Identifying the Barriers to Quality

The Mental Health Quality Forum (MHQF), a 2-meeting multidisciplinary panel, was held in March and June 2013 to identify problems and opportunities in the management of serious mental illness (SMI). In the first meeting, participants from a range of mental health care—related backgrounds identified components of quality care and the key issues that cause delivery of that care to be suboptimal.

Keys to Value-Driven Care

The ecosystem breakout sessions identified 5 major categories considered to be critical in providing value-driven quality care in SMI:

  1. Improved or stabilized patient function
  2. Access to and appropriate use of hospital or other inpatient facilities
  3. Access to and appropriate use of community-based care
  4. Patient satisfaction with care
  5. Cost-effective care
Barriers to Value-Driven Care

Provider-centered barriers.

Personnel-related issues focused on inadequate levels of personnel to care for patients with SMI, particularly involving medication management. The significant shortage of psychiatrists, especially in child/adolescent and geriatric psychiatry,1 was mentioned. A nursing shortage also exists in psychiatry,2 and often there may not be enough nursing staff to administer injectable antipsychotics.3,4 Moreover, many community mental health centers and residential facilities have frequent staff turnover5 and may have inexperienced staff.

Non–personnel-related issues included a lack of health information technology infrastructure. While the Patient Protection and Affordable Care Act (ACA) has mandated use of electronic medical records,6 these systems do not always talk to each other and may be difficult to use.7 Another facility-related issue was suboptimal office space, especially for the administration and storage of injectable antipsychotics.3,4

High case loads were cited as a cause of inadequate time spent with patients and inability to conduct proper screening. Furthermore, the need for early screening and intervention, better continuity of care, consensus guidelines for practice, and improved social services were cited as provider-related issues.

Patient-centered barriers. Co-occurring substance use disorders act as barriers to treatment access and success.8,9 Cognitive impairments may lead to both a lack of insight into one’s diagnosis and treatment and difficulty understanding medication regimens, which may contribute to nonadherence.10,11 Housing was also mentioned as a problem; about 30% of people who are chronically homeless have mental health conditions,12 and transient patients may lack transportation to appointments.

Access-related barriers. Many patients with SMI are covered by Medicaid, and there is a great deal of variability in coverage from state to state.13,14 Formulary restrictions and the prior authorization process were seen as barriers to care. Prescriptions often have limited refills; therefore, psychiatrists may need to see patients more often, in part to meet frequent prior authorization requirements. Furthermore, availability of prescribing providers adds to the difficulty of medication access and consistency. Finally, patients may have difficulty attending follow-up appointments after a hospitalization, which increases use of emergency room services.

Financial barriers. The funding streams that do exist for SMI are “siloed,” in that they cannot be used collaboratively. Panelists expressed that financial incentives for providers are not linked to quality outcomes. Providers commented that while they would like to use injectable antipsychotics more often, reimbursement rates for the injections often do not cover their cost.15,16

Patients with SMI also have health care coverage and financial difficulties. A recent survey by the National Alliance on Mental Illness (NAMI) reported that approximately 37% of people with mental illness are covered by Medicaid and 37%, by Medicare, while 10% have no insurance at all.14 Even a $5 copay for an antipsychotic may be too high for an uninsured, unemployed patient.

Other barriers. Other barriers mentioned involved frequent inpatient readmissions and, for some patients, incarcerations.

Improving Quality of Care: What Will Have the Most Impact?

Next, panelists met as a larger group to discuss the issues they had identified in their breakout groups. Eight broad, interrelated categories of issues impacting quality of care were identified as high priority in terms of their potential impact on quality of care (AV 1).

AV 1. High-Priority Issues Impacting Quality Care in Serious Mental Illness (00:54)


Care Integration

Panelists recognized that care for the population with SMI is fragmented. Optimal treatment often requires integration of many providers, including hospitals as well as entities such as community-based physicians, substance abuse providers, the justice system, homeless shelters, halfway houses, and food pantries.

Panelists noted that the current focus of the US health care system is on reduction of readmissions from other diseases—not readmissions for behavioral health issues. Participants were hopeful that the new accountable care focus may create better integration in the treatment of SMI patients. One panelist mentioned integration of primary care and mental health care via patient-centered medical homes for the mentally ill. The goal of patient-centered medical homes is to coordinate services patients might need, and further implementation of this model could benefit SMI patients.17

Insufficient effective communication between providers results in suboptimal collaboration in care, screening, and follow-up, and many primary care physicians are undertrained in mental health conditions. Inadequacy of information on medical records was also cited.18 Some attributed this incompleteness to the stigma of mental illness, while others felt that information is often deemed “confidential” and not necessarily part of health information exchange between providers.19,20 One participant commented:

“Not to blame mental health professionals, but they’ve sort of created their own problem by thinking that patient information about mental illnesses needs to be behind glass. Actually, legal regulations say that it doesn’t, as long as the information is isolated....Mental health information can be on a portal not for the world, but for the primary care doctor to see in order to coordinate care as needed.”

Infrastructure/Enabling Technology

Panelists observed that the lack of adequate health information technology throughout the care continuum, combined with poor documentation, makes sharing information between providers difficult. A recent study of 13 of the top US hospitals determined that in over 70% of the hospitals, nonpsychiatric physicians lacked full access to psychiatric records.19

The recently introduced Behavioral Health Information Technology Act of 2013 bill would incentivize the meaningful use of electronic health records and may be a positive step in the direction of care coordination if passed.21

Tools for Accountability

The panelists emphasized that financial incentives for providers should follow the quality of care given. The CMS Stars bonus programs and Value-Based Purchasing programs22 have drawn significant attention to those measures included in the program; however, mental health measures are not included. Until the use of quality-of-care measures is expanded, incentives and accountability cannot occur. Accountability is dependent on both access to and type of care. Further, patient engagement, which is required to ensure accountability, may be a challenge.

Development (and Use) of Practice Guidelines

Participants also noted that few definitive treatment guidelines exist, and when they do exist (for example, those by the American Psychological Association23), clinicians may feel that they are too prescriptive and do not apply to the patients they see:

“Clinicians see guidelines as practicing ‘cookbook medicine’ and don’t use them.”

Early Screening and Intervention

Panelists expressed a strong feeling that assessing children and adolescents for signs of SMI and treating them at an earlier stage may help prevent future, more serious events.

This point echoes the argument that the US health care system does not focus on illness prevention, emphasizing treatment of a condition rather than screening and early intervention to prevent disease progression.

Enabling Financial Structures

Current financial structures do not enable adequate treatment of mental illness. There are too few dollars available to treat SMI, and the allocation of the dollars that do exist is skewed. This is especially apparent due to the prevalence of public payer coverage in this population.

Misaligned financial and quality incentives were mentioned as an issue also affecting pharmacists:

“As pharmacy providers, we’re not incentivized for quality, and payment structures are not necessarily set up properly.”

Administrative burden was mentioned. One survey showed that for every hour spent in direct care of dually eligible psychiatric patients, psychiatrists and their staff spent 45 minutes on administrative tasks.24

Participants felt that a change is needed in how services are reimbursed. Fee-for-service models may be inappropriate and result in suboptimal care of SMI patients.25

Diagnostic Consistency Among Providers

Panelists believed that no single diagnostic scale is effective and that the lack of a uniform diagnostic tool contributes to poor continuity of care.

Further, interrater reliability between providers is inconsistent. Patients are often treated by multiple providers, and each may diagnose a patient differently; this may lead to concern among payers that patients may be receiving inappropriate treatment. Lack of consistent diagnoses may lead to fractured care and conflicting treatment regimens.

Patient Access to Appropriate Care

Access to higher levels of care can be challenging, especially substance abuse programs26 and halfway houses. However, the ACA includes substance abuse treatment as a mandated service, and it includes provision for training and development of a larger workforce.27

Social support systems are also often lacking. Patients may have difficulty in finding transportation to appointments and pharmacies. Social support can also encourage patients to adhere to treatment regimens.11

Accessing medication may also be difficult. Delays in treatment may occur due to prior authorization requirements.28,29 Furthermore, required monitoring and side effects of medication can be challenging and result in medication noncompliance.30

Setting the Stage for Change

Participants suggested focusing on a pilot project with manageable and measurable goals in the short term (under 3 years); the pilot would then be used to lobby for larger changes in incentives, care integration, and related societal issues. A stepwise approach based on using payment change to drive clinical change was recommended, as shown in AV 2.

AV 2. Steps in Initiating Payment Change to Drive Clinical Change (0:47)


The participants suggested an order of prioritization of the problem areas to be addressed in future pilot projects:

  1. Early screening and intervention
  2. Adequate quality measures
  3. Infrastructure development
  4. Financing structures
  5. Accountability to evidence-based care
  6. Coordination of care
  7. Access to care
  8. Patient engagement
  9. Definitive diagnosis

Panelists noted that the enhanced focus on efforts to coordinate behavioral and physical health care31 brought on by the ACA could help gain support for a pilot project.

Panelists also felt that it was critically important to align financial incentives with program outcomes, as accountability and compensation will drive change in the provider community:

“As they say, money talks…If you start changing some of the reimbursement infrastructures and align your financial structures and accountability—and you pay—word travels fast.”

The MHQF panel categorized barriers to quality care in SMI as patient-related, provider-related, access-related, financial, and other issues. Panelists were concerned with the current lack of quality performance measures in mental health care.

Panelists believed that a preliminary focus for strategies should be on straightforward structures and processes implemented via pilot projects that would be manageable and measureable in the short term.

The second Brief Report in this series will summarize the panelists’ recommendations for pilot designs to create a blueprint for change.

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09US15EUP0047 April 2015

Mental Health Quality Forum Participants

Carol L. Alter, MD

Georgetown University

Jacob Balinky, PMHNP-BC, MN

LifeWorks NW

Rakesh K. Bansil, MD

Catholic Charities-Newark

Jeffrey A. Buck, PhD

Centers for Medicare and Medicaid Services

Douglas Del Paggio, PharmD, MPA

Alameda County Behavioral Health Care Services

Adrienne Hlavati, APRN

Mental Health Cooperative

Charles S. Ingoglia, MSW

National Council for Behavioral Health

Matthew M. Keats, MD, MMM


David L. Larsen, RN, MHA


Stuart H. Levine, MD, MHA

Accretive Health

Wayne Lindstrom, PhD

Mental Health America

Junqing Liu, PhD, MSW

National Committee for Quality Assurance

Nina Marshall, MSW

National Council for Behavioral Health

Clare Miller

American Psychiatric Foundation

Marcia A. Palmer, PharmD, MBA

UnitedHealth AmeriChoice

Mark J. Peterson, RPh

Genoa Healthcare

Andrew Sperling, JD

National Alliance on Mental Illness

Bradley D. Stein, MD, PhD

RAND Corporation

The meetings, manuscript development, and development of this brief report were supported by Otsuka America Pharmaceutical, Inc. All participants received a fee for service from Otsuka America Pharmaceutical, Inc. for participation in the meetings.

J Clin Psychiatry 2015;76:e00

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