Value-based care in behavioral health is confusing. All the jargon makes it seem like everyone is speaking a different language.

A value-based care arrangement can mean many things, including full-risk, pay-for-performance, or even shared savings. But the biggest obstacle to a value-based care future is the lack of national standards.

To complicate matters, these conversations around moving towards value-based behavioral health care have been ongoing for decades. It almost seems like “a bad joke,” according to speakers at Behavioral Health Business’ VALUE event.

Still, there are glimmers of hope and more concrete examples of value-based care arrangements that work. And some payers are getting upfront with what they really want out of a partnership.

What can a working VBC contract look like?

For example, Doug Henry, vice president and medical director of enterprise behavioral health at Highmark Health, is looking for providers to take on some level of risk.

“I’m really interested in shared risk models because they have so much more potency to change provider behavior rapidly,” Henry said. “We have [a partnership] with the Allegheny Health Network, which is a network of 14 hospitals in western Pennsylvania and western New York. We have the largest value-based shared risk arrangement in the United States, covering 350,000 lives in western Pennsylvania and western New York. So that is a bold step that we took in 2024, and 2025 will be our second year of that shared risk arrangement, but it’s working very well.”

Pittsburgh, Pennsylvania-based Highmark Health provides health insurance to 6.9 million members in Pennsylvania, West Virginia, Delaware and New York.

While risk-based models are perhaps the north star for payers, they can be trickier for providers moving into alternative payment models. And more often than not, value-based care contracts are not uniform across an organization and may vary by treatment type and payer relationship.

“We have a lot of models. We take care of patients for the long term in our comprehensive treatment centers,” Dr. Stephanie Eken, chief medical officer of Acadia Health, said. “We also have acute care facilities and have specialty divisions. Some contracts we’ve done in the past year are not total risk but are really pay-for-performance types of contracts where you have a per diem and then some quality metrics that we’re trying to hit. I would say, if we could, as an industry, also come together on what that means to look well from our patient population, that would help get us further.”

Acadia Health (Nasdaq: ACHC) is the largest behavioral health provider in the country. It operates roughly 260 behavioral health facilities across 38 states and Puerto Rico.

However, Acadia isn’t the only large provider that plays with various types of value-based arrangements in behavioral health. LifeStance Health, the largest outpatient provider in the country, is tackling the implementation of value arrangements at scale.

“At LifeStance Health, we don’t have a one-size-fits-all just because of the scope and scale we have right now,” Dr. Ujjwal Ramtekkar, chief medical officer of LifeStance, said at VALUE. “One approach that we’re taking, which I call radical, is redefining value from a financial term to a clinical outcome and engagement term. An example is a financial and clinical model aligned with quality measures, engagement, and outcomes. We have some straight-up pay-for-performance models with some of the regional payers, but notably with Optum and… some smaller payers, we actually have clear metrics that are focused really on the longitudinal engagement and the quality metrics that we are designing.”

LifeStance (Nasdaq: LFST) operates approximately 550 centers in 33 states and employs around 6,800 psychiatrists, advanced practice nurses, psychologists and therapists.

What are the important measures?

For a value-based care contract to work, there must be an agreed-upon measure of value between the provider and payer. While there are no universal standards, many payers and providers are beginning to discuss what they are looking for openly.

“We measure a laundry list of items, but what we have found so far is the No. 1 measure that we can execute against that drives total cost of care savings is therapeutic alliance,” said Amy Ayrault, president of Evernorth Behavioral Care Group. “So as we look at what that means, typically, we understand that to be three sessions with the same therapist, within a defined period of time. And we’ve actually been able to demonstrate with one of our payer partners that drives down total cost of care by up to 20%. Turning that into a number is like $1,800.”

In 2024, Cigna’s (NYSE:CI) health service division launched the Evernorth Behavioral Care Group. The hybrid behavioral health group, launched with over 1,000 clinicians, focuses on value-based and measurement-based care.

The therapeutic alliance could be a good indicator to measure patient engagement, and engagement is a predictor of longer-term outcomes.

“We found that if somebody is engaged in their outpatient [care] within the first 90 days of initiation of treatment, that predicts their longer-term outcomes, and we pair it with the standardized tools to actually showcase the improvements as well,” Ramtekkar said. “It’s not enough to think about somebody’s improvement in their health or weight loss because they enrolled in the gym. They have to go to the gym and work out. … We’re not only looking at the successful linkage to our initial services for treatment initiation, we’re actually tracking their overall engagement over time very aggressively, in the first 90-day critical period, and then also making sure that we are doing data-driven pivots in their treatment plans based on the symptoms.”

Meanwhile, Eken said that she thinks about value from a patient perspective. Some specific metrics she is looking at are readmission rate, length of stay and how long patients are away from their families and jobs.

For longer-term programs, such as comprehensive treatment centers where patients are often getting treated for substance use disorders, Eken said she is looking at how quickly Acadia can get them the appropriate dose of medication so that they can return to their daily functions.

Patient-reported data can also be a large part of measuring value.

“The one data point that I haven’t heard mentioned, and that is meaningful to me, is days to remission from a certain scoring band, usually for depression or for anxiety,” Henry said, “where we have pretty well-established norms and standards and words when you say moderate to severe, everyone knows exactly what that means, and that’s not true across diagnostic categories.”

While the industry is likely still years away from one standardized measure of value, the future will likely include some combination of patient-reported outcomes, engagement, and financial measures.