Implementing Value-Based Reimbursement in Behavioral Healthcare

Residents of western New York will have access to the region’s first behavioral healthcare provider group with a value-based reimbursement arrangement, BlueCross BlueShield of Western New York announced in a statement emailed to journalists.

BlueCross BlueShield entered into the value-based reimbursement arrangement with Value Network. The provider group has over 100 providers in behavioral healthcare in Western New York.

“BlueCross BlueShield of Western New York is proud to partner with the region’s leading behavioral health care providers to introduce the first payment model designed to directly enhance quality care for our members with mental health and/or substance use disorder diagnoses,” said Thomas Schenk, MD, senior vice president and chief medical officer at BlueCross BlueShield of Western New York. 

Thus, it is significant that when BlueCross BlueShield allied with Value Network, it brought 23 providers into its network who have been licensed through OASAS as well as the New York State Office of Mental Health and the Home and Community Based Service Providers (HCBS).

The contract includes an upside risk agreement and follows the payer’s Best Practice approach to value-based reimbursement for primary care providers. 

Best Practice is a patient-centered, population-based care model that reimburses providers based on the full scope of care management. 

The model uses a per member per month capitated payment along with some fee-for-service payments, specifically in preventive care. 

Capitation payments are based on historical claims and nontraditional patient engagement methods such as telehealth. It also takes into account a member’s risk score, including chronic disease management needs, to further compensate providers whose patients require more complex care. Lastly, the model accounts for healthcare environment factors, like CMS regulations and utilization trends.

Quality measures for this model are aligned with HEDIS quality metrics.

The new payment model is intended to foster patient-centered care, raise quality, and lower costs to advance value-based care.

“This is another step we’re taking to build a behavioral health care model that’s designed to effectively treat the whole person,” Schenk said of the value-based reimbursement arrangement with Value Network. 

In general, the state of New York has been highly successful in making mental healthcare available to its residents. Mental Health America ranked the state second in the country overall for low prevalence of mental illness and higher rates of access to care.

The partnership, therefore, may be largely motivated by the opioids crisis which has particularly taken hold in the western region of the state.

In 2017, New York’s emergency department visits related to opioid overdoses were largely concentrated in western counties, according to the state’s opioid annual report of 2019. 

At least seven counties located in the western part of the state had crude rates greater than or equal to 91.2 opioid overdose emergency department admissions for every 100,000 residents.

In total, 15 New York counties fell into this quartile. Five of these seven had high rates of admission to an New York State Office of Addiction Services and Supports (OASAS)-certified chemical dependence treatment program, “high” being at or above 538.8 individuals per 100,000.

OASAS has been a significant force behind improving New York’s behavioral healthcare efforts in substance abuse care.

Outside of this program, BlueCross BlueShield has made many efforts in its approach to behavioral healthcare, both in the community and with its members.

In particular, the payer expanded its team of behavioral healthcare professionals in 2017, which resulted in increased member engagement in behavioral healthcare by almost 120 percent.

Other Blue Cross Blue Shield Associations are also making strides toward expanding value-based care. 

Most recently, Blue Cross Blue Shield of Massachusetts used its value-based care model for primary care providers, Alternative Quality Contract, to create a value-based contracting agreement for dental providers.

And other payers in the region have been doing their part. 

MVP Health Care, which serves New York as well as Vermont, expanded its behavioral healthcare telehealth options for commercial, Medicare, and Medicaid beneficiaries in 2018. The payer spread its use of telehealth across multiple healthcare needs, resulting in a 94 percent four out of five stars in patient satisfaction.

In 2019, UnitedHealthcare started covering physical therapy and chiropractic care benefits to help prevent increased reliance on opioids for pain treatments. The benefit extended to five states including New York and the payer intends to expand it in 2020 and 2021.

The opioids epidemic has begun to retreat in the face of united payer and provider opposition. Overdoses fell two percent from 2017 to 2018, CDC reported, a small but important victory.