An overabundance of options typically isn’t a bad thing. Yet the influx of novel ways to access therapy and mental health services – propelled by the increased attention to behavioral health during the pandemic – has left payers, providers and patients questioning what is quality and what is not.
As the behavioral health industry simultaneously grapples with an ongoing quest toward standardizing measurements, the overabundant options for care have only added confusion.
“The No. 1 issue in addition to access to care among other things that people are concerned about is the explosion of available options to take care of your mental health and navigating which solutions may be best,” Jason Youngblood, senior director of behavioral account management and sales operations at Cigna, said during a recent BHB Perspectives podcast episode. “There’s confusion because there are so many different ways to take care of yourself, but who needs what and when? And how do we assure that people are getting into high-quality care?”
Bloomfield, Connecticut-based Cigna (NYSE: CI) is one of the largest health insurance companies in the United States, with more than 172,000 behavioral health providers in its network.
Among its swath of behavioral health providers is Meru Health, a digital therapy program that allows patients to access video sessions, daily therapy exercises and direct chats with an assigned, licensed therapist via their smartphone.
While the explosion of care options may have created some confusion, it has also been a driving force in necessary dialogue around measurements of care quality, Kristian Ranta, CEO and founder of Meru Health, said during the podcast.
“There’s been more and more talk about the quality of care. Access is great, but then how do you make sure that access is to something that’s actually effective and good?” Ranta said. “I think it comes down to the fact that behavioral health, historically, hasn’t really been data-driven or measurement-based.”
As increased access has paved the way for an escalated movement to define measurements and quality, urgency has also risen around value-based care conversations with payers.
The quotes below are excerpts from a conversation on the Behavioral Health Business Perspectives podcast. Responses have been edited for style, length and clarity.
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BHB: What are some of the challenges to delivering high-quality behavioral health care?
Ranta: There are systemic challenges, in a sense. If you think about it, most providers out there have not been doing measurement-based care.
It’s kind of changing, but still, a majority of providers are not doing that. So I think that’s a systemic shift that needs to happen one way or another, and it’s going to take some time.
I think another challenge is how to incentivize measurement-based care. If we all accept and believe that it’s going to yield better quality in the future – which I think has been shown in many research studies to be the case – can we build in incentives to reward providers that are actually practicing measurement-based care? And what are some of those ways? I think incentives are really powerful.
I think it’s just that mindshift and infrastructure shift. But I think that is where [payers] have a lot of power in this change – to incentivize the high-quality care. In therapy, there are various needs, there are various flavors and colors, but as a general movement, I think it makes sense to start really trying to move towards more measurement-based care.
How easy or difficult is it for Cigna to find high-quality behavioral health care partners?
Youngblood: There’s been some stigma around outpatient professional clinicians who participate in insurance company networks. I’ve dealt with that stigma throughout my career. However, our behavioral health network of outpatient professional counselors has doubled in size. I think we’ll hit the half-a-million mark by the end of the year. The attrition rate on our network is very low.
My first mentor in my first job taught me that providing therapy was more art than science, and I’ve seen a shift. I didn’t quite buy that back then, but I’ve seen a shift. We are focusing more on the science to complement the art.
I think there has been a nice evolution in the industry and in the field, as more clinicians are part of groups or clinics where there are practice management systems that can have easy measurement around some metrics. There’s a focus on it because people want to do good work and make a difference. Measuring that can be difficult, but it has gotten much easier.
So I would say we’ve had no problems in recruiting providers. We’re getting better every year at defining what high quality is, how to measure that and how to communicate with our providers. They’re interested, and they want to know what the quality metrics look like.
Can you both share tips from your experience on how providers and payers can work together to align goals and forge agreements?
Ranta: We have a very different kind of way of providing mental health care. We combine the mind and the body very strongly. We also have a biofeedback wearable for members as a wellness device. Then we also have a programmatic offering, so kind of a therapy, which has a beginning and an end for most of our patients, so people can really dive in and get the benefits in a limited time frame versus being in endless therapy.
This model isn’t the typical model. So for us, contracting with the payer, getting reimbursed and figuring all that stuff out is by no means trivial. We are very grateful that we were able to have years ago, found a way to get contracted with Cigna for this novel model. But generally for us, it has been a challenge working with payers in the market. It’s just not easy to fit into the existing standard fee-for-service structures with all of these varieties of services that are bundled together.
Youngblood: Talking about money can be very uncomfortable for everyone, whether you’re an outpatient individual who has your own company or your own practice, or whether you’re part of a clinic or a group or an organization.
The second thing I want to acknowledge is when you’re in a well-established system that is really big, it is really difficult to think about how to do things differently. Sometimes it takes, at the baseline, a passionate commitment to doing what’s best for others and building on that connection.
At Cigna, with Meru, we’ve come together, and we’ve had many discussions. Together, we get really excited in some ways, then have to step back a little bit and then get excited in other ways to keep that conversation going.
Understand it’s not easy on either side, but you have to really kind of meet each other at your commitment to improving the health, well-being and the behavioral health of those that we serve.
What reimbursement trends do you both have your eyes on?
Ranta: We announced last year that we put 100% of our fees at risk against performance guarantees outcomes, access, time and patient engagement. What we’ve learned is that for most payers, it is actually really difficult to administer.
Most people would immediately agree that for us as a provider, putting 100% of our fees at risk to serve the members and get quick access, great outcomes and great engagement, is a positive thing. Still, the systems are so often difficult to adapt to these kinds of structures that we can’t administer or deploy these models.
I think, generally, value-based care, putting fees at risk and performance guarantees are very important for the further development of quality of care and building the right incentives in the market. But it’s quite difficult. The historical structures, reimbursement structures and contracting structures do not easily allow this.
Youngblood: I think as we’re trying to make some of these changes in the industry, it seems like things are dragging slowly, but time does get away from us.
Fee for service is very standard in the industry. I think it will always have its time and place. I think we’re seeing some of this shift in the Medicare and Medicaid space and in the commercial employer business, where most large employers, especially, are self-funded. But we can’t just change our reimbursement models without really helping them understand that what we’re doing is delivering high-quality care and high value.
It is very complex, but we are moving toward that. While fee-for-service is foundational, we do believe that value-based care arrangements are the wave of the future. In some regards, I think it can’t happen fast enough, but I think we will see continued slow evolution up until we hit a tipping point, and then things will go very fast.
