The slow progress in the behavioral health space, especially toward quality and accessibility of care for behavioral health and substance use disorders (BH/SUD), is concerning. While payment reform is spreading rapidly in this as well as other areas of the health care system, there continues to be significant barriers to adequate behavioral health treatment.
Both mental health and substance use disorders are highly prevalent and costly at the state and national levels. Researchers from Milliman estimated that the price tag nationally for treating mental health and substance use disorders was $752 billion annually in 2017, representing a 7.5 percent annualized increase in costs since 2014. In California, a national survey on drug use and health published by the Substance Abuse Mental Health Services Administration (SAMHSA) reported nearly 20 percent of Californians over the age of 18 experienced a mental illness, and nearly 8 percent experienced a substance use disorder between 2015-2016. Mirroring national trends, the majority of Californians received no treatment for their mental illness or substance use disorder.
The silver lining? There is increasing momentum to address these access, quality, and parity barriers in behavioral health, especially as the health care industry and lawmakers continue to shed the stigma historically associated with mental health and substance use. The American Psychiatric Association Foundation’s Center for Workplace Mental Health published an employer toolkit and literature review on the business case for mental health and substance abuse treatment. Here at CPR, we took the pulse on the state of the mental health marketplace in Summer of 2018.
When searching for guidance on how alternative payment models can spur further progress in this area, look no further than the Kennedy Forum. Founded in 2013 by former Congressman Patrick J. Kennedy, the Forum leads efforts to advance effective ideas and policies in behavioral health. In its efforts to advance behavioral health parity, The Kennedy Forum publishes reports, issue briefs, and toolkits, among other resources that are accessible to the public. In a 2017 report published on payment reform and opportunities in BH, the Forum identified four core values that all alternative payment models should share, regardless of the diversity in structure and topic.
- Measurement based care (MBC) focused on measuring symptom severity and treatment pathways based on patient outcomes
- Technology for supporting clinical decisions and advancing innovation- as well as maintaining accurate records and measurements of patient outcomes;
- Utilizing value-based payments to reward and incentivize providers to deliver high quality, cost effective care.
- Flexibility in care delivery. Current payment arrangements utilize the fee schedule and billing codes as their backbone, practices which often do not account for the complex or chronic nature of behavioral health treatment, or co-morbidities. Instead, the Forum emphasizes flexibility in developing BH centric APM.
The Forum’s 4 core tenet are:
Additionally, we’re keeping an eye on examples of APM initiatives underway in the behavioral health space, such as:
- The Addiction Recovery Medical Home (ARMH) model, launched by an alliance of leaders including Leavitt Partners, Facing Addiction with NCADD, and Remedy Partners. The model utilizes a broad continuum of care from emergent and acute care settings to community based support service. The payment model incorporates fee-for-service, episodes of care, quality-adjustments, and shared-savings- aligning the interests of providers, payers and patients through the risk-based model. The program emphasize flexibility to prioritize integrated care delivery. The model will first be piloted in two markets in 2019.
- The Medicaid Addiction and Recovery Treatment Services (ARTS) in Virginia, which expanded addiction treatment services for all Medicaid enrollees and increased payment rates to providers for these services, beginning in 2017. An independent program evaluation by Virginia Commonwealth University found that the program successfully increased the number by of Medicaid members receiving SUD treatment by 57%, while reducing emergency department visits related to SUD by 14%. When CPR interviewed health care leaders in the Commonwealth of Virginia in 2018, we heard that the ARTS program can serve as a litmus test to see how changes to the fee schedule can be an effective tool to booster the supply of clinically-proven care that has been traditionally underutilized.
As behavioral health and substance use disorders continue to be top of mind for employers and other health care players, CPR continues to work with subject matter experts, vendors and employers to develop resources such as our purchaser-oriented How-To Guide on Tackling Substance Use Disorders and Toolkit for Evaluating High-Value Mental Health Care.