There is an eagerness across the behavioral health industry to transition from fee-for-service into value-based contracts.

But, at times, this urgency can actually be a hindrance instead of a help, industry insiders recently explained at the Behavioral Health Business VALUE conference.

Crafting value-based care infrastructure, understanding how and what to measure and defining the mechanisms by which to report outcomes to payers should be processes that take time.

“This is really hard – and it takes a long, long time. We’re going to be talking about this and innovating on it for quite some time,” Shannon Werb, CEO of Array Behavioral Health, said at VALUE. “Don’t expect from the investments you’re going to be making this year that you’re going to see dividends on the value-based care side, even maybe next year.”

Mount Laurel, New Jersey-based Array Behavioral Health is a digital-first psychiatry and therapy practice that also delivers integrated care services.

Additionally, when shifting away from quantity to quality outcomes, it’s also important to know what payers aren’t looking for in value-based contract arrangements.

Phoenix-based Magellan Health, a payer primarily focused on behavioral health services, uses a scorecard during these conversations with providers. Among its considerations, it evaluates the number of encounters and claims providers have per year, the consistency of the patient population, focused treatment and established baselines.

Providers that have fewer than 10 patient claims per year, a variety of different diagnoses – rather than just treating depression, for instance – or high fluctuations in patient volume, are likely not the candidates to move into value-based arrangements right away, Steve Mihalacki, vice president of network analytics at Magellan Health, explained.

“Is the juice worth the squeeze? When you enter into a value-based arrangement with Magellan, you’re going to be getting some of our resources. You’re going to get access to clinical resources, analytical resources. You’re going to have an analyst coaching you through this process,” Mihalacki said at VALUE. “So you’re tying up a lot of resources, and if you’re not going to move the needle, and you’re looking at maybe having just $100 in annual savings, then it’s probably not worth it just yet.”

Moving the needle

Agreeing on the exact metrics to measure that indicate quality and value in behavioral health care is still something the industry seems to be far away from.

Utilizing Patient Health Questionnaires (PHQ), General Anxiety Disorder (GAD) scores, and Healthcare Effectiveness Data and Information Set (HEDIS) measures is a good place to start, however.

“What is quality in mental health? That’s the million-dollar question,” Dan Ferris, chief growth officer of LifeStance (Nasdaq: LFST), said at VALUE. “ … PHQ and GADs, I think, are the most widely agreed upon measures of quality. They may not be perfect, but they are something. The other thing that we can probably all agree on is that patients need timely access.”

That’s another “relatively basic thing” that any provider group can measure, Ferris noted.

Scottsdale, Arizona-based LifeStance is one of the largest outpatient behavioral health providers in the nation, operating across 550 centers in nearly three dozen states.

Using custom metrics that showcase the quality of care may add complexity to the process, but if something is being done uniquely and can be demonstrated in payer conversations, the investment is worth it. 

“If you’re doing something different, unique, tech-driven, that’s something that you would maybe come into a payer and say, ‘I’m doing it differently than my peers. I should be paid differently,’” Mihalacki said. “I think that’s one way to bridge the gap.”

Metrics may tell the story, but lacking the technological resources to aggregate that data, classify patients and measure outcomes continuously will ultimately hinder progress toward value-based care.

Getting clinician buy-in for technologies and measurement tools while also incrementally working toward the integration and sharing of patient data will help move toward this goal industry-wide, Werb explained.

“Building trust and ensuring that the providers and the payers are sharing data going in both directions is an important part of the process,” Werb said. “It’s really hard to understand where the right or trusted data is going to come from. We’re going to need to rely upon patient-reported data. We think about it also around the psychosocial and then the physical side of it.”

Measuring patients’ social determinants of health is also an opportunity for gaining insight from metrics and proving value, he added.

Improving before proving

A barrier for behavioral health providers can also be determining who gets credit for the savings when working with primary care or measuring physical health outcomes.

“I think the only way we solve the mental health crisis in our country is by integrating into primary care … ” Ferris said. “There’s no one right answer on what primary care integration looks like, but it is critical. I think it has to start with aligned goals, alignment on enrollment responsibility, and a program that financially and clinically is going to drive results for all parties, patients, the primary care practice and mental health providers.” 

Primary care is further along in transitioning to full-risk, value-based care than the behavioral health field, as it’s generally easier for physicians to demonstrate the quality of care across physical well-being outcomes.

True integration of care and parity incorporates mental well-being improvements, but as of now, there isn’t strong enough visibility into the data to point exactly to where the patient’s improvement came from: the primary care side or behavioral health care.

“I think there are ways for the work that we do on the behavioral health side to get an appropriate amount of credit for the work that we’re doing,” Werb said. “There’s no reason why we can’t align around the fact that you’re going to benefit from some of those shared savings or the upside payments that [primary care] is receiving.”

Incrementally, as technology advances and data interoperability improves, the behavioral health sector may be able to have more ownership over the metrics and measurement capabilities it can point to.

Until then, attribution is going to continue to be a challenge.

“Attribution is obviously really hard … ” Ferris said. “But you can’t let perfection impede progress. What we’re trying to do is deliver high-quality care, measure the things we can measure, and make sure that our primary care providers and the patients we’re serving are better because of our presence.”