Tech Facilitates Tighter Collaboration Between Payers, Providers

Behavioral health trends point to a pressing need for new approaches to care, accessibility and quality across the payer-provider-patient lifecycle. The global pandemic led to a 25% increase in behavioral health-related visits between 2019 and 2020. In January 2021, there were 3.3 times more visits to a psychologist or psychiatrist than virtual primary care appointments. That same month, 60-minute psychotherapy became the most common telehealth procedure.

Traditionally, behavioral health has been segregated and treated in complete isolation from the medical and physical needs of the patient. The pandemic exposed the fact that 70% of adults with a behavioral health disorder also have a physical health condition. In connecting the dots between behavioral and physical health, the pandemic drove the need for a unified, integrated, whole-person approach that offers a complete picture of a patient’s physical and mental health conditions. In many instances, legacy systems with siloed patient data and manual, time-consuming clinical processes are a roadblock to the potential improvement found in this type of integrated approach.

Pre-pandemic, customer support from health payers and providers for behavioral health was often relegated as a health management afterthought. In putting off development of the right behavioral health programs and systems to serve their customers, many payers and providers found themselves unprepared to manage the pandemic-fueled demand for such services. Working in a manual one-to-one environment made it difficult to identify macro trends in service needs and apply those key insights to implement programs that would best serve members.

The global pandemic, however, has presented opportunities for payers and providers to adopt new models for care and utilization management. This is helping them to address mission-critical challenges efficiently, rapidly and at scale.

Behavioral Health 2.0: Strategies to shift, adapt and evolve

True behavioral healthcare transformation requires a technology-enabled solution framework that facilitates tighter and more efficient collaboration between payers and providers while also joining patients’ medical data with behavioral data. This solution must also keep pace with the challenging, ever-changing, and increasingly complex regulatory and compliance requirements for behavioral disorders and coverage. For example, payers have discovered that a significant percentage of the member base have medical comorbidities: This is a very expensive challenge which makes it difficult to administer high quality services. That information needs to be housed in one place; payers need a centralized hub for this to be able to operationalize clinical processes and decisions based on access to a 360-degree member view and curated content from various sources like evidence-based guidelines, as well as National Committee for Quality Assurance (NCQA), Centers for Medicare & Medicaid Services (CMS) and state-specific regulatory compliance.

By using a centralized platform where all patient information exists in one place, innovative companies can operationalize clinical decisions based on access to curated content from various sources.

A roadmap for transformation

The first step in the transformation process is to evaluate your legacy technology stack to identify elements that are not talking to each other (e.g., customer relationship management, electronic medical records, patient engagement, care management, and call center as well as decision support tools). With insufficient data exchange among behavioral, mental and physical healthcare providers and payers, there is a critical need for more unified technology platforms that surface co-occurring complex health conditions to support more efficient care coordination and required approvals.

Next, identify the processes most impacted by disconnected systems. We discover a lot of “swivel chair processes” at payers and providers where clinical staff search for medical policies and guidelines in one place and then have to manually enter that information, sometimes in multiple places, to build the actual care plans for treatment. In some cases, they are spending more time doing these administrative parallel processes than they are spending time with patients.

We’re also finding that the disconnect between payers and providers is even more evident in behavioral health where network adequacy is severely limited for mental health care, especially in the case of Medicaid services. Focusing on standardizing and automating inefficient utilization management processes like prior authorizations (the most costly, time-consuming administrative transaction for providers according to the Council for Affordable Quality Healthcare 2019 Index) can help close the gaps that prevent timely access to affordable care and deliver huge cost savings for both payers and providers.

Combining care management and utilization management workflows on a single platform is transforming the way clinical and administrative information is exchanged between payers, providers and patients, facilitating a whole-person approach for more efficient care coordination and faster approval cycles. This model makes medical policy and evidence-based guideline content available in the same pane of glass as pre-built care plan templates and processes for seamless decision support and patient handoff.

Establishing a baseline for your most critical areas of improvement and tracking your progress over the first 90 to 120 days are also essential. With the right data and technology in place, you can leverage real-time analytics to refine programs, highlight successes and improvements, and inform next-phase upgrades to roll out to additional groups and populations.

Hamp Hampton is chief revenue officer for Cadalys.