Fixing the Growing Payer-Provider Divide in Behavioral Health

Behavioral health’s odd-duck status requires a unique approach to the payer-provider dynamic.

Historic challenges have demonstrated that payer-provider negotiations and partnerships require an approach fundamentally different from other types of business, even other health care segments.

Often, involved parties need to alter their expectations to reflect reality instead of a vision of the future. For example, paying attention to the nitty-gritty details of payers’ administrative and technology systems shows why idealistic attempts to prompt change via technology are much easier said than done.

“Let me put it this way, there are probably 20 to 30 different ways to bill intensive outpatient programs (IOPs) and partial hospitalization programs (PHPs),” Dr. Frank Webster, chief medical officer of Behavioral Health for Health Care Service Corporation (HCSC), said during the Behavioral Health Business conference INVEST 2024. “Nothing on the medical side of the house looks like that. It’s one code. Between the hodgepodge of poorly defined revenue codes and vague HCPCS and CPT codes, it’s a mess.”

He added that HCSC operates on “40 or more” legacy technology systems with a system architecture that “would give most people a screaming headache fit.”

“It definitely does that to me. The words COBOL and fax should not be used in health care,” Webster said. “Yet it is every day.”

The hodgepodge of systems means that traditional and digital behavioral health providers need to expect a much longer timeline when working with payers. Where a provider organization may imagine a 90-day timeline to get something done, payers would require two years.

The downstream effect of that type of internal payer dynamic often requires that behavioral health providers withstand enormous delays in establishing deals and partnerships, Webster said. During the interim, models that are feasible under more cut-and-drive reimbursement or partnership models are more likely to get where they want to go.

“That actually helps to grease the wheels so that they can work on doing something more innovative,” Webster said. “So if you can afford that, that actually is a really good strategy for dealing with insurance.”

Eric Frieman, co-founder and CEO of Forge Health, said that time is a vital element in getting payers to recognize the value of its population-specific approach, which has been key to its growth. For example, one of the hybrid in-person and digital behavioral health provider’s specialty populations is the first-responder community. It wasn’t until there was enough time to generate a large volume of referrals from police departments, including NYPD, that payers took note and added commensurate value to its specialized services.

“Anyone can say that we have a specialty program,” Frieman said. “A payer will not pay attention to that. But, obviously, after doing the work and proving the worth, ultimately, the payer will pay attention.”

Forge Health also focuses on partnerships with other health care providers. Getting physical health care provider organizations to recognize the importance of addressing behavioral health with specialized efforts still takes time. One study found that patients with both physical and behavioral health conditions drive nearly 57% of health care spending. Paying attention to the interplay of behavioral health and physical health outcomes has been vital to the company’s growth, Frieman said.

Forge Health most recently unveiled a psychosocial oncology program.

Using care outcomes and other measures to prove a behavioral health provider is a worthwhile partner is a must when engaging with health plans, Stuart Archer, CEO of Oceans Healthcare, said during the panel.

“I think all too often behavioral health providers say, ‘Pay me more; I’m underpaid,'” Archer said. “In defense of the payer, [some providers] never bring their quality forward to say, ‘This is why, and this is what I think is unique about me.'”

Oceans Healthcare’s historic focus has been on operating treatment facilities that treat behavioral health conditions on an inpatient basis, especially for those who are elderly and those that have serious mental illnesses (SMIs). However, the company is opening an increasing number of IOPs and PHPs that have wider patient age targets, including some for pediatric patients.

The company’s focus on underserved populations has led it to being one of the — if not the — only providers where it operates at a local level. Such expansions of services are meant to be responsive to community members and demonstrate access to a spectrum of coordinated care services. The company is bolstering this effort by rolling out an electronic health record, a rarity in the psychiatric hospital segment. 

One change in Ocean Healthcare’s dynamic with commercial payers has been an emphasis on the value of outpatient services, Archer said.

“There’s been this growing awareness that if we don’t have these wraparound services if we don’t have some of these other pieces of the pie, we’re just going to continue to replicate the same outcome,” Archer said.