State Medicaid programs and their managed care organization (MCO) partners are amenable to value-based care contracting. However, misconceptions remain as the industry navigates the early stages of value-based care adoption.
This openness allows companies to come to the table with new or different approaches to contracting, opening the door to escaping the fee-for-service paradigm.
“The biggest misconception is that you have to fit into a box in order to have these contracts,” Jay Talyor, chief growth officer of Brave Health, said during a panel discussion at VALUE 2024 in Miami.
Brave Health is a telehealth company that provides mental health services to Medicaid beneficiaries under value-based care contracts. It raised $40 million in a funding round announced in October 2022, led by Town Hall Ventures.
The physical health care segment has seen greater development of value-based care arrangements. But this familiarity with innovative models within Medicaid opens the door for behavioral health. This is increasingly true for Medicaid, which sees a higher prevalence of behavioral health issues than other insured populations.
Taylor contends that “many” MCOs are willing to work outside of traditional frameworks if they can improve key areas of care and operations with the right reimbursement incentives.
“It doesn’t need to be an episode of care or a total cost of care construct,” Taylor said. “But if we’re able to define those key areas that we want to impact and put financial incentives around them, that is the essence of value-based care. Many of the payers are willing to make those contracts — many aren’t — but there are those good partners out there that are willing to take that step.”
Negotiations over value-based care arrangements tend to succeed when value-based care talks address the MCO’s pain points, Dr. Patricia Ares-Romero, chief medical officer with Nomi Health, said at the panel.
“How can we help with those gaps and those issues in treatment?” Ares-Romero said. “Then we come to a solution for a value-based contract.”
Orem, Utah-based Nomi Health is a tech-focused direct health company that partners with employers and focuses on telehealth.
Some of the most common pain points for MCOs are follow-up appointments post-discharge from inpatient facilities, Ares-Romero said. Data from the National Committee for Quality Assurance shows that the national average for Medicaid patients going to a follow-up visit within 30 days after an appearance in the emergency room for a substance use disorder is 36%.
Ares-Romero highlighted that increased attendance at follow-up appointments helps prevent untimely deaths from addiction or other significant behavioral health issues.
Behavioral Health Business“We could really make a difference in these lives if we’re able to get them to those follow-up appointments,” Ares-Romero said. “That’s where things like telehealth services are so vital and important because a lot of the time, patients with SMI or substance use can make it to that appointment.”
Other pain points include timely access to care. Payers see this as an upstream issue that nullifies the potential for other reimbursement innovations. Further, top payer executives at VALUE said that the collective behavioral health industry can’t move forward with value-based care until access, quality and industry standard issues are resolved.
Misconceptions also arise for value-based care contracts with MCOs based on how little time Medicaid beneficiaries stay with those plans.
“People are not on Medicaid potentially as long as they are on commercial insurance,” Rachel Sokol, senior vice president of payer partnerships, said. “They are certainly there for enough time where, if you are targeted about what you are going after and about the spend, you can really make a difference for the member.”
Groups Recover Together is a hybrid outpatient addiction treatment provider that focuses on group therapy. About 88% of the company’s contracts are centered on value-based care.
Clearing technology hurdles in Medicaid
A frequent complaint from behavioral health providers endeavoring toward value-based care is that their payer partners don’t have administrative and technology systems that will accommodate means of billing outside of the fee-for-service paradigm.
However, Groups Recover Together has found that most systems have ways of making payments if they are dedicated enough to the cause. This magnifies the degree of customization and difference across different plans and states.
“We have probably 200 different types of value-based contracts; we’ve yet to encounter a claim system that we can’t work within,” Sokol said. “I think when there is a really good partnership and open communication between the health plan and the provider, there is ultimately a solution that we can find.”
State organizations also have a role to play as well. More states are mandating that MCOs that contract with states are required to provide some portion of their behavioral health services under value-based care, Sokol said. She added that iteration and reassessment are vital as well.
“MCOs are going to have to think about how to accommodate those payments if they’re going to be able to meet the state requirements, not just the providers’ asks,” Sokol said.
Taylor also said a willing partnership is key to overcoming technical barriers. Still, the claims systems “are the beating heart of the health plan” and likened adjusting those systems to accommodate value-based care to “open heart surgery.”
Telehealth, while a potential solution for care access issues, may present a barrier for some Medicaid beneficiaries. This is especially true for “higher acuity” patients Brave Health works with, Taylor said.
“We actually remove as much technology as possible from the front-end user experience as we can,” Taylor said. “We focus more on the technology side and the back end of our business … What I’m really talking about is the barriers to having that initial telehealth appointment — not having an app to download, not having to log in and not having to do some of these additional steps.”
Companies featured in this article:
