The Shift to Value Based Reimbursement Needs to Address Behavioral Health Access and Costs

CMS recently announced that the Center for Medicare and Medicaid Innovation (CMMI) is interested in lowering the cost of care for Medicare and Medicaid beneficiaries with behavioral health conditions while improving the quality of care and the overall access to care for those patients, and will convene a public meeting in the fall to discuss ideas to accomplish these goals. Notably, CMMI indicated that such a model may include participation by other payers, qualify as an Advanced Alternative Payment Model, improve health care provider participation in telehealth services, and address the needs of beneficiaries with care deficiencies in certain areas that lead to poor clinical outcomes or potentially avoidable expenditures, such as substance use disorders, mental disorders with comorbidities, Alzheimer’s disease, and/or behavioral health workforce challenges. As we deal with an aging population and continue to confront the reality that clinical interventions account for only a small part of managing population health, and current ACO models likely do not go far enough to confront behavioral health issues, CMMI’s meeting announcement is a welcome development in the wake of the current controversies surrounding health care reform.

Currently, many providers participating in ACOs integrate behavioral health in the primary care setting, and several piloted these efforts within their own self-insured health plans before deploying them in their ACO models. Many providers have sought to tackle the high-risk, high-cost patients that are typically part of the dual eligible population by collaborating with patients, payors, and other providers to address their unique needs. CMS advanced this trend by adding new Part B billing codes for physicians who furnish behavioral health services. With its recent announcement, CMMI is poised to continue the momentum to ensure that value-based reimbursement efforts don’t overlook behavioral health issues, and in turn, social determinants of health, in the redesign of the health care payment system. As payment transformation efforts continue to consider ways to address access and other issues via mechanisms such as waivers of fraud and abuse laws, better payment for telehealth services, and innovative ways to address emergency department overuse and readmissions, addressing behavioral health issues by going beyond traditional clinical interventions to address social determinants of health and relaxing barriers to accessing behavioral health services will further solidify the trend towards success in value based reimbursement