When New York City-based Nema Health launched in 2020, CEO and co-founder Dr. Sofia Noori knew that designing the care and business models in tandem would better position the company for value-based arrangements as it grew.
Rather than starting out in the traditional fee-for-service pathway and eventually squeezing what worked into a new framework, Noori focused on baking in payer needs, measurement-based outcomes and patient experience from the outset.
It’s something she was thinking about before the pilot value-based care arrangement between Nema Health and Horizon Blue Cross Blue Shield of New Jersey even launched.
“I was already talking to payers before we even started the pilot, because I wanted to know what were the outcomes that they cared about,” Noori said during Behavioral Health Business’ VALUE conference in March. “I designed the care model and the business model at the same time, because I just don’t think you can do it any other way. If you try to take a fee-for-service model and shoehorn it into value-based care, it doesn’t land for the payer authentically and it may not even provide the outcomes you want it to.”
Noori and her team at Nema Health believe that PTSD could be the “next pandemic” in mental health care because trauma is becoming more common and demand for services is growing, she previously told BHB. That is the backdrop against which she set out to partner with a payer for value.
PTSD is a complex condition that can exacerbate other physical health conditions. Nema provides services that go beyond the scope that traditional billing codes cover. That aspect actually made it a good fit for a value-based arrangement to begin with, Rachel Goldberg, senior director of client and provider success at Horizon Blue Cross Blue Shield of New Jersey, explained.
Horizon has focused on a combination of approaches to help providers move into a value-based arrangement, including not using fee-for-service standards, helping them think differently about outcomes and measurements, and having conversations with providers, building the clinical models to better understand the services they offer to keep patients well. Data is an extremely important part of that.
“We create these strategic relationships where there are nonstandard payment terms, and we are all focused on very particular clinical outcomes and operational outcomes and oversight,” Goldberg said during BHB’s VALUE conference. “There has to be a level of trust in terms of moving through this gap together, and that includes status sharing. So we hold all of our providers to very particular metrics, as well as Nema. We don’t do nonstandard treatment arrangements with organizations that don’t have fidelity to the evidence-based practice for their particular condition and that don’t use standard scales to measure products.”
Nema Health’s value-based care pilot with Horizon began in 2020 and then the arrangement fully launched in 2024 out of its pilot phase. Part of what has made the agreement work so well, Goldberg and Noori said, is the way they fostered their payer-provider relationship from the beginning.
“After that first meeting with Nema Health, I knew that we had to move forward with work together. Nema’s model is focused on the evidence-based practices for PTSD… so it really wasn’t a question of if we were going to work together,” Goldberg said. “It was when.”
Even though at the time Nema Health was not even operational in New Jersey, Noori began meeting with Goldberg proactively. At the time, she had data from a pilot cohort to share and kept in touch for about a year before things moved forward.
“The thing that I’m glad we did was that we started the relationship early,” Noori said. “We got to know each other before we started contracting things. So I had a good understanding. I think that a lot of providers wait to do that. They want to just get into contracting. You really need to understand the payer’s perspective in order to even design the right arrangement.”
As the value-based care arrangement has evolved between Nema Health and Horizon, the primary shifts have been in referral and relationship workflows, Goldberg and Noori said, rather than in the contract mechanics themselves.
“The contract itself actually hasn’t changed very much, but I also think it’s because we felt pretty confident in our outcomes and the value that we could provide from the get-go,” Noori said. “Since we did have some data already to demonstrate some of that in the beginning, the arrangement itself has actually continued to work out.”
For providers looking to enter value-based contracting but aren’t sure where to start, Goldberg recommends not overstating experience, data or impact and beginning from a place of trust.
“For companies that have lived in a fee-for-service world that are trying to get out of the fee-for-service world, the most important thing, I would say … is you cannot hyperbolize your experience or data … or like hyperbolize the actual value or impact that your solution can have,” Goldberg said. “That happens all the time. It’s easy to see through. If you don’t have outcomes, but your solution is based on some sort of clinical evidence. That’s what it is. Then you can start from a place of trust and figure out the next steps.”