by Mike Lardieri, LCSW on July 6, 2022
Essentially all of healthcare is moving to value-based and risk-bearing arrangements. An Open Minds report recently noted that the proportion of U.S. healthcare reimbursement dollars paid in advanced value-based reimbursement models — those contracts with shared savings, downside financial risk, and/or population-based payments — just surpassed 40%. There's every reason to believe this percentage will steadily increase, and we may even see a significant surge in the adoption of value-based models in the coming years.
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What does this mean to behavioral health providers? In short, they should expect a large portion of their reimbursement either directly or indirectly — e.g., as a downstream provider — will soon come from value-based or risk-bearing arrangements. That's neither good news nor bad news. It's fact. What isn't is that behavioral health providers are assured success in this value-based world. That's going to largely come down to whether providers add the technology they need to effectively participate in these arrangements.
Before I dive into why technology is so vital to behavioral health value-based care success, let's review why our industry is behind other medical services concerning value-based arrangements and what's necessitating the industry to quickly catch up.
Brief History of Value-Based Care and Behavioral Health
One of the most significant — if not the most significant — reason behavioral health finds itself behind medical services boils down to when each started down the value-based payment path. The passage of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) in 2009 essentially represented the start of federal government money going to providers to support and encourage technology adoption. But while providers like hospitals and medical practices received those dollars, behavioral health providers were one provider type that did not.
Since technology, as I will discuss, is a necessity if an organization desires to participate in value-based payment arrangements, the earlier adoption of electronic solutions by medical providers naturally accelerated their ability to participate in these arrangements and the desire of payers to move these providers to such arrangements. Since the HITECH Act did not incentivize behavioral health providers to add technology, most chose to delay moving from paper to electronic documentation, with some providers still relying heavily upon paper today. That's why we see so much disparity between the percentage of medical providers and the percentage of behavioral health providers with value-based payment arrangements.
We're now 13 years from when federal money was first made available to medical providers. Since that time, we as a country have moved to recognize that integrated care is substantially important. For the purpose of this column, integrated care refers to integrating medical and behavioral health together, whether you're providing services in two different organizations and sharing data between them or you're providing all services within a single organization. When such integration between medical and behavioral is successful, both sides have a complete view of care being delivered to the patient. We've come to the realization that such communication and understanding is pivotal.
Over the last two-plus years, the COVID-19 pandemic has further elevated the importance of integrated care between medical and behavioral health. This is due to the issues that have arisen, such as more people becoming depressed, being anxious over COVID, leaving the workforce, and struggling with housing. All those factors over the past few years have pushed behavioral health to the forefront of healthcare.
The growing appreciation and recognition of integrated care, and the key role behavioral health plays in it, is why behavioral health should be — and is — moving toward value-based payments. We're seeing the federal government believes this as well. The Centers for Medicare & Medicaid Services (CMS) is increasingly pursuing a strategy and focus on value-based arrangements. We know what happens with CMS then drives what occurs at the state level with Medicaid and also what drives, to a large part, what happens with commercial payers.
Behavioral health providers cover the gamut of payers. For those in the public sector, they support mostly Medicaid patients. They usually also still bill Medicare and have commercial insurance contracts. However, these contracts may be a smaller part of their business. With the increase of states moving to managed care, more and more state business will be through value-based arrangements, with the plans managing the Medicaid dollars. It's easy to see that behavioral health revenue will increasingly come from value-based contracts.
Crucial Role of Technology for Value-Based Care (Behavioral Health)
Now that we've explained why there's such significant momentum behind the movement to value-based care and how this is affecting behavioral health, let's discuss what is needed for behavioral health providers to participate in these payment arrangements.
We'll start by identifying what you can't use: paper and pencil. It's simply way too difficult. Why? Once a behavioral health provider is involved in managed care — either via a Medicaid plan or if Medicaid subcontracts to a managed care organization(s) in your state — that MCO is likely going to try to move the provider into a value-based payment arrangement. Once that happens, the provider will need to provide the payer data on specific, target measures — data that identifies exactly how well the provider is performing on those measures. Examples of such measures include:
- How many of your patients had an appointment within seven days after the patient left the hospital?
- How many patients had appointments within three days following an emergency room visit?
- How many patients experienced a decrease in their depression or PHQ-9 scores of 50% or more?
- For patients who scored above 9 to begin with in their depression or PHQ-9 scores, within 12 months, are they at 5 or below?
These are the types of data points behavioral health providers will need to share with insurance plans, and these are the types of metrics value-based incentive payments are based on. If you don't provide the data back to the insurance plan, you're not going to earn the extra money you planned on making from these value-based or risk-bearing arrangements. The result is that you'll either break even or, in a worst-but-likely scenario, you will receive no pay increase and you will lose money because you put extra resources into completing the work only to find that you're not performing well enough.
Why do insurance plans care so much about these measures? There is currently a significant movement in the insurance industry toward building networks. When an insurance company begins to look at which providers in their area they want to work with and send their members to for care, they're going to look to contract with those providers performing well in these measures. Strong performance generally translates to better care, thus allowing the plan to reduce what it spends on care for members.
In addition, plans are expected to report on their performance concerning Healthcare Effectiveness Data and Information Set® (HEDIS®), a set of performance measures in the managed care industry, and and/or state measures. When insurance plans achieve a certain percentage of improvement in a measure, they can receive millions of federal or state dollars.
This brings us back to the role of the behavioral health provider in a value-based arrangement. For the provider to help the insurance plan improve its performance with HEDIS® or other measures, and for the provider to earn some of those value-based dollars, the provider must collect and report data — data that is simply too expansive and extensive to document and report using paper and pencil. Consider that participation in value-based or risk-bearing arrangements will require behavioral health providers to do at least the following:
- Monitor clinical quality and specific metrics by payer contract
- Monitor clinical quality across all payers and populations
- Calculate total cost of care for a service
- Monitor referral and engagement timelines
- Determine the effects social determinants of health (SDoH) have on the patient population
- Have solid treatment engagement strategies
It is only through using technologies (e.g., advanced analytics, automated workflows and tracking mechanisms, integrated patient portals) that data can be effectively and accurately gathered and assessed and then provided in a way that insurance plans can consume.
Is Your Behavioral Health Organization Prepared for Value-Based Care?
Now that we've established why technology is nothing short of a requirement for behavioral health participation in value-based and risk-bearing arrangements, let's take a closer look at the qualities and features that behavioral health technology needs so providers can succeed with value-based care. Consider these three questions:
- Does the technology embed analytics and sophisticated workflows in the electronic health record (EHR)?
- Can the technology track processes and flag the provider to intervene prior to being out of compliance or missing a milestone?
- Does the technology assist in guiding evidence-based practice workflows?
I think these questions serve as an effective basis for an initial assessment of behavioral health technology solutions. Let's examine at each one.
Behavioral Health Analytics
Concerning the first question, having data and reporting analytics embedded in the technology and available in real time is important as it allows the provider to effectively manage their measures. Behavioral health providers must have systems that have the capability to track measures on a real-time/near-real-time basis. If you look at the data once a month via an external system or once a quarter, you're likely to find that you're unable to affect any meaningful change in outcomes. The time lapse is simply too great.
On the other hand, if the data for these measures is available in real time or near real time, then you can look at them day to day, week to week, month to month. With this information, you can make process improvement changes, see the effects of those changes, and then respond accordingly. This is difficult to impossible if your data is ported out to another system and it takes a week to generate the report or if you only receive the report on a monthly basis. While it's true that some reports are designed for monthly review, many of the others are only valuable or have their value maximized when you can look at them in much shorter timeframes, such as daily and weekly.
Onto the workflows and EHR. Where we often fall short in behavioral health is people simply falling through the cracks. A significant, contributing factor is that workflows are often documented on paper. When this happens, a disconnect occurs. The organization loses track of who is supposed to see the patient next and in what timeframe, who is supposed to provide a specific service that is part of the treatment plan, or which staff person was supposed to notify others about what happened at a particular stage of care. When technology can guide workflows and issue alerts to the next staff member(s) identifying what they need to do next in the treatment process and in what timeframe, that's extremely valuable to providers. Embedded dashboards across all programs or patients allow staff and administration access to timely information needed to intervene and make targeted changes so processes proceed as intended.
As an aside, it's important to note the measures we're largely talking about in behavioral health today concern process rather than outcome and tracking whether a patient improved. The reason: There are currently only a few outcome measures. The industry is moving towards identifying more outcome measures. For the moment, we're generally looking at process measures with the assumption — and hope — that if you complete the right process, a patient is going to get better.
Behavioral Health Processes
This leads well into my second question concerning tracking processes. Why is the ability to accurately track process in behavioral health so important? Oftentimes, the process falls apart because when it's not effectively tracked, nobody can see exactly what is happening for a patient. Consider clinician or staff member #1 completes their process, but clinician or staff member #2 does not know it's their time to continue the process.
With the right technology, clinician or staff member #2 can be notified and see in their "to-do list" queue that it's now their responsibility to take action and keep the process moving forward. In addition, administrative staff gain the ability to see an organization-wide dashboard and identify resource bottlenecks. They can then adjust staff or resource allocations proactively to meet demand.
Such functionality, and the ability to use technology to help support clinicians and administration performance monitoring, is important to ensuring that clinical interventions, SDoH referrals, and regulatory requirements occur as planned.
As we move towards measuring outcomes, it becomes even more important to have the right technology. When you begin to look at outcomes data, you're going to see some patients and some providers have better outcomes than others. Providers require the ability to review their data and analytics easily and in real or near real time. If outcomes for some patients and providers are poor, it may be because there were social determinants of health issues involved with these patients.
Consider patients who have depression. They are all in the same treatment protocol, yet an organization sees that some are improving, some are not. A deeper dive in into the organization's data may reveal that those who are not improving all have housing issues. It's only natural that a person in such a situation is going to lack the ability to effectively take care of their depression until they are in stable housing.
Real- and near-real-time analytics allows the organization to uncover these disparities and allocate the appropriate resources to provide the care that will help patients improve. Efforts may go toward helping get them into consistent housing or securing additional finances so they can maintain their current housing. Once the right resources are in place, it increases the likelihood that these patients will show improvement with managing their depression.
Without technology to view data through a population health lens, behavioral health providers will never get ahead of the game. They will always be wondering why some patients are getting better and some are not getting better, as opposed to gaining the ability to focus on the real problems, which are not always clinical. Sometimes clinical issues are ancillary to the real-life issues of food, shelter, and clothing.
As more outcomes measures are developed and become tied to value-based arrangements, behavioral health providers will need the ability to effectively look more closely at their population and the myriad issues involved in their care. If providers are unable to do so, acceptable outcomes performance and improvement will not be achievable.
Evidence-Based Behavioral Health Practices
Now let's speak to the third question, and what is becoming an increasingly important expectation for the delivery of behavioral healthcare: evidence-based practices. Behavioral health providers need technology if they hope to follow evidence-based practices consistently and appropriately.
If behavioral health providers and organizations hope to achieve meaningful and long-lasting improvements to their processes and outcomes, thus allowing them to achieve value-based arrangement success, they are going to increasingly need to provide care that follows evidence-based practices.
The issue of evidence-based practices concerns fidelity to these practices. Following evidence-based practices usually requires a series of interventions and activities, sometimes associated within a defined timeframe.
It's not unusual to hear behavioral health clinicians identify that they were unable to maintain fidelity to an evidence-based practice due to time or other considerations. EHRs need to guide providers through the evidence-based practice, prompting them along the way. This provides the organization with a tool to evaluate outcomes based on fidelity to the specific model. By consistently analyzing outcomes in this manner and sharing outcomes with other providers, we have the opportunity to continually improve practice. The EHR should support this activity.
Recognizing the rapidly growing importance of evidence-based practices, we at Core Solutions have built a workflow engine useful in mapping and guiding evidence-based practice workflows. Providers are prompted all along the way as to what steps are required when, assisting them to maintain fidelity to the practice. Administration can monitor at the organizational, program, site, and patient cohort levels.
Do More With Core's Behavioral Health Technology Platform
At Core Solutions, we've devoted significant resources to ensuring our behavioral health technology platform can help providers achieve success today and position themselves to meet and exceed the care requirements of tomorrow, including those accompanying value-based and risk-bearing arrangements. Our technology is enabling care to be more closely linked to value by making data more available in the workflow at the time of the provider encounter; more immediate and personalized, with analytics and insights to deliver the right messages to the right staff and patients at the right time; and delivered more seamlessly by integrating capabilities and experiences across the patient journey.
To see these capabilities firsthand, schedule a demo. Whether you're looking to transition from paper to electronic or researching alternatives to a legacy EHR that's failing to meet your needs, I am confident the Core technology platform will surpass your expectations.
