While many health care business lines have adopted and benefited from value based payment models, primary care and behavioral health are notable exceptions. For many providers, especially those operating independently, the financial and operational disruption of a new payment model is regarded as too big a burden to bear.
Increasingly, evidence shows that integrated behavioral health services available from primary care physicians can support both types of providers in their transition away from fee-for-service models. Patients receive care that’s better tailored to their behavioral and clinical care needs, improving health and well-being while lowering the cost of care downstream. Succeeding in value-based primary care, however, requires routine documentation of the care delivered and the outcomes achieved to demonstrate improvement.
Today, most health care services are paid on a fee-for-service basis, meaning a practice is reimbursed based on what services it delivers. This has led to widespread concern that organizations are incentivized to provide a high volume of care, even if services may not be necessary.
In response, federal policymakers and payer stakeholders have encouraged the adoption of value based care models, also known as alternative payment models. In these arrangements, practices are reimbursed – sometimes up front – based on outcomes such as cost, quality and equity of care.
Analysis from the Health Care Payment Learning & Action Network shows about 41% of payments in the United States flow through value based care models vs. 59% for fee-for-service models. However, primary care physicians are lagging, according to the Commonwealth Fund, with 71% of PCPs receiving revenue from fee-for-service models. Most do so because of the financial risk associated with value based care.
Behavioral health has similarly been on the outside looking in when it comes to value based care. A MedCity News commentary attributes this status to several factors, including health insurance carve-outs, low reimbursement rates and limited parity for behavioral health compared to other specialties. As a result, most behavioral health services are delivered outside the “traditional” health care system and paid for out of patients’ pockets.
This poses two problems. One, it limits who has access to care. The American Hospital Association indicated white patients are more likely to receive treatment, while a broad spectrum of underrepresented populations experience challenges accessing care. Two, it leads to delays in diagnosis – sometimes as long as a decade, according to a paper in Health Services Research. These delays lead to complications and comorbidities, coupled with the increased complexity of treatment required.
In 2017, the Centers for Medicare & Medicaid Services (CMS) aimed to remedy this by introducing billing codes that let PCPs bill for Behavioral Health Integration services. These codes fit into two categories: One is for general BHI services and the other covers a range of Collaborative Care Management services.
The American Academy of Family Physicians notes that reimbursement for BHI services can help PCPs as they shift to value based payment models. That’s because integrated behavioral health services let practices support behavioral health “in new and innovative ways.” These services could include joint care planning that involves primary care and behavioral health, brief but frequent interventions as part of a broader treatment strategy, and the use of virtual care to overcome access gaps, geographic barriers or workforce shortages.
Addressing behavioral health in primary care has been linked to improved clinical outcomes and cost savings. The Agency for Healthcare Research and Quality points to benefits that include access to behavioral health in a familiar care setting, better management of treatment plans and medication utilization for chronic conditions, and shorter wait times for necessary care.
From a financial standpoint, the Making Care Primary model that CMS introduced in 2023 is further poised to help practices transition to value based primary care and integrate behavioral health services. The Commonwealth Fund points to several characteristics of the model that should help practices address the challenges they’re likely to face:
Whether Medicare, Medicaid, or private insurers administer a value based primary care program, measurement is critical to success for providers and payers. Both entities need to track whether patients are being screened and treated, as well as whether patients’ symptoms are improving.
A case study in Psychiatry Online highlighted several possibilities for quality metrics. These range from percent of patients with documented treatment plans and progress notes to changes to emergency department utilization and patient reported outcomes measures (PROMs). Tracking these metrics has the twofold benefit of making practices accountable for providing high-quality care and enabling payers and providers to set shared incentives and establish common frameworks for what constitutes value based primary care.
Clinical workflows that streamline behavioral health intake and evaluation can help practices screen patients, identify a potential diagnosis and automatically monitor a patient for clinical outcomes. This can further help practices ensure the right patients receive the right care and document encounters and outcomes electronically to meet the requirements – and reap the benefits – of value based care.
To find out more about how the Proem workflow solution can support the delivery of BHI, book a meeting.
