By 2030, it is anticipated all Medicaid payments will be on a value-based model, rewarding providers for their quality of care rather than patient volume.
“Value-based programs reward healthcare providers with incentive payments for the quality of care they provide to people with Medicaid.” That’s according to how the Centers for Medicare & Medicaid Services (CMS) defines the relatively new paradigm. Value-based programs support CMS’ three-part aim: to provide better care for individuals, improve health for diverse populations, and to lower the cost of healthcare services.
The transition toward value-based payment models isn’t optional. All traditional Medicaid beneficiaries will be treated by a provider in a value-based care model by 2030. CMS made that expectation clear on September 15, 2020, when it guided state Medicaid directors to advance the adoption of value-based care strategies across their healthcare systems.
Aligning provider incentives across payers is one of the goals. Their ability to improve quality of care in a cost-effective manner or lower costs while maintaining standards of care is how healthcare providers are reimbursed under value-based care.
This is in contrast to traditional Medicaid reimbursement models that reward volume of care. And, in the spirit of better health for all populations, value-based healthcare for serving Medicaid patients is also designed to address social determinants of health and healthcare disparities.
Caring for individuals with a substance use disorder
So, what does value-based care look like when behavioral healthcare providers are caring for individuals with a substance use disorder?
CenterPointe, based in Lincoln, Nebraska, is a CARF-accredited provider of Medicaid behavioral healthcare services, including substance use disorder treatment. CenterPointe has had several value-based contracts with payers in recent years. The majority of persons served at CenterPointe are experiencing cases of mental illness and addictions. Nearly all of these persons have minimal or no income when they enter CenterPointe programs.
With the right value-based contracts, excellence is rewarded
According to CenterPointe Vice President/Director of Quality Improvement & Data Management Center Isaac French, M.A., LSSBB, given the right value-based contracts, excellent providers are often rewarded for practices and outcomes that are commonplace in their patient-centric organizations.
His advice for behavioral healthcare providers considering the necessary pursuit of value-based contracts is to ”be prepared with reports and data. That’s huge.” It’s the source of “negotiation power.”
“You have to start measuring in advance, showing evidence-based improvements over a period of time, even years,” French continued. He said, for substance use disorder treatment providers, it all makes sense when you have “shared” goals with the payer, like reduced hospitalizations; reduced jail time; and reduced returns to emergency rooms, crisis centers, and residential treatment centers.
Participation in outpatient therapy, psychiatric appointments, medicine management, and peer support services, as well as showing evidence of recovery and treatment plans, has led to welcome bonuses for CenterPointe from payer Nebraska Total Care, a Nebraska-focused managed care organization (MCO), according to French.
Michelle Nelson, CARF International’s new managing director of substance use disorders, is well versed in CenterPointe’s success with value-based contracts. A Licensed Alcohol and Drug Clinician (LADC), a Licensed Independent Mental Health Practitioner (LIMHP), and a Professional Counselor, Nelson recently joined CARF after 28 years with CenterPointe, where she most recently held the position of chief clinical officer/clinical director. She was previously director of the Drug Crisis Center and served in many other positions throughout her career at CenterPointe.
“There are lots of people in America who aren’t receiving quality behavioral healthcare, if they are receiving care at all,” Nelson said. “Most Americans understand that the cost of behavioral health is too high and there are too few providers.” So how does one find high quality behavioral healthcare providers specializing in substance use disorders and what does high quality addiction treatment look like?
Finding high quality substance use disorder treatment providers
Nelson highly recommended selecting a behavioral healthcare provider specializing in substance use disorder services that are accredited by CARF. She emphasized that accreditation is an important tool in assessing the quality of services. It demonstrates a healthcare provider’s commitment to enhancing performance, managing risk, and distinguishing service delivery. And payers recognize accreditation as a demonstration of superior performance due to clearly defined and internationally accepted standards.
Since 1966, CARF’s field-driven, international-consensus standards have evolved and been refined with input from global stakeholders, including healthcare providers, consumers, and industry experts. All have demonstrated a commitment to continuously improving services, encouraging feedback and serving the community.
As a longtime CARF client at CenterPointe, Nelson is passionate about the opportunity to engage with more providers. She is charged with expanding CARF’s reach in behavioral healthcare, especially to substance use disorder treatment providers.
Nelson is well qualified and recognizes firsthand the challenges substance use disorder treatment providers are facing, including a diminished workforce, overwhelmed administrators, a lack of infrastructure and electronic health records (EHR), and a lack of integration between the silos of behavioral health and primary care. Furthermore, value-based payment models haven’t always been well explained to substance use disorder treatment providers.
Evidence-based research influences clinical practice
Research shows that addiction can be treated using certain clinical practices, but there are no quality standards that require addiction treatment facilities to deliver these practices. As a result, the quality of care varies and it’s unclear whether facilities are consistently utilizing helpful practices. This can add challenges for people looking for high-quality addiction treatment programs for themselves or their loved ones.
Atlas (Addiction Treatment Locator, Assessment and Standards Platform) is a tool recommended by CARF. It was created by the nonprofit addiction treatment advocacy organization Shatterproof “to help people search for, and compare, addiction treatment facilities to find care for themselves or their loved ones.”
Atlas follows Shatterproof’s National Principles of Care©, the key elements of high quality addiction treatment. According to Shatterproof, evidence has shown and continues to show these principles improve the health of persons with addiction.
Nelson said there is a growing national movement to integrate behavioral healthcare and primary care, which she sees as critical as all Medicaid healthcare providers, not just those treating substance use disorders, move to value-based contracts with payers by 2030.
Although the importance of integrating behavioral healthcare and primary care has been recognized, Nelson would like to see more action in practice. Of course, Nelson would also like all substance use disorder treatment providers to be worthy of CARF accreditation and available everywhere through search on Atlas. If this were the case, she would know their patients are being well cared for and that primary care and behavioral healthcare are being integrated. They are also likely to be on the road to being ready for those value-based contracts with payers that are rapidly approaching. The year 2030 is less than eight short years away.