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  • Writer's pictureMuhammad Sair Khan

Applying Value-Based Care to Behavioral Health




In last week’s blog, I talked about third-party payor audits and what they mean for your behavioral health facility. Before writing the article, I interviewed a representative from Anthem and Verscend (the third-party vendor conducting audits). During my conversations, I was surprised to hear that the purpose of these new audits is not to scrutinize behavioral health facilities but to push forward the value-based care initiative.


This week, I reached out to Aetna, Cigna and United Healthcare to gather more data. I also did research to understand exactly what value-based care is and the impact it is predicted to have on the healthcare industry. With initiatives being lead by major insurance companies, industry experts are predicting that by 2020, more than 75% of Medicare payments will go to physicians who participate in the value-based care model.


What is Value-Based Care?


With the increasing cost of medical insurance, the value-based care model aims to provide an increase in quality by switching from a fee-for-service payment structure to a model where physicians receive higher reimbursement for the health outcomes they receive with their patients. According to Anthem, value-based care models look to “transform clinical and payment methodologies to align incentives across providers, employers, members and payers in an effort to improve quality and cost outcomes, increase accountability and use medical technology more effectively.”


Value-Based Care Models Include:

  • Clinical integration and coordination

  • National Committee for Quality Assurance (NCQA)-based standards

  • Utilization of evidence-based medicine

  • Wellness and prevention services

  • Rationalized utilization of labs and other costly services

  • Innovative use of technology – electronic medical record (EMR)

  • Patient engagement, coordination, and navigation


Clinical Integration and Coordination


At the foundation of value-based care is the idea that general practitioners, specialists, hospitals and payors all work together to care for their patients. These groups of aligned physicians are referred to as Accountable Care Organizations (ACO). Each patient has a primary care physician who manages the patient’s overall health and refers to his/her network if the patient needs additional treatment, i.e. lab work, specialty care, hospital stays, etc. According to United Healthcare, “Unlike a patient-centered medical home, which is a single practice with multiple doctors, an ACO may include multiple physician practices as well as hospitals or other entities across an entire community.”


By sharing information and working together to treat and prevent illness, patient care is expected to be more thorough, accessible and efficient.

National Committee for Quality Assurance


The NCQA is a not-for-profit organization that develops standards among many specialties to help improve the quality of healthcare. Providers are encouraged to measure their practices against NCQA standards to improve their services. Payors also use NCQA standards to give quality recognition. Third-party payor audits are one example. Anthem is also using the NCQA standards to develop their quality improvement program, ‘Blue Precision.’ The Blue Precision program highlights doctors who are known for quality. It is currently operating in 12 states across the U.S.


Click Here to view the entire list.

Wellness and Prevention Services


The value-based care model places high importance on preventative health services. Because the utilization rate for preventative care is historically low due to access and financial burden; most health plans now waive copayments and deductible fees for services such as annual screenings, vaccinations, and counseling. Additionally, major insurance companies have initiated community health programs and introduced online portals to educate their members on ways to improve their overall health.

Innovative Use of Technology


New technology provides the opportunity for physicians to more easily cross-reference and share information with one another. This could dramatically decrease the amount of money insurance companies pay for lab work and other specialized tests. In one example, the Harvard Business Review describes a new system that allows a physician to electronically enter a lab request into a database that will automatically sync and scan the patient’s prior medical chart. The physician can then access historical data to determine whether or not the new test is necessary.


Although this could potentially decrease physician revenue in the short-term; it aligns with the value-based care framework which should financially benefit physicians in the long-run.

Implications on Behavioral Healthcare

Behavioral health professionals and those who receive treatment for mental health services know that behavioral health and traditional “medical” conditions have not been treated equally. Behavioral health has been excluded from mainstream discussion, leaving a gray area in regards to insurance coverage and reimbursement. The more media attention it receives, however, the more likely it is to be recognized by lawmakers and the medical community.


So what does this mean for behavioral health facilities and providers?


It is critical to connect with providers whose ideas and values you align with. Referrals and networks among behavioral health providers are not uncommon, but by also partnering with primary care physicians, hospitals, and other specialties, you will set yourself up for better patient outcomes, increased referrals and larger insurance reimbursement (according to the value-based care initiative).


Behavioral health facilities and physicians should conduct consistent internal audits using the NCQA standards and SAMSA guidelines to ensure quality, value-based services. This will ultimately position your facility or practice to participate in payor-provider networks and collaborate with other recognized professionals. Those who do not remain up to standard will find it increasingly difficult to receive authorization from payors and reimbursement for the services they provide.


The push for results-based treatment beginning with preventative services provides an excellent opportunity for behavioral health and medical communities to integrate. Substance abuse facilities and primary care physicians, for example, can work together to identify risk and address addictive behavior before the problem worsens. Last month, a bipartisan bill cleared the U.S. Senate allowing the Centers for Medicare and Medicaid Services to offer incentives to behavioral health providers who implement electronic health records, providing the opportunity for behavioral health specialists to work more efficiently with primary care physicians.


These changes are not going to happen overnight and may not have the revolutionary outcome that we hope. It is essential, however, to understand what direction the healthcare industry is moving and the impact that new fee structures and changes in legislation can have. With this knowledge, we can better prepare for the future by forming strategic partnerships with payors and other physicians. We can also focus more on sharpening policies and procedures to align with industry standards and take a more progressive approach to the way we think about health care.


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