Reimbursement and Workflow For Value-Based Care

Value-based care holds great potential for improving health care by changing providers’ incentives away from volume and more toward managing cost and improving quality. The move to value-based reimbursement has yielded positive results in primary care and there are emerging alternative payment models in specialty care for other chronic conditions. As payers now begin to focus on behavioral health, those in mental health, I/DD and Substance Use Disorder organization settings will need to strengthen quality-driving workflows and rapidly adopt new competencies. Traditional mental health documentation software or systems based solely around fee-for-service behavioral health billing workflows aren’t enough.

But what will readiness for value-based reimbursement look like in practice?   

Behavioral Health Workflow for Value-Based Care - Needs and Competencies

Value-based reimbursement requires providers to hit a payer’s metrics around quality performance and the effectiveness of treatments given. Many value-based contracts focus on specific measures, such as assessment scores as a measure of outcomes, and others tie to episodes of care, pinning achievements on metrics achieved jointly across bundled services or even in conjunction with other providers. 

Regardless of a particular contract’s terms, it is key for the behavioral health provider to have metric goal-setting and measurement capabilities as well as a workflow system to support the steps necessary to meet and record metric achievement. 

Several areas are crucial in preparing for payment change and will largely hinge on having the right technology support. Foundations in an EHR to look for to aid readiness are as follows. 

Accurate Health Tracking and Outcomes Measurement 

 Infrastructure needs to be in place that can effectively reflect a patient’s health prior to and during treatment. Understanding patient health and measuring the impact of interventions over time will require accurate and complete capture of patient demographics; appropriately timed screening, diagnostic, and assessment workflows; and structured data in progress notes.  

 Results management also is key. The right EHR will provide easy access to a patient’s current and previous test results. Real-time transparency decreases the likelihood of inefficiencies and preventable errors, such as test duplications or diagnoses formed by incomplete information. Simplifying the management of this information can improve patient care and increase the efficiency of testing and coordinating care with other providers. 

Workflows that Enable Evidence-Based Interventions 

 Behavioral health providers also need a means for assessing treatment progress and recognizing the need for intervention or systematic follow-up. Alerts with triggered workflows are important in this regard. The right EHR will notify behavioral healthcare providers of the need for screenings and assessments at certain points of care or when symptoms warrant. In addition, the EHR should supply clinicians with evidence-based decision support. Evidence-based prompts can be built into the behavioral health workflow to provide clinicians with timely access to practice protocols, which fosters alignment with clinical best practices when the provider is formulating care plans. Having these behavioral health workflow supports in place makes it easier for the organization to hit quality goals over time. 

Seamless Data Capture and Alerts to Support Payment 

 Quality metrics change over time. Thus, the ability to configure billing as needed to payer-specific business rules for claims payment and automatically capture associated data will give an organization the greatest flexibility. Workflows should aim to minimize the amount of time and resources needed to verify and enter diverse and ever-changing data requirements. Mental health documentation software needs to consider the entire data set needed to obtain payment. As an example, pre-built alerts can help meet regulatory requirements, such as the Physician Quality Reporting Initiative (PQRI), as they notify providers that they need to complete associated data elements to optimize billing functions associated with the value-based contract.

Open API Technology to Support Efficient Care Coordination 

 A secure, open API enables different software applications to safely communicate with each other. This feature directly affects healthcare data exchange capabilities and general communication between providers.  

 For behavioral health providers, the ability to coordinate care with primary care physicians and others is crucial for clients’ health. As an example, mental health conditions such as eating disorders, anxiety disorders, and substance use often show comorbidity and result in multiple providers playing a role in care. The mental health care patient management system needs to reflect the full continuum of care being provided that is impacting care plans. With some payers taking interest in structuring payment around episodes of care, the ability to collaborate across the continuum of care only becomes more pressing. 

Strong Communication Systems to Support Patient Engagement and After Care  

 For care plans to be successful, engaging patients is necessary. Outcomes can be affected by ease of appointment scheduling, the ability for patients and providers to communicate directly with each other, and the capability to directly share forms and other information, such as screenings, through a patient portal. Workflows that automatically trigger follow-up alerts for appointment scheduling can reduce the likelihood of gaps in care. 

 Another important behavioral health workflow is the risk-based routing of patients. The right mental health care patient management system should allow the user to identify and prioritize those individuals who need care the most with of-the-moment risk scoring. Factors affecting risk level should reflect the patient population served and might include things such as past suicide attempts, a chronic pain diagnosis, or recent hospitalizations.  

Performance Analytics and Meaningful Business intelligence  

 Deep data analysis is needed to identify performance trends, recognize best practices, and drive widespread improvements in care processes. The right technology will support tracking quality performance at an individual and population level. 

 Also, business intelligence needs are complex with value-based arrangements. Providers need to be able to determine and predict the true cost of care. The right EHR will also help when calculating likely performance scenarios under different contract terms and with different patient populations.  

Making the Transition Together 

To learn how Core Solutions can help your organization prepare for value-based reimbursement, view a demo by clicking here.