Missing the whole story: Behavioral health slow to adopt new pay models
A few weeks ago, Dr. Kevin Bozic saw a 68-year-old patient who appeared to exemplify the "perfect bundle" under Medicare's test payment program for knee replacements. She was only in the hospital for one night. She wasn't readmitted and didn't report complications within 90 days.
But in their follow-up visit, she was miserable. That perplexed Bozic, an orthopedic surgeon and chair of the surgery and perioperative care department at the University of Texas at Austin's Dell Medical School. The surgery, performed by a different surgeon, was 18 months ago. The patient's X-rays looked fine, her range of motion was good and there wasn't any swelling or redness around her knee.
Then Bozic checked out her preoperative X-ray, which showed very little arthritis to begin with.
"I suspect this was a patient who had significant anxiety that was manifesting itself as knee pain and perseverating on that, became fixated on that knee pain as the source of her problem and saw a well-meaning surgeon who said, 'I know how to fix that. I'll do surgery,' " he said.
Bozic's practice now screens all patients for behavioral health conditions like anxiety and depression that could be contributing to their pain prior to surgeries, a protocol that wasn't in place when the 68-year-old patient had her knee replaced. If providers detect such conditions, they advise patients to see their in-house therapists before agreeing to surgery. Since making the change in June 2016, the practice has reduced the number of orthopedic procedures it performs by nearly 50%, while increasing the number of patients treated using different modalities.
"You need a multidisciplinary solution where you can step back and say, 'OK, what else is going on with this patient?' And then you need the ability to treat the other things that are going on with that patient," he said.
Value-based purchasing hasn't caught on in the behavioral health sector at nearly the same level as other medical specialties. That's partly due to the fact that most providers don't use standardized metrics to gauge outcomes and some small providers are reluctant to adopt expensive electronic health record platforms and other technology necessary to facilitate data collection and sharing. To be sure, a wealth of pilot programs are actively testing behavioral health value-based purchasing among commercial and government payers in several states. But so far, they're happening in silos.
The Scattergood Foundation, a Philadelphia-based not-for-profit that awards grants to improve the behavioral health sector, released a report in September that highlighted 11 such models, but none have been scaled, said Joe Pyle, the organization's director.
"I think we're starting to see it, but not at the level that we need to," he said.
The CMS last year rolled out new diagnostic codes that providers can use to bill for patients with psychiatric or behavioral health conditions, including substance abuse, who are treated by a primary-care team with physical and behavioral providers working in collaboration. Codes for the Psychiatric Collaborative Care Model were updated in January.
The Center for Medicare and Medicaid Innovation hosted a town hall in October 2017 to brainstorm a more comprehensive way to change how behavioral health services are paid for, including value-based purchasing, but the agency has not announced further plans. A CMS spokesman was unable to provide an update.
Pyle said he left the event feeling optimistic.
"This is where the government can be a leader," he said.
Experts interviewed described the new codes as a good first step, but agreed what's sorely needed is a comprehensive payment program that ties everything together.
"There's a desire for a particular model that the Innovation Center could put forward, because they would have the ability to create a more consistent approach where you can capture the data and really evaluate the effectiveness," said Jeff Micklos, executive director of the Health Care Transformation Task Force, an organization that unites patients, payers and providers around value-based payment and care delivery transformation.
In comments to the CMS as the codes were being developed, the National Council for Behavioral Health suggested the government expand a two-year pilot program—the Certified Community Behavioral Health Clinics program—that's currently happening in eight states. Under the Substance Abuse and Mental Health Administration program, intensive clinics have been set up for people with untreated severe mental illness or addiction. They receive fixed payments from Medicaid based on their anticipated costs. The program uses standardized quality metrics across the states. The program received a $100 million, two-year boost in the recent omnibus budget package signed by President Donald Trump.
"A lot of voices have said this makes sense," said Chuck Ingoglia, the National Council for Behavioral Health's senior vice president of public policy and practice improvement. "Hopefully that holds some sway with the CMS and the Innovation Center."
Part of the holdup is that value-based care relies almost entirely on data to measure outcomes and quality, and that means using standardized metrics to gauge patients' improvement, or lack thereof. In behavioral health, that's easier said than done.
Today, few providers—medical or behavioral—use standardized outcome measures when they treat behavioral health conditions and substance-use disorders, despite the diligent use of lab tests in the treatment of medical conditions like heart disease and diabetes, said Dr. Henry Harbin, a psychiatrist and healthcare consultant who closely follows the implementation of value-based care in behavioral health.
Before value-based purchasing can truly have an effect in the sector, providers need to agree on such metrics, said Harbin, formerly the CEO of Green Spring Health Services and Magellan Health.
"CMS and private insurers could step up and say, 'Look, I'm already giving you money for behavioral health conditions, but you're not providing me with the level of data that I would need to know how many you're treating and how the care is going,'" Harbin said. "But they are requiring that for other conditions."
Another setback: Behavioral health providers don't always use the same EHR platforms as other providers, which hampers the data-sharing that's so critical to value-based care.
In some cases, behavioral health providers don't have an EHR at all, Micklos said. "There's a lot of paper-based practices on the behavioral health side still."
Joe Mulligan, managing director with the healthcare investment bank Cain Brothers, said the hallmark of effective value-based purchasing programs is access to real-time data, especially behavioral health data, which often contributes to medical conditions.
"They have to get a complete picture of not only the health history, but also some of this behavioral history is increasingly becoming part of it," he said.
Another lesson Bozic took away from the "miserable" knee-replacement patient was that bundling payments at the procedure level simply encourages more procedures, exactly the problem value-based purchasing strives to correct.
"If you're bundling at the procedure level, you're just assuming that the procedure was appropriate in the first place, so let's make the procedure as efficient as possible," he said. "As opposed to, 'Well, let's back up and say, 'Is surgery even the right way to treat this patient?'"
His practice now bundles at the condition level for knee or hip arthritis, and that payment is the same regardless of which services the patient receives, whether it's surgery or counseling.
In addition to surgeons, Bozic's practice has in-house social workers to counsel to patients with behavioral health diagnoses, nutritionists to help patients lose weight and physical therapists to help patients exercise.
"Some of those patients who are treated with those modalities, their pain gets better and they're effectively treated," Bozic said.
Other patients still require surgery, but they're better-equipped to handle the procedure and the recovery, he said.
Bill Kramer, executive director for national health policy with the Pacific Business Group on Health, likens the transition to value-based care to having one foot on a dock and the other in a boat. Providers and payers aren't sure whether the boat will sail or not, and they pull back at the first sign it may tip or leak, said Kramer.
His not-for-profit group represents 60 organizations, including large companies like Boeing and Intel, that collectively spend $40 billion a year buying healthcare services.
"What we want to do is ensure that the boat is not leaking," he said. "It's solid and there's not only a safe place for providers to go, but that it's the best place for providers to go because the dock itself is starting to rot away."
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