There’s numerous buzz in healthcare in regards to the promise of value-based care (VBC) and the way it can reign in skyrocketing prices, whereas delivering improved affected person outcomes. And certainly, the transfer to VBC has yielded optimistic leads to main care and there are rising various fee fashions in specialty care for different continual situations. So it’s solely pure that VBC has come to knock on the entrance door of behavioral well being. The query is: Are behavioral well being suppliers able to open it? And what awaits them on the opposite facet?
Partially it’s taken VBC a very long time to make its technique to behavioral well being as a result of – for higher or worse – it’s totally different from the remainder of healthcare. The “outsider” standing of behavioral well being suppliers is rooted within the historic fragmentation of the healthcare system that separates the thoughts from the remainder of the physique. This cut up has been perpetuated by medical insurance carve-outs, weak enforcement of psychological well being parity, and low reimbursement charges. Behavioral well being is additional “othered” by advantage of the unbelievable stigma surrounding behavioral well being situations, main limitations to entry, and the predominantly female-dominated occupation.
Historically, behavioral well being suppliers, notably these practising outdoors of main well being methods, have been unnoticed of the technical and monetary improvements which have formed most different components of the fashionable American healthcare system. Most importantly, behavioral well being suppliers together with social staff, neighborhood psychological well being facilities, and suppliers not affiliated with main well being methods had been excluded from the Well being Data Know-how for Financial and Medical Well being (HITECH) Act, enacted as a part of the American Restoration and Reinvestment Act of 2009, and thus lack the sources and assist to implement digital well being data (EHRs). It’s nonetheless a standard observe for unbiased and small practices to make use of paper data, or different EHR methods which might be incompatible with Well being Data Exchanges (HIE) and may’t “discuss” to different suppliers throughout well being methods or payers. Moreover, EHR adoption and HIE integration nonetheless lags for acute psychiatric and substance use therapy amenities.
It took a world pandemic for many Individuals to expertise and perceive the societal and monetary price of behavioral well being situations. Usually the prices related to psychological well being or substance use issues have been hidden beneath the price of co-occurring bodily well being situations like diabetes or COPD. Industrial insurers have been targeted on growing value-based care fee fashions and Accountable Care Organizations centered on main care, whereas different specialty situations, and behavioral well being particularly, have remained on the sidelines of different fee mannequin growth. That is each as a result of behavioral well being care (and thus price) is more difficult to “attribute” to a supplier, and that the prices and outcomes in behavioral well being are tougher to untangle from the remainder of healthcare. Who’s finally accountable for sufferers with a number of intersecting well being situations? Who will get “credit score” and to share within the financial savings when a affected person improves? And the way can we measure enchancment in behavioral well being anyway? All good questions with out simple solutions, which partially explains the lag in behavioral well being value-based care.
When business insurers, and even Medicaid managed care organizations, do try to develop value-based care fashions for behavioral well being, they encounter a number of important challenges. It’s onerous to agree on what or the right way to measure “outcomes” in behavioral well being the place the sector lacks the clear scientific measurement of “enchancment” available in an A1c or blood strain. However even when a payer can develop a framework for assigning sufferers to behavioral well being suppliers, teasing out the related price, and defining significant and measurable outcomes — they nonetheless should get behavioral well being suppliers to the desk and able to take part and reach value-based care.
Well being plans have historically had weak, and even adversarial relationships with behavioral well being suppliers due to many years of fragmentation, non-parity, and carve-outs to different managed care organizations. Many behavioral well being suppliers, psychiatrists particularly, nonetheless observe in a cash-only system outdoors of insurance coverage due to low reimbursement charges and administrative burden. For these in-network, behavioral well being suppliers usually view insurers because the “enemy” whom they’ve to barter with for elevated charges or wrestle with to obtain authorization for providers. Payers have usually held behavioral well being suppliers and their skilled organizations at an arm’s size, seeing them as auxiliary specialists at finest, and exploitative or fraudulent at worst. The results of these misunderstandings is mutual distrust and a chasm between suppliers and payers that takes funding – each time and monetary – to shut.
So, if payers are prepared to show their consideration to value-based care in behavioral well being, and invite behavioral well being suppliers into the room – are suppliers able to enter and totally take part in VBC? What do they should be profitable and the way do they get there?
First, it begins with rebuilding the relationships and the belief between payer and supplier. On a really sensible stage, payers can rebuild belief by providing the proverbial olive department – rising reimbursement charges and delivering on the promise of psychological well being parity (particularly with telehealth in a post-pandemic world). Deepening relationships begins with clear communication between payers and suppliers. Once I was at Blue Cross NC, we started this course of by way of the event of a Behavioral Well being Supplier Advisory Board, together with suppliers from totally different demographics, scientific specialties, and geographies. We additionally actively reached out to key suppliers {and professional} organizations to satisfy with them, perceive their issues, and produce them into our strategic growth planning.
Second, suppliers want schooling to grasp what value-based care means for behavioral well being. Behavioral well being suppliers need to be a part of this dialog on the transfer to worth, however many lack the publicity or understanding of what payers truly imply after they say “value-based care.” They flashback to poor previous experiences with chart audits and administrative oversight. Suppliers want to listen to “what’s in it for me” and in addition validation that they are doing sturdy scientific work and making strides in direction of improved outcomes, and this is a chance to reveal that success. Moreover, the fee fashions should be easy, and the measures and fee significant to get suppliers to buy-in to any program that requires further effort, not to mention some type of monetary threat. The monetary incentives tied to efficiency should be important sufficient to encourage habits, however sufficiently small to be realized within the short-term. On the finish of the day, behavioral well being suppliers need to do no matter is of their energy to assist their sufferers enhance, and never get slowed down in further work that doesn’t add worth.
Lastly, suppliers want assist, time, and funding within the instruments and know-how obligatory to realize these outcomes. As I famous earlier, behavioral well being suppliers lag behind different healthcare suppliers of their adoption of and class with digital well being data. Equally, measurement-based care and the usage of instruments like patient-reported end result measures (just like the PHQ-9, GAD-7, or PTSD Guidelines) are slowly rising in observe, however nonetheless not extensively or recurrently used. Behavioral well being suppliers may also leverage extra superior analytics to grasp their affected person inhabitants, determine care gaps, and flag behaviors they will take to forestall or follow-up at care escalation factors. A efficiency reporting dashboard will help suppliers get suggestions on their very own efficiency and make changes to their therapy plans or care supply to enhance outcomes. All of those instruments and applied sciences can go a great distance in direction of serving to behavioral well being suppliers understand success in value-based care — however these take monetary sources and time to implement, and longer to create sustainable change.
There’s cause to have hope that behavioral well being suppliers are prepared – and might be supported – to cross the edge into value-based care fee fashions. Early outcomes on the impression of CCBHCs (Licensed Neighborhood Behavioral Well being Clinic) has been promising, together with elevated entry to care and reductions in emergency division and hospital utilization amongst different outcomes. Each sorts of potential fee methods obtainable to CCBHCs are precisely the kind of value-based care mannequin that may assist behavioral well being suppliers ease into extra superior fee fashions, and stability monetary flexibility with scientific high quality. Whereas CCBHCs required important federal funding to get off the bottom, and continued technical help to assist this system’s reporting necessities, there’s a rising alternative for extra suppliers to turn into CCBHCs. President Biden’s latest State of the Union Tackle and dedication to funding psychological well being care is the best endorsement of federal assist for behavioral well being since President Kennedy first established neighborhood psychological well being facilities in 1963. Extra federal funding, in addition to assist from business payers and managed Medicaid organizations, will assist behavioral well being suppliers transition to EHRs and HIEs and be prepared for the kind of data-driven care supply that may assist them excel in value-based care preparations. States may also proceed to strengthen necessities for behavioral well being value-based care in Medicaid procurements. If business payers comply with swimsuit, there are efficiencies to be gained when behavioral well being suppliers are offering behavioral well being care throughout their whole panel.
The alternatives for these suppliers to enter value-based care is in entrance of us now and their impression on healthcare prices, outcomes, and fairness current an incredible alternative. Payers ought to present the assist and funding required, and suppliers ought to willingly step into value-based care, or threat having the door closed on them.
Picture: Nuthawut Somsuk, Getty Pictures
