The Do’s and Don’ts of Value-Based Behavioral Health Contracting 

Value-based care has been part of the health care discourse for decades. But behavioral health providers have only recently placed a new emphasis on breaking away from the fee-for-service paradigm.

While still nascent in practice across the industry, several behavioral health organizations are seeking to introduce models that feature elements of risk sharing, trading outcomes and processes and accountability. Now, the conversation is about preparing for what could be a swift transition should enough payers get behind value-based care in earnest.

“I believe that we are there now, and I think that we’ve been there,” Dr. Tom Britton, CEO of the eating disorder treatment company Accanto Health, said at the Behavioral Health Business’ VALUE conference. “If you’re in the fee-for-service model, you will be outdated very shortly, if you don’t move quickly.”


Granted, Britton acknowledged that the past ten years have seen claims of each year being “the year” come and go. Dr. Benjamin Nordstrom, chief medical officer for the outpatient addiction treatment provider Behavioral Health Group, added that value-based care is “too good of an idea to give up on.”

He pointed to electric cars. Intuitively, the product makes sense, but until recently, there has been a hesitancy to have the disadvantage of being a first mover.

On the commercial side of addiction treatment, Behavioral Health Group has been able to get payers to ask them what the measurement and outcome foundation of the contract should be. In that scenario, there is still a diversity of potential outcomes to measure. This may complicate value-based care contracting. But it also allows each provider to establish deals that work for them and not be shoehorned into something incongruent with the provider’s operations.


Do be accountable for what you can control

Britton notes that payers generally want to lower overall health care utilization among members. He maintains that improved behavioral health will lead to lower total health spending. Payers know this. Evernorth, the services division of the health plan company, published findings that show outpatient mental health services alone reduce plan cost by about $1,400 per person in one year and about $3,100 per person across two years.

However, given the specific focus of behavioral health, it’s not wise to assume accountability for things that are far beyond a provider’s reach. Nor would it be advisable to tie accountability to measures that don’t truly reflect the impact of that organization’s work.

“The very first ‘do’ is to determine your goals going in and where on the spectrum you are comfortable with risk,” Britton said. “If you understand your data, if you understand your population, and you understand your goal, I think you can set a good target.”

Still, health is multifaceted and care needs to address several and, at times, overlapping needs that may extend beyond behavioral health care. One strategy to address this is collaborating with other care providers, an approach taken by youth- and young adult-focused collaborative care and behavioral health provider Bend Health.

To make the collaboration work in conjunction with its bundled payment strategy, Bend Health gathers and shares as much data as possible with its payer partners and other care partners, Dr. Monika Roots, the president and co-founder of the organization, said during the panel.

Bend Health uses an adaptation of the collaborative care model. It recently announced it would expand its clinical focus to young adults.

Do anticipate and account for friction

Agreeing to specific measures that capture the value of the behavioral health care provided avoids issues that complicate the execution of value-based care contracts. Often, well-established measurement tools are too generic to accurately reflect the value of the work. Ensuring accurate and genuinely useful measures can also go a long way in rolling out value-based care initiatives with clinicians.

“There are many practitioners out there that were not trained in measurement-based care,” Roots said. “They think that, in some ways, it’s almost a judgment and that it’s extremely subjective.”

Training clinicians on value-based care-focused practices such as outcomes tracking must include clear ties to improving the care. This approach can also help improve clinicians’ abilities. It can also identify when a case may be beyond the scope of practice for that clinician, allowing patients to get the level of care they need.

“I think that emphasizing paying for quality is an important shift that we need to do and that needs to be part of the training,” Roots said.

Tying initiatives like measurement-based care back to better care also helps establish clinician buy-in. Nordstrom mentioned that measures such as the Brief Addiction Monitor can be built into familiar frameworks for clinicians to use in their daily practice.

“They can see why what we’re doing can actually be used as an assist for them to do their job, as opposed to just one more damn thing that they have to do,” Nordstrom said.

Don’t do everything all at once

Britton’s previous roles as CEO of the addiction treatment providers American Addiction Centers and Gateway Foundation showed that scale alone wasn’t enough to push large payers toward value-based care. Seven years ago, he heard in meetings with a national payer that the plans’ technology for handling claims wouldn’t be able to accommodate a value-based care contract. However, payers, especially large Medicaid payers, have more capabilities and more interest in alternative payment models.

Still, payers must resist the temptation to move fully to a value-based model. He worked “very incrementally” on adoption and expanding value-based care in his organizations.

“If you don’t have a really good understanding of your data, if your staff are not trained, if you don’t have the needed technological infrastructure, you’re going to totally put your whole organization at risk,” Britton said.

The incremental progress started with pay-for-performance to small and increasing amounts of risk on reimbursement. He doubts any scaled company will go 100% at-risk unless the provider is “very cut and dry.”

Don’t settle for less than premium rates

The value-based care model is premised on care providers going beyond providing quality health care. It often calls for that care to account for many other facets of human health, such as physical health conditions or social determinants of health — very little of which is paid for in the fee-for-service paradigm.

Taking on more of those challenges is likely to lead to better outcomes, and payers have clear incentives to do that, Britton said.

“The risk-shared model is: you will pay us more because we are assuming an expectation that our treatment will deliver better results,” Britton said. “The better our results, the more profitable it is for the company; the worse our results, the less profitable the company. So, I think you should get paid more.”

Nordstrom said that providing quality care that genuinely lowers health care spending can be seen as a proxy for reducing human suffering. On top of that, a payer system that incentivizes quality will edge out lower-quality providers.

“You can make a pretty good business case for that because you don’t have to compete with them” as a provider, Nordstroms said. “They shouldn’t be out there. If your money is how you vote on what exists in this world, we shouldn’t vote for crummy providers to exist.”

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