‘You’re Taking Their Word for It’: Dangers of Ceding Data to Payers in SUD Value-Based Care Models

The journey to value-based care in the addiction treatment space has produced a number of roadmaps with common mile markers for progress, leaving a list of do’s and don’ts for the industry.

These include well-defined data tracking, working up to more robust arrangements with willing payer partners over time and negotiating the operational implications of working with multiple payers.

It also increasingly includes picking up the data collection and analysis role traditionally attributed to payers.


“The data exchanges that we’ve experienced between payers and us are not as robust as they may claim: they’ve been relying on us a lot,” Paul Trivette, chief strategy officer of Cedar Recovery, said during a panel discussion at VALUE 2024 in Miami. “They have the claims data. But if claims data are only part of the picture, we’re being held responsible for submitting more information to them and then processing that.”

Mount Juliet, Tennessee-based Cedar Recovery operates nine office-based opioid treatment (OBOT) locations in Tennessee. It also runs a virtual mental health service and an intensive outpatient program (IOP).

What doesn’t work?

The company’s investment in data has had major implications for the company. If for no other reason, enhanced tracking of process measures and care outcomes provide the “footing to push back if you’re not reconciling with the payer,” Charlie Sposato, vice president of product innovation at BrightView Health, said during the panel.


“We don’t have the same access to information that the payer does. So you’re taking their word for it to some extent,” Sposato said. “Then you’re just looking for internal consistency between, like the reports that they send you over time and, sometimes over time, you catch discrepancies in that.”

BrightView Health, a Cincinnati-based OBOT and opioid treatment program (OTP) operator, tracks measurement-based care outcomes and other data as part of its value-based care contracts.

“Our data is the standard that we go by,” Sposato said.

Cedar Recovery hired a data analyst over two years ago and had them build real-time dashboards that incorporate data from the company’s electronic health record in preparation for a value-based care contract to help make estimates of what the company should get paid.

After the first month of the contract, the payer and Cedar Recovery were $8,000 apart from what the company thought they were owed. That touched out a seven-month process that resulted in an admission that the payer didn’t actually have data that were to be tracked according to their contract.

“They said, ‘Just send us your data. That’s what we’re going to use,'” Trivette said. “So, they wrote us a massive check at the end of this last year. But if it weren’t for [the data analyst] and the analytics and us being able to prove it, we would have never got there.”

Trivette painted a skeptical view of how payers are approaching value-based care contracting in the addiction treatment space.

Cedar Recovery sent a proposal to a payer that included pay-for-performance metrics that were based aon HEDIS measures and medication adherence with a data tracking plan. The payer said no because of the additional work to manage the data and contract. Further, other providers, Trivette said of this interaction, had completely different value-based care proposals in addiction treatment.

“The payers specifically have been the biggest challenge, and what’s not working in value-based contracting is the payers,” Trivette said.

What does work?

While much of BrightView Health’s business is still fee-for-service, Sposato’s role is to secure and implement value-based care contracts.

He sees promise in Medicare-like bundled payments for addiction treatment services, especially for commercially insured patients that have high levels of cost sharing. Theoretically, these could allow one-time cost shares like copays and lower patient burdens and, thus, barriers to care. Some of BrightView Health’s payer partners will consider bundled payments.

Bundle payments could also include considerations of lab testing, one of the few truly objective measures of treatment and recovery in addiction treatment, Sposato said. However, payers are largely skeptical of lab services because of high-profile scams run by addiction treatment providers in the past. For example, law enforcement officials in Florida successfully prosecuted a $110 million urinalysis and sober living fraud case.

“We want to get away from looking at how many analytes that the tests were performing or looking at — that’s an outdated reimbursement scheme,” Sposato said. “It costs a certain amount to take care of a patient. Labs are part of it. Let us worry about that. Let’s just focus on what [payers] care about, and how we’re saving [them] money, how we’re delivering a better quality of life for patients.”

Trivette said 100% of Cedar Recovery’s payer contracts come through bundled payments. The company’s management of costs and care must manage those bundled payments. These are largely from Medicaid managed care organizations (MCOs). But the company’s real value-based care work is in pay-for-performance contracts with measures that focus on consecutive delivery of buprenorphine prescriptions and patient retention. That is supported by a “care management fee” that helps cover activities to enable patient retention.

Cedar Recovery outsources lab services. This takes that bias off the table for the company, allowing it to be more forward about pushing for increased bundled payments and for value-based care initiatives.

Adding services for sake of VBC

To some degree, much of the value-based care conversation contemplates a holistic approach to patients’ health, one that payers tend to offload onto providers in their individual capacity. This contemplates a wide spectrum of services.

BrightView Health has taken this track, offering comprehensive outpatient services including psychiatry, therapy and other wraparound services. The company has opted to contract out peer support services, Sposato said. The company is leaning more into providing mental health services.

Cedar Recovery rolled out an intensive outpatient program to address increasingly complicated and severe cases of addiction. However, the payers treat the IOP very differently from OBOTs and Cedar Recovery hasn’t yet found synergy across contracts, Trivette said.

Looking to get paid for what you’re already doing 

Cedar Recovery’s moves to pursue pay-for-performance contracts was an attempt to generate revenue that the fee-for-service paradigm doesn’t validate with reimbursement but has a tremendous positive impact on patients. The addition of the “care management fee” starkly contrasts the disincentive for addiction treatment providers to engage in top-notch operations and clinical care.

Further, seeking reimbursement for what providers already do simplifies the application of value-based care contracts across several payer partners, Sposato said.

“We can’t have a half-dozen different agreements that we’re trying to manage operationally,” Sposato said. “We run our business and measure our data against the outcomes that we find really important.

“We’re already doing the things that provide value for the payers. And then when we go to the contracting table and negotiate with them, we’re only really negotiating around those things that we’re already doing to just not add additional complexity to services, or to our operations.”

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