Historically, payers considered timely patient access to be the gold standard for measuring quality of care.
In part, that is because payers have been incentivized to prove network adequacy and curb ghost networks. Therapist enablement platforms have helped remedy these issues to some extent by offering more in-network options.
Now, payers are expanding their definition of value and seeking providers who can demonstrate outcomes.
”Therapeutic alliance is at the top of the list [of quality measures]. Availability — and actually being able to match [providers] to a member’s preference for language, ethnicity, faith, etc. — I think that is one key area,” Miriam Ferreira, vice president and head of mental well-being at Aetna, said at the Behavioral Health Business’ VALUE event. “And also online scheduling capability; being able to have the right match, and then having the ability to schedule seamlessly. We have [this] in place for the [range of] aggregators, but for the face-to-face services that we provide, we have [it] to a lesser extent.”
Some organizations are building therapeutic alliance criteria into their platform. Jennifer Christian-Herman, head of clinical strategy at Headway, noted that at her organization, patients are asked their personal preferences for their provider, including faith, speciality, ethnicity, etc., and that is then put into an algorithm.
A major component of surfacing quality metrics is the ability to share data. Ferreira noted that interoperability is a core principle at Aetna and it has made some inroads with its aggregator partners.
“We now currently have a quality case review process where we evaluate the clinical documentation that was submitted, we evaluate the appropriateness of codes that were submitted, the appropriateness of prescriptions, when that is applicable,” Ferreira said. “So being able to have, from an interoperability perspective, a seamless data sharing component, and then being able to also assess, per provider, what is the level of efficacy against their peer group.”
She noted that this process allows the payer organization to compare how many sessions it takes one provider versus another to reduce symptomology in a group of patients. It can mainly help pinpoint outliers, both high-performing and potential bad actors.
And quality of care doesn’t always mean the same level of care over time. Berto Torres, vice president of business development at Octave, noted that quality of care means getting the right care at the right time and being able to refer to a higher level of care or even to a coaching platform for a lower level of care.
In order for quality care partnerships to work, data sharing needs to go both ways.
“When you think about true patient outcomes like it’s total health,” Christian-Herman said. “There are pieces of data that the aggregator or the provider or direct network have. There are pieces of data that you as the payer have. So I think again, that data sharing is critical to really look at a complete picture of outcomes.”
Headway is a patient-matching platform. It has raised more than $320 million and is valued at $2.3 billion.
But data sharing is only part of the equation — payers and providers also need to come together to decide what gets measured in the first place.
“Historically, people who decide what value looks like are the ones with the checkbook,” Torres said. “Our payer partners are asking us for what they should be measuring. For example, we’re constantly iterating on metrics that should be impacting as your construct, moving beyond just a collection of PHQ-9s and GAD-7s.”
Octave is a hybrid behavioral health provider that treats depression, ADHD, bipolar disorder, chronic insomnia, eating disorders and substance use disorders.