3 Pillar Approach: Behavioral Health's Shift to Value-Based Care

Health plans are increasingly embracing value-based care, which aims to incentivize care quality and outcomes over volume, and lower total healthcare costs. However, the same can’t be said for all areas of health care. While value-based care is becoming increasingly prevalent for physical health, behavioral health remains in the waiting room. 

A major reason for this is we treat behavioral health as separate – and not as important – as physical health. That’s a mistake. Treating behavioral health drives a clear ROI. According to Milliman, people with serious behavioral disorders have medical costs 10 to 15 times higher than patients without psychiatric illnesses. And healthcare spending is two to three times greater for patients with a mental or behavioral health diagnosis than for those without.

Complications with one-size-fits-all models for behavioral health

Payers have begun to migrate behavioral health from fee-for-service to value, but have tried to apply a one-size-fits-all model to behavioral health. This won’t work for two reasons: cost and data collection.

Cost of care

On cost, behavioral health providers experience financial and administrative constraints that make traditional value-based models less appealing. For example, the majority of behavioral health providers do not have a sophisticated Electronic Medical Record (EMR) to capture data due to cost. This issue stems from behavioral health providers being left out of an important financial incentive program. 15 years ago, HITRUST, a government-led incentive for physical health providers to adopt EMRs, was adopted, minimizing time and cost resources previously allocated for audits required of organizations. However, behavioral health providers were left out of the incentive program and in turn, left without a robust data collection tool. 

Data collection

As such, behavioral health providers have adopted cheaper, lightweight technology platforms called Practice Management Software (PMS). These programs tend to allow for sophisticated note-tracking but largely fall short of the rich data collection an EMR can ingest. Data collection is critical for health plans to employ value-based care. In behavioral health, “quality” is measured via assessments. Because claims can take months to mature, it is nearly impossible to attribute to physical health cost reductions, where many behavioral interventions ROI is captured.

Health plans need to pay for and/or drive the adoption of data-collection applications to allow for the wide adoption of value-based care models. While a larger physical health office may have the administrative bandwidth to do this, the majority of behavioral health providers are owner-owned and operated.  SAMHSA reported of all mental health facilities, 81% were privately-owned: 63% were operated by private non-profit organizations and 18% were operated by private for-profit organizations  Given the skepticism in ROI for behavioral health, the onus is on behavioral health providers to adopt technology that tracks and measures outcomes proactively.

Cerebral is leapfrogging this issue by driving value-based care adoption proactively for health plans. We put together a three-pillar approach to value that is patient-centic, provider-friendly, and quality-driven while incentivizing provider and payer stakeholders accordingly.

Here’s a quick overview of the three pillars we will cover:

1. Create a universal approach to quality metrics
2. Update the technology infrastructure to track quality
3. Create the right incentives to push toward quality

1. Create a universal approach to quality metrics

Unlike innovations within the physical health environment, there is no objective way to measure and track progress in behavioral health. The standard way outcomes are tracked is with subjective, patient-reported outcomes. These capture information from the patient’s perspective. They are standardized and validated, but they are by no means as objective as say a blood test.

Varying metrics and outcome data make it difficult for decision-makers like health plans and employers to identify high-quality providers in an extremely crowded competitive space. In fact, new behavioral healthcare startups raised more than $5.1 billion, more than any other clinical space. But without an agreement on what metrics should be tracked, every new startup has the potential to create its own metrics and standards.

The solution to tracking quality metrics

Solving this requires universal, widely-adopted quality standards for behavioral health, and sets organizations up for success to create patient-centered care models. These standards should be specific to the diagnosis, measurable through data, and involve a range of stakeholders, such as payers, providers, employers, and even patients themselves. They also need to be actionable for clinicians. Importantly, payers and employers must lead the way by overseeing universal quality metrics to minimize bias and create a level playing field. 

Example of creating actionable standards for quality metrics tracking 

Cerebral is able to innovate in this field because of our patient engagement tools, robust EMR, and best-in-class data science team. As a result of our technology infrastructure, for example, we are able to measure patient-reported outcomes well beyond assessments, including messaging frequency and type, as well as suicidal ideation. Another example of our technology infrastructure allowing for more robust data capture is that we can deploy Clinical Decision Support through our EMR and understand in real-time the impact of such interventions on not only assessments but clinical outcomes and hospitalizations, which meaningfully drives HEDIS scoring.

One example of this is lab work. By reminding our clinicians to order labs through notifications and educating patients about the importance of getting them, we can ensure consistent blood draws for patients that require it due to medications. We’ve been able to maintain a 100% compliance rate with lab monitoring for tens of thousands of patients.

2. Update the technology infrastructure to track quality

Behavioral health needs to widely adopt EMRs. Although there are a few behavioral health-specific EMRs currently, they are not widely used due to cost or are not sophisticated enough to track data on a scale that can bring meaningful impact.

According to a Behavioral Health Business article, payers appear to be at the forefront of standardizing value-based mental health care. While this is exciting, the progress for providers is disproportionate. We shouldn’t be surprised by this as the prior payment models tied to fee-for-service didn’t incentivize it.  However, building out processes and workflows you need to support innovative quality measures (along with traditional ones, like HEDIS measures), requires building out parts of your technology beyond the status quo.

The solution to updating technology infrastructure

We acknowledged that there is a lack of behavioral health technology infrastructure, so we built our own. 

Cerebral’s proprietary EMR system can longitudinally track a range of evidence-based clinical data and outcomes, such as clinical assessments (PHQ-9, GAD-7, MDQ, ASRS, ISI), lab monitoring, hospitalizations, and other value-orientated measures, at scale. It can also seamlessly integrate with partners – health plans, employers, and health systems – removing claims from silos, providing unique transparency into quality, and enabling actuaries to finally be able to attribute cost savings to behavioral health.

3. Create the right incentives to push toward quality

Behavioral health providers are set up to maximize the cost per visit, not the outcomes per visit, and thus, cash-paying customers present a more lucrative opportunity. Additionally, many behavioral health providers do not participate in insurance networks due to low reimbursement and a burdensome claims process. 

For high-acuity and high-risk patients with serious mental illness that need advanced care, there is actually far less incentive to provide quality care, because there is essentially zero financial incentive to do so because providers are required to do much more work and carry more risk. 

The solution to creating the right incentives

This is another area where Cerebral is proactively moving the behavioral health industry forward in an effort to drive value-based care more quickly. For example, we are actively adding to the number of conditions our in-network providers can cover, which includes opioid use disorder, bipolar, and schizophrenia, among many others. To do this, we not only pay for clinician education, clinical decision support, and other educational initiatives, but we also pay clinicians extra for engaging patients in ways that are not covered by fee-for-service. In our most recent white paper, Cerebral showcased how our incentive program to pay providers to make contact with a patient experiencing suicidal ideation on the phone outside of scheduled appointments resulted in 49.7% no longer report suicidal thoughts after an average of 6 months.

At Cerebral, we are excited to move more quickly to value-based care. These initiatives have drawn significant interest from health plans, health systems, employers, and others. If you represent one of those groups or are interested in learning how Cerebal can drive patient-centric, value-based care, please reach out.