Health care policy has steadily shifted its focus from quantity to quality – with a slow but steady move towards more value-based reimbursement (VBR). This shift has led to many debates about whether and how to use VBR for behavioral health services.
We’ve covered this topic before (see For All The Performance Measurement, Are We Really Measuring Performance? and When Does Performance Not Matter?). But it jumped to top of mind again this week after I read two recent articles on the topic.
The first, Can We Pay for Performance in Behavioral Health Care?, is a literature review of 100 articles and 15 empirical studies on value-based care, published last week in Psychiatric Services. The review suggests that while there have been some positive results of pay-for-performance in behavioral health care, these models can be difficult to execute and more research is needed on the outcomes and effects of these models.
The second article, How Value-Based Payment Arrangements Should Measure Behavioral Health, is a discussion about the challenges of value-based care for the behavioral health market by executives from the New York State Office of Mental Health, Thomas Smith, Robert Myers, Lloyd Sederer, and Joshua Berezin. The authors conclude that behavioral health process and outcome measures lag behind those for physical health; that it is hard to justify shared savings for participating behavioral health providers; and that there is no way to identify when consumers are receiving substandard care. The authors offer four solutions to manage this industry-wide deficiency in positive performance measurement strategies:
- Measure treatment response: A key conflict between primary care and behavioral health is the wide-held belief that mental health care lacks the necessary precision to assign accurate measures. The solution is to find where conditions co-occur (e.g., depression and other chronic medical conditions) and require monitoring of symptoms and treatment response for behavioral health conditions, for value-based reimbursement.
- Measure acute behavioral health service use: For physical health, acute and ambulatory care sensitive conditions all come with corresponding measures focused on reducing readmissions. Behavioral health on the other hand, does not. Value-based contracts can further the cause by incentivizing hospitals and community-based behavioral health providers with corresponding measures to monitor care transitions and readmissions.
- For critical outcomes, measure key treatment processes: Not all beneficial measures are outcomes measures, especially when the outcomes are too rare to show marked improvement in value-based contracts (the authors point to suicide and violence as an example). Instead, certain circumstances can provide meaningful process measures such as engagement, retention in care, timeliness of visits, and frequency of visits, instead of possible outcomes when those are missing.
- Develop social and functional outcomes measures: Finally, not all behavioral outcomes need be health care outcomes. Case in point, many behavioral health and substance abuse conditions lead to poor (and proven) outcomes in employment, education, social connections, quality of life, and independent living skills. For value-based reimbursement, measuring these can serve as a proxy for more direct health care measures.
How else can we approve value-based purchasing for behavioral health care? For an answer to that question, I reached out to OPEN MINDS senior associate Sharon Hicks, who noted:
The largest barrier to quantifying behavioral health “value” is the very limited savings opportunities when compared to physical health. Instead of over-utilization, there is more likely under-utilization in terms of persons who need care but get none. While the current discussion tends to focus on the small number of persons who receive extensive services, there is a significant portion of the population who are not getting any care, and who would benefit from identification and treatment of behavioral health disease.
One effect that has been demonstrated from a number of managed care programs in the Medicaid population is that penetration rates have increased, meaning more people are able to get services. Until we can think about “value” as improved health and life-functioning, rather than cost savings, behavioral health will likely lag behind physical health in terms of effective and meaningful participation in pay-for-value programs.
I would add just add a few professional perspectives on this issue. First, the move to pay-for-value will happen with or without the participation of the professional and advocacy community – which is exactly why we need active participation from those communities. Payers feel bound to move to value-based payment models by shareholders and public expectations. And the health plans representing the payers need to make this change in order to be competitive. The question is how do we optimize this market force and use it to improve care for consumers.
Second, like my colleague Ms. Hicks, I think that the best measure of the value of behavioral health treatment is measured in improvement of specific health status measures and reduction in overall utilization of high-cost health resources.
For more on performance measurement in behavioral health, check out these resources in the OPEN MINDS Industry Library:
- Using Outcomes Measurement As A Performance Management Tool
- Performance Management = Long-Term Strategic Advantage
- Getting Your Team Ready For Performance Management
- No “Performance” Without “Training”
- Massachusetts Medicaid Waiver Approved: State To Begin Transforming Integrated, Value-Based Care
- Why Value-Based Purchasing Is Harder For Community Behavioral Health – And What To Do About It
- Arizona’s Next MTLSS Contracts To Link 50% Of Payments To Value-Based Strategies
- The Value Challenge, Again
- Community-Based Providers In A Value-Based World
- Aligning Clinical Compensation For The New Value Equation
And for more on value in behavioral health contracting, join Brian Wheelan, chief strategy officer and executive vice president of Beacon Health Options, on February 16, 2017, at The 2017 OPEN MINDS Performance Management Institute session, Partnering With Provider Organizations: How To Make Risk-Based Contracting Work.