Behavioral Health Care Quality Ratings on the ACA Exchanges

This morning, Psychiatric Services has published an article that I co-authored with Drs. Jean Abraham and Coleman Drake as well as Sih-Ting Cai. We examined Behavioral Health Care Quality Among Marketplace Insurers in 2019##. This is in the same vein of work that we published in Journal of General Internal Medicine earlier this fall.

We looked at 2019 care quality ratings for four attributes:

• antidepressant medication management
• follow-up care for children prescribed ADHD medication
• follow-up care within 7 days after hospitalization for mental illness
• initiation and engagement of alcohol and other drug dependence treatment

We were curious if plan characteristics mattered, so we looked at ownership status, Blue Cross affiliation, Medicaid Managed Care status and if the insurer offered a Preferred Provider Organization (PPO) option. Our priors were that non-profits, and Blues would have higher quality and Medicaid Managed Care organizations would have lower quality.  We thought that PPOs would show lower quality as the insurer has less leverage with their provider network than HMOs and EPOs.

So what did we find?

We found a few noteworthy things.

Average quality ratings across all domains are low.  Antidepressent medication treatment and management led the pack at 62% of eligible patients receiving the desired standard of care while initiation of drug and alcohol treatment was the laggard at 23% of eligible patients receiving the desired standard of care.  This is a big difference compared to our care quality paper where three out of the four metrics we examined had at least 75% of patients receiving the expected standard of care.  Behavioral health is an area of possible and significant improvement in care delivery.

Secondly, we found that insurers that were good in one domain were likely to be good in another domain but the correlation was not particularly large or strong.

Although the correlation coefficients were positive for all pairs, only four were statistically significant and were moderate in magnitude (r=0.15–0.33, p<0.05). Specifically, correlation coefficients were largest between follow-up after hospitalization for mental illness and antidepressant medication management (r=0.33) and between follow-up after hospitalization for mental illness and initiation and engagement of alcohol or other drug dependence treatment (r=0.27).

 

Finally, we again found that non-profits were more likely to be better than average in making sure their members get the desired standard of care for antidepressant medication. Blues and PPOs had no statistically significant difference in care. Medicaid Managed Care Organizations performed significantly worse on three out of the four metrics.

So what does this mean?

Picking plans is tough. Picking on quality is tough. Right now, the ACA’s subsidy structure which is a price linked system tied to a floating benchmark (2nd cheapest silver) that can be strategically gamed means, that if we assume there is a premium-quality trade-off, low quality plans can undercut high quality plans. Insurers don’t get paid for quality directly. They may get paid for quality through risk adjustment, but that is a long delay with uncertain results.

It also means that behavioral health care quality is not particularly good. Even the best insurer classes (non-profits) don’t have great ratings on the four measured metrics. We need to do better.

## https://doi.org/10.1176/appi.ps.202000115