Getting to the Heart of the Matter – How Behavioral Health Works in Harmony With New Healthcare Business Models

Van Morrison once said, “Music is spiritual. The music business is not.”

This statement is apropos for the current state of business for behavioral health service organizations as well. Once a mission-driven public service model sustained through block grants, behavioral health organizations are now faced with current changes and challenges accompanying the privatization and business of healthcare. Gone is the day of block grant funding and now is the day of rapid replacement of fee-for-service revenue with outcomes-based “earned” revenue. This revenue, to be earned through demonstration of outcomes through performance reporting, often ties to outcomes outside of traditional behavioral health outcomes reporting.

Perhaps even more concerning for behavioral health organizations is that the value of behavioral health or social services may not be fully understood in the new carve-in value-based paradigms. This is demonstrated in the Open Minds November 11, 2018 News Report which includes a concern and recommendation expressed by a coalition of behavioral health organizations. This coalition cites the lack of attention to key performance measures associated with behavioral health in the new Medicare ACO requirements and encourages more attention and investment for behavioral health services in these new risk-based models for fear that behavioral health will be under treated. It seems behavioral health organizations are starting behind the curve in proving their value.

How do we help behavioral health organizations know and demonstrate their value to grow and sustain their business during these changing times?

As a 30-plus year veteran of the behavioral health industry, it is mind boggling to me that our industry’s ability to thrive in the new business of healthcare is so hard. I wonder why we should advocate to be at the table when we know:

  • Persons with chronic health conditions, such as diabetes, have healthcare expenses that are two to three times costlier when also experiencing a behavioral health disorder.
  • Behavioral health and social determinants are the biggest contributors to overall health outcomes, per emerging research. Upwards of 90 percent of health outcomes are determined by social, behavioral and environmental factors with the contribution of direct medical care accounting for a mere 10 to 20 percent.
  • The toll of the opioid crisis extends way beyond the healthcare dime, affecting the economic and social fabric of our community in ways that have yet to be curbed. Despite efforts to curb the crisis, still more people are dying daily from opioid overdose than vehicular accidents.

Bruce Springsteen: “It is hard to get an audience. It is even harder to sustain one.”

The behavioral health industry is experiencing a dilemma in determining how to be a key player in the business of overall healthcare. For behavioral health organization executives to get and keep an audience for business, consider adopting these five tips:

1) Present your value to your payer partner in a data-driven framework that is tied to their key performance metrics

Present your value story simply in one or two slides or in data points that distinguish your services and expertise, and your impact on the payer’s bottom line or key performance markers. For example, how your services reduce overall cost of care, or how your open-access model diverts ER presentation. Show the payer how you can help them meet their goals with your unique contribution.

2) Know the win-win for your payer-provider partnership

It is critical that you do your homework before meeting with the payer. Know what keeps the CEO up at night, any known public vulnerabilities, key state priorities for the health plan and how they are performing against their peers. Know what you can bring to the table to address these pain points. At the same time, know your own vulnerabilities and limits regarding what you can bring to the partnership or are willing to contribute. Know your top line and your bottom line, and what you imagine success to look like for yourself and your payer. Do you desire more referrals? A higher rate? Are you willing and able to accept downstream risk? Does your payer need help with readmission reduction? Patient satisfaction? Tie your wins together and ‘talk out loud’ about what mutual success looks like for each partner.

I strongly encourage you to seek data transparency and data exchange (a full data set for the population being served) as a part of your win. Your value story will be more about demonstrating how your services impact the health plan’s bottom line (total cost of care reduction) and less likely about behavioral health outcomes. Be prepared to have a data discussion and ask for complete accessible population data set so you can perform your own analyses relative to your performance contract. The expected outcomes and methodology must be agreed upon up front and you are vulnerable if you don’t have access or capability to run your own “numbers.” This is a core competency of the Relias solution, and we have seen many of our behavioral health clients create strong partnerships with their payers by making the best use of their data, like in this case study with Illinois BHHC.

3) Develop and maintain trust with your payer

As most trained clinicians know, trust grows from proximity and familiarity. Maintain a regular cadence of meetings with a shared agenda. Successful partnerships come from shared goals, desires and passions. Talking about them in the proximity of real people in real time helps them become realized.

4) Link clinical and financial goals

Warren Buffet said, “Price is what you pay, value is what you get.” All outcomes must link the clinical action to the overall financial goal or total cost of care impact, to have a win-win for a payer. Linking improved PHQ9 scores to reduced use of Emergency Room Services or overall improved metabolic screening markers is an example of a clinical-financial outcome link.

5) Expand your toolkit

Recognize the move to a value-based paradigm is not just a business shift but a culture shift, both within organizations and across the payer-provider divide. Continuous training and workforce development is important, as is getting comfortable with 80 percent efficiency while you iterate and reiterate how your organization functions, to stay in lockstep with changes in service delivery and plans for desired goals. You should be reevaluating your technology suite to determine what might be added for great gains – this is an important part of the journey in today’s world.

Interested in more information on how Relias can assist you with building and growing your value-based competencies and toolkit? Email us to get the conversation started. For a sample case study, read here.

Carol Clayton

VP of Population Health Management, Relias

Carol Clayton, PhD, is a licensed, practicing psychologist with 30 years of healthcare experience in the public and private sectors, including non-profit and private practice work. Before joining Relias, she served for four years as the CEO of Care Management Technologies (CMT), a health IT data analytics company acquired by Relias that serves as a foundation to the evolving Relias performance management platform. Prior to her tenure at CMT, Carol worked at the executive level with Merit Behavioral Health Care (now Magellan Total Health Solutions) and as the Executive Director for the NC Council of Community MH/DD/SA Programs during the transformation of public sector services to managed care behavioral health.

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