If you’ve never heard about “value-based care,” it’s time to catch up, and fast! This July, Medicare will be premiering a 10-year pilot model called ACCESS: Advancing Chronic Care with Effective, Scalable Solutions. While Medicare certainly has had other value-based innovations in the past, ACCESS is different because, for the first time, behavioral health is included.
What is value-based care?
The short and sweet definition is when a payer (Medicare, Medicaid, or an insurance company) pays for population outcomes rather than procedures. While in theory that makes sense if you break your leg or have a heart attack, how realistic is this in practice for behavioral health?
Probably many of us would scoff, saying that it’s not. How do you measure outcomes in mental health at scale? And is a decreased score on the GAD or PHQ really indicative of a positive treatment outcome? (I’m not qualified to answer that question…)
Sure, practices can, and should, measure outcomes with their clients in whatever ways they feel are clinically appropriate. But unless you’re a huge group, you’re not measuring large numbers of clients. Nor is measuring outcomes the only definition of value-based care.
“Paying for outcomes” shows clearly that value-based care is also a financial arrangement. In private practice, you may reliably be demonstrating positive outcomes with your clients, but Medicare, BC/BS, etc., are still paying based on the CPT code billed. In other words, payment is based on claims that represent you as having delivered a session: 90837, 90834, 90847, etc.
The less short, and definitely not sweet, finances of value-based care
Value-based care involves financial capitation. Here’s how capitation works: the payer begins by determining a population to be covered. For example, let’s say that Aetna wants to contract with an entity to cover all behavioral health services for the 10,000 Aetna members living in a specific city.
Aetna decides how much they will pay per enrollee, or “per head” – hence the term “capitation,” which comes from the Latin term for “counting of heads.” An easy way to remember capitation is to think about what “decapitate” means – to cut off someone’s head!
Gruesome joking aside, to continue with the example…
Aetna selects a provider entity who sub-contracts. In that contract, the provider entity agrees to provide all covered services to the members. Once done, Aetna simply pays the per-head (per-member) amount to the subcontractor/provider, and then washes their hands of responsibility thereafter to pay for care for any member in that group of 10,000 members. The subcontractor is now responsible for providing -and managing- all care.
Which places the subcontractor/provider financially at risk. Why? Because the more services are provided, the less profit they make. Their payment from Aetna is fixed. Aetna gets a great deal. The subcontractor/provider…who knows? Maybe it’s a great deal also. Maybe it’s not.
The clinical ethics of a value-based arrangement are usually enough to give most mental health professionals a sense of the “ickies.”
So capitation, the payment method for value-based care, requires scale. It isn’t going to be offered to even a group private practice, unless the group was seriously large (and probably financed by venture capital).
See where this is headed?
The Targets of ACCESS
Who provides mental health services at a scale large enough for a payer like Medicare to sit up, pay attention, and consider capitated reimbursement on the basis of outcomes rather than CPT codes?
Ah yes. Now we come to it. The platforms!
Sometimes morphed with, or looking like, national in-person or hybrid groups, because not all platforms hire clinicians as 1099’s. Then there’s a whole slew of AI, digital health, and apps.
Here’s a list of the platform entities which have signed up with Medicare as of April 23rd to participate in the behavioral health ACCESS program. (More may be forthcoming – Medicare’s deadline to sign up isn’t until May 15th).
- Headway
- Insurer investors: HCSC (BC/BS IL, MT, NM, OK, TX)
- Innerwell (specializes in at-home ketamine tx, therapy platform)
- Venture capital, but no known insurer investment
- Isaac Health (specializes with dementia/caregivers)
- Insurer investors: CareSource, Intermountain Healthcare
- SonderMind
- Insurer investors: Venture capital, but no known insurer investment
- Total Life
- Insurer investor: GEHA
- Other investors of note: Google, Charm EHR
In Medicare’s own words, “The ACCESS Model will test whether an alternative payment methodology—Outcome-Aligned Payments (OAPs)—for technology-enabled chronic care reduces expenditures while preserving or enhancing quality of care for Medicare beneficiaries.”
Rules of ACCESS
For those who are interested in all the arcane details of ACCESS, Medicare’s 63-page description is here.
These are just a few highlights.
To participate in ACCESS, entities must enroll as an organization eligible to bill under Part B, have valid state licensure, comply with HIPAA, and appoint a Medicare-enrolled physician to act as Medical Director. (which nicely eliminates the platforms’ contention that they’re just billing/credentialing services!).
ACCESS will be available to both Original Medicare and Medicare-Medicaid dual-eligibles. Opting into a program under ACCESS will be the choice of the beneficiary, with no reduction in other Medicare services. Medicare beneficiaries enrolled in “Advantage” plans will not be allowed to participate. And, for any Medicare recipient who enrolls in an ACCESS track, the ACCESS organizational participant (Headway, etc) will be forbidden to receive fee-for-service Medicare part B payment for that individual during their 12 months of ACCESS enrollment.
The only qualifying behavioral health conditions for beneficiary enrollment in ACCESS are a diagnosis of either depressive and/or anxiety disorder. And the only “Outcome-Aligned Payment Measure” is listed as
- Control or minimum improvement in symptoms (assessed via PHQ-9 for depression and GAD-7 for anxiety)
Payment will be a fixed amount to ACCESS organizations, payable over a 12-month period, and the amount will be prorated up or down, depending on the reported outcomes.
Hmmmm….any potential for fraud here?
The idea is apparently for the ACCESS participant organizations to utilize some form of technology to achieve the goals. These are some of the listed AI/app technologies that have signed up to participate in ACCESS:
- Altitude Cares Inc – their website proudly trumpets that it was built by leaders from CVS, Devoted Health, and Optum (is this a GOOD thing?!?)
- Ciba Health
- Headspace
- Limbic Care, PC
- M3 Information. – An AI tool for primary care providers to asses mental health conditions
- Meomind AI – RECORDED ACTUAL SESSIONS TO LISTEN TO, via an app. Plus live chat. Seems like a sort of BetterHelp model. Their website claims that clients gave consent for their therapy sessions to be recorded and published.
- Mindset Health
- MyHealthTrack
- NeuroTap Health, Inc
- Slingshot AI -the Ash therapy chatbot
In the fall of 2024, it was reported by Behavioral Health Business that Headway, in conjunction with the National Quality Forum, has been engaged in an initiative called Aligned Innovation, to develop a patient self-reporting outcomes tool that, in theory, will one day replace all others, and become the standard of care – whether insurance is paying for care or not.
““Measures will become broadly adopted and used, not just by one payer saying that they want to use them…, but when multiple payers in a market all align and say, ‘We’re going to all hold you, providers in our network, accountable for this measure, and we’re all going to use the same measure and do it in the same way,”’ Dana Gelb Safran, president and CEO of NQF, told BHB.
I’m not making a clinical argument about the necessity for measurement of outcomes, which is important. But when entities with a financial stake control both the development of the outcome measure and then leverage their power to mandate its use, which in turn determines how much and what type of treatment they’ll cover, I smell a serious conflict of interest, if not outright abuse of power.
And what’s disheartening is that CMS, for all the recent exclamations in the news about stamping out fraud, seems as if they might be opening up Medicare to fraud in newer areas.
Time will tell. But even if no fraud results, I do have to wonder about where this leaves solo behavioral health clinicians and smaller groups. If fee for service payment is ultimately discarded in favor of value-based care, what happens to the clinician who can’t or doesn’t want to scale? I seem to recall from my graduate statistics classes that small sample sizes aren’t valid for determining conclusions – which means value-based care could never be offered to independent clinicians. Is this a signpost on the road to extinction, if the dominant method of payment for healthcare becomes value-based??
That’s only one question. It seems to me that another major potential flaw concerns co-occurring diagnoses, severe histories of trauma, and lack of client privilege/history of marginalization (whether racial, economic, occupational/educational, ability/disability, other social determinants of health, religious background, gender, LGBTQ+, employment, etc). Clients with any of these characteristics might predispose ACCESS organizations to subtly discourage their enrollment into the value-based ACCESS program. Enough “severe” clients – there go your stats, and whoops! Your money too…
All in all, it seems to me that Medicare’s ACCESS, while well-intentioned, raises a lot of unanswered questions, at least as it pertains to behavioral health. Trying to figure out what value-based care would mean for your practice? Book a consultation and let’s talk it through.
