There’s a lot of buzz in healthcare about the promise of value-based care (VBC) and how it can reign in skyrocketing costs, while delivering improved patient outcomes. And indeed, the move to VBC has yielded positive results in primary care and there are emerging alternative payment models in specialty care for other chronic conditions. So it’s only natural that VBC has come to knock on the front door of behavioral health. The question is: Are behavioral health providers ready to open it? And what awaits them on the other side?
In part it’s taken VBC a long time to make its way to behavioral health because – for better or worse – it’s different from the rest of healthcare. The “outsider” status of behavioral health providers is rooted in the historical fragmentation of the healthcare system that separates the mind from the rest of the body. This split has been perpetuated by health insurance carve-outs, weak enforcement of mental health parity, and low reimbursement rates. Behavioral health is further “othered” by virtue of the incredible stigma surrounding behavioral health conditions, major barriers to access, and the predominantly female-dominated profession.
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Traditionally, behavioral health providers, particularly those practicing outside of major health systems, have been left out of the technical and financial innovations that have shaped most other parts of the modern American healthcare system. Most significantly, behavioral health providers including social workers, community mental health centers, and providers not affiliated with major health systems were excluded from the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, and thus lack the resources and support to implement electronic health records (EHRs). It’s still a common practice for independent and small practices to use paper records, or other EHR systems that are incompatible with Health Information Exchanges (HIE) and can’t “talk” to other providers across health systems or payers. Furthermore, EHR adoption and HIE integration still lags for acute psychiatric and substance use treatment facilities.
It took a global pandemic for most Americans to experience and understand the societal and financial cost of behavioral health conditions. Often the costs associated with mental health or substance use disorders have been hidden underneath the cost of co-occurring physical health conditions like diabetes or COPD. Commercial insurers have been focused on developing value-based care payment models and Accountable Care Organizations centered on primary care, while other specialty conditions, and behavioral health in particular, have remained on the sidelines of alternative payment model development. This is both because behavioral health care (and thus cost) is more challenging to “attribute” to a provider, and that the costs and outcomes in behavioral health are more difficult to untangle from the rest of healthcare. Who is ultimately accountable for patients with multiple intersecting health conditions? Who gets “credit” and to share in the savings when a patient improves? And how do we measure improvement in behavioral health anyway? All good questions without straightforward answers, which partially explains the lag in behavioral health value-based care.
When commercial insurers, or even Medicaid managed care organizations, do attempt to develop value-based care models for behavioral health, they encounter several significant challenges. It’s hard to agree on what or how to measure “outcomes” in behavioral health where the field lacks the clear clinical measurement of “improvement” readily available in an A1c or blood pressure. But even if a payer can develop a framework for assigning patients to behavioral health providers, teasing out the associated cost, and defining meaningful and measurable outcomes — they still have to get behavioral health providers to the table and ready to participate and succeed in value-based care.
Health plans have traditionally had weak, or even adversarial relationships with behavioral health providers because of decades of fragmentation, non-parity, and carve-outs to other managed care organizations. Many behavioral health providers, psychiatrists in particular, still practice in a cash-only system outside of insurance because of low reimbursement rates and administrative burden. For those in-network, behavioral health providers often view insurers as the “enemy” whom they have to negotiate with for increased rates or wrestle with to receive authorization for services. Payers have often held behavioral health providers and their professional organizations at an arm’s length, seeing them as auxiliary specialists at best, and exploitative or fraudulent at worst. The result of these misunderstandings is mutual mistrust and a chasm between providers and payers that takes investment – both time and financial – to close.
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So, if payers are ready to turn their attention to value-based care in behavioral health, and invite behavioral health providers into the room – are providers ready to enter and fully participate in VBC? What do they need to be successful and how do they get there?
First, it starts with rebuilding the relationships and the trust between payer and provider. On a very practical level, payers can rebuild trust by offering the proverbial olive branch – increasing reimbursement rates and delivering on the promise of mental health parity (especially with telehealth in a post-pandemic world). Deepening relationships starts with transparent communication between payers and providers. When I was at Blue Cross NC, we began this process through the development of a Behavioral Health Provider Advisory Board, including providers from different demographics, clinical specialties, and geographies. We also actively reached out to key providers and professional organizations to meet with them, understand their concerns, and bring them into our strategic development planning.
Second, providers need education to understand what value-based care means for behavioral health. Behavioral health providers want to be part of this conversation on the move to value, but many lack the exposure or understanding of what payers actually mean when they say “value-based care.” They flashback to poor past experiences with chart audits and administrative oversight. Providers need to hear “what’s in it for me” and also validation that they are doing strong clinical work and making strides towards improved outcomes, and this is an opportunity to demonstrate that success. Additionally, the payment models need to be simple, and the measures and payment meaningful to get providers to buy-in to any program that requires additional effort, let alone some form of financial risk. The financial incentives tied to performance have to be significant enough to motivate behavior, but small enough to be realized in the short-term. At the end of the day, behavioral health providers want to do whatever is in their power to help their patients improve, and not get bogged down in extra work that doesn’t add value.
Finally, providers need support, time, and investment in the tools and technology necessary to achieve these outcomes. As I noted earlier, behavioral health providers lag behind other healthcare providers in their adoption of and sophistication with electronic health records. Similarly, measurement-based care and the use of tools like patient-reported outcome measures (like the PHQ-9, GAD-7, or PTSD Checklist) are slowly growing in practice, but still not widely or regularly used. Behavioral health providers can also leverage more advanced analytics to understand their patient population, identify care gaps, and flag behaviors they can take to prevent or follow-up at care escalation points. A performance reporting dashboard can help providers get feedback on their own performance and make adjustments to their treatment plans or care delivery to improve outcomes. All of these tools and technologies can go a long way towards helping behavioral health providers realize success in value-based care — but these take financial resources and time to implement, and longer to create sustainable change.
There’s reason to have hope that behavioral health providers are ready – and will be supported – to cross the threshold into value-based care payment models. Early results on the impact of CCBHCs (Certified Community Behavioral Health Clinic) has been promising, including increased access to care and reductions in emergency department and hospital utilization among other outcomes. Both types of prospective payment systems available to CCBHCs are exactly the type of value-based care model that will help behavioral health providers ease into more advanced payment models, and balance financial flexibility with clinical quality. While CCBHCs required significant federal funding to get off the ground, and continued technical assistance to support the program’s reporting requirements, there’s a growing opportunity for more providers to become CCBHCs. President Biden’s recent State of the Union Address and commitment to funding mental health care is the greatest endorsement of federal support for behavioral health since President Kennedy first established community mental health centers in 1963. Additional federal investment, as well as support from commercial payers and managed Medicaid organizations, will help behavioral health providers transition to EHRs and HIEs and be ready for the type of data-driven care delivery that will help them excel in value-based care arrangements. States can also continue to strengthen requirements for behavioral health value-based care in Medicaid procurements. If commercial payers follow suit, there are efficiencies to be gained when behavioral health providers are providing behavioral health care across their entire panel.
The opportunities for these providers to enter value-based care is in front of us now and their impact on healthcare costs, outcomes, and equity present a tremendous opportunity. Payers should provide the support and investment required, and providers should willingly step into value-based care, or risk having the door closed on them.
Photo: Nuthawut Somsuk, Getty Images
Susan Foosness has worked in the field of behavioral health and social services for twenty years including as a child and family psychotherapist in North Carolina; and later as a Senior Consultant at Public Consulting Group; Senior Business Operations Advisor at Blue Cross NC; and now as Associate Vice President of Value Based Care at Quartet Health. Throughout her career Susan has remained focused on ensuring individuals have access to high-quality behavioral healthcare through direct services, policy advisory, program development, and value based care strategy. Susan holds a Bachelor of Arts in Psychology from Lewis & Clark College, a Master in Social Work from the University of Washington, and a Master in Public Policy from Duke University.
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