by Mike Lardieri, LCSW on July 23, 2024
As value-based care (VBC) continues to shift the focus of the healthcare industry from fee-based services to achieving better outcomes at reduced costs, organizations are seeing positive results in primary care. However, the person-centric VBC approach is complicated in the behavioral health space due to complex client needs that can require nuanced approaches to treatment and support as well as sophisticated care coordination across a variety of specialists. This can contribute to reimbursement challenges and a need for streamlined workflows to help ensure accurate and timely value-based payment.
The Centers for Medicare & Medicaid Services (CMS) is stepping in to help frequently siloed providers with its introduction of the Innovation in Behavioral Health (IBH) Model, scheduled to begin in the first quarter of 2025. The model, aimed at improving the quality of behavioral healthcare — particularly for mental health and substance use disorders — will integrate physical healthcare and other services into behavioral health settings. Success will greatly depend upon the efficacy of interprofessional care teams, driving even more need for providers to strengthen current processes, rapidly build on existing competencies, and adopt a top electronic health record (EHR) to better ensure care delivery meets the quality-driven thresholds for value-based reimbursement. Traditional software centered around fee-for-service billing workflows isn’t enough and may actually be a detriment to VBC success.
But what does readiness for value-based reimbursement look like in practice?
1. Prioritizing New Metrics
Value-based payment requires providers to hit a payer’s metrics around quality performance, the effectiveness of treatments and the level of support given. Many value-based contracts focus on specific measures, such as assessment scores as a measure of outcomes and others are tied to episodes of care, pinning achievements on metrics achieved jointly across bundled services or even in conjunction with other providers.
Regardless of a contract’s terms, behavioral health providers must be able to review quality metrics-based requirements, measure progress in meeting them, and submit successful claims through behavioral health billing solutions
Achieving accurate health tracking
Infrastructure must also be in place to effectively capture the status of a clients’ health before and during treatment and support, particularly in integrated behavioral health settings, to correctly report on outcomes. Understanding client health and measuring the impact of interventions over time will require accurate documentation of client demographics; appropriately timed screening, diagnostic, and assessment workflows; and structured data in progress notes. Understanding the environment in which clients live and work and how these may impact their health is also essential to painting a complete picture and delivering more equitable care, a key component of VBC. Core Solutions’ Cx360, an EHR designed for behavioral health and intellectual and developmental disability (IDD) providers, offers an AI-backed solution that can track these social determinants of health (SDOH) at the point of care.
Results management is crucial as well. The right EHR will provide easy access to a client’s current and previous test results. Real-time transparency decreases the likelihood of inefficiencies and preventable errors, such as test duplications or diagnoses informed by incomplete information. Simplifying the management of this information can enhance client care, increase the efficiency of testing and care coordination with other providers, and lead to better outcomes that are vital for value-based payment success.
2. Enabling Timely Evidence-Based Interventions
Behavioral health providers also need a means for assessing treatment and support 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 providers of the need for screenings and assessments at certain points of care or when symptoms warrant them.
In addition, a modern EHR should supply clinicians with evidence-based decision support. Evidence-based prompts can be built into behavioral health workflows to provide clinicians with timely access to practice protocols, which fosters alignment with clinical best practices when the provider is formulating care plans. These supports make it easier for the organization to achieve quality goals over time.
3. Ensuring Seamless Data Capture to Support Payment
Quality metrics can change. Thus, the abilities to configure billing as needed to payer-specific claims payment rules and automatically capture associated data through behavioral health billing solutions will give an organization the greatest flexibility. Workflows should aim to minimize the amount of time and resources required to verify and enter diverse and ever-changing data requirements.
Machine learning-backed revenue cycle management, like that found in Cx360, can help by reviewing dozens of rules before claims are filed, increasing performance with key metrics, such as clean claim and denial rates. The best EHRs for behavioral health also have pre-built alerts that notify providers when they need to complete associated data elements to optimize billing functions associated with the value-based contract.
4. Driving More Efficient Care Coordination
For behavioral health providers, the ability to carefully coordinate care with primary care physicians and others is invaluable for many clients’ health. Conditions such as eating disorders, anxiety disorders, and substance use disorders often have comorbidities that require multiple providers to play a role in care. With some payers structuring payment around episodes of care, they need to be on the same page to achieve optimal, positive outcomes. All stakeholders must therefore be able to view and follow the full continuum of care to create cohesive and correct treatment and support plans.
A secure, open API enables different software applications to safely communicate with each other, strengthening data exchange and information-sharing capabilities.
5. Increasing Client Engagement and Assessment
Client engagement is essential for treatment and support plans to be successful. Outcomes can be affected by ease of appointment scheduling, the ability for clients and providers to communicate directly with each other, and the capability to share forms and other information (e.g., screenings) through a client 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 clients. The right EHR 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 client population served and might include matters like past suicide attempts, a chronic pain diagnosis, or recent hospitalizations.
6. Improving Care Delivery With Performance Analytics
To drive widespread operational improvements and set themselves on the path to more consistently deliver against VBC requirements, healthcare organizations must have a process for deep data analysis to identify performance trends, recognize best practices, and implement timely, appropriate changes that lead to improvements. The right technology will support tracking quality performance at an individual and population level.
Also, business intelligence (BI) needs are complex with value-based payment arrangements. Providers need the ability to determine and predict the true cost of care. The right EHR will further help to calculate likely performance scenarios under different contract terms and with different client populations.
Supercharge Your Workflows With Cx360
To learn how Core Solutions can help your behavioral health organization navigate the VBC landscape and adapt to new requirements for integrated behavioral health, request a Cx360 demo.
