,000 with individual contracts
Solo practice
Number of panels
Volume of UBH patients/provider
• Monitoring & measuring behavior
– Claims
– Audits
– Surveys
• Sustainability - After the researchers leave…
– Administrative burden is high and yield may be low
– Volume of patients per clinician makes the incentive
unpredictable decreasing motivation
Next Steps
• Assess feasibility for using administrative data for each
behavior/incentive package
– Monitor desired behavior
– Provide the required incentives reasonably and
inexpensively
– Test in real-time through quantitative analyses
• Convene consensus panel with 10-12 stakeholders who
participated in interviews
– Present top 5 “feasible” behavior/incentive packages
– Break-out into 5 groups to brainstorm about how to
implement each package
– Reconvene to report, discuss, and vote on “best”
package
• Conduct small pilot study to test the intervention at UBH