The do’s and don’ts of value-based behavioral medicine contract design

Value-based care has been part of the healthcare discourse for decades, but only recently have mental health providers placed a new emphasis on moving away from the fee-for-service paradigm.

Although this approach is still in its infancy industry-wide, several mental health organizations are trying to adopt models that include elements of risk sharing, trading in outcomes and processes, and accountability. The challenge now is to prepare for what could be a rapid transition if enough payers get serious about value-based care.

“I think we’re there now, and I think we’ve been there before,” said Dr. Tom Britton, CEO of eating disorder treatment company Accanto Health, at the Behavioral Health Business’ VALUE conference. “If you’re still holding onto the fee-for-service model, you’re going to be obsolete very soon if you don’t act quickly.”

Admittedly, Britton acknowledged that over the past decade, there have been repeated claims that every year is “the best year.” Dr. Benjamin Nordstrom, chief medical officer of outpatient addiction treatment provider Behavioral Health Group, added that value-based care is “too good an idea to give up.”

He referred to electric cars. Intuitively, the product makes sense, but until recently there were concerns because of the disadvantage of being a pioneer.

On the commercial side of addiction treatment, the Behavioral Health Group was able to get payers to ask them what assessment and outcome basis the contract should have. In this scenario, there are still a multitude of potential outcomes that need to be measured. This can complicate value-based care contracts. But it also allows each provider to create agreements that work for them and not be forced into something that doesn’t align with how they do business.

Take responsibility for what you can control

Britton points out that payers generally want to reduce health care utilization among members. He believes improved mental health will lead to lower overall health care spending. Payers know this. Evernorth, the health insurance company’s services division, released findings showing that outpatient mental health services alone reduce plan costs by about $1,400 per person in one year and about $3,100 per person in two years.

However, given the specific focus of mental health, it is not wise to take responsibility for things that are well outside the reach of a provider, nor would it be wise to attach responsibility to actions that do not truly reflect the impact of that organization’s work.

“The very first thing you have to do is set your goals and decide where on the scale you are comfortable with the risk,” Britton said. “If you understand your data, if you understand your population and if you understand your goal, I think you can set a good goal.”

Still, health is multifaceted, and care must address multiple and sometimes overlapping needs that may extend beyond mental health care. One strategy to accomplish this is to collaborate with other care providers, an approach taken by adolescent and young adult-focused collaborative care and mental health provider Bend Health.

To make the collaboration work in line with its bundled payment strategy, Bend Health collects and shares as much data as possible with its payer partners and other care partners, said Dr. Monika Roots, president and co-founder of the organization, during the panel discussion.

Bend Health uses an adaptation of the collaborative care model. Recently, the company announced that it would expand its clinical focus to include young adults.

Anticipate and consider friction points

Agreeing on specific measures that capture the value of the behavioral health care provided avoids issues that complicate the execution of value-based care contracts. Often, established measurement tools are too general to accurately reflect the value of the work. Ensuring accurate and truly useful measures can also go a long way when implementing value-based care initiatives with clinicians.

“There are a lot of physicians who are not trained in measurement-based care,” Roots said. “They think that in some ways it’s almost a judgment call and that it’s extremely subjective.”

Training clinicians in value-based, care-focused practices such as outcomes tracking must have clear links to improving care. This approach can also help improve clinicians’ skills. It can also identify when a case may be beyond the scope of practice of that particular clinician, so that patients receive the care they need.

“I think we need to put the emphasis on paying for quality. That’s an important change we need to make and that needs to be part of the training,” Roots said.

Linking initiatives like measurement-based care to better care also helps gain physician buy-in. Nordstrom mentioned that measures like the Brief Addiction Monitor can be integrated into familiar frameworks that physicians can use in their daily practice.

“They realize that what we do can actually support them in their work and is not just another damn thing they have to do,” Nordstrom said.

Don’t do everything at once

Britton’s previous roles as CEO of addiction treatment providers American Addiction Centers and Gateway Foundation have shown that size alone is not enough to move large payers to value-based care. Seven years ago, during meetings with a national payer, he learned that plans’ claims processing technology would not be able to support a value-based care contract. But payers, particularly large Medicaid payers, have more options and are more interested in alternative payment models.

Still, payers must resist the temptation to move entirely to a value-based model. He worked “very gradually” to introduce and expand value-based care in his organizations.

“If you don’t really understand your data well, if your employees aren’t trained, and if you don’t have the necessary technology infrastructure, you’re putting your entire business at tremendous risk,” Britton said.

The incremental progression began with performance-based compensation and moved to small and increasing amounts of risk in reimbursement. He doubts that a scaled company will take 100% risk unless the provider is “very clear.”

Don’t settle for less than premium prices

The value-based care model assumes that providers go beyond providing quality health care. It often requires that care address many other aspects of human health, such as physical illness or social determinants of health—very little of which is paid for in the fee-for-service care paradigm.

Addressing several of these challenges will likely lead to better outcomes, and payers have clear incentives to do so, Britton said.

“The risk-sharing model is that you pay us more because we believe our treatment will produce better outcomes,” Britton said. “The better our outcomes, the more profitable it is for the company; the worse our outcomes, the less profitable the company is. So I think you should get paid more.”

Nordstrom said that providing high-quality care that actually reduces health care spending can be viewed as a means of reducing human suffering. In addition, a payer system that encourages quality will crowd out lower-quality providers.

“It makes a pretty good business sense because as a retailer you don’t have to compete with them,” Nordstrom said. “They shouldn’t be out there. If you’re voting with your money on what exists in this world, we shouldn’t be voting for crappy retailers to exist.”