For behavioral health providers, being overworked and underpaid is often the norm. Low reimbursement rates mean less incentive for new clinicians to enter the space, perpetuating the industry-wide supply and demand mismatch and making it harder for patients to receive care.
While most providers agree payment innovation is the answer, getting payers on board can be challenging. But as the pandemic continues to highlight the importance of behavioral health care, that’s getting easier, according to Greg Keilin, co-founder and CEO of Prosperity Behavioral Health, a business process outsourcing firm focused on financial operations to support behavioral and mental health care providers.
“We’re starting to see an appetite by the payers to think differently, and now it’s really up to the providers to meet that challenge,” Keilin said during a recent webinar hosted by the national law firm Polsinelli.
However, that challenge is not insignificant, especially for the mom-and-pop providers prevalent in the behavioral health space. Shifting to a value-based model can be a huge undertaking for smaller organizations like them, as they often lack the sophisticated data analytics capabilities of larger hospitals and health systems.
Data is essential to moving to a value-based system, as it helps inform care and reimbursement. But implementing data initiatives comes at a cost, explained Bragg Hemme, a shareholder and health care attorney at Polsinelli.
“It’s going to require investment, and it’s going to require a change in culture,” Hemme said during the webinar. “It’s a big strategic shift in how we have interacted with payers and in our care model.”
Keilin likened data investment to the chicken and the egg paradox: Behavioral health organizations want to participate in value-based agreements so they can receive higher reimbursement rates and provide better care. However, in order to do that, they first have to take a financial hit of sorts.
“The posture by the payers, generally speaking, is: ‘Prove to me that this works, and then I will talk to you about how you get paid for it,’” he explained. “And that puts a tremendous burden on providers to shoulder that expense without any guarantee of a return on that investment.”
Keilin added mom-and-pop behavioral health providers usually have relatively small patient populations to draw data from, making it harder for them to mitigate risk and implement value-based models than their larger counterparts.
He recommended those providers prioritize their business plans and the cost side of the equation before thinking about reimbursement. That means understanding factors such as the type of revenue necessary to succeed in a value-based care model, in addition to the level of tolerable risk they’re able to take on.
In terms of the data behavioral health providers should be collecting, payers want to see biopsychosocial metrics such as abstinence and family structure, as well as the utilization of health care services post-discharge. The latter is admittedly harder to get, Keilin said.
“It’s a hurdle, on the one hand, because that’s really hard data for providers to collect — and that’s really important data for the payers to be able to justify or price a value-based reimbursement model,” he said. “But on the other hand, it’s an opportunity because that is data that the payers have very easy access to.”
That opportunity is exciting given payers’ growing willingness to work with behavioral health providers in defining what quality care looks like, Keilin said, and organizations willing to make the plunge stand to benefit.
“[Those investments] may not have a guaranteed return, but … are going to position them … to thrive over the long-term — the five- to 10-year time horizon, as opposed to the six- to 12-month time horizon,” Keilin said.
