Imagine you receive a letter from a Medicaid managed care organization. It outlines new value-based payment requirements tied to “patient outcomes and follow-up rates.” In other words, they’re offering a value-based care (VBC) contract.
Would you know what such a contract requires of you? Does your EHR track patient outcomes, and could it generate the kind of report that would satisfy the payers’ new requirements? With more payers moving toward VBC models, you may have to answer these questions sooner than you think.
A value-based payment model means you get reimbursed based on patient outcomes and not just on the services you provided to the patient. This requires you to measure patient outcomes and report them to the payer as part of your billing process.
VBC software, in this context, is an EHR that supports you in doing that. It offers the clinical documentation, outcome tracking, and reporting capabilities that allow you to prove patient outcomes to your payers.
What Value-Based Care Means for a Behavioral Health Practice
What does value-based care mean for behavioral health? Traditionally, behavioral health providers have been paid for the services they deliver, such as making a diagnosis, conducting a therapy session, prescribing a medication, etc. Value-based care is a model in which your compensation is partially based on the results of your service; i.e. whether and how it helped the patient.
Common outcomes-based reimbursement models in behavioral health are pay-for-performance bonuses, shared savings contracts, and Medicaid managed care agreements that tie payment to outcomes. In practice, these models tend to reward a provider for improving a payer’s cost and quality targets, rather than just increasing the volume of patient visits.
Pay-for-Performance Bonuses
Pay-for-performance arrangements add a bonus to your reimbursement when your practice hits specific quality benchmarks. Those quality benchmarks are usually easily trackable outcomes. PHQ-9 measurements, depression remission after 12 months, follow-up after hospitalization, and similar outcomes are common behavioral health quality measures used.
For example, your payer may offer an additional reimbursement amount if your clinic improves timely follow-up after psychiatric hospitalization. Or, the bonus could be tied to meaningful patient improvement as measured on the PHQ-9 scale. These factors are concrete and provide trustworthy data on the quality of your services.
Pay-for-Performance bonuses are attractive to payers and providers because they keep the traditional fee-for-service billing in place while layering in a quality incentive. This gives you a new way to earn more reimbursement without totally upending the way you are used to billing.
Want to stop leaving money on the table with your payers? Download our free whitepaper and get 10 actionable steps to implement value-based care and negotiate better contracts.
Shared Savings Model
Under a shared savings model, providers are paid a baseline amount for their services but also receive a share in any cost savings they help generate for a payer.
For example, if you provide exceptional care, and that care reduces ER visits for mental health, or readmission rates, or other avoidable costs over a certain period, you’ve reduced costs for the payer. When these costs are calculated at the end of the measurement period, you’re entitled to a share of the savings.
These contracts tend to be very clear on the rules for how savings and quality performance are calculated, so you’ll want to pay attention to the details when considering this kind of contract.
Medicaid Managed Care Contracts
State Medicaid agencies increasingly push managed care plans to improve behavioral health outcomes through withholds, incentive pools, or bonus payment tied to contract measures. Common measurements include follow-up after hospitalization for mental illness, follow-up after ER visits for substance use, and initiation and engagement of treatment.
The contracts often work by holding back part of capitation and then paying it back only if the plan meets performance goals. That structure has made Medicaid managed care one of the most active players in behavioral health VBC, because states can use a few high-value measures to drive broader access and quality improvement.
5 Ways Value-Based Care Software Maximizes Client Results
More payers than ever have realized that using measurement-based care can improve patient outcomes, and savvy behavioral health practices are jumping onto the VBC bandwagon. If you want your practice to succeed at value-based care, you’ll need some core capabilities directly in your software platform. Here are five of the most important.
1. Standardized Outcome Measure Administration at Every Visit
You’ll need to administer validated mental health assessment tools for value-based care consistently and at defined intervals. Rating scales like the PHQ-9, GAD-7, Columbia Scale, and others can’t be given to patients ad-hoc. They need to be administered regularly, and the outcomes tracked over time.
VBC software automates administration of outcome measurement by auto-delivering the scales to clients, recording the results in patient records, and tracking trends over time.
2. Longitudinal Outcome Tracking Across the Care Episode
You want to demonstrate improvement over time with these measures, so VBC-ready software tracks scores longitudinally. This serves two purposes. One, to show payers a concrete report on the positive results of your care.
Two, it alerts you to deterioration trends in individual patients, so clinicians can intervene before a patient falls out of care or requires more intense levels of care. This is good for the payers, good for your practice, and good for your patients who are supported closely at every step of their journey.
3. Quality Measure Reporting Aligned to Payer Requirements
HEDIS and state-specific Medicaid quality measures operate from specific definitions, eligible populations, and measurement periods. This can be a lot to manage for busy behavioral health staff and practitioners as they try to generate reports that show results while meeting all these criteria.
The margin for error is wide. That’s why Valant performance reporting features generate these reports from your clinical documentation without requiring anyone to manually pull a chart or extract a spreadsheet.
In general, practices that can’t produce a quality measure report in under an hour are not ready for value-based care. If you want to strengthen your position in the value-based care market, find software that gives you stellar outcome measures reports.
4. Follow-Up and Care Gap Identification
Follow-up measures, such as follow-up after hospitalization (FUH) and after emergency department visits (FUE) are frequently required in value-based care contracts, so gaps in follow-up can significantly hurt your chances of being successful in VBC. Software that is VBC supportive should flag these care gaps when patients miss their follow-up appointments, so you and your staff have time to reach out proactively before the measurement period closes.
5. Documentation Supporting Both Clinical Care and Payer Reporting
The documentation that drives VBC reporting can’t be a separate workflow from clinical care. Outcomes, clinical notes, and the resulting billing are too closely entwined. The data payer’s need should be captured right in the notes as a natural part of the clinical encounter.
VBC-ready software will structure its clinical documentation to capture these elements. That way, you’re not relying on clinicians to do post-visit data entry that meets all the VBC requirements. That would be just another task adding to their workload and burnout risk.
Is Your Current EHR VBC-Ready? A Self-Assessment
Ask yourself the following questions to see if you are VBC-ready on your current platform. If you answer “no” to three or more of these questions, you may need new software to be successful with VBC contracts:
- Does your EHR administer and track PHQ-9 scores automatically at defined intervals?
- Can you pull a report of patients whose PHQ-9 has worsened by five or more points in the last 90 days?
- Can you generate a follow-up after hospitalization report for a defined date range?
- Does your clinical documentation capture the data elements your payer needs regarding quality measures, without a separate data entry step by staff or clinicians?
- Can you export quality measure results in a format your payer accepts?
Frequently Asked Questions About Value-Based Care
Want more insight on how value-based care software and related operations work? Look no further than these often-asked questions and our team’s answers.
What is value-based care in behavioral health?
Value-based care in behavioral health is a payment model in which providers are reimbursed for patient outcomes and quality measures, like symptom reduction, treatment adherence, and follow-up rates, rather than just the volume of services delivered. Behavioral health practices under VBC contracts with payers or Medicaid-managed care organizations need EHR platforms capable of tracking outcomes, generating quality measure reports, and documenting care in a way that supports payer reporting requirements.
What quality measures are most commonly used in behavioral health value-based care contracts?
The most commonly used quality measures in behavioral health VBC contracts are depression remission at 12 months, PHQ-9 response rate, follow-up after hospitalization for mental illness (FUH), and follow-up after emergency department visit for mental illness (FUE). State Medicaid programs may add specialty-specific measures. Review your specific payer contract language to see which measures apply, and to make sure your EHR can generate the reports your payer needs.
How do I know if my behavioral health EHR supports value-based care reporting?
The clearest test is whether your EHR can generate a follow-up after hospitalization (FUH) report or a PHQ-9 response rate report for a defined patient population without a manual chart pull. If you have to export data to a spreadsheet, or call your EHR vendor for a custom report, your platform isn’t built for VBC reporting at scale.
See How Valant Supports Value-Based Care for Behavioral Health Practices
Valant’s clinical reporting tools, documentation, and outcomes tracking are built to support value-based care requirements in behavioral health. Valant software automatically administers outcome measures, tracks scores longitudinally, and offers quality measure reporting.
If your practice is navigating a VBC contract, or schedule a demo now preparing for one, to see how Valant can help you handle VBC documentation and reporting right in your clinical workflow.
