Three months in and one thing we have seen is that some of our peers in the field of addiction either don’t understand what we are talking about when we use the word, “value” or they feel threatened by it because somehow they think it equates to less care or lower quality of care for our patients. In fact this couldn’t be further from the truth. We are huge advocates for both increased access and more care for mental health. By shifting and re-framing the conversation from the “price” of siloed mental health care to one of total value delivered to the patient by providing integrated care, we feel we can realign the interests of payers, patients and providers in a way that ultimately results in higher quality of care at a lower TOTAL cost to the payer.
The notion of applying value in behavioral health for me began years ago when my wife would come home day after day feeling beaten down by payers who continually challenged the “medical necessity” of the care that she knew her patients needed. This would often result in a patient’s coverage being denied, despite Kim’s best efforts to advocate for her patient, and despite the data that shows the inherent long term value of proper treatment of these deadly and incredibly costly diseases that only get worse, both “mentally” and emotionally” if not treated properly. When treated properly, however, so many far more costly medical co-morbidities are potentially avoided, people can return to their lives and remain productive workers, families and marriages can be saved, relapses and re admissions go down, quality of life gets better for our patients, etc. Treating someone’s addiction is not only the right thing to do but it is also something that can save society and payers an incredible amount of money. If money is what drives these decisions, then as providers let’s show them the value (or money they can save by investing in what we do!) by spending a few more dollars in a relatively inexpensive way. By working to peel the data back and show the naysayers just how valuable and relatively inexpensive this treatment can be, we get our patients the treatment they deserve.
People ask… What do you mean by saying you track “outcomes” and want to improve “value” and that there should be “risk sharing”? In mental health we have all seen and continue to see pressure from payers to cut back on treatment. This, despite so called parity and the press the opiate crisis has created. Average length of stays at the residential level are down dramatically in recent years, reimbursement rates continue to race to the bottom even in outpatient settings and in many cases quality of care is suffering as a result. This is worst case scenario for our patients and their families and yet we believe there is a solution that creates value rather so we don’t have to watch it get destroyed even more. The conversation between payer and provider is currently all about “price” when in fact it should be all about the long term value that proper integrated and evidence based treatment provides to our patients. We all know that proper treatment saves lives and we also know that it can also save billions in healthcare dollars. Some statistics backing this up; Researchers have noted that, “the vast majority of individuals with mental illness who receive appropriate treatment improve….. For major depression, panic disorder and obsessive compulsive disorder rates (of improvement) are about 70%. This is comparable to rates of improvement for people who suffer from physical disorders, including diabetes and asthma at 70-80%, cardiovascular disease from 60-70% and heart disease at 41-52%. The National Institute on Drug Abuse estimates that every dollar invested in addiction treatment programs yields a return of between $4 and 7$ in reduced drug related crime, criminal justice costs and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1! Just by integrating medical and behavioral services, The National Council for Behavioral Health estimates that between $26- $48 billion can potentially be saved.
When we look at the data, this is what we see. We see the VALUE in treating these diseases where value is measured by outcomes that matter to patients per dollar spent. Patients want to improve, they want to see their total health to get better, they want integrated treatment of both the emotional and the physical, they want the society in which they live to have less crime and as more and more of the costs of healthcare shift from traditional insurance products to patients they will want to know they are spending their money wisely and receiving the best possible care in the process.
Outcomes help us quantity and qualify the success that we as providers are having with our patients. They show us what we are good at, where we could do better and where maybe we should not be. This we can share with our patients and their payers in an effort to justify the value of the cost of our provision of care. They enable patients to have data from which to make informed choices about where to go for treatment and why. They enable payers to reward those of us who are truly increasing value for our patients and they hold us all accountable for our provision of care that we agree to provide. If our patients do well, we do well. If they do not do as well, we do not do as well. Of course we aren’t on the hook for a patient who leaves treatment and heads straight to the bar. That’s not value and no provider in their right mind would agree to share in that risk. However, we may be on the hook to some degree if we treat a patient diagnosed with a co-occurring case of substance use disorder and depression, for example, if we only treat the substance use and not the underlying depression. In this case we know if the depression is left untreated the chances of a relapse and subsequently more medical and behavioral problems are significantly higher both in the short run and long run. In other words, if we treat a patient with sub optimal care based on their diagnosis and they don’t do well, maybe we should share in some of that risk. And even if we don’t agree that a provider should share in any of the risk surely we all agree that the provider in this case who successfully diagnosis and treats the co-occurring depression and substance use disorder with medication assisted therapy and other modalities aimed at the depression should get paid more than the provider who only treats the substance use disorder- and not just because their costs of treatment may be higher. In this case the latter provider is much more likely to achieve better outcomes for the patient, which means their treatment is more valuable to the patient and the payer; thus, their service is more valuable and they should be rewarded accordingly. Better alignment and real integrated coordination creates an environment where we are all working together to optimize results for our patients, and where our patients have the highest chances of success. It is really that simple.
Our conversation about value is based on our recognition that the current fee for service model is fragmented and broken and whether its capitation or some form of value based reimbursement, SCH wants to be a part of the conversation and what we see is a solution for our patients. Once this value is recognized by all, our patients will be in a much better position from which to receive the care they both need and deserve.