Despite the long-term cost savings and improved outcomes associated with behavioral health care, providers in the space are typically rewarded with meager fee-for-service reimbursement rates.
As such, many behavioral health organizations struggle with slim margins, making it hard for them to offer all the services that are beneficial for patients.
But in the next few years, that could change, as the health care industry accelerates its march toward value-based reimbursement.
“We are moving that way, and it’s going to be accelerated as we emerge from the pandemic,” said Eric Bailly, business solutions director and head of substance use disorder (SUD) strategy at Anthem (NYSE: ANTM). “I would imagine within the next five years, we will have very few organizations that are still really heavily weighted on the fee-for-service models.”
A licensed alcohol and drug counselor, Bailly made those comments during a recent webinar on how to make value-based care reimbursement work in behavioral health. The virtual event was hosted by World Congress, a global provider of health care conferences.
Bailly said the transition to value-based care is inevitable — and necessary to improve health care outcomes, patient experiences and costs.
“We don’t have a choice,” Bailly said. “This is where we’re headed.”
For decades, fee-for-service reimbursement has been widely used to pay health care providers for their services. But the model has its weaknesses. Among the most troublesome, it prioritizes quantity of services over quality, incentivizing providers to maximize reimbursement rather than to do what’s best for patients.
Meanwhile, value-based care focuses on quality. The model reimburses providers for the long-term impact of their services, making the option especially attractive for behavioral health providers.
Plus, those providers typically get a say in the creation of value-based care contracts, unlike most other reimbursement agreements. Just ask Lili Brillstein, CEO of BCollaborative, an advisory company that helps stakeholders move from fee-for-service to value-based care models.
“This is how I managed care has historically worked: As payers, we basically said, ‘We’ve invited you here today to discuss a decision we have already made,’” Brillstein, who was also a panelist on the World Congress webinar, said. “And in value-based care, we don’t do that. We invite people in to help us build … it together.”
At Anthem, a growing number of behavioral providers are already working with the insurer on value-based arrangements, Bailly said. In fact, it’s been a focus for the Indianapolis-based health insurance giant since its 2020 acquisition of Beacon Health Options, a behavioral health management company that serves 40 million people nationwide through employers, health plans and government agencies.
“As we integrate our services with Beacon, looking for opportunities for value-based reimbursement has been an integral part of provider partnerships across the Anthem footprint in every single market that we serve,” he said.
Bailly said he prefers the value-based reimbursement framework because it allows for fluidity of care and gives providers the financial freedom to offer extra services — like peer education and transportation — that can have a huge impact on patients’ recovery.
“I’ve been incredibly inspired by providers’ willingness to roll up their sleeves, get creative and come to us with ideas,” he said. “Some organizations are a little bit further down the road in presenting us with what that looks [like].”
As such, each one of Anthem’s value-based behavioral partnerships looks a little bit different. However, many of those reimbursement structures are based directly on Healthcare Effectiveness Data and Information Set (HEDIS) measures.
Broadly, HEDIS measures are used to track quality of care. They include effectiveness of care, access and availability of care, experience of care, utilization and relative resource use and health plan descriptive information.
“Those are measures that, from a quality perspective, are important to both payers and providers,” Bailly said. “That partnership to drive for improvements benefits everybody, most importantly, the patients and the members that we’re serving.”
Additionally, HEDIS measures can help open up other ideas in forming value-based relationships.
“[Can] we use the base-level expectations of HEDIS and then raise the bar a notch and take a look at how we can push the envelope?” Bailly said. “How can we stretch in those mechanisms?”