Separating the Wheat from the Chaff in Digital Mental Health: Why Quality Will Win

Until recently, digital health – and particularly mental health – solutions were barely on the radar. But times have changed: There are more 350,000 health apps available globally. And there’s no hint of this trend slowing down, as evidenced by US-based digital health startup funding nearly doubling in 2021, totaling $29.1 billion.?

So in this vast and growing sea of digital healthcare options, what will distinguish one solution from another? How should consumers, employers and payers choose?

These were two of the big questions addressed in a webinar I participated in, called “The Matchmaker is In: Connecting People with the Right Care in the Age of Hyper-specialization.” Joined by several industry leaders – including Paige Minemyer of Fierce Healthcare, Adrienne McFadden, M.D., of Buoy, and Joshua Dunsby, at Mercer – we covered a lot of ground on the future of choice in digital healthcare.?

My main takeaway? The winners and losers will be decided by whoever prioritizes quality. Here’s why.

Quality over quantity

The mayhem of 2020 brought with it skyrocketing rates of anxiety and depression among U.S. adults, swelling from 11 percent in 2019 to 42 percent in December 2020. Coupled with a shrinking number of providers and the growing acceptance of telehealth, the burgeoning demand for care led to a boom in new services. In 2021 alone, mental healthcare startups raised more than $5.1 billion, more than any other clinical space.

Overall, this is promising development. Patients often wait weeks and sometimes months before they can schedule their first appointment. The new digital solutions have the ability to democratize mental healthcare to millions of people. So in a way, the question has evolved from “How can I get care?” to “How good will it be?”

Quality care is the answer, but that’s easier said than done. Ensuring quality care is challenging, especially in mental health. The vast majority of mental health providers do not regularly monitor clinical outcomes. As a result, providers are effectively subjecting patients to trial-and-error care. Without outcomes data, employers and health insurers have trouble differentiating the high quality providers from others that prioritize growth instead.

This problem is compounded by the deluge of new digital solutions entering the market. Without agreed upon quality standards, every new app company defines its own metrics for what it deems quality care.

Standard setting and Quality Indicators

So what's the solution? We need to establish a universal quality standards for mental health that is widely adopted so that payers and employers can make more informed decisions. There are multiple features of usable quality indicators in mental healthcare.

First, quality indicators for clinical outcomes in mental health need to be specific to the diagnosis. This sounds intuitive enough, but the vast majority of providers either do not measure at all, or if they do, they only use a single clinically validated survey such as the PHQ-9 for depression. This is inappropriate for patients who have anxiety disorders, who should be screened with the GAD-7, or bipolar patients, who should be screened with the MDQ, to just name a couple. At Cerebral, we ensure that every patient's screening is tailored to the relevant diagnoses. Furthermore, providers should also publish engagement rates with surveys as well as outcomes in order to provide a true picture. If a clinic with 10,000 patients publishes data on just 200 patients, you should be skeptical.

Second, quality indicators cannot be abstract, and need to be very actionable for clinicians on the ground. For every indicator, there needs to be clearly defined next steps for improvement. For example, the Clinical Quality team at Cerebral wanted to ensure that patients on medications that require regular lab monitoring actually do get blood draws. For patients who are not getting the labs, we remind the clinicians to order the labs through repeated notifications, and we also educate patients on how important their compliance is for their health and safety. By empowering clinicians with specific next steps, we are able to maintain a 100% compliance rate with lab monitoring for tens of thousands of patients.

Third, quality indicators need to be prioritized correctly. Coming up with a list of 15 measures of quality is overwhelming, and not feasible for providers to track. There should be a prioritization process to identify which handful of metrics are most important. This process should not only include academics, but also needs to involve key stakeholders such as payers, providers, employers, and patients themselves. Only with the buy-in of major stakeholders will these indicators be adopted. Similarly, these metrics need to be easy to monitor at scale. For example, medication fill rate is important for care adherence (and Cerebral monitor this metric carefully), but I actually don't think it should be a prioritized quality indicator. Most clinics do not have integrated partner pharmacies, and would have to manually call pharmacies in order to monitor this variable. The best metrics should not further burden clinicians.

Importantly, a neutral party will be needed to institute these standards to minimize bias and ensure a level playing field. This can be a digital front door like Buoy, a non-profit, a government agency, or any group who benefits by helping payers and employers identify high quality providers. You'll find that the highest quality providers will welcome this approach, whereas legacy volume-based providers will resist the change. ?

The Cerebral Approach to Quality and Safety

Behavior change in healthcare is hard. On average, it takes physicians an average of 17 years to widely adopt findings from basic science research. At Cerebral, we've been able to reduce this adoption lag to just 1-2 months. We designed a way to empower clinicians through a data-driven feedback loop. Every month, every therapist, counselor, and prescriber gets a report on several dimensions of their clinical care. The reports include both aggregate metrics and actionable client-level data. For example, prescribers can see which patients have remained severely depressed despite treatment, and prioritize follow-up appointments for those in greatest need. Clinicians also meet to review feedback and brainstorm approaches to complex cases through clinical huddles. In terms of safety, we have created indicators for the presence of suicidal ideation, safety plan documentation, crisis response protocol enactment, and more.?

These approaches achieve real, measurable results. On average, most patients fill only 65 percent of their antidepressant prescriptions. But Cerebral patients maintain a 94 percent medication adherence rate. Additionally, between their first and last assessment, Cerebral patients experience a depression scores drop an average of 5 points, and anxiety scores drop an average of 4.2 points.?

The Cerebral approach is neither easy nor cheap. We have invested in creating two dedicated psychiatrist-led teams to push forward efforts in both clinical quality and clinical safety. We designed our system to gather clinical quality indicators that spans several validated domains, including clinical effectiveness, efficiency, safety, and timeliness of care. We work closely with health plans to reduce unnecessary emergency visits and improve their HEDIS scores.

This is a lot, and I can understand why other provider groups have not followed suit: by and large, we healthcare professionals are paid by volume and not quality. The transition to value is slow and arduous. However, if universal clinical outcomes were more widely available, and if they became increasingly influential in payers' and employers' decision-making, more providers will join us in our mission to improve clinical quality.

Thank you to HLHT and Buoy for hosting the webinar. Be sure to listen to the full version. And let me know in the comments what you think health companies should be focusing on. I’d love to hear from you!