Contributors: Wren Keber, Lisa Soroka, and Z. Colette Edwards, WG'84, MD'85
To learn more about Wren, Lisa, and Colette, click here.
In Part B of the sixth article in our series, we continue our focus on behavioral health (BH) services. Healthcare providers have many considerations in this period of recovery as the most disastrous waves of the pandemic start to recede.
In Part A, we recapped the current behavioral health landscape, including the rapidly changing framework for behavioral health services: from broader screening and improvements in diagnosis to payment and delivery transformations. We also touched on the impact of the COVID-19 pandemic on the decline of emotional well-being, specifically, the increased prevalence of depression and anxiety. In this article, we are focusing on a handful of considerations for integrated health systems which offer any level of behavioral health services. These organizations are often the center of care delivery in the communities they serve, along with affiliated providers such as Federally Qualified Health Centers (FQHCs) and community-based or faith-based groups. The tactics below are most impactful when a variety of stakeholders find common ground, align, and work together.
Generally, we have organized these tactics in a “waterfall” of descending order. We start with tactics that generate more revenue – working collaboratively with payers – and transition into tactics that expand capacity, improve workforce, and tap into opportunities available through smart partnerships.
- Build and execute payer strategies that include behavioral health. Providers are increasingly finding that commercial payers are more willing to negotiate behavioral health reimbursement alongside payment for other physical health services. This is partly because payers are increasingly realizing that carving out behavioral health doesn’t align with the overall objectives of integrated payment and care delivery to achieve optimal clinical outcomes. Despite mental health reimbursement parity laws, we still observe effective differentials between the average reimbursement level for non-BH medical services in the physical health arena and behavioral health services. Payers have complex systems to administer reimbursement arrangements, and sometimes it takes dialogue between payers and providers to arrive at a correction. We see these lagging “legacy” rates most often when BH benefits were outsourced to third parties. Insourcing opens the door for amicable discussions about reaching parity. Additionally, increases in payment for BH services usually don’t regularly adjust (e.g., annually) using the same mechanisms as other service categories. For providers looking to ensure a behavioral health service line (BHSL) covers its operational costs, adjustments that increase average reimbursement on a periodic basis should be included in every contracting discussion.
- When coupled with the above, acute care facilities may have an increased opportunity for expanding capacity. For example, bringing reimbursement to a level where a BHSL line is at least covering its own costs, serving more BH patients becomes a logical next step. Increasing inpatient licensed beds designated for psychiatric services can be complex (and potentially costly), but an extreme lack of access in some markets can make the undertaking worthwhile. This can be evaluated with a bed need study that assesses the demand trend for inpatient psychiatric services, along with workforce requirements and availability and associated estimated direct and indirect costs. Additionally, many markets would benefit from adding or expanding outpatient services to include partial hospitalization and intensive outpatient programs. BH service line leaders can often provide insight on specific clinical needs in the community. Where increasing beds for inpatient residential capacity is untenable, exploring outpatient program capacity expansion might offer an opportunity to serve more patients. These approaches often require less capital investment (they can sometimes be co-located in the same physical space as other outpatient services) and can generate sufficient revenue to cover direct costs. Health systems and other providers with multiple locations should ensure they consider all service locations to understand if office-based services should also be enhanced, perhaps with partnerships from previously unaffiliated therapy and counseling providers.
- Understand and augment the provider complement for behavioral health clinicians. Many organizations offering BH services find themselves chronically understaffed, dealing with high turnover, and spending precious resources to maintain staffing for existing physical capacity (expanding to serve more patients is a near impossibility.) Root causes for workforce challenges include historically low reimbursement levels (including steep rate differentials for advanced practice providers [APPs]), limited workforce availability, high burnout (even more than in the broader healthcare profession1), and high baseline stress. Behavioral health services are difficult to render, and day-to-day job requirements can take a toll. Sometimes, these challenges can be solved with additional funding from either health plan payers, large employer groups, or even philanthropic organizations; a case can be built for an increase in reimbursement, or for a one-time payment, to build and/or enhance workforce development/wellness programs. Enhancement or transformation programs focused on workforce are an excellent starting point to explore partnerships with BH-focused startups (regardless of funding source). The culture of these organizations often attracts talent away from traditional health systems and office- or clinic-based delivery settings. These established organizations can look to their start-up siblings to explore opportunities to improve access to the BH care delivery workforce, rather than fostering more competition among employers. Beyond development programs, simply recruiting more providers can result in shorter shifts and better balance for over-burdened clinicians, while adding non-clinical staff can also provide relief for the clinical segment.
- Engage meaningfully with safety-net payers or build partnerships to enhance or augment BH services at the community level. Depending on the regional provider makeup, there may be opportunities for health systems and other provider organizations to work together to meet the behavioral health needs of the wider community. In most states, there are significant investments underway to invest in strengthening BH services offered. Additionally, funding streams are directed to or though safety-net providers, often public entities such as county or municipal organizations.
Many of these priorities center around Medicaid and uninsured populations, and programs include delivery system reforms, alternative and value-based payment models, and other transformative initiatives such as a data exchange. In addition, many states are investing to reduce health inequities, which can have an additive positive impact when coupled with other programs/funding streams (we covered some of these considerations and tactics in a prior article.)
In New York, a proposed 1115 waiver program will, if approved by CMS, invest billions of dollars in the Medicaid system, with a material allocation earmarked for behavioral health providers. Among the proposed programs is a framework for Medicaid managed care organizations (MCOs) to partner with value-based provider networks comprised of behavioral health organizations (known as behavioral health care collaboratives). Health systems (and other providers with a predominantly primary care service complement) can partner with the BHCCs (and vice versa) to expand service capacity and meet the needs of regional communities over time, while simplifying contracting with MCOs and improving the patient experience for Medicaid members struggling with behavioral health conditions.
In conclusion, we believe there are significant opportunities to improve all aspects of behavioral health, from payment and delivery to improved clinical outcomes and management. An unanticipated, perhaps positive, “side effect” of the COVID-19 pandemic is the unprecedented attention paid to the importance of diagnosing and treating BH conditions at the same level as physical health. We believe organizations that move proactively to integrate these tactics alongside more traditional avenues will make the most of financial and clinical opportunities available in this unique post-pandemic period.
Contact Wren at: [email protected]
Contact Lisa at: [email protected]
Contact Colette at: [email protected]
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