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Behavioral Health Providers Face Challenges in Value-Based Care

By Dr. Martin Lustick

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Value-based care (VBC) continues to be a popular expression across the health care landscape, but the challenges and opportunities it offers are quite different across specialties. Behavioral health (BH) providers are an important case in point. The opioid epidemic combined with increased recognition and prevalence of mental illness secondary to the pandemic have brought behavioral health to the forefront, but for BH providers the transition to VBC continues to present significant challenges. 

BH organizations that combine in-patient, outpatient and residential services are reasonably well positioned to enter into value-based payment arrangements for episodes of care. Substance Use Disorders (SUDs) and Serious Mental Illness (SMI) are two obvious areas of focus, but even for those providers that serve the entire continuum of BH services, there are daunting challenges. Primary among them is that within each service category, it’s likely that some portion of a provider’s clients go elsewhere for other categories of service. For example, significant portions of a group’s outpatient clients may go to other organizations for inpatient and/or residential services. When that happens, the provider essentially loses control of portions of their patients’ care. Regardless of the detailed arrangements in a value-based contract, losing control of services that impact quality measures, clinical outcomes, and overall cost of care, puts a provider in a nearly untenable position in terms of managing the inherent risk in such contracts. For those providers that focus on one or two components in the continuum of care, the challenges are significantly compounded. They often lack both insight and influence on services that they don’t provide themselves. 

Congressional Support to Improve Behavioral Health Services

To help overcome some of these challenges and drive improvement in care for those with SUDs and SMI, the U.S. Congress has taken several important steps in the past seven years. In April 2014, they passed the Protecting Access to Medicare Act, which included a provision directing the Centers for Medicare & Medicaid to create demonstration projects to improve BH services for Medicaid recipients. The legislation prescribed a series of attributes that would define a Certified Community Behavioral Health Clinic (CCBHC), primarily focused on ensuring these organizations could be accountable for meeting the needs of those with SUDs and SMI. CCBHCs brought various components of BH and social services together in a collaborative arrangement so they could take risk on episodes of care within BH. They must be able to either directly or through formalized relationships with other providers ensure a core set of services, level of service and coordination of services that are critical to meet the needs of these patients. One could think of a CCBHC as a Clinically Integrated Network (CIN) for behavioral health.  

Expansion Beyond First Eight States

Eight states were chosen to begin the demonstration project in 2017. Congress then appropriated grant funding in 2018 for CCBHC readiness, and in 2020 expanded beyond the original eight states so today there are 340 CCBHCs spanning 40 states. This framework and funding has clearly advanced the capabilities of BH providers to meet the clinical and business requirements of a value-based care, but there is still much work to be done. 

Working Toward Whole Person Care

Given that over two-thirds of people with mental health disorders have a comorbid chronic physical disease, the ideally-positioned provider organization for this population is one that has already begun to integrate primary care and behavioral health. In addition to the practical value of integrating services around the global needs of the population being served, by combining the two, payers can begin to use standard attribution logic and move beyond bundled payments as a mechanism to align payment with outcomes. Federally qualified health clinics have increasingly integrated BH into their primary care practices, even as BH organizations have begun to incorporate primary care into their portfolio of services. It will be important to both support and track the progress of these organizations as we work to realize the potential of whole person care. 

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Dr. Martin Lustick

Senior Vice President, NextGen® Advisors

Dr. Martin Lustick is a principal and senior vice president with NextGen Healthcare focused on supporting provider organizations in their successful transition from volume to value-based care…

Dr. Martin Lustick is a principal and senior vice president with NextGen Healthcare focused on supporting provider organizations in their successful transition from volume to value-based care.

Dr. Lustick earned a BA in History from Cornell and an MD from Columbia. After completing his pediatric residency at Children’s Hospital National Medical Center in Washington, DC, he was in clinical practice for 17 years with Kaiser Permanente of the Mid-Atlantic States. While there, Dr. Lustick held various management and leadership roles, including chief operating officer for the 800-physician medical group. He oversaw development of their hospitalist program, population health capability, and open access delivery model.

Dr. Lustick then served as chief medical officer for ThompsonHealth—a small health system in Canandaigua, NY—where he provided clinical oversight for hospital, SNF, nursing home, IT, and out-patient physician practices.

In 2005, Dr. Lustick assumed the role of SVP & CMO for Excellus BCBS which covers 1.6 million lives comprised of Medicare, Commercial, and Medicaid. In his 13+ year tenure there he led a variety of strategic initiatives, including a patient-centered medical home program which served as the foundation for the plan’s value-based payment strategy. He also led the implementation of an automated authorization program for care management services, development of a clinical quality improvement strategy, and creation of innovative programs in management of low back pain, screening and prevention, opioid addiction, and chronic disease management.

Dr. Lustick has also been very active in the community, serving on boards and committees confronting issues such as: healthcare capacity planning, Health Information Exchange, mental health, substance use disorders, social determinants of health, and childhood obesity.

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