Measuring Efficiency at the Interface of Behavioral and Physical Health Care

Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both).

To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development.

We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included.

85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31).

Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes.

We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified.

Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care.

Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts.

There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.