I am fascinated with public transportation. I’ve seen excellent examples of how this is done well, and pretty poor examples where it’s almost non-existent. Recently on a trip to Europe, I was experiencing their mostly stellar rail system when a certain notice caught my eye. I was standing in one of the cars watching the scenery pass by, when I started reading a policy document posted on the wall of the train.
As you can see from the picture below, if your train is late, you are eligible for compensation. It took me a minute to sort this one out as it was such a foreign concept for a transportation company to publicly hold themselves accountable to delivering on what you were paying them to deliver.
I can’t tell you the number of times I have been late or missed meetings because of a late flight and received nothing but grief. Thankfully, it looks like the this is changing here in the US with a new rule coming out of the Department of Transportation where airlines are going to be held accountable for paying us when we are late because of them. About time, I say!
I love the idea of receiving some compensation for when what we pay for wasn’t what we expect or doesn’t deliver on the promise of what it’s supposed to. When you look into this, you find that there are actually quite a few companies who do this:
Hotel Bookings: Many hotel chains have a "satisfaction guarantee" policy where guests can receive a refund or discount if their stay doesn't meet certain standards, such as cleanliness, noise levels, or amenities not being as described.
Food Delivery Services: Companies like DoorDash and Uber Eats offer refunds or credits if an order is incorrect, late, or unsatisfactory in quality.
Retail Purchases: Retailers like Amazon provide refunds or replacements for products that arrive damaged, are not as described, or fail to work as expected.
Utility Services: Some utility companies offer bill credits or refunds if they fail to provide consistent service, such as prolonged power outages not caused by natural disasters.
Software and Subscriptions: Many software and subscription services, like Netflix or Adobe, offer refunds or credits if there are significant service disruptions or if the service doesn't work as advertised.
Online Marketplaces: Platforms like eBay and Etsy often provide buyer protection programs, offering refunds if the purchased item doesn't arrive, is significantly different from the listing, or is damaged.
What this train notice reminded me of is the importance of setting clear expectations for services. It's about protecting the customer. If we know what to expect and the service doesn't deliver, there should be some recourse.
Transparency is good, but accountability is better.
In health care, and especially the mental health space, we have very little of either. This isn’t for lack of trying. People have been calling for more transparency and accountability in health care for decades. Our collective frustration has pushed us to a place where it feels almost like this is an aspirational goal that may never happen.
Thankfully, we are beginning to see some progress.
Recently the state of Colorado began the process of increase data around mental health for the public. This “Performance Hub” launched by the Colorado Behavioral Health Administration, is basically a simplified data dashboard that aims to increase transparency and help with accountability in the mental health sector. While that sounds super important, and it is, if you actually look at the website and what it does, it’s clear that it falls short in providing concrete insights into outcomes and the quality of care. The portal currently offers data on service access and complaints(!), but lacks detailed information on the effectiveness of treatments and the actual improvements in patient well-being. That being said, it’s a start.
Other states have done similar type of efforts. Consider Ohio’s data dashboard, Washington state, or North Carolina. The NHS in the UK actually has a pretty sophisticated data dashboard; however, all of these dashboards have limitations.
To truly transform the mental health system, we must go beyond basic transparency and focus on measuring and reporting meaningful outcomes that reflect the quality and impact of the services provided. Knowing how many people accessed care is nice, but it doesn’t tell you the rest of the story. There are meaningful data we never see, which limits how we are able to take action.
Imagine if mental health systems, providers, payors were held to the same standards as public transportation or airlines. What if we received compensation or some form of redress when mental health services failed to deliver? It would revolutionize the way we approach mental health care, driving improvements and ensuring that the care we receive truly helps us heal and thrive. I mean why should you pay your premiums, deductibles, co-pays and more when what your paying for is denied or ineffective? Shouldn’t there be something that comes from this? Without data, it’s hard to even be able to have this conversation.
This is a complicated and critical issue to discuss. While I don’t have all the answers, I do think there are some simple ideas we should consider infusing into our discussions around mental health. I realize that many of these are a pretty sizeable shift from what we are currently doing - so see these as fuel for our ongoing work.
Implement Performance-Based Accountability: Establish metrics for mental health providers that focus on patient outcomes and satisfaction. Providers should be held accountable for meeting these metrics and face consequences for underperformance.
Transparency in Reporting: Require mental health systems to publish detailed reports on the effectiveness of treatments, patient outcomes, and satisfaction levels. This information should be easily accessible to the public in some consistently updated data dashboard. Let’s become more informed how well our systems are doing.
Compensation for Poor Service: Introduce policies where patients can receive compensation if the mental health services they receive fail to meet established standards or promised outcomes.
Regular Audits and Reviews: Conduct regular independent audits and reviews of mental health providers, payers, and systems to ensure compliance with federal and state policy, performance standards, and transparency requirements. While this does cost money, it allows all of these systems to engage in ongoing quality improvement activities, compliance checks, and more.
Patient Feedback Mechanisms: Create robust channels for patients to provide feedback on their care. Use this feedback to continuously improve services and hold providers accountable. This also gets to the heart of measuring what matters and introducing new metrics that are based on what matters to people and their health.
Incentives for High Performance: Offer incentives to mental health providers who consistently meet or exceed performance standards, encouraging a culture of excellence in care delivery.
Comprehensive Data Collection: Develop comprehensive data collection systems that track a wide range of outcomes, from treatment effectiveness to patient well-being, and use this data to inform policy and practice. While more data is not always the answer, having the right kinds of data can indeed help guide our decisions around investment and policy.
User-Friendly Data Dashboards: Create intuitive and user-friendly data dashboards that not only provide comprehensive information on service effectiveness, patient outcomes, and satisfaction levels but also allow users to easily navigate and understand the data. These dashboards should be updated regularly and made accessible to all stakeholders, including patients, providers, and policymakers, to promote transparency and informed decision-making.
My experience with Europe's efficient rail system, where passengers are compensated for delays, got me thinking about accountability in services and how we should publicly let the community know more about their rights, care effectiveness, and other issues that matter to them. We often pay for things that don’t meet our expectations, yet we rarely see any options for us when that happens.
Accountability is missing in mental health care because there is often a lack of clear standards and metrics for evaluating the quality and effectiveness of services. No one knows the data, its not available, and we often make decisions blindly. We rarely have the opportunity to compare “apples to apples.” Without consistent measures, transparent reporting, and performance-based accountability, all the major players in the mental health space are not consistently held responsible for outcomes, which can lead to variable and sometimes substandard care. This lack of accountability undermines trust in the system and fails to ensure that patients receive the care they deserve. Implementing accountability measures and displaying those data publicly is crucial to improving mental health services.
Oh, my trains? They were never late - they delivered.
Mental health services falter precisely because there are very few economic and political consequences for those who are supposed to provide the services and don't. Undoubtedly, the threat of being forced to refund money would make many of the private equity companies in control of these services want to comply, if not legal action stemming from refusals to comply.