Why value-based care should be the standard for behavioral health

Traditionally, healthcare in the US has been based on a fee-for-service reimbursement model, where providers are paid for each service they provide to patients. The problem with this model is that payment is tied to volume, not outcome—in fact, providers are incentivized to perform additional tests and procedures, emphasizing treatment at the expense of prevention and wellness.

To address this misalignment in incentives, healthcare is moving toward a value-based care (VBC) model, where pay is linked to outcomes and providers are financially rewarded for keeping patients healthy. Is. As described in the Health IT Playbook of the Office of the National Coordinator for Health Information Technology (ONC), value-based programs support better care for individuals at lower costs and better health for populations. The ONC continued to report that VBC programs reduce “perverse incentives” to increase the volume of care, making it possible to reward physicians who:

  • Emphasize prevention and wellness

  • focus on results

  • Help patients navigate the healthcare system

  • Integrate and coordinate care

  • invest in practice change such as health information technology

VBC programs are increasingly becoming the standard for physical health care, while behavioral health—including mental health and substance use disorder (SUD) treatment—lags behind the rest of health care.

So what’s slowing adoption? In Western medicine, physical health has traditionally been separated from behavioral health, and holistic care systems have recently reflected this. Well-defined, traditional procedures such as surgery, treatments for various physical ailments, and research in acute care, diagnostic codes and documented outcomes are well suited to the VBC model. Furthermore, powerful legislative, regulatory, and financial incentives have led to widespread adoption of VBC in traditional care.

In contrast, most behavioral health conditions and treatments lack the research, data tracking, outcomes, and incentives needed to transition to the VBC model. However, in the wake of COVID-19, easing of prescribing regulations and rapid adoption of digital health, behavioral health providers and payers are under increasing pressure to join the VBC movement. As pressures mount, so do the challenges facing payers moving to the VBC model, including:

  • How to measure outcomes for behavioral health. Patients with a physical illness or injury are prescribed a procedure or treatment, and the health event usually resolves. Behavioral health, on the other hand, can involve issues with treatment spread over long periods of time with little outcome data. Donors and program providers need to collaborate and agree on what success looks like. A good starting point is creating a quality framework focused on behavioral health access, health outcomes and costs. An example of this is the cost-based care arrangement between Blue Cross North Carolina and Quartet Health. The two organizations partnered on a program to measure quality of care, incentivize providers for better patient access to in-network care, and improve patient health outcomes. Another step up is the 100-percent-fee-at-risk pricing model. Under this value-based approach, a company gets paid only when it meets strict clinical, engagement, satisfaction and operational performance goals for its programs.

  • data storage. Providing high-quality care starts with tracking and leveraging outcome data. Measurement-based care (MBC) – the systematic assessment of patient symptoms to inform behavioral health treatment – ​​is widely used in behavioral health, with fewer than 20% of behavioral health practitioners integrating it into their practice. Collecting and using measurable data from evidence-based assessments and intake processes is critical for improving the documentation of outcomes for patients and populations.

  • Access to high quality care. In the wake of COVID-19 and the relaxation of telehealth and e-prescribing regulations, digital solutions for behavioral health have grown rapidly, expanding access to care. Increased emphasis on evidence-based care and increased ROI are slowly helping to ensure the quality of that care. Improved access to quality care enables solution providers and physicians to track outcomes that demonstrate payers’ improvement in behavioral health conditions.

From our company’s own experience providing access to quality SUD care, as well as industry data, we understand the potential financial and wellness impact of an integrated, VBC approach to behavioral health care. This is due in large part to mental health and SUD costs hidden in medical claims for heart and liver disease, diabetes, cancer, chronic kidney disease and other conditions. In a recent claims analysis by our company for a large retail business, for example, costs for individuals with an alcohol use disorder or opioid use disorder cost an average of 335% more than those without a diagnosis.

Other recent studies supporting VBC cost savings potential include:

  • An analysis of claims data conducted by Cigna Corporation’s Evernorth for more than 275,000 patients recently diagnosed with a behavioral health condition (such as anxiety, depression, or SUD) found that a psychologist’s office or virtual Treatment takes place in an outpatient setting such as visits. Fewer emergency department visits and inpatient hospitalizations. This reduces costs by $1,377 per person in one year and $3,109 per person in two years. [Editor’s Note: Evernorth is a customer of the author’s employer.]

  • 2015-2019 A CMS Transforming Clinical Practice Initiative Involving a Network of 275 Behavioral Health Practices Serving 258,000 Medicaid Patients in Outpatient Mental Health and $204 in Cost Savings in Substance Abuse Treatment Settings in New York State More than a million have been generated. These savings were largely due to a reduction in hospital utilization for all causes.

Employers, payers, and the federal government are all pushing for a value-based care approach to behavioral health, and the faster behavioral health moves toward value-based care, the more beneficial it will be to stakeholders. Employers facing a recessionary, high-cost health care environment are increasingly demanding ROI data and performance guarantees, and payers are leading the way with demands for greater accountability and concrete outcome data. At the federal level, the Centers for Medicare and Medicaid Services (CMS) is promoting its new behavioral health strategy and finalizing its 2023 Physician Fee Schedule (PFS), which affects Medicare payments and behavioral health.

The CMS Behavioral Health Strategy includes several elements including access to prevention and treatment services for SUD, mental health services, crisis intervention and pain care. The strategy also enables well-coordinated and effectively integrated care. Among its stated goals are:

  • Strengthen equity and quality in behavioral health care through improved access to high-quality, affordable, person-centered behavioral health care, including through telehealth and by addressing disparities in treatment.

  • Improving access to and quality of mental health care and services, including expanding workforce capacity and capability related to the identification, diagnosis and management of mental disorders.

  • Improve access to SUD prevention, treatment and recovery services, by identifying and addressing barriers to evidence-based treatment and recovery services to better detect, diagnose and manage such conditions.

Compared to other areas of health care, behavioral health has been slow to adopt VBC models – even though they will expand access to behavioral health services, remove barriers to care, and improve the quality of mental health and substance use care. Will improve.

Despite the complexities involved, establishing value-based care as the standard in behavioral health will help payers achieve cost savings and predictability, while providing providers and patients with greater flexibility in treating chronic behavioral health conditions .

Photo: Hong Li, Getty Images


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