Value-Based Care has Loyalty, but It Needs More Clarity

Expectations for value-based care (VBC) need tempering. Advocates often seem more passionate than one might expect over a financial model. Healthcare funding always involves difficult trade-offs, and so we need to debate those under VBC. No funding strategy can avoid hard choices.

Aspects of VBC are quite familiar. It often means reimbursement is tied to outcomes and not services. It means the provider of care takes some financial risks in exchange for less care management by payers. Treatment facilities might receive a case rate but get no payment for 30-day readmissions. Outpatient care is more challenging for VBC designs, but payers are in the process of formulating new models.

While medical systems have more experience with VBC than our field, concerns are being raised by leaders throughout healthcare. A health plan CEO recently argued that we may be minimizing the pitfalls of VBC. It has “become akin to religion” in that the industry is “taking it on faith” that value-based models will produce beneficial changes in healthcare, SCAN Health Plan CEO Sachin Jain, MD, told Fierce Healthcare.

Value has been approached conceptually in 2 ways in our field. It can be seen to rest on a foundation of either clinical outcomes or clinical practices. While outcomes lend themselves to quantitative analysis, VBC discussions rest more often on a commitment to evidence-based practices. Are these practices measurable, other than by asking clinicians what they are doing?

Artificial intelligence is beginning to address this, and health plans are taking note. The behavioral health CMO for Anthem has shared his vision in a recent interview with BH Business. Anthem will evaluate how well network clinicians use evidence-based practices. How will they gauge a therapist’s empathy or cognitive work? They will utilize AI-enabled analysis and transcription of therapists’ sessions.

Anthem’s model will also evaluate how practice patterns relate to claims costs. This rests on an assumption. Anthem will treat evidence-based practices as being synonymous with strong clinical outcomes. They see no need to measure clinical results given their presumption that the right techniques get the right results. These early ideas from Anthem are troubling and merit debate.

While questions of value can be narrowly focused on specific contracts, value-based care also addresses the broader question of what services deliver the most value for designated populations. While behavioral executives generally have more experience with VBC for specific programs and services, attention is beginning to shift to behavioral health’s role in the total healthcare needs of a population.

VBC will impact our field dramatically as we become part of comprehensive healthcare contracts. How well might our services be funded as part of the total healthcare budget for a population? VBC debates in the medical world often focus on specialty budgets. We will join other specialties in fighting for adequate funding. There will also be internal debates about how we divide behavioral health’s funding.

These questions will become controversial. For example, how do we decide the relative value of medication management versus psychotherapy? Some leaders in our field disparage therapy as being low value if not diagnostically oriented and guideline driven. Tom Insel’s celebrated book, “Healing,” suggests it would be reasonable to deprioritize “humanistic,” less structured types of therapy.

The size of behavioral networks is another value question to resolve. If VBC follows the lead of many accountable care organizations (ACOs) managing multi-specialty budgets today, behavioral healthcare will be quite limited. Many ACOs are restricted to very narrow networks of psychiatrists and therapists.

Whatever the potential risks, behavioral leaders inside health plans want to move behavioral costs into global healthcare budgets. UnitedHealth tells BH Business it is preparing for “a total cost of care approach,” hoping patients benefit from a holistic orientation with more integrated care. While “bringing alignment to behavioral and physical health” sounds good, what is really involved?

The honest answer is that we do not know. We have few positive examples of how our field fits into a total cost model, and there are far too many ways a long stigmatized and underfunded specialty like ours could be marginalized. Behavioral healthcare has never received adequate funding. Will adequacy finally arrive by rolling our services into mega-budgets with every other healthcare specialty?

Some behavioral health leaders are intent on tackling total healthcare costs. Their embrace of VBC has grown from success at showing behavioral care can lead to a “tangible reduction in the total cost of care.”

This evokes the once hopeful, largely forgotten, work in our field to promote “medical cost offset.” Some thought we could fund behavioral care by reducing medical costs. We found we could only do so in limited cases. This wrong turn was not corrected until the Affordable Care Act recognized behavioral care as “essential” healthcare. An essential service need not justify itself by reducing other costs.

Aspects of VBC seem welcome, but is it a grand solution or just a vague funding model getting overly hyped? Let us debate it actively and widely, for it could be an entrenched reality tomorrow.

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.