Behavioral health is still largely stuck in the fee-for-service reimbursement model, but industry insiders have hung their hopes on value-based care changing that paradigm. Still, this shift may just be the first step in behavioral health’s reimbursement evolution.
Population health management could stand as the future of behavioral health beyond value-based care, which payers often call value-based purchasing (VBP).
“I think that there is a next step that comes after VBP and that is population health management,” Dr. Steven Pratt, senior medical director of Magellan Healthcare’s employer segment, told Behavioral Health Business. “In this system, provider organizations are paid to manage a population such as youth in Medicaid in a county.”
Frisco, Texas-based Magellan Healthcare is a subsidiary of Magellan Health, which sells services, programs and solutions to payers. Magellan Healthcare provides behavioral health and other services.
Magellan Health’s population-based model of care identifies populations with unmet clinical needs and charts a care pathway designed to accelerate recovery. This approach is designed to improve outcomes and reduce costs, according to the company.
Population health management how-to’s
There is no one universally accepted definition of population health. Broadly speaking, while traditional behavioral health care approaches involve targeting the individual patient, population health management oversees a cohort of patients at the population level.
Specific cohorts of patients can include geographic populations, employee groups, ethnic groups, disabled persons, or any other defined group.
Provider groups are paid to care for a specified group, according to Pratt, and have more flexibility in their choices of interventions than with a fee-for-service-based system which requires the use of established billing codes.
“Provider organizations may find that much broader use of care managers facilitates achievement of efficiency and effectiveness goals,” Pratt said.
The American Health Association (AHA) has identified six “foundational” concepts for population health management. These basic principles include a focus on social determinants of health, the belief that the health system must address key demographic shifts and embrace innovative incisional models and that health creation requires partnerships across health care organizations.
American Hospital AssociationPartnerships may also involve organizations outside the health care system, such as social service organizations, Pratt said.
Population management approaches can differ based on population and the type of care being offered. According to the AHA, a strategy that seeks to improve the mental health of individuals within a defined population requires providers to develop a multi-disciplinary care team that may involve community-based interventions, ensure patients have 24/7 access to a care provider, use evidence-based practices, integrate physical, behavioral and chronic health care and develop relationships with patients and families.
Other requirements must also be met for this particular example, according to the AHA. These requirements include data and analytics to determine optimized care pathways. Providers must identify and track clinical quality measures at the system, practice and patient panel levels to drive performance improvement, ensure safety, effectiveness, and equity and improve methods and tools.
“Our approach to population health is looking at that data in that holistic approach, and looking at what are the ways to begin to manage that population of patients,” Dr. Anil Singh, senior vice president and executive medical director of population and curated health at Highmark Health, told BHB. “It’s also leveraging data and analytics as well as predictive modeling to say, which [condition] is driving the other. In certain cases, finances could be driving a behavioral as well as a physical condition. In other cases, the physical is driving the other two. In other cases, the mental is driving. So it’s determining, where do you begin?”
Pittsburgh, Pennsylvania-based Highmark Health is a health organization that includes a health insurance plan with 6.9 members and a regional hospital and physician network.
The company has placed a special focus on whole-person behavioral health care, which aligns closely with a population health strategy.
Obstacles and benefits
Before the behavioral health industry can progress to an approach other than fee-for-service, it must first contend with at least one major obstacle, according to Pratt.
The American health care system is fragmented, and different models of care are “often poorly coordinated,” Pratt said. Siloed health care systems could pose barriers to the levels of communication and coordination necessary to employ a population health approach.
Financing models and policy requirements must also be met, according to the AHA.
Payment mechanisms must be in place to fund or incentivize health care organizations to meet improvement goals for patients, which can include pay-for-performance, bundled payment, shared savings, or other financial models. Regulations should also be in place for payers to choose “consistent meaningful quality metrics that focus on outcomes (as opposed to process),” per the AHA.
Population management will, overall, produce healthier people, Singh said. It may also reduce health care costs.
“[The benefit is] just healthier individuals,” Singh said. “Our goals are to really improve the health of that population to the best we can. It’s really creating that proactive, upfront, preventative type of care. The more we can do, the better the health of the population and therefore reduce the unnecessary utilization in the healthcare system, which we know is not sustainable in a future state.”
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