While payers and providers share a strong interest in value-based payment arrangements, existing infrastructure, such as data-sharing barriers, can pose significant hurdles to adoption.
This is particularly true for smaller providers that don’t have the scale to make it worth payers’ time to build new arrangements and data-sharing capabilities.
Health plans want to know that the type of care they are paying for works and is grounded in evidence-based practices.
“From our standpoint as payers, we get a large amount of information about a limited number of things,” Dr. Taft Parsons III, chief psychiatric officer at CVS Health and Aetna, said at Behavioral Health Business’ VALUE conference. “So usually what comes across in a claim tells you who the person was, what the diagnosis was, and who the service provider was who provided stuff like that. And so you get a lot of information, but it’s very basic. It doesn’t give you any insight or hindsight into the care delivered during that unit of service. And so what we’re trying to do is get to a point where we have a little bit better insight into whether or not the members of our insurance plan are getting evidence-based care during these units of service.”
CVS Health is a health care conglomerate that offers clinical services, pharmacy services and health plans.
These types of insights include patient-reported outcomes, such as PHQ-9s and GAD-7s, used in care. It could also mean that evidence-based treatments were used in care. Parsons noted that tech-forward companies tend to have greater capabilities to share data and information, giving them a leg up.
“I think a barrier that a lot of traditional providers face is that the data has to be collected on top of whatever the clinical workflow is, and that represents operational complexity,” Dr. Nzinga Harrison, CMO, Eleanor Health, said at VALUE. “And so being able to build the technology that collects data from your workflows, I would say scale is a significant barrier.”
Eleanor Health is a hybrid addiction treatment provider. It has raised more than $104 million in funding.
But certain types of behavioral health providers face greater challenges in data sharing between payers and providers. For example, substance use disorder treatment providers are required to follow stricter data-sharing requirements, though some new changes could help in this department.
“I see that payers are very reluctant to provide meaningful data that’s going to help us move the needle when it comes to SUD services for most of our clients, though we are, hopeful that some of the changes revisions with 42 CFR Part Two that more closely aligns it with the HIPAA requirements,” Rob Marsh CEO, Bradford Health Services, said at VALUE. “And so we’re hopeful that there’ll be additional information that we’re able to ascertain.”
Bradford Health is an SUD provider operating in five state markets and with more than 40 drug and alcohol rehabilitation facilities across the Southeast.
Still, having a good relationship with a payer can help partners work together to exchange helpful data.
“I would say that for those payers where we are engaged in value-based care, we do have workarounds in order to make sure that we’re getting the data that we need, and that we’re sharing with them, and that they’re sharing with us appropriate medical information about the clinic,” Marsh said.
A lesson for small providers
Because value-based care arrangements take up so much time and energy for both payers and providers, health plans tend to prioritize providers with scale.
“To prove a value-based care model, you have to have a sufficient population to be actuarially sound — and show that you’re making a difference in quality metrics and total cost of care metrics,” Harrison said. “And so the time that it takes to get to building that size of population before you can get to your value-based care contracts in a meaningful way, with payers understanding it is not fair to ask the payer for a value-based arrangement on a population of ten members.”
When a provider serves only a few dozen members, it’s difficult to justify the investment in data-sharing infrastructure needed to support value-based care.
“The unfortunate part of this is … most behavioral health provider organizations are very small from a payer perspective, and so to get active prioritization, in order to get somebody to manually build the [systems] that need to be built, in order to exchange data this way, it’s not that we don’t want to do it,” Parsons said. “It’s just that we may have primary care clinics and value-based contracts that have 50,000 members assigned to them. And that’s just going to come [before] a small organization that has like 10 members assigned to it. And so there’s that practical nuts and bolts issue of bandwidth for us to do everything for everybody at the same time.”
Fee-for-service arrangements could still be a beneficial way for smaller operators to begin working with a payer and demonstrating quality.
“When you are at a small startup, the best way to get your foot in the door with payers is through that fee-for-service methodology,” Parsons said. “That’s what we’re used to, that is what is easy until you have enough of one payer’s membership to prove out that you can actually save them money reliably.”
It’s also important to note that there are many ways to do value-based care. Harrison said to think about reimbursement on a spectrum. There is pure fee-for-service on one side and full-risk on the other. But in between there is fee-for-service plus quality upside, fee-for-service of enhanced rates, quality bonus metrics and bundled case rates.
Harrison noted that Eleanor Health started with a value-based care model when it was founded in 2019. At the time, they had investors behind them and the company was keen to get into these types of arrangements. But achieving a full value-based arrangement required several steps.
“We had relationships with bigger payers that had the latitude to try new things, and we really had to figure out how to get in fee-for-service and network rates, build a membership with them, show them the quality that we have, and start a negotiation to move along that spectrum,” Harrison said.