Evaluating Value-Based Contracting in Behavioral Health: A Q&A With Vanessa Bobb, MD, PhD, FAPA

Vanessa Bobb, MD, PhD, FAPA, vice president of Behavioral Health & Medical Integration at CDPHP, moderated a session at AHIP 2022 titled, "Real Evidence for Value-Based Contracts: A Mental Health Integration Case Study."

Bobb speaks with The American Journal of Managed Care^® on findings of the case study, as well as further progress she would like to see on the use of value-based payment models in behavioral health and preventive mental health care overall .

AJMC^®: At this year's AHIP meeting, you moderated a session on findings of a mental health integration study that provided real-world evidence for at-risk vendor contracts. Can you first explain what at-risk vendor contracts are and how they compare with other value-based alternative payment systems?

Bobb: An at-risk vendor value-based contract is a contract between a health plan and a vendor that includes a performance guarantee related to measurable outcomes. Hence, reimbursement is tied to performance. In our case, the health plan, we can feel more confident about contracting with a vendor, in that that they're going to be paid or incentivized when they meet certain metrics. It reduces risk for us, and it puts more skin in the game for the vendors, and ensures that the vendor and payor goals are aligned.

When designing an at-risk vendor value-based program (VBP), select performance outcomes that are relevant to plan and vendor. Performance outcomes must also be measurable with claims or internal data. Impact on total cost of care, return on investment, and impact on quality measures, are commonly used as quantitative performance outcomes in at-risk vendor contracts.

Qualitative evaluations such as surveys and interviews can be incorporated. Qualitative evaluations are helpful, because they can elucidate the intricacies of how the quantitative outcomes are achieved. An independent neutral third party evaluator is often used to evaluate performance, and provides additional credibility, objectivity, and expertise.

In addition to payer-provider and payer-vendor; value based models can be created for members and for pharmaceutical manufacturers. Value-based arrangements drive high value care and can be made between the payer and many types of “customers.”

A lot of times we think about VBPs with providers, sometimes VBPs with regards to pharmacy—now, we're looking more at how can we have VBPs with different types of vendors through the whole notion of getting value.

AJMC^®: What data trends were noteworthy in measuring the quality- and cost-related impact of the behavioral health care integrated program?

Bobb: This was a fantastic program. Specifically, this was a collaboration between Blue Cross Blue Shield (BCBS) of North Carolina that worked with an outside vendor—Ish Bhalla of BCBS of North Carolina and Amy Helwig of RTI Health Advance described their integrated behavioral health program for health plan health members within primary care.

The program utilized an integrated care technology platform, VBP for behavioral health providers, and an independent evaluation for an at-risk contract in order to connect members to care and measure the impact of the program.

Some of the things that they looked at were what we kind of want to see—they looked at total cost of care, and part of the guarantee was that with this relationship, they should have seen reductions in total cost of care for members who used the vendor application. Specifically, some of the outcomes assessed along with the total cost of care were hospital readmissions, they measured the different cohorts that were in it, as well as emergency department (ED) visits, looked at ED reductions and utilization, pharmacy utilization, as well as rates of outpatient care.

What they found there were outcome savings with over $2.7 million in savings with regards to total costs of care in those parameters made up of inpatient and ED spending in behavioral health treatment services. They saw increased cost with regards to overall primary care spending and specifically the behavioral health care spending went up.

The intervention was extremely successful, demonstrating millions of dollars in reduction in total cost of care. Of note, primary care and outpatient behavioral health services increased, while total cost of care, inpatient, ED, and residential spending decreased.

AJMC^®: Underscoring the real-world significance of these findings, what takeaways should be top of mind for payers, patients, and providers considering adoption of these at-risk vendor models?

Bobb: This was a risk-based, value-based program for vendors, and it addressed behavioral health. Specifically with this program, the lines of business used were Medicare and commercial. One of the things that I've noticed with regards to the behavioral health space, and even a lot of the behavioral health value-based payment programs and behavioral health telehealth, a lot of it is aimed at higher functioning people—people who can be cared for easily within a primary care or people that are able to have diagnoses like anxiety and depression.

One of my observations is is that there is low enrollment and retention of people with diagnoses like bipolar and schizophrenia within behavioral health value-based payment programs and expanded behavioral health telehealth services. Their participation rates appear low, even when controlled for community prevalence. A take away might be, for plans to spend time thinking about how to create behavioral health value-based payment programs to specifically address the needs of members with severe mental illness; and members with mental illness and co-occurring substance use disorders.

AJMC^®: In looking at how alternative payment models (APMs) have traditionally been used in the behavioral health setting, what further growth would you like to see?

Bobb: Currently, many of the behavioral health-related VBPs are in the primary care setting. For example, primary care providers will be incentivized for performing PHQ-9 scores, and conducting appropriate metabolic screening with patients with behavioral health conditions or medications that may induce metabolic side effect.

To date, VBP’s with primary care has generally occurred more readily as compared to some behavioral health providers, due to insufficient electronic health records, and inability to easily share records across disparate data systems. I would like additional intellectual thought put forth as to how to better engage and support behavioral health providers with their ability to participate in value-based programs. We should also be considerate in that many behavioral health providers may not be able to participate in risk-based programs, but they may be able to participate in incentive payments for high value care.

Another area of growth might be VBP’s which facilitate workforce expansion in the use of peers, mental health counselors, psychiatric nurse practitioners, family navigators, and digital health in addition to the typical behavioral health workforce. There should also be a quality component to ensure that desired member clinical and quality of life outcomes are met.

AJMC^®: As payers and providers prepare for the rollout of the 988 mental health crisis hotline, and the increase in behavioral health care utilization that may come with that, how can APMs be leveraged here?

Bobb: There’s going to be a whole system of care and that's part of what folks are working on right now. One thing that's going to happen immediately with 988 is that it will help triage. So, you'll have 911 for more of those medical emergencies, fire emergencies, and then you'll be able to divert to 988 for more of that specific behavioral health.

Within that, a big component is going to be mobile crisis teams. Whether some of it might be virtual, at-based, or people that will be able to come out to the scene and then assess what level of care those folks are going to need. Are they going to be able to follow up with a rapid appointment in a day or 2? Are some of those people going to need to come in to the ER? So, really just identifying the appropriate care for that individual person.

What ultimately would happen if we're thinking about this in a VBP—risk-based vendor VBP can be made with any type of vendor contract. Fundamentals include having a well defined value proposition. The impact on members should be measurable by claims, or the impact on operations should be measurable by internal data. The performance outcome should be meaningful and important.

AJMC^®: Was there anything else you want to add from your session at AHIP 2022?

Bobb: I think one of the upsides of the pandemic is that there is increased awareness of behavioral health, substance use disorders, as well as mental health disorders. There really is a need to come up with novel and effective ways to manage the preexisting demand, as well as existing demand, and also placing an additional emphasis on not forgetting people with severe mental illness.

The other piece I would also mention is just the whole notion of when we think about these things, value-based payments, and we look at return on investment, we often think about it in a 1 to 3 year cycle. But if we can, as an industry, as well as society, look at things with a longer lens, then we can pay more attention to prevention, and also working on mechanisms that will help to ameliorate the initial drivers—poverty, help with housing, trauma. A lot of these factors which ultimately end up causing behavioral health difficulties, if we derive methods to address some of the root causes, as well as help to bolster resilience factors and how to create payment structures that can help with these ideals.