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Two-Tiered Outpatient Behavioral Care System a Potential Fit for Modern Healthcare Landscape
Demands for outpatient care are growing, and new care delivery ideas are needed. There may be resistance to the scale of changes needed to address unmet behavioral needs. Yet this should not deter us from designing a robust, scalable system. Let us focus on:
1. Securing adequate funding for a 2-tiered delivery model; and
2. Understanding healthcare’s complex new cost management models.
Managing Costs Through Value-Based Care
Few in our field understand the concept of value-based care (VBC). This is because VBC is an umbrella term for various funding arrangements, and few behavioral companies have entered such contracts. VBC could fund our services in minimal ways. To understand this, we must start with the idea of funding allocations.
Health plans can use VBC to limit their financial risk for a population by giving a single entity, such as a health system, a global payment to cover a set of services, often including behavioral health. Critical decisions about care delivery are passed down to the health system. Funding for each discipline will vary. The pie size is set, but the behavioral portion is TBD.
We should not assume the allocation for behavioral care will meet the needs of a given population. Instead, health systems could fund high levels of multi-specialty medical care for chronic conditions, leaving behavioral care underfunded. It may seem paradoxical, but health systems could underfund our services while viewing them as quite valuable. The problem is the historical rate of expenditures.
Medical/surgical spending dwarfs behavioral, and shifting historical allocations from medical to behavioral will be difficult. Every specialty has good arguments for its slice of the pie. Many challenging negotiations are ahead for our field as we argue for adequate funding. The problem is in the definition; unfortunately, our field’s own ideas and tools can be used for defining adequacy in limited ways.
Managing Care With Home-Grown Tools
Diagnosis is a major tool for limiting care, usually done by confining behavioral services to major disorders. This was one of the first methods used in the early 1990s when managed behavioral healthcare organizations were created. In the VBC model, a limited budget might only be able to treat the most severe conditions in a population. Funding might not reach many who want help.
Some believe therapy is often elective and best relegated to self-pay. Most therapists would counter that reported distress is a legitimate basis for care. Again, diagnosis fuels this debate. Those seeking to limit the perceived overuse of services want to prioritize diagnostically based therapies. Evidence does not support this approach as more effective. Regardless, it could become an avenue for restricting care.
Integrated care is a significant current example—while our field seems prepared to increase its funding in primary care, the extent is unclear and depends on the integration model used. Our top models—the collaborative care model (CCM) and the primary care behavioral health (PCBH) model—involve limited staffing. These consultative models are mainly designed to advise PCPs on complex cases.
A tech-based example is digital therapeutics. These excellent, low-cost tools could become a self-imposed limitation for our field to the extent that they are used to replace rather than supplement care.
Imagine a Robust 2-Tiered Outpatient System
Our field needs to articulate how outpatient behavioral care can be comprehensive and efficient. The historical ceiling over our funding will be hard to pierce, but our best approach is to be bold: We should dare to propose how our services could meet the enormity of behavioral needs. To have an efficient yet broad model, we need 2 locations or tiers of service—primary and specialty behavioral care.
Primary care provides fewer barriers to accessing services and can promote prevention and early intervention. It is tailored for brief interventions, not therapy for every issue, with a general focus on behavior change. We know behavior can exacerbate illness and speed recovery.
The focus brought to primary care by the CCM and PCBH models is too restrictive. We need a much more robust presence in primary care, and the strongest case for this starts with the idea of “inseparable care” (https://www.hmpgloballearningnetwork.com/site/bhe/perspectives/pursuit-inseparable-care-and-new-healthcare-culture). This integration model supports the notion that behavioral care is primary care. It could fund our field broadly with brief, efficient interventions.
Yet, apart from primary care, clinicians are needed for complex behavioral conditions. We have long offered our specialty services outside of primary care and must continue doing so. Executives must be able to paint the entire canvas of needs and capabilities to justify a bigger slice of the funding pie.
Some will view this as a crass effort to maximize revenue for our field, others as genuinely patient-centered. Funding deficiencies have left many needy people without help. Our leaders need a bold plan for those with all levels of distress, whatever its origin or diagnosis. They must reject home-grown funding limits—surely the most insidious—and pierce the funding ceiling hanging over our field.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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