Value-based payment models that reward providers for quality improvement over the volume of services provided are transforming healthcare. Although value-based care has not yet fully arrived in applied behavior analysis, when it does, it will fundamentally change the relationship between service provision and reimbursement.
To prepare for the transition, BHCOE held a webinar to help ABA providers understand the key components of value-based care and the steps organizations can take to prepare for value-based payment arrangements. Webinar panelists included Kristine Rodriguez, director of clinical development and outcomes for Autism Learning Partners, Yagnesh Vadgama, Vice President, Clinical Care Services Autism at Magellan Health, and Lori Geary, Chief Health Outcomes Officer at BHCOE.
As an ABA provider, Kristine Rodriguez has been preparing for value-based payment for some time and shared her perspectives during the webinar. Rodriguez says that ABA providers have an opportunity to collaborate with industry peers to help shape the future of value-based payment in behavioral health.
“It’s our role to come to the table with our vision for what quality means and what we believe are appropriate measures for quality in our industry,” says Rodriguez. “The first step is to align our values around best practice literature and collect and analyze data to define what quality measures matter most to our industry.”
An overview of value-based payment models
Many states and organizations are testing value-based payment models that could be applied to behavioral health. Here are several models in use across healthcare:
- Capitation: Providers are paid a set payment per patient to cover specified services. For example, under a capitation arrangement, a provider would get a monthly payment for providing services to a patient with an autism spectrum diagnosis.
- Pay for reporting: Rewards providers for reporting results on quality measures.
- Pay for performance: Ties financial incentives to performance on cost, quality and efficiency measures.
- Bundled payments/episode-based payments: Provides a single negotiated payment for all services delivered for a clinically defined episode of care. The model incentivizes coordination of care among providers.
- Shared savings: Rewards providers for reducing healthcare spending on their patients below a level set by the payer, giving the provider a portion of the savings.
- Shared risk: Provider must cover part of the costs if they don’t meet savings targets.
A framework for value-based care
Value-based healthcare incentivizes providers to focus on the quality of services rendered rather than the quantity. Under a value-based payment model, providers are compensated based upon patient outcomes. The four components of any value-based payment framework are quality measurement, stakeholder engagement, data and analytics, and industry standards and central tendencies.
The three main buckets of quality measures are structural, process and outcome measures. Structural measures demonstrate the healthcare provider’s capacity and systems to provide high-quality care, such as the number of clinics a provider organization has, average years of experience and whether the organization uses an electronic medical record. Process measures cover the accepted recommendations for clinical practice. For example, for autism spectrum disorder screenings, there are recommendations about when pediatricians should conduct screenings. Finally, outcome measures reflect the impact of care that has been delivered, such as complications following surgery, improvement in depression systems or patient-reported outcomes on quality of life.
Engaging stakeholders is a critical component in any value-based payment arrangement. During the webinar, BHCOE’s Chief Health Outcomes Officer Lori Geary discussed how BHCOE works with stakeholders to define value and quality and determine how to measure it. At BHCOE, it begins with subject matter experts developing accreditation standards of excellence and sharing the draft standards with BHCOE and the ANSI Commission. Once those standards are implemented, the Quality Measurement Provider Panel does some measurement using the data that is collected. Other stakeholders, including technical experts, the BHCOE Person and Family Workgroup, and payer partners, are also involved in discussions about quality standards.
Data and analytics
Data and analytics are essential for identifying measures that address an opportunity for improvement, such as wide variation in how care is delivered. Data is also vital for risk modeling and payment adjustment calculations.
Industry standards and central tendencies
The final piece of the value-based payment framework is to understand and adopt industry standards and central tendencies. These include clinical and process guidelines, best practices, accreditation standards, industry averages and new research.
Geary points out the distinction between clinical and process guidelines and best practices. “Person and family engagement in measure development is a best practice to ensure you’re defining things that matter to patients, but it is not required,” she says. “Best practices are industry expectations, such as giving aspirin to a heart attack patient upon arrival at a hospital.”
Preparing for value-based payment models
Performance measurement in ABA is in its infancy. There are few recognized quality metrics in behavioral health compared to physical healthcare. Although it’s not clear yet what type of value-based payment model will work best for ABA, the webinar speakers agreed that quality and value will be significant components. Further, an emphasis on quality of care and continuous improvement will lead to better patient outcomes, higher patient satisfaction and more efficient workflows.
To accelerate readiness for value-based payment, ABA providers work together to define and standardize quality and outcomes measurement. “We have to start thinking about quality and delivering care in similar ways to optimize outcomes,” says Vadgama. “We have to look at the big picture, including social determinants, physical health impairments, comorbidities, and family dynamics, and what we can do as an ABA industry to deliver coordinated care.”
In addition to getting industry alignment on ABA quality metrics, another step to take now is to understand your data. “You don’t want to get visibility into your data for the first time when you enter into a value-based payment arrangement, says Rodriguez. “You want to know what your baseline was. You want to have improved it already and understand which interventions operate those levers.” She adds that it isn’t necessary to have an electronic medical record in your practice, but if you are still tracking data with pencil and paper, consider using a spreadsheet.
Watch the entire BHCOE webinar on How Value-Based Care Will Benefit Your ABA Organization or download the checklist on How Providers Can Prepare for the Transition to Value-Based Payment Models.