Over the past few years, America has witnessed its health care system shift from a predominately pay-for-service model to one with various reimbursement models that focus on long-term behavioral health improvements, promoting efficiency and reducing costs. It may seem like a tall order for physician payment methods to improve patient care, but the industry agrees there’s a clear connection. When health care providers are paid based on the value they provide to their patients, they become accountable for using evidence-based, appropriate and necessary services.
The Pay-For-Service Model
The major reimbursement model within the U.S. health care industry has been fee-for-service. Health care organizations or physicians are reimbursed for the specific services they provide. This makes sense when you consider a physician is paid for an office visit or a diagnostic blood test. However, this reimbursement model can theoretically encourage physicians to run services that are unlikely to improve their patients’ outcomes. More testing and procedures don’t always lead to a good result.
Effects of the ACA
The ACA changed the entire landscape of the U.S. health care industry. Millions of individuals have gained private insurance or Medicare or Medicaid coverage since its implementation. In addition to broadening health care coverage, the law sought to improve behavioral health outcomes by reforming reimbursement systems.
New payment models include bundled payments, global payments, pay-for-performance, and pay-for-value reimbursements. All of these models strive to improve patient care while effectively managing costs, according to Qualifacts, a behavioral EHR provider. When patients’ long-term behavioral health care needs are met, long-term costs of care can actually be decreased.
The statute also created Accountable Care Organizations, which are groups of health care providers that work together to offer coordinated care to patients. The ACOs receive bundled payments in which one reimbursement is allocated to a provider for services offered during a period of care, not for each individual service, explains Qualifacts. The ACOs enable physical and mental health care providers to offer integrated mental health care at a lower cost to patients.
Are Value-Based Payments the Future?
While there are multiple reimbursement models that can be used to drive improved outcomes for patients, value-based payments have grown in popularity. Instead of a physician being paid for each service, the physician receives reimbursements based on performance criteria. The Centers for Medicare and Medicaid Services is front and center in the push for value-based payments, according to BDO’s Consulting Managing Director and Chief Physician Executive Dr. William Bithoney. The CMS has a goal of coupling 85 percent of its payments to value-based outcomes by 2018.
Value-based reimbursements push physicians to strive for improvement in their patient’s conditions by utilizing only the most necessary and appropriate services. Because they won’t be paid for unnecessary tests, physicians are forced to determine services and treatments that have the potential to be truly helpful.
Vince Bianco, President of Advanced Medical Reviews (AMR), an independent medical review organization, notes that value-based payments can also improve the quality of Utilization Management (UM) reviews. “Using an evidence-based approach can enhance the quality of patient care. The goal in AMR’s review process is to make sure that patients are getting the care they need when they need it, based on scientific evidence.”
Fee-for-value emphasizes basing behavioral health decisions on scientific evidence, Bithoney explains. Physicians have the responsibility to continue their educations and keep up on research to ensure their diagnostics and treatment plans are evidence-based, not unproven. Evidence-based care is important everywhere, but there’s a genuine need for it in mental health issues and alcohol and substance abuse treatment because non-credible therapies are still commonly deployed.
Value-based pay also shifts accountability onto health care providers, Bithoney writes. When providers are held responsible for beneficial outcomes, they focus on long-term improvement and stability. To improve long-term outcomes, behavioral health care providers work more closely with other physicians, like primary care doctors, to ensure the patient receives integrated care. This is particularly important, as individuals with mental health issues need more stable, on-going care and not momentary interventions.
Problems in Implementing Pay-For-Value Reimbursement
As beneficial as the value-based model has proven to be, there are still hurdles to its implementation, particularly in the behavioral health sector. Issues arise when there aren’t standardized outcomes and quality care measures for specific types of care. Doug Nemecek, Cigna’s Chief Medical Officer for behavior health, discusses in the publication Behavioral Healthcare how variations in addiction treatment make it difficult to implement fee-for-value reimbursement because insurers don’t have standardized measures of improvement and beneficial outcomes.
Many physical medical specialties have standardized measures of care. There are clear, measurable signs of improvement. But behavioral health issues like depression, anxiety, and substance abuse don’t necessarily have well-regulated treatments or benchmarks for improvement.
By all accounts, health care spending under the ACA has only grown. America continues to be a top-spending nation on health care. However, there’s hope that the increased spending in combination with new reimbursement systems is benefiting patient care models and leading to improved patient outcomes.