Q&A: Value-based care can provide lower costs, better outcomes
Value-based care offers a pathway to solutions when treatments do not always work, according to a presenter at the American Psychiatric Association annual meeting.
Healio/Psychiatry spoke with presenter Nicole M. Benson, MD, a child and adolescent psychiatrist and chief medical information officer at McLean Hospital in Belmont, Mass., to learn about the components of value-based care and what it means for practicing clinicians and their patients.
Healio: Please describe “value-based care.”
Benson: Value-based care often refers to a health care delivery model in which providers are paid based on predetermined patient health outcomes. In particular, opportunities for increased payments to clinicians are typically established to be delivered in return for improved population health outcomes and reduced cost.
These types of contracts or frameworks incentivize clinicians to think about the whole patient and their different types of needs, offering flexibility in how clinicians provide the services. The goal is to lower the cost of care for a cohort of patients using evidence-based practice, while aiming to improve outcomes. This model is roughly adapted from the “value equation,” where value is defined as quality over cost. The value model comes from measuring health outcomes against the cost of care delivery. Value-based care differs from a traditional fee-for-service or capitated approach, in which providers are paid based on the amount of health care services they deliver.
Healio: Are any institutions in the U.S. implementing this practice yet?
Benson: Several different value-based care programs have been established in the U.S. For example, accountable care organizations (ACOs), such as the Medicare Shared Savings Program, are designed so that health care systems and providers work together to deliver coordinated care, sharing risk and reward with the payers.
There are other types of programs, including hospital value-based purchasing, which incentivizes hospitals to provide higher quality care — by reducing adverse events — and adjusts payments accordingly.
Bundled payments are another type of contract where payments are provided covering a full care cycle – for example, hip and knee replacements. If the surgery goes well and the hip or knee is replaced with fewer complications, the health care system retains more of the bundled payment.
Within psychiatry, value-based care programs are still relatively new. Some alternative payment models have demonstrated an impact on mental health outcomes. For example, the Pioneer ACO was associated with a reduction in mental health admissions and mental health spending in the first year after the program.
Another example of a value-based care arrangement is through a partnership between Blue Cross North Carolina and Quartet Health. They describe the creation of a quality framework around behavioral health access, health outcomes and cost. They then developed payment models incorporating accountability for health and cost outcomes, even for providers outside of larger alternative payment models. For example, they offered bonus payments to providers for those who had high quality scores.
Recently, there has been emerging enthusiasm around bundled payments to cover patients with first episode psychosis, specifically in the early years of illness to support access to coordinated specialty care. My sense is that the mechanism and details of any bundled payments are still being sorted through, but there seems to be a lot of promise in this area.
Healio: How would clinicians practice differently under this model?
Benson: Essential to these types of payment arrangements is measuring outcomes, the practice of using data collected before and during treatment to guide clinical care. Within psychiatry, this typically involves systematic evaluation of patient symptoms to inform treatment.
As of 2018, however, fewer than 20% of clinicians had integrated measurement-based care into their practice. Patient reported outcomes or outcome measures are one form of measurement-based care examining quality measures from the patient perspective. In psychiatry, this is typically functioning, symptoms, treatment experience.
The difficulty with outcomes in psychiatry is that we do not have a robust quality framework around defining good psychiatric care or outcomes. We know that clinicians are not routinely using measurement-based care and that smaller practices may have difficulty implementing some of these metrics and participating in value-based contracts.
That being said, there are several ways that psychiatry can benefit from value-based care. Because these types of models allow for care that is not traditionally reimbursed to be reimbursed, we can incorporate other types of services that are helpful for patients. For example, intensive case management programs or connection to peer recovery coaches.
Healio: How would patients receive their care differently?
Benson: In value-based care arrangements, patients ideally experience a more integrated health care experience with lower costs and better outcomes. For example, this might entail coordinating mental health care into primary care or with other specialty visits.
Healio: Please explain the benefits.
Benson: There are several theoretical benefits to value-based health care. For patients, ideally, they experience lower costs and better outcomes. Providers are incentivized to provide better care efficiencies, and health care payers have the ability to control cost and reduce their risk, particularly for providers who are not performing. In theory, this type of contract should be better aligning prices with outcomes in the population.
A major benefit is the ability to take a holistic approach to patient care and address a variety of needs patients might have. In an article, Sachin H. Jain, MD, MBA, the CEO of SCAN Health Plan, provides an example of being able to provide a fridge for a patient who was repeatedly seen in the ED for his diabetes. It turns out, the patient did not have a safe way to store his insulin. Once he had the fridge — and a safe place to store his insulin — he was better able to manage his diabetes.
At the end of the day, Jain advocates that in order for these types of contracts to work, systems must ensure that any practices to reduce cost are balanced with the needs of the patient, and that the idea to always do what is right for the patient remains at the forefront.
Healio: What do you foresee as a timeline for an entity to make this transition?
Benson: I think there are several examples of how to incorporate behavioral health metrics and outcomes into value-based payment arrangements. That being said, there are several challenges to broad adoption of these alternative payment models. Across health care, we are moving forward towards this, and my hope is that these types of arrangements will continue to evolve within behavioral health care.
References:
Forbes. Everybody’s talking about value-based health care. Here’s what they’re saying. https://www.forbes.com/sites/sachinjain/2022/04/12/what-is-value-based-healthcare-really/?sh=1861511dd8af. Published April 12, 2022. Accessed June 28, 2022.