Traditionally, healthcare in the US has been based on a fee-for-service reimbursement model in which providers are paid for each service provided to patients. The problem with this model is that payment is tied to volume, not results—in fact, providers are incentivized to perform additional tests and procedures, emphasizing treatment over prevention and wellness.
To address this incentive mismatch, healthcare is moving toward a value-based care (VBC) model, where pay is tied to outcomes and providers are financially rewarded for keeping patients healthy. As described in Health IT Playbook of the Office of the National Coordinator for Health Information Technology (ONC), value-based programs support better care for individuals and better health for the population at a lower cost. ONC continues to report that VBC programs reduce the “perverse incentive” to increase the volume of care, thereby making it possible to reward clinicians who:
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Emphasize prevention and health
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Focus on results
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Help patients navigate the healthcare system
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Integrate and coordinate care
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I invest in practice transformationsuch as health information technology
VBC programs are quickly becoming the standard for physical health care, while behavioral health—including mental health and substance use disorder (SUD) treatment—is lagging behind the rest of health care.
So what is delaying adoption? In Western medicine, physical health has traditionally been viewed separately from behavioral health, and the entire system of care has reflected this until recently. Well-defined, traditional procedures such as surgery, treatment of various physical ailments, and emergency care have study volumes, diagnosis codes, and documented outcomes appropriate for VBC models. In addition, powerful legislative, regulatory, and financial incentives have led to the widespread adoption of VBC in traditional care.
Conversely, most behavioral health conditions and treatments lack the array of research, data tracking, outcomes, and incentives necessary to move toward VBC models. However, post-Covid-19, relaxed prescribing regulations and the rapid adoption of digital health are putting pressure on behavioral health providers and payers to join the VBC movement. As these pressures grow, so do the challenges facing payers moving to VBC models, including:
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How to measure behavioral health outcomes. Patients with a physical illness or injury are prescribed a procedure or treatment and the health event is usually resolved. Behavioral health, on the other hand, can involve problems with developing treatments spanning long periods of time with very little outcome data. Payers and program providers must collaborate and agree on what success looks like. A good starting point is the creation of a quality framework focused on behavioral health access, health outcomes, and costs. One example of this is the value-based care agreement between Blue Cross North Carolina and Quartet Health. The two organizations partner program to measure quality of care, create incentives for providers to improve patient access to in-network care, and improve patient health outcomes. Another is the move to 100 percent risk fee pricing models. Under this value-based approach, a company gets paid only if it meets strict clinical goals, engagement goals, satisfaction goals, and operational goals for its programs.
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Data collection. Delivering high-quality care starts with tracking and using outcomes data. Measurement-based care (MBC)—the systematic assessment of a patient’s symptoms to inform behavioral health treatment—is grossly underutilized in behavioral health, with less from 20% to behavioral health practitioners who integrate it into their practice. Collecting and using measurable data from evidence-based assessments and intake processes is critical to improving the documentation of patient and population outcomes.
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Access to high-quality care. As a result of Covid-19 and the easing of telehealth and e-prescribing regulations, digital behavioral health solutions have grown exponentially, greatly expanding access to care. Improved quality through greater emphasis on evidence-based care and return on investment is gradually helping to ensure the quality of that care. Better access to quality care enables solution providers and clinicians to track outcomes that show payers improvement in behavioral health conditions.
From our company’s own experience in providing access to quality SUD care, as well as industry data, we understand the potential financial and wellness impact of integrated, VBC approaches to behavioral health care. This is largely due to mental health and SUD costs that are hidden in medical claims for heart and liver disease, diabetes, cancer, chronic kidney disease and other conditions. A recent analysis of claims performed by our company for a large retail business, for example, revealed that individuals diagnosed with an alcohol use disorder or an opioid use disorder cost an average of 335% more than those without diagnoses.
Other recent studies supporting the cost-saving potential of VBC include:
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Ann claims data analysis conducted by Cigna Corporation’s Evernorth on more than 275,000 patients newly diagnosed with a behavioral health condition (such as anxiety, depression, or SUD) found that treatment in an outpatient setting, such as a psychologist’s office or virtual visits, resulted in fewer visits in the emergency department and hospital admissions. This reduces costs by up to $1,377 per person over one year and up to $3,109 per person over two years. [Editor’s Note: Evernorth is a customer of the author’s employer.]
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2015-2019 CMS An initiative to transform clinical practice involving a network of 275 behavioral health practices serving 258,000 outpatient mental health and substance use patients in New York State generated more than $204 million in cost savings. These savings are largely due to a reduction in the use of all-cause hospitals.
Employers, payers, and the federal government are pushing for the adoption of value-based care approaches for behavioral health, and the faster behavioral health moves to 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 pushing back with demands for more accountability and robust outcomes data. At the federal level, the Centers for Medicare and Medicaid Services (CMS) is promoting its new Behavioral Health Strategy and its finalization 2023 Physician Fee Schedule (PFS) affecting Medicare payments and behavioral health.
CMS’s behavioral health strategy encompasses multiple elements, including access to SUD prevention and treatment services, mental health services, crisis intervention, and pain care. The strategy also enables care that is well coordinated and effectively integrated. Among the stated goals are:
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Strengthen equity and quality of behavioral health care, in part through improved access to high-quality, affordable, person-centered behavioral health care, including through telehealth and by addressing treatment disparities.
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Improving access to and quality of mental health care and services, including by expanding the capacity and capabilities of the workforce related to the detection, diagnosis and management of mental disorders.
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Improving access to SUD prevention, treatment, and recovery services, in part 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 further expand access to behavioral health services, remove barriers to care, and improve the quality of mental health and substance use care.
Despite the complexity involved, establishing value-based care as standard in behavioral health will help payers achieve the cost savings and predictability they demand while giving providers and patients more flexibility in treating chronic behavioral health conditions.
Photo: Hong Li, Getty Images