The team at SCH is looking to align with like-minded treatment centers, mental health professionals and business leaders as we form an alliance designed to enable close collaboration around patient care and quality improvement initiatives in the behavioral health space- specifically the addictions and mood disorders space in which SCH operates. The name of the alliance is VMH, for Value in Mental Health. We are seeking to create an atmosphere in which we as healthcare professionals are able to openly discuss outcomes data with each other in order to drive an increase in quality of care, a decrease in total cost and data which clearly shows the value that we in the mental health field provide to patients, their families and their payers. Please contact David Newton at SCH to learn more.
If ever there was a time for mental health providers to work together to demonstrate, document and prove the value that our care provides, now is that time. The fact remains unfortunately that a relatively large percentage of people in our country simply do not want to pay for mental health services. Human behavior teaches us that people generally don’t want to pay for something if they don’t see the value in it. This is absolutely the case in mental health. Those of us who have done the research, who have lived with these diseases and/or who have treated these diseases know first-hand just how valuable and powerful proper and effective treatment can be. Lives can be saved, dollars can be saved and families can be saved. However, so many people don’t know this or they don’t believe it and as a result they simply don’t want to pay for it.
We see this being played out in Washington DC with the new healthcare act coming down the pipeline, which will inevitably cut funding for mental health treatment one way or another. We also see this being played out in the way treatment is currently paid for by managed care with the sometimes ridiculous hurdles they often put providers through. At SunCloud Health, we have had two cases in the past three weeks where managed care denied our right to submit clinical’s on two separate patients (who absolutely needed what we were recommending) based on their claim that they did not receive the request to submit clinical’s in a timely manner (Yes, you read that right). Drilled down for those of us who are forced to spend and waste countless hours on contentious “peer reviews”, the facts are as follows: We were initially and in our opinion unjustly denied for the requested level of care at the pre-auth stage, we opted to advocate for the patient and elected to escalate to the next level, we left the voice mail advising as much, we have proof that we left the voice mail, they denied receiving the voice mail and as a result they closed the case and refused to even consider the case for the level of care we recommended. They never looked at the additional clinical information available for review, they did not speak to anyone on our clinical team and they refused to authorize the level of care for the patient. Clearly they do not see the value in the care being provided. If they did, this would not happen this way. It just wouldn’t.
When a payer can get away with not paying for legitimate care based not on a patient’s clinical’s but rather a technicality such as they supposedly did not receive a voice mail, when more than 50% of the highest leaders in this country are debating not whether or not to cut access and funding to mental health but rather how to cut it and when some people still believe many mental health illnesses are choices rather than diseases, we most definitely have a problem.
Living in a country and in an economic system where we pay for goods and services based on the perceived value that we place on those goods and services, the most effective way to successfully address this problem is to prove to the world that there is in fact value in what we do. We know it’s there. Our job is to convince those who don’t know it or who don’t believe it that it is there. This is done with honest and reliable data and a clear message. It requires collaboration and cooperation between like-minded quality providers who deserve to be paid for the work that they provide not just because they feel like it but because there is real tangible VALUE in the service they are providing.
To show value, we must be able to effectively and clearly show people the results (or outcomes) of the treatment we provide, and the cost to achieve those outcomes. And we must do so in a way that our patients, their families and their payers can easily understand and in a way where they can compare our services against one another so as to determine what each of us do well and what we may not do as well. It is only with this perspective that comes with being able to compare products and services that people will be able to confidently assign a value both to what we provide as an industry and as individual providers.
To actually do this, we need collaboration among ourselves as providers and we need the buy in from payers who hold all of the claims data to agree to do the analysis with the data that they have and the results that we will provide them. Together, we need to agree on a standardized set of outcome tools that we all use and we need to pool as much data as possible so as to make a convincing case. We need to be ready and willing to learn from the measurements we will be taking as we learn what we do and do not do so well, and to work to continuously improve where we can. We MUST be willing to shift our mindset and our business models from being rewarded for the volume of services that we provide to being rewarded for the value that we provide our patients and their families. We must be willing to share in some of the risk with our patients and their payers, which simply means we do better when our patients do better and we don’t do as well when they don’t do as well (due to something that was or is in our control). We should we interested in having patient representation on quality improvement teams, as patients know sometimes better than we do where we can improve. Where we can take our cooperation a step further and create mutually beneficial alliances which optimize and leverage our strengths, we should do so. And of course we need to continue to advocate for our patients and their families every chance we get.
An inspiring article was released this month from ICHOM, an international consortium based in Cambridge which measures, documents and publishes meaningful health outcomes, about a group of hospitals in the Netherlands that decided to form an alliance that would enable close collaboration around patient care and quality improvement initiatives. The group is called Santeon and what they have been able to accomplish by taking many of the steps mentioned above is simply remarkable. Though they are not in the mental health space, there are still many lessons to be learned and the path they took toward changing the paradigm is one that at the very least is worthy of looking at.
The business of healthcare has changed a lot in the past ten years. Providers are being held more and more accountable for our provision of care than at any time in recent history. The shift from paying for value over volume is one that has moved in to many area of healthcare, and it is one that mental health providers should embrace arguably more than any other specialty. Payment for our services is currently under attack from just about every angle and this is primarily because we have a very difficult time showing people just how valuable and powerful our services can be. By working together and changing the way we do business, we can address this attack head on. And the beauty is that while we do this we will not only save ourselves from the attack on everything that we do, but we will improve quality of care, we will reduce total cost and we will do our part in providing as much access as possible to patients and their families who are in dire need of our services.
Click here for the ICHOM article on Santeon.