Article Abstract

Article Abstract

Online ISSN: 1099-176X Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 27, Issue 3, 2024. Pages: 109-113
Published Online: 1 December 2024

PERSPECTIVE
Has Value-Based Reimbursement Arrived for Behavioral Health?A Payer Perspective

Stuart L. Lustig,¹ Vikram Shah,² Lisa Kay,³ Andrew DiGiacomo,⁴ Douglas A. Nemecek⁵

¹M.D., M.P.H., National Medical Executive for Behavioral Health Strategy and Product Design, The Cigna Group, Bloomfield, CT, USA.
²M.D., M.B.A., National Medical Director for Quality & Network Performance Cigna Healthcare, Washington, DC, USA.
³M.S.W., M.B.A., Clinical Quality Leader, Evernorth Behavioral Health Inc., St Louis, MO, USA.
⁴M.B.A., National Provider Network Strategy Director, Evernorth Health, Inc., St Louis, MO, USA.
⁵M.D., M.B.A., Chief Medical Officer, Behavioral Health, Evernorth Health, Inc., St Louis, MO, USA.

*Correpondence to: Stuart L. Lustig, M.D., M.P.H., National Medical Executive For Behavioral Health Strategy and Product Design, Cigna Healthcare, 400 N. Brand St., Glendale, CA 92103.
Tel.: +1-415-269-5067
E-mail: Stuart.lustig@cignahealthcare.com

Source of Funding:All authors are paid employees of Cigna Healthcare or Evernorth which are both wholly owned subsidiaries of The Cigna Group.

Abstract

The purpose of this study was to estimate the direct health care costs associated with the treatment of mental ill-health in Canada. The results were classified Value-based reimbursement (VBR) has become increasingly common among medical practitioners but not for mental health practitioners (MHPs). Historically, VBR has been challenging to implement due to a shortage of MHPs in payer networks. Technological challenges such as the absence of electronic medical records required for efficient data analysis and immature data-sharing capabilities, have hindered VBR, as has a culture of clinical practice that relies on clinical intuition as opposed to measured outcomes. VBR is now gaining traction based on overwhelming evidence for measurement-based care, a prerequisite for outcome reporting that larger practices have begun to achieve. Multiple stakeholder organizations have been advocating for measurement-based care. Payers and MHPs should structure VBR contracts to align greater reimbursements with achievable increases in quality. Contracts can focus on process metrics such as time to care, treatment adherence, and appropriate avoidance of emergency care, along with clinical and functional outcomes.  

Background: Value-based reimbursement (VBR) has become increasingly common among medical practitioners but mental health practitioners (MHPs) have largely remained in fee-for-service (FFS) arrangements. Aligning payment incentives to clinical outcomes rather than volume of services, VBR aspires to achieve health care’s quadruple aim, namely improved patient experience, improved population health, reduced costs, and improved work life of health care providers.

Aims of the Study: (i) Describe both the historical challenges to implementing VBR for mental health care within the United States, along with the shifting healthcare landscape which now enables VBR arrangements between payers and MHPs; (ii) Highlight considerations for defining quality care and establishing VBR contracting.

Results, Discussion and Implications: Historically, VBR has been challenging to implement due to a shortage of MHPs in payer networks. Technological challenges such as the absence of electronic medical records required for efficient data analysis and immature data-sharing capabilities, have hindered VBR, as has a culture of clinical practice that relies on clinical intuition as opposed to measured outcomes. VBR is now gaining traction based on overwhelming evidence for measurement-based care, a prerequisite for outcome reporting that larger practices have begun to achieve. Multiple stakeholder organizations have been advocating for measurement-based care. Payers and MHPs can and should collaboratively structure VBR contracts to align greater reimbursements with achievable increases in quality across multiple domains. Contracts can focus on numerous process metrics, such as time to care, treatment adherence, and appropriate avoidance of emergency care, along with clinical and functional outcomes. In some instances, case rates for episodes of care can meanwhile help payer and MHPs transition from FFS to VBR.

Received 19 January 2024; accepted 16 July 2024