Join Behavioral Health Business at our annual VALUE conference, March 4-6 in Orlando, Florida. Hear industry leaders from CVS Health, Evernorth, Carelon, Gateway Foundation, Microsoft and others discuss the future of value-based care contracting. Register here.
Data is at the heart of value-based care contracting. While payers and providers can agree on this principle, they often disagree on what should be measured and what data should be shared.
Providers entering value-based contracting can often be surprised by the information payers consider when entering these discussions.
“The first time I walked into such a meeting, I was shocked at the gap of information between what the payers had and what we had as a provider,” Jeremy Klemanski, president and CEO of Gateway Foundation, said during Behavioral Health Business’ recent webinar.
“They had much more longitudinal data than we did, because they are tracking all the claims and all the expense history of their covered lives. And we had a piece. We had a snapshot of our continuum of care, reflecting what we knew. I was also, I think, the other big gap that I see is that what we valued internally as a successful outcome was not necessarily what they saw as a longer-term successful outcome. And how we measured success and how they measured success were really different.”
Gateway provides mental health and substance use disorder services to patients across Florida, Georgia, Illinois, Michigan, Missouri, New Jersey, Texas and Wyoming. The provider serves more than 30,000 people annually.
Klemanski, who will be speaking at VALUE, noted that Gateway used to think about measuring success in terms of whether patients were taking their medications, whether a patient in recovery was able to stay employed and had housing. Still, they didn’t have visibility into other health outcomes or how to measure them.
While providers are often focused solely on clinical measures, payers have a more nuanced approach to outcomes.
“The biggest gap is that providers expect the conversation to be about clinical philosophy, but really, payers start with operational proof in those first few meetings. Payers want to understand three things and three things very quickly,” Shannon Fitzpatrick, senior healthcare partner development manager of global partner solutions at Microsoft, said during the webinar. “Can you measure outcomes consistently? Can you manage risk across a population, and can you act on data in near real time as a behavioral health clinician that can feel really uncomfortable, but it’s the reality of value-based care.”
Still, data often lives in silos within a fragmented system, making it difficult for providers to see the full picture of a patient or population.
The other major challenge when working with payers on demonstrating value is the long-term effects of care. Klemanski noted that the easier parts of value-based contracting are showing engagement efforts, including following up with patients in a certain amount of time after care.
The harder parts are the longer-term efforts. He noted that Gateway can demonstrate better patient outcomes based on length of stay. However, if a payer expects that treatment will lower overall health care costs within the first six months to a year of care, the provider can’t take that risk. During that period, patients are often stabilizing and getting their physical health addressed after years of neglect. For example, they might be getting their teeth fixed or taking blood pressure medication.
“We don’t see savings, usually until 18 months, sometimes sooner,” Klemanski said. “It depends on the patient, and that’s one of the reasons why, if we’re measuring something in a tight window, six months to a year, a year to 18 months, or even a year to two years, it’s hard for us as a provider to capture value. And one challenge for the managed care population, whether it’s a Medicaid or a commercial plan, is that people are moving. There’s movement between plans, and one of the things I’ve learned from the insurance sector is that they don’t always have people for multiple years as enrollees. Sometimes they do, sometimes they don’t. So even their ability to capture savings and monetize them is challenged.”
Still, it is crucial for providers to bring as much data to the table as possible to enable conversations about behavioral health’s role in value-based care and holistic health.
“Behavioral Health is non-linear, and progress often happens in stages,” Fitzpatrick said. “Another challenge is hospitalization reduction targets without proper social risk adjustment. The most effective pushback is data-driven and collaborative. Providers should bring baseline performance, show outcome variability and explain the clinical reality at Microsoft. We see providers succeed when they propose phase metrics, alternative outcome measures or proxy indicators that still meet payer goals while remaining clinically valid.”