Even before the pandemic put an increased burden on behavioral health providers, forward-thinking organizations were developing value-based arrangements in behavioral health to give provider networks the tools they need to address whole-patient care. A March 15 panel discussion hosted by the World Congress looked at how payers and providers are aligning incentives in this space and some of the barriers to change.
One of the speakers was Eric Bailly, business solutions director, substance use disorder strategy, for Anthem Inc., which recently completed an acquisition of Beacon Health Options, the largest independently held behavioral health organization in the country, serving more than 36 million people across all 50 states. The acquisition offers Anthem the opportunity to combine its current behavioral health capabilities with Beacon’s model and support services in order to enhance whole-person care.
Bailly, who is also a licensed professional counselor and a licensed alcohol and drug counselor, said that Anthem, as it integrates its services with Beacon, is looking for opportunities to transition to value-based reimbursement. “What really drives that is attempting to improve a couple of different things: primarily, quality of treatment services that are delivered, and then the patient experience, and then of course, cost efficiencies as well,” he said.
He added that the shift to value-based arrangements has not been without its challenges. “The industry has been very ingrained in a fee-for-service reimbursement approach, and it can get very frustrating to break down some of those barriers, and some of those really old habits of maximization of reimbursement,” he said. “We are looking at how to work with our providers to incent quality services that recognize the importance of continuity of care, while offering the provider flexibility in service delivery, and recognizing that it takes partnership with the payers and thinking about things holistically.”
Anthem has been working with an organization called the Alliance for Addiction Payment Reform for several years, Bailly said, to create a framework to be able to leverage services such as peer recovery support and care coordination. This offers the ability to shift to different levels of care by recognizing that at least in the context of substance use disorders and other mental health issues, “this is a marathon, not a sprint, so it takes a long time for there to be some success in establishing recovery and sustain that over the long term,” he added. “So how do you recognize that from a payment perspective?”
The session was moderated by Lili Brillstein, M.P.H., CEO of BCollaborative, a consulting firm that works with stakeholders to make the move from fee for service to value-based healthcare. She was formerly the director of specialty care value-based models for Horizon Blue Cross Blue Shield of New Jersey.
“In the fee-for-service environment, we're really talking about units of care and units of cost,” she said. “We're not talking about the comprehensive whole picture, and looking at how food impacts a patient's outcome, for instance. We have this tremendous opportunity to rethink what has an impact on outcomes, and it's not just about how do we get the payer to pay more. It's how do we come together to figure out what are the most important aspects that will affect a patient's outcome? And how do we reconfigure the payment structure so that it's based on the patient's outcomes?”
Amanda Brooks is a licensed clinical social worker and certified alcohol and drug counselor serving as senior integrated care consultant for a company called NeuroFlow, which offers a behavioral health and care management technology solution. She previously served as chief population health officer at PCC Community Wellness Center, a federally qualified health center provider in Chicago.
“When we're thinking about mental health within the FQHC, this goes beyond the idea that we just screen our patients annually for depression or anxiety,” she said. “We want to build the care in such a way that the necessary expertise exists within the interdisciplinary team so that we can address the continuum of health and psychosocial needs of the patients that we're serving. Within this model, there's a tremendous opportunity for innovation, particularly when we're addressing physical and behavioral health comorbidities.”
For instance, Brooks added, when thinking about populations with opioid use disorder, what are the necessary and integral members of the team to ensure that patients feel safe and supported to engage in care? This includes behavioral health providers, but also peer recovery specialists and care managers who help coordinate everything. It also calls for a focus on social determinants of health. “There are tremendous comorbidities between depression and diabetes,” she said. “If we can't ensure that our patients have access to healthy foods within grocery or food deserts, we aren't providing our patients with the necessary tools that they need to improve their health.”
Concerning measurement, Brooks noted that measuring behavioral health outcomes is challenging. “There are so many complicating factors in terms of what contributes to mental health disorders and managing those events,” she said, but in terms of process measures, the first step is universally screening, but also making sure that the patients who are screening positive have some sort of intervention, she said. “We want to make sure that not we're not just finding it, but we're doing something about it. We know 20 percent of the population may at any time have a mental health diagnosis. I want that population to have at least one interaction with a behavioral health provider every year. So part of my measures were what percentage of my population being served in the FQHC is actually being touched by a behavioral health provider?”
Bailly noted that in terms of engaging with behavioral providers on value-based care programs, you have to set some realistic expectations with respect to the size of an organization and some of the shared desires for outcomes. That drives the conversation about what specific metrics to start looking at. “One of the things that we have worked on is, how can we improve SBIRT [Screening, Brief Intervention and Referral to Treatment] screening in primary care environments? The first step is to make sure that their primary care environments are invested in doing that in the first place. What we found is that primary care offices are oftentimes happy to do that, but they need some help making sure that the service delivery system can respond in a way that's quick enough to help people get their needs met.”
“If we improve SBIRT screenings by 10 percent over the course of a calendar year, how will that impact payment for the following year? Does it mean an increase in an established case rate? Do we look at shifting from a bundled case rate to something that has both upside and downside risk? There are a lot of different flavors that this can take depending, on the size of an organization and how willing they are to take some of that risk,” Bailly explained. “But definitely it can get pretty complicated. The place to start is to roll up your sleeves and take a look at the current state and how we can improve things.”
“I never advocate for shifting to risk as quickly as possible,” Brillstein noted. “I advocate for being in a simulator for a period of time where there's plenty of opportunity to learn together. Providers still get paid fee for service, and they have an opportunity to earn additional money if they meet the metrics that you collectively agreed to, and earn more money. It gives you an opportunity to create a collaborative model.”
Bailly noted that scaling up across the country is complicated by the fact that there are different drivers and cultures in each market. For instance, there are hybrid telehealth and brick-and-mortar organizations that have a desire to be in as many Anthem markets as they can. “But each market we go into, we have different conversations with the provider contracting folks in terms of how the contract is going to look,” he said. “What is their level of trust? Is there a level of creativity that we can exhibit in actually entertaining some of the value-based reimbursement models, including bundled case rate structures that have been successful in other markets? So when we approach another market saying this worked in Georgia, so let's see if we can make this work in Indiana, we have to recognize that there'll be some nuances.”
Brooks said that digital tools like the ones offered by her company, Neuroflow, can help with provider shortages and a population health approach by using technology to screen patients and make sure that the right level of care is being provided. “We all know who our high-risk patients are — those are the ones who are utilizing care,” she said. “What we don't always know are those emerging risk patients. And so these digital health solutions like Neuroflow can give you the opportunity to keep an eye on your entire population,” she said. “Because with COVID we're seeing more episodes of crisis, and we're seeing more patients identify with depression and anxiety. We didn't have enough providers before; we definitely don't have enough providers now; and we're not going to have enough providers in the next two to five years. So we've got to integrate physical and behavioral health with digital solutions to ensure that everybody has access and that we can appropriately move patients within the levels of care based on the needs that they're presenting.”
Bailly agreed that value-based reimbursement can offer the flexibility to allow for use of digital tools, telehealth and care coordinators and peer recovery specialists — things that traditionally aren't paid for by fee for service. “As a payer, we recognize that what is in it for us is that when you have a substance use disorder or mental health issue that's being treated adequately, you're going to see that in terms of total cost of care. And we see that in our statistics. We see how expensive it is over the long term to not recognize and treat these conditions.”