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Leveraging the Payer Provider Model in Behavioral Healthcare

Behavioral healthcare used to operate as a mission-driven public service model sustained through block grants. Now, however, the field faces changes and challenges accompanying the privatization and business of healthcare. The rapid replacement of fee-for-service revenue with outcomes-based “earned” revenue is causing a paradigm shift. Revenue, earned through demonstration of outcomes via reporting, is now tied to outcomes outside of traditional behavioral health outcomes reporting. To that end, understanding the payer-provider model has never been more important.

5 steps to better utilize the payer-provider model

Behavioral health and social determinants are the biggest contributors to overall health outcomes, per emerging research. Upwards of 90% of health outcomes are determined by social, behavioral, and environmental factors. The contribution of direct medical care, however, accounts for a mere 10-20%.

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

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 model

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. Understand your top line and your bottom line, and what you imagine success to look like for yourself and your payer. For example:

  • Do you want more referrals or a higher rate?
  • Are you willing and able to accept downstream risk?
  • Does your payer need help with readmission reduction or patient satisfaction?

Tie your wins together and “talk out loud” about what mutual success looks like for each partner within the payer-provider model.

It is strongly encouraged 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.

Prepare to have a data discussion and ask for a complete accessible population data set so you can perform your own analyses relative to your performance contract. You and your partners must agree upon the expected outcomes and methodology upfront. If you don’t have the access or capability to run your own “numbers,” you leaver your organization vulnerable.

3. Develop and maintain trust with your payer

As most trained clinicians know, trust grows from proximity and familiarity. Successful partnerships come from shared goals, desires and passions.

Thus, it’s important to maintain a regular cadence of meetings with a shared agenda. Talking about these goals in the proximity of real people in real-time helps inspire action and bring these goals to fruition.

4. Link clinical and financial goals

In a successful payer-provider model, all outcomes link the clinical action to the overall financial goal or total cost of care impact. This creates a win-win for a payer.

A great example of linking clinical and financial outcomes would be tying improved PHQ9 scores to reduced use of Emergency Room Services or overall improved metabolic screening markers.

5. Expand your toolkit

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% efficiency while you iterate and reiterate how your organization functions) in order to stay in lockstep with changes in service delivery and plans for desired goals.

You should periodically reevaluate your technology suite to determine what you can add to help make greater gains.

Solutions for Behavioral Health Treatment Providers

For behavioral health and substance use treatment organizations, including Certified Community Behavioral Health clinics, changing regulations, variable funding and staff burnout can be ongoing challenges. Relias offers proven solutions to help your staff optimize their performance with the most effective training and data insights so they can achieve the best outcomes for their clients.

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