By changing attitudes about the provider-payer relationship and investing in business systems, behavioral health providers can better negotiate with payers.
The past few years have seen a shift in the attitudes of the most powerful payers to behavioral health. For example, UnitedHealth Group Inc. (NYSE: UNH) Established holistic care model, including values-based care and behavioral health across nearly all sectors.Similarly, Aetna and CVS Health (NYSE: CVS) are Part of an all-in-one approach for healthcare.
But it should come as no surprise that new value-based payment models mean higher payout rates. Providers must prove their worth and negotiate. One of his early value-based care approaches is pay-for-performance. This is a model that ties incentives to specific outcomes.
Such links between performance and payments help payers recognize the link between behavioral health and the rest of the health care of the member. This connection between health and healthcare costs requires a data-driven collaborative approach.
“If you look at a busy primary care doctor’s office, and look at the waiting room, if patients improve on four things, the waiting room isn’t half as busy: eat better, sleep better, exercise better, Coping with stress better, Vincent Bellwoar, Senior Advisor for the Eastern Region of Refresh Mental Health, said at a recent Behavioral Health Business webinar. Is there anyone better than a behavioral health expert?
“It was the least expensive intervention to make people healthier, and along with PCP was a form of preventive care.”
Refresh Mental Health has been acquired by one of the nation’s largest outpatient mental health providers with at least 200+ in the United States. Optum in March.
A belligerent stance in negotiations with insurers is all wrong for those seeking higher reimbursement and new models of care, Bellwoar said.
Knowing the value of behavioral health is key when negotiating with payers. This brings confidence in dynamic situations where leverage clearly favors large and powerful payers.
This makes behavioral health providers look like “problem solvers,” Bellwoar said, making it a winning approach for payers. Payers focus on her two main factors apart from healthcare itself, relying on healthcare providers to know how to best care for people.
“If you feel they are their enemy, I guarantee that it will come through in the way you talk to them,” Bellwoar said. The first people are trying to do the same job — they are trying to provide affordable health care to large numbers of people…and they are trying to measure the quality of that health care.
Know what your payers want
Insurers are primarily focused on maintaining premiums at levels acceptable to their members, but at the same time understanding the total cost of care and a measure of the value of care provided.
This creates another approach that calls for higher reimbursement and different models. Strengthening premium claims and maximizing healthcare costs lead to value issues. And a consideration that must be addressed is access to care, even before care is provided.
“They know it’s a big problem,” says Bellwoar. “The number one concern for all insurers is access, which means they can’t get their patients to see healthcare providers across the country. .”
This is one reason payers prefer large mental health providers. They have some confidence that patients are available at those providers. It is also more efficient for payers to partner with larger providers. Smaller providers can maximize their scale by offering multiple specialties, Bellwoar said.
It also helps you understand payer terminology. Understand patient costs per patient per month and know the data that is the frame payers use to measure the world.
get the data
To agree to a value-based contract, payers need something to assess the provider’s impact and value. You need data for that. According to Milliman’s research, his 10% highest paying individuals account for his 70% of total medical expenses. studyWithin that high-cost group, 57% have a behavioral health condition.
According to Bellwoar, patients with behavioral health conditions have an average of 273% higher annual costs across Medicare, Medicaid, and private health plans.
Healthcare providers also have an obligation to know the ins and outs of their patient data. It is a mistake to assume that the payer is willing or able to produce the data submitted by the provider. Payers have thousands of agreements with providers, often using data systems that do not work at the level of individual organizations or providers.
“We assume [payers] You know your data – no, no, no,” Bellwoar said. “We think insurers know more than they actually do.”
Retention of internal data requires the use of other technologies such as data collection and electronic health records. This is where behavioral health providers struggle. In part, the industry is mandated or supported by the federal government to adopt electronic health records.
About 37% of private mental health organizations that use Medicaid use an electronic health record (EHR). Additionally, 32% of private substance use disorder treatment providers who accept Medicaid use his EHR. according to reports By Medicaid and CHIP Payment and Access Commission (MACPAC).
A Winning Approach for Rising Rates
The value-based care movement in behavioral health is still in its infancy, meaning there are no clear industry standards for best practices.Payers and providers are working on this through specific partnerships.
This leaves room for the basic bargaining of a pay-for-performance model.
“I am looking at these contracts as a whole, these indicators, what [payers are] measurement, what they want [providers] It is a very basic thing to do, and one that can be easily achieved. But that’s where they are,” Bellwoar said.
This would allow the provider to pitch the provider and do what the payer wants, for example, in exchange for a 5% annual bonus, he said. Mr. Bellwoar said that using the EMR gives him bonuses and even raises his office fees for therapists who provide access to psychiatric services.
Another major trend Bellwoar mentioned is the use of outcome-based care using validated measurements. He noted that while some clinicians do not assess PHQ-9 or GAD-7 health to track depression or anxiety, payers do something to assess the value of care. In one case, a payer offered to pay a fee for simply using a patient outcome measure.
The balance comes down to finding results that clinicians will accept. He specifically mentioned the TOP rating.
“When you go to an insurance company, they don’t expect you to bring the data,” says Bellwoar. “When you bring data to them, they are surprised and want to have a conversation with you…they are not an evil empire.”
