What Behavioral Health Providers Need to Know about Value-Based Reimbursements
Value-Based Reimbursements change the game by offering outcome-based incentives to In-Network providers. Learn more about this important trend.
Value-Based Reimbursements give In-Network providers an incentive to remain in a payer’s network, while tying a portion of their payments to patient outcomes. In doing so, the Value-Based system could help bring the cost of healthcare under control.
And that’s not the only reason providers should embrace outcomes-based reimbursements. As of 2018 The Joint Commission will require outcomes-based data as a conditioned for accreditation. Other accreditation bodies are sure to follow suit.
In this report, we look at how Value-Based Reimbursements, AKA “outcome-based reimbursements,” work and how providers can adapt to get out in front of this massive industry change.
Insurer reimbursements are changing once again. This time, payments are being tied to outcomes. We see this as not a “trend” but a long-term solution to the issues that have long plagued payer-provider relations, the biggest being the disparity between In-Network and Out-of-Network payments.
Traditionally, In-Network providers received a reduced rate for services, with the trade-off being that insurers funneled more patients to their practices. Out-of-Network providers, however, could charge whatever they deemed appropriate. This meant a huge gap between what In-Network and Out-of-Network providers were being paid for the same service, and led to In-Network providers crying foul.
In theory, Value-Based Reimbursements change the game by offering outcome-based incentives to In-Network providers.
In this report, we look at how Value-Based Reimbursements, AKA “outcome based reimbursements,” work and how providers can adapt to get out in front of this massive industry change.
Delivering Value: Understanding Outcome-Based Reimbursements
In a nutshell, “outcome-based reimbursements” are incentives or “bonuses” that payers give in-network providers for positive outcomes.
A few important notes:
- A provider’s entire reimbursement is not tied to the patient’s outcome.
- At this time, Value-Based Reimbursements are primarily for In-Network providers only.
- Providers can work with insurance companies to determine fair and appropriate outcomes.
- Value-Based Outcomes are not likely to go away, but will likely evolve as Congress continues to reform healthcare.
Value-Based Reimbursements give In-Network providers an incentive to remain in a payer’s network, while tying a portion of their payments to patient outcomes. In doing so, the Value-Based system could help bring the cost of healthcare under control.
And that’s not the only reason providers should embrace outcomes-based reimbursements. As of 2018 The Joint Commission will require outcomes-based data as a conditioned for accreditation. Other accreditation bodies and commercial payers are likely to follow suit.
But, before providers agree to outcomes-based contracts, they must first work with payers to determine precisely what outcomes they are being measured against.
Determining Appropriate Outcomes
Providers and accreditation organizations both play a role in helping insurers define precisely what a positive outcome is for their patients.
In the behavioral health sector, outcomes could be tied to sobriety, or a patient’s successful re-entry into society (e.g. holding down a job, or regaining custody of their children) and other life skills such as those included on your bio-psychological assessment form.
For this reason, it’s important that providers have a say in determining what outcomes they are being measured against. But it’s also important to understand that, as medical technologies and outcomes-based data improves, the metrics that define positive outcomes will change over time.
Tracking Patient Outcomes
In order to participate in an outcomes-based program, it will be important to track the outcomes of your patients long after they have left treatment. This is where implementing an alumni support program can be valuable.
The following aspects are key to tracking patient outcomes.
- Practitioner-gathered data. This data may be stored in your EMR and can be used to track vitals and symptomology.
- Patient follow-ups and interviews. These can be done through your alumni program or through an outsourced case management company.
Your current alumni support program may not be enough. This is because keeping data on individual patients is key in tracking patient outcomes. This is because keeping data on individual patients is key in tracking patient outcomes, and your support program may not have been originally designed for that intent. So, casual peer-to-peer alumni programs may not be effective enough for your outcomes-based program.
Here are a few models to consider:
- Internal Alumni Outcome Departments: In this model, dedicated case managers monitor and track patient outcomes.
- Outsourced Patient Tracking: If your facility is small, you might consider hiring an outside case management consulting company.
- Automated patient outcome tracking: Automated web-based and software systems can be used to help patients self-report their progress.
Note: It is important that your patient monitoring system meets the requirements of your accrediting body. These will be specific to the accrediting body, and may change over time.
Negotiating the Terms of Your Value-Based Program
A Value-Based Reimbursement Agreement can and should be the result of a negotiation between provider and payer. In order to get the best terms possible, it’s important to hire someone well versed in network negotiations.
This individual will both have the clout to get your treatment center in an insurer’s network and be able to work with payer on your behalf to get the best terms for value-based care.
For this reason, it’s important that whomever is negotiating on your behalf be well versed in behavioral health in general, and your facility in particular. This can help ensure that the contracted terms are in line with outcome metrics typical for your industry and facility.
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