Payers, Providers Join Forces to Standardize Value-Based Care in Outpatient Mental Health

Payers appear to be at the forefront of standardizing value-based care. But they still share the reins with other major forces in behavioral health, especially in the outpatient mental health space.

Until the industry settles on standards, the value-based care negotiations are likely to produce reimbursement arrangements that are one-offs or otherwise unique. On the other hand, the lack of standardization gives payers the latitude to make deals that are responsive to local needs.

“We have several different models throughout Centene,” Francis Terway, vice president of behavioral health business intelligence for Centene Corp. (NYSE: CNC), said during a panel discussion at Behavioral Health Business’ event VALUE. “Most of them are very market specific or provider specific.”

Even with several value-based care models in play, Centene developed over the last two years a broader, more standardized outpatient model that’s capable of being scaled up in its 30-state footprint for its Medicaid patients, Terway said.

Centene is one of the nation’s largest insurers, with 26.2 million total members as of March 31, 15.3 million of whom (58%) are on Medicaid plans. The company reported $126 billion in 2021 revenue, according to Securities and Exchange Commission documents.

Other national-leading health plans have likewise given considerable attention to mental health and value-based care.

UnitedHealth Group Inc. (NYSE: UNH), a large national payer and major health care services provider, could exert influence on standardizing behavioral health value-based care through its health plans as Centene could: UnitedHealthcare, the insurance arm of UnitedHealth Group, covered 50.6 million lives through its health insurance products at the end of 2021.

UnitedHealth Group could add additional influence over behavioral health value-based care standardization on the provider side of the health care equation as well. Optum, the health services arm of UnitedHealth Group, at the end of March acquired the second-largest provider of outpatient mental health services — Refresh Mental Health.

Why providers are less enthusiastic

Katherine Tripple, vice president of value-based care for Foresight Mental Health, said that outpatient mental health providers face steep barriers when moving to value-based care.

Typically, these include major investments into systems and infrastructure that historically haven’t been needed nor were part of the business model under the present norm of fee-for-service reimbursement.

Berkeley, California-based Foresight Mental Health provides in-person and telehealth mental health services in 23 states.

“I think that few organizations have the bandwidth to do that,” Tripple said of the significant investment to move to value-based care. “To build out the processes and workflows you need to support those HEDIS measures, you need to build out parts of your business that honestly didn’t exist before.”

Tripple said she is looking forward to any additional momentum that blockbuster transactions — such as the deal between Optum and Refresh, which UnitedHealth executed with value-based care in mind — could imbue into value-based care standardization.

However, she stressed that standardization must focus on driving quality care and improved patient outcomes.

“It was interesting to hear all the speakers talk about the fact that they’re really open to outpatient value-based care, because as an outpatient provider, it has not felt that way,” Tripple said. “The momentum for the providers is not felt in the same way I think payers feel like it’s felt.”

Services providers also push standardization

Yet another potential place for standardization may come from organizations that provide services to both payers and providers that enable value-based care, such as Quartet Health.

Susan Foosness, associate vice president of value-based care strategy of Quartet Health, described her company during the VALUE panel as “the technology and services engine behind this partnership between the payer and the provider.”

Through its vantage point as a go-between for payers and outpatient mental health providers, Quartet Health could help establish industry-standard outcomes to track and the best incentives to establish for providers to pursue them, Foosness said.

“Incentivizing outpatient providers for value gives them some more flexibility to have other non-clinical supports,” Foosness said, giving the example of engagement from care coordinators and nurses as “those things that happen between the billable sessions that are not reimbursed in a fee-for-service arrangement.”

The more-common fee-for-service model often doesn’t allow outpatient mental health providers the financial latitude to invest in tracking and coordinating patient care when they aren’t in the office. This makes it harder to reach high-risk patients, Terway said.

Value-based care measures

The outpatient mental health value-based care model that Centene is rolling out includes standardized behavioral health assessments, patient satisfaction-focused HEDIS measures, a mainstay in value-based care, as well as incentives for community tenure and for engagement. The model also includes a risk adjustment to its engagement measure.

“We know the highest-risk members are harder — it takes more work to establish that relationship and get them coming back into treatment,” Terway said. “So we incentivize more, once that engagement is established.”

Quartet Health is among the many organizations that work with Centene. Speaking of the new Centene model, Foosness said it’s not “one size fits all” and is targeted to “folks who we’ve identified are at risk or falling through the cracks, or having some issue with engagement in high-quality outpatient care.”

It’s also not for all providers. Rather it’s focused on investing in providers that are able to reach high-risk populations.

“We’re very sort of strategic and selective in who is eligible and who participates,” Foosness said. “And we believe that’ll drive the best outcomes.”