Blue Cross Blue Shield of Minnesota’s Focus on Virtual Specialty Behavioral Care
Brett Hart, Ph.D., a clinical psychologist and vice president of behavioral health and mental health parity at Blue Cross Blue Shield of Minnesota, recently spoke with Healthcare Innovation about securing URAC’s Mental Health/Substance Use Disorder (MH/SUD) Parity Accreditation and the payer’s strategy of collaborating with several virtual specialty behavioral health providers.
Healthcare Innovation: I saw you quoted as saying you believe we're never going to get our arms around affordability if we don't get our arms around behavioral health. Can you explain the strong connection there?
Hart: It's a great question and one that actually comes up quite a bit as I talk with people in the community. Studies have shown that approximately 20% to 40% of individuals who have a medical condition have a co-existing behavioral health condition, and about 70% of individuals with a behavioral health condition have a co-existing medical condition. What's true of all of those individuals is that their total cost of care is about three to six times higher than individuals who don't have a behavioral health condition.
Ultimately, what that translates to is that around 57% of total healthcare costs tie back to the presence of the behavioral health condition. So that's why I say if we're going to be serious about getting our arms around affordability, we have to be serious about addressing behavioral health.
HCI: And for a lot of those people, is the behavioral health condition often untreated?
Hart: For a certain percentage of those people, oftentimes it is untreated, or it's treated as less critical, less important. Depending on the situation, there are times when it may not be detected. For example, somebody with diabetes might have depression but might not even be assessed for that depression element. Other times it's known and being treated, which is obviously the ideal situation, but I think it's a mixed bag there. The question is are people being trained to look for it? Are they using proper screening tools?
HCI: We’ve interviewed some health systems that have been working hard to integrate behavioral health and primary care more more tightly. Are you seeing some of that in in Minnesota?
Hart: Yes. We are seeing several health systems in Minnesota that have made that move to bring behavioral health into the practice setting, to have an actual physical presence there, and that's so important, because oftentimes one of the barriers to getting effective behavioral healthcare is the lack of efficient handoffs for primary care physicians. Primary care physicians are obviously very busy. They see a lot of patients in the course of a given day. They need to be able to refer somebody efficiently and confidently when there's the presence of a behavioral health condition. So having somebody physically present, available, ready to accept that patient when they're referred, is an excellent way to facilitate effective behavioral healthcare.
HCI: Are you seeing much in the way of the behavioral health providers being included in value-based care contracting?
Hart: It’s interesting you bring that up, because many times when the topic of value-based care comes up, the response is, well, that's been around for ages and it’s not a new thing. That's certainly true in the physical health arena. I think in the behavioral health arena, though, it's a much newer concept. At Blue Cross Blue Shield of Minnesota, for example, we are placing significant emphasis on moving our behavioral health providers into value-based arrangements, and we've actually added quite a number just over the last year to those arrangements.
HCI: Is it trickier to figure out which outcomes to track in terms of quality measures in behavioral health than in primary care or other specialties?
Hart: It certainly can be more challenging, and that's where, at least in our case at Blue Cross, we're relying heavily on our relationships with providers to help inform what those outcome measures look like.
HCI: I read that your organization was among the first to successfully complete URAC’s Mental Health/Substance Use Disorder Parity Accreditation. Could you talk about why that is important?
Hart: We were actually one of the first two health plans in the country to secure URAC’s parity accreditation. There are a number of regulatory entities that oversee parity compliance. It happens at the state level, often among several different state entities. It happens at the federal level, also from several different entities. We also know that there are a number of interpretations of parity. We know one payer may interpret it differently than another payer, and some regulators may interpret it differently than other regulators. To cap it all off, we know that the implementation of the final rule is somewhat uncertain at this stage. So because we care deeply about being compliant with parity, we believed one of the best things we could do is seek out an external entity who can objectively review our parity compliance as an organization and give us feedback and an assessment of our standing. I'm pleased to say we not only passed the audit, but did so without any findings, and scored 100% on our desktop audit. So we felt very good about that. It it gives us an extra level of confidence that we're adhering to the strictest standards available, both along regulatory standards and objectively developed standards in terms of what's required.
HCI: So for other health plans that struggle with parity regulations, is one issue this idea of “ghost networks” — providers might be listed in directories but aren't actually taking new patients, so that the members have trouble finding a provider?
Hart: That can be a barrier. When we think about parity, what we're wanting to ensure is that we're eliminating any barriers that may exist to having access to effective behavioral healthcare. Certainly, this concept of a ghost network can be a barrier and could potentially fall into the parity domain, and certainly within compliance evaluation, one of the things that we do evaluate is our network adequacy and our network effectiveness. So that's an element, but not the only element.
HCI: Can you describe other issues that payers might struggle with?
Hart: When you look at parity, it breaks down into what we refer to as quantitative treatment limitations and non-quantitative treatment. Within the realm of quantitative, that's where you're talking about things like ensuring you have the same number of sessions available in medical and behavioral, and you have the same co-pays. Within the non-quantitative realm, it can be things like: is your network comparable? Is the process you use for prior authorization for medical comparable to behavioral health?
HCI: We hear this all the time from providers and payers in other states, so I assume that you're going to say yes, but is there a mismatch between the supply of behavioral health providers and the demand from members in Minnesota?
Hart: Yes, absolutely. There's no question that there is an increasing demand for behavioral health services, and the supply is not keeping pace with that demand, which has forced us to begin to implement innovative solutions for behavioral health, such as virtual solutions and other types of capabilities that historically were not as prevalent in behavioral health.
HCI: I read that you recently added two virtual care providers to your network: Charlie Health and Little Otter. Are they targeted at specific segments of your membership?
Hart: They are and actually we've added some others beyond that, including Pelago Health and Equip Health. In general, the reason we're adding these is because we see challenges around rural access, cost pressures, and wait times, but another variable is that there's a high percentage of individuals, especially under age 30, who actually prefer to obtain behavioral healthcare virtually versus in person. So when you put all of those realities together, it really calls for the implementation of solutions that will help meet those gaps and those needs.
For example, Charlie Health is a behavioral health solution for adolescents, and it especially fills that gap in intermediate levels of care, meaning between outpatient and inpatient. Little Otter is a solution for children, and it's especially designed to respond to the long wait times that can often exist for children to receive care. Sometimes children could wait three to six months to access behavioral healthcare. And we know that nationally, only about one in five children who has a behavioral healthcare need is actually able to see a behavioral healthcare professional. Little Otter is a solution that allows children who have urgent needs to be seen within 48 hours, which I think is paradigm-changing. Beyond that, we have Equip, which is a virtual solution for eating disorder treatment, which is a great alternative for people who may not be able to travel long distances to receive residential treatment. Pelago is a virtual model to treat substance use disorders. We're very excited about all these and the gaps they fill.
HCI: How do you assess the efficacy of these virtual providers you partner with? Do you have metrics you look at or member surveys?
Hart: We do that on multiple levels. The first level is that we assess them thoroughly before ever bringing them into our network as a solution. We thoroughly vet them. We look at existing research around their model and outcome data that they have available that we can review. But once we make a decision that a solution is appropriate for us, we then put in place a number of metrics to monitor performance over time. We're looking at things like clinical outcomes, speed to care, and member satisfaction. We track those on an ongoing basis, and we meet on a regular cadence with those solutions to review that data, and should anything be trending in the wrong direction, we develop a plan together for how to correct that.
HCI: Are there other other ways you're using technology or your data to help get people get the care that they need?
Hart: Yes. I think at its core this is really a navigation issue. We have to make sure that we're getting individuals to the right care at the right time, and that starts with looking at data. Specifically, we look at individuals from a demographic perspective. As an example, does this individual live in an underserved area? Do they live in a rural setting or are they at an age that places them at risk for certain conditions versus others?
We're also looking at specific clinical data. For example, individuals with certain conditions are also at higher risk of associated behavioral health conditions. Once we have all that data brought together, we can proactively push solutions to individuals and let them know that this may be something that would be of value to you at a certain point, and then we help navigate them to that.
HCI: Is there anything else you want to mention about the work you’re doing?
Hart: We are putting a lot of focus right now on early detection and prevention, especially around children. We have a couple of solutions we're going to be bringing forward this year around early detection of childhood conditions. We also just launched a campaign for screening for youth between the ages of one and three to help detect developmental diagnoses and navigate those individuals to care. So we're going to be bringing a lot to market this year and beyond on prevention and screening, as I think that's really an area of great promise when it comes to behavioral health.
