‘It’s Extremely Difficult’: Payvider Models Demonstrate How Far Behavioral Health Integration Challenges Go

The struggles of Optum and CVS Health Inc. (NYSE: CVS), two of the country’s largest health organizations, to integrate assets into a cohesive “payvider” model illustrates the deep challenge of creating value-based care models. 

Optum, the health services division of UnitedHealth Group Inc. (NYSE: UNH), and CVS Health, which owns Aetna, one of the largest health insurers in the U.S., have found creating payvider models a tantalizing but laborious prospect.

These challenges highlight the toil required to upend and reform legacy approaches to health care. 

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“It’s extremely difficult,” Trip Hofer, the CEO of Optum Behavioral Health Solutions, said at Behavioral Health Business’ VALUE conference. “[Even] in an ecosystem where we own the assets, getting those assets to be able to collaborate — because I really believe that having integrated care through the primary care provider is so important for mental health — is a slog.”

Hofer continued, noting that the several health care provider organizations that Optum acquired want to integrate systems and data. But even the willingness to do so runs headlong into “the reality of how you do it.”

“I want to be very real here,” he said. “I firmly believe in it. But it takes a lot of time and it’s a one-off conversation in all these systems.”

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A key challenge is reconciling several different information technology systems and making other business arrangements with the entities Optum has acquired. 

In 2022 alone, there were at least six big-time deals by Optum, according to reports. This includes the acquisition of the second-largest outpatient mental health care provider in the U.S.: Refresh Mental Health

In April 2022, UnitedHealth Group’s CEO said the Refresh Mental health deal fit into its “value-based proposition.”

But integrating those acquisitions into the continuum of care has had its challenges. For example, in 2022, Optum acquired Kelsey-Seybold Clinic in Houston, which employs over 500 health care professionals. 

“Kelsey Seybold says, ‘Trip, here’s my issue. I have access problems for depression, stress and anxiety for adults.’ And I’m like, ‘Well, we have a ton of solutions for you,'” Hofer said. “Six months later, we still can’t get it implemented because it’s like, ‘Well, how do I get data back to them?'”

While the health insurance industry is increasingly moving towards a “whole-person care” approach to care, the inclusion of behavioral health complicates matters, Dr. Deborah Fernandez-Turner, deputy chief psychiatric officer of Aetna, said at VALUE. 

Trip Hofer of Optum Behavioral Health Speaking at VALUE 2023 Behavioral Health Business
OptumHealth Behavioral Health Solutions CEO Trip Hofer speaks at VALUE 2023.

Behavioral health is “unique and different” in comparison to other segments of health care, yet it can’t be parsed out and left aside. This makes creating these kinds of payvider models more complicated and time-consuming to build, Fernandez-Turner said. 

On the health care provider side, CVS Health’s MinuteClinics have started co-locating mental health providers or telehealth access for mental health services on site in its drug stores.

“I think, as a society, we’re really understanding that the brain and the body are interconnected,” Fernandez-Turner said.

CVS Health’s and Optum’s efforts to bring about greater integration of behavioral health into the health care system even extend to venture investing.

Optum Venture has put money into several tech-backed or tech-focused behavioral health startups including Brightline, Alma, Equip and Groups Recover Together, to name a few. Optum acquired Hofer’s previous company, AbleTo, in April 2020. He was named to his role in June 2022.

More recently, CVS Health Ventures led a $25 million funding round with Array Behavioral Care, a company that integrates telepsychiatry services into physical care settings. 

Deborah Fernandez-Turner of CVS Health at VALUE Behavioral Health Business
Deborah Fernandez-Turner, deputy chief psychiatric officer at CVS Health’s Aetna, speaks at VALUE 2023.

Meanwhile, Optum Behavioral Health Solutions operates two distinct businesses: a 5,000-provider-strong outpatient mental health network and a $7.2 billion managed behavioral health benefits “carve out.” The provider group brings in about $600 million, Hofer said.

The carve-out business works with 350,000 providers nationwide.

“To me, the more exciting part is the provider side and how you start to influence the provider community and get behavioral health integrated with physical health,” Hofer said.

Referring to the Refresh Mental Health and other health care provider acquisitions, Hofer said Optum is acquiring health care assets to influence how care is provided, and owning care assets is the way to do that.

He added that Optum will continue on the acquisition path with the behavioral health group “because there’s so much richness in integrating the behavioral side with the physical side.”

Outside of the payvider model, where one organization owns both payer and provider assets, it’s even more difficult to assess the value of what any part of the health care spectrum contributes in terms of value or payers or patients, Mark Friedlander, chief medical officer of behavioral health for Universal Health Services (NYSE: UHS), said at VALUE.

“If someone has a substance use problem and a mental health issue and a chronic pain condition, they’re super expensive for the payers,” Friedlander said. “But what is the key active ingredient in getting that person on the right path?”

Trip Hofer of Optum Behavioral Health Speaking and Mark Friedlander of UHS at VALUE 2023 Behavioral Health Business
Trip Hofer of Optum Behavioral Health, left, and Mark Friedlander, chief medical officer of behavioral health at Universal Health Services, middle, speaking at VALUE 2023.

The costs to care for complex patients extend to behavioral health providers, pharmacies and physical care providers. But the savings for effective interventions for each level are only realized on the physical health side.

“But we on the behavioral health side don’t get the data to quantify that — so we don’t know,” Friedlander said.

One part of the challenge is the exclusion of the behavioral health industry from governmental support that enabled the adoption of electronic health records (EHRs) in hospitals and related settings. This prevents the sharing of “meaningful data,” he added.

“We need to be able to share the data so that we can figure out who does what, who contributes what,”  Friedlander said. “It’s not all about the dollars and who deserves what share of the pie. It’s more [about] can we integrate the information?”

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