Sink or Swim: Value Based Care Is Coming
Season 1: Episode 2- Sink or Swim: Value-Based Care is Coming
Hello everyone and welcome to episode two of The Behavior Breakdown. I’m your host, Lynette Elizabeth, and for those who are just tuning in, which I am assuming is most of you since we just launched this project, I am a Behavior Analyst, working in the field of Applied Behavior Analysis, or ABA as it is most often referred to. I created this podcast because throughout my decade of experience in behavioral health, I have been consistently presented with questions from parents and professionals about how to navigate the labyrinth of clinical and financial details of ABA. My goal is to provide enlightening and factual episodes, interviews with professionals with a wide range of viewpoints, and round table dialogues where we hit the hard topics facing our families and industry.
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Today’s episode talks about the shift from the fee-for-service model we are all accustomed to, into the value-based care model. What is value-based-care? I’m glad you asked, because this episode will cover what the it is, where it came from, and what this means for clinicians and families seeking behavioral healthcare. Buckle up, because I sure didn’t know most of this was going on heading into the research this week, and I’m going to bet most of you didn’t either.
So you may have heard the term Value Based Care or VBC becoming more popular in the last few years, but very few of us BCBA’s actually know what Value Based Care really is, where it came from, or what it means for our future. Well let’s break it down and pull back a few layers on this onion to figure out how much of an impact this may have for us. Based on a journal article written in 2019, published byBMC Health Service Research, they say “In 2006 the concept of Value-Based compensation in Health Care (VBHC) was introduced by Porter, a professor of Business Strategy at Harvard Business School. During the previous years, health care in the US, and other Western countries had been heavily criticized for its high costs and suboptimal quality and safety. Porter introduced a twofold strategy to tackle this. First, health care should be reorganized into ‘value-based’ care pathways around patient groups. These pathways should no longer be merely focused on increasing production, while shifting costs to other providers, but they should strive for the highest value for patients, i.e. the best possible outcomes, for acceptable costs. Second, these pathways should compete for the favor of patients and health care purchasers. Patients should – in turn – behave more as critical health care consumers, while purchasers ‘buy’ the best possible health care for the lowest possible cost. During the last decade, VBHC has been embraced by almost all stakeholders in most of the Western health care system. Although it is widely believed that VBHC contributes to more efficient clinical pathways, a focus on relevant outcomes, cost awareness, and transparency, evidence of its effectiveness is still scarcely available. While it seems like VBHC has been around for almost 20 years, why do we, as consumers and clinicians, have such limited information about what it actually means to us? While ABA is new in the healthcare system since the adoption of insurance-based funding, I would expect as a healthcare consumer, that I would have some knowledge of what appears to be a common-place model in today’s healthcare.
Well, According to Aetna's website, value-based care is defined as a health care delivery model in which providers are paid based on the health outcomes of their patients. The payment model reimburses providers based on the quality of outcomes they deliver, as opposed to the services they render, which is the case in the current fee-for-service model. For those who are not familiar, a fee-for-service model pays a provider an agreed-upon fee for the number of “units” billed to the insurance company. A “unit” in ABA is often broken down into 15 minute increments or 1 hour segments. So essentially, for every hour you provide a service, you get compensated at a standardized rate, similar to an hourly wage. Well, this has been a perpetual barrier in the field of ABA and its expansion into areas of need which can often be limited by socioeconomic status, geographical region, or simply the high cost level that can be upwards of $60,000 per year per child! It also provides hurdles for companies when trying to stabilize technician schedules, analysts caseloads, and managing cancellations among staff and families in order to produce enough revenue to fund the massive overhead costs required to maintain these organizations. By transitioning to a value-based care model, it might increase the possibility for organizations and insurance companies to effectively provide services to a wider range of patients needing services. However, under many value-based contracts, providers share benefits as well as financial risk with health insurance companies. In addition to negotiated payments, they can earn incentives for providing high-quality, efficient care. However, if they do not meet the terms of the negotiated contracts, for example by not meeting the outcomes they agree to, providing effective services, or becoming less cost effective, they can be liable for additional fees or penalties. While quality care can be provided under both models, it is the difference in how providers are paid, paired with the way patient's care is managed, that provides the opportunity for health improvements and savings in a value-based care environment.
But what is the financial and proverbial cost of transitioning to this model in ABA? While healthcare leaders and policymakers have expressed the need to transition to a value-based payment structure for decades, the majority of the US health-care system still operates under a fee-for-service model while speculating how to meet the standards for value based care. Which, if you think about it, why is it such a struggle for our medical providers to show that their services produce beneficial outcomes for their patients? A partial explanation I ran across throughout my research is that fee-for-service models translate into a reduced focus on preventive care and more focus on acute situations which in turn drives costs. Preventative care tackles a patient’s health PRIOR to a medical condition that requires an immediate response. An acute situation would be a medical event which would occur AFTER medical treatment is the recourse to reduce symptoms. I mean that sounds ridiculous, but based on my own experience dealing with insurance, that sounds about right to me.
Value-based care is highly focused on an integrated healthcare system, and although we do make efforts to coordinate care to some extent in this industry, payors will expect more. This means that we, as providers, will need to spend more time connecting with a client’s entire treatment team including their physicians, neurologists, psychologists, speech therapists, occupational therapists, and school related services. Who has time for that, right? Value-based care will point clinicians towards quality services and integration of wraparound services, such as the examples I just provided, to ensure that we're benchmarking what we're doing, not just to the patients themselves, but to others.
The most essential areas being looked at by payors to integrate a value-based compensation system into applied behavior analysis, are cost of services, quality of outcomes, and family satisfaction. According to the Behavioral Health Center of Excellence, also known as the BHCOE which provides accreditation to ABA facilities, there are few value-based payment models that are currently being implemented across healthcare. The first is Capitation where 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. Another option is Pay-For-Reporting. This rewards providers for reporting results on quality measures. Quality measures have yet to be standardized across the field of ABA, but some providers and insurance companies have begun to partner together in order to begin the process. I will go into this further later in the episode. Another model is Pay-For-Performance which ties financial incentives to performance on cost quality and efficiency measures. Next is bundled payments or episode-based payments which provides a single negotiated payment for all services delivered for a clinically defined episode of care. This may look like an agreed upon wage for an entire 6 month contract, which is the standard preauthorization agreed upon by insurance and providers. The model incentivizes coordination of care among providers which we discussed just a moment ago. The last two models go hand-in-hand and those are shared savings, and shared-risk. This is where reimbursements would reward providers for reducing healthcare spending on their patients below a level set by the payor, giving the provider a portion of savings. Conversely, it would require providers to cover part of the cost if they don't meet savings targets. The level of data available on the effectiveness of Value Based Care has simply not had enough time to determine if it truly is more valuable for the patient or the provider. I speculate, in theory, this model would benefit both the patient and provider, however a number of different variables could easily affect how probable it is that ABA companies will be able to successfully execute the requirements.
According to the BHCOE, there are four main elements of any value-based payment framework: Quality measurement, stakeholder engagement, data and analytics, and Industry standards.
Let's break that down a little bit further and talk about what information an ABA company would need to access in order to be successful in adopting Value Based Care. First let's start with quality measurement. There are three main components of quality measurement which include structural measurements, process measurements, and outcome measurements. Structural measures would include things such as the number of clinics an organization has, the average years of experience, and whether the organization uses paper or electronic medical records. Process measurements cover accepted recommendations for clinical practice including autism screenings, development of treatment plans, and clinical delivery of services. Finally outcome measures reflect the impact of care that has been delivered through progress shown by the client, positive family and patient feedback, and meaningful gains in socially significant goals. The second component of value-based care is stakeholder engagement. This would require companies interacting with stakeholders to define the value and quality of service and determining how to measure it. There are a few different ways this is currently being managed which we will talk about shortly. The third component is data and analytics which are essential for identifying measurements that address an opportunity for improvement including client to client variability. This has become a difficult task considering how wide a variety of ABA care is being delivered across clients. Behavior plans and skills goals vary GREATLY from agency to agency, and even from analyst to analyst. So the industry as a whole will have to settle upon ways to measure these types of single-case measurements across the population as a whole.
The final component is industry standards and central tendencies. According to the BHCOE these include clinical and process guidelines, best practices, accreditation standards, industry averages, and new research.
What we can expect once ABA moves to a value-based care model, is more payor auditing, a greater need for transparency, and sharing of data across providers. We will also need to determine what outcome data is and what the impact and importance of the data will be. ABA has historically been focused on single subject analyses and our industry will have to collaborate to produce aggregate data beyond a single subject case. There is high variability in the methodology of treating individuals with ABA, so collaboration is also needed across providers to agree on standardization benchmarks. This could be defining what “progress” means by using things such as standardized assessments, measuring mastery of goals across all clients, which in turn requires standardizing goal language. Additional variables may include deciding what assessments to administer to clients, how and when we are conducting the assessments, how we write treatment plans, how we write goals, collecting data, company protocols, and predictability of outcomes. There will also be a need to measure outcome data over a long period of time. As you can see, this can be a slippery slope of variables that ABA currently measures on a case by case basis. And if those variables aren’t enough to consider, Value-Based Care also requires a focus on how to measure impacts of comorbidity, which is when multiple diagnoses are affecting someone such as a child with Autism and ADHD, ecological factors, and whether these factors can be measured through coordination of care with physicians and other professionals. ABA providers have long struggled to measure the quality of their outcomes, given the fact that autism symptoms and progress vary considerably from one child to the next. That makes value-based care tricky to adopt as the model is built around rewarding outcomes. Effectively transitioning to a value-based care model will require adjusting things at the patient level and also adjusting for the clinical severity of the case.
Is all this work beneficial to agencies, because it sounds like a giant undertaking? Well, after a company is done troubleshooting areas in need of progress, effective data can be used to gain leverage with funders, get higher rates, negotiate for better policies with their contracts, increase referrals, and increase legislature leverage. Additionally, getting a handle on cost to deliver service, time to deliver service, and efficient protocols, will be essential to being effective when value-based care comes. This is a tall order that will turn the tides in procedures and processes in ABA in the most dramatic shift in healthcare reimbursement systems since legislators began adopting laws that would require Insurance to fund ABA services beginning around 2008. And while there are not currently a lot of good models yet for value based care in ABA, we are starting to see some agencies pulling ahead of the industry average in an attempt to define these critical measures.
Figuring out just how each ABA company plans to stay in the VBHC game is going to vary widely for a period of time, but although ABA has just recently begun transitioning to technology forward practices that start to address these variables, we have already seen massive improvements in data-collection tech. According to Cheryl Michael, the Chief Product Officer of the applied behavior analysis software company, CentralReach, “whether through mergers or acquisitions, providers will need to have a handle on the data that drives their business but also potentially be able to integrate it into other areas like HR and financial systems.” During the Autism Investor Summit, Michaels also discussed technology's role in the transition to value-based care, which experts say is where the healthcare industry is headed in the years to come. Technology can help providers crunch numbers and quantitatively assess the quality of care patients receive, making it easier for them to transition to value-based models. She went on to say that "we recognize that practices are looking for a way to operate more efficiently, optimize a return-on-investment, and provide superior services and outcomes to their learner’s. Technology continues to evolve, and evolve rapidly. The healthcare sector will continue to look for ways to leverage these capabilities to drive efficiency."
It is expected that many providers will be resistant to the standardization practice required for a value-based care model. But it is essential that the providers develop standards for the organization and reporting of data at State and National levels. According to an article written by Chris Larson, in April of 2022, a behavioral health executive with Owl, conducted a survey in which about 24% of executives said they felt a little or not at all prepared for value-based care arrangements with another 24% saying they assessed the preparation as a lot or a great deal. The remaining 52% said they felt moderately prepared for value-based care but responded to an open question regarding their concerns, to which their answers centered around data collection and providing treatment ".
Critics of VBHC have been vocal in their attempts to bring attention to the barriers affecting the “idealistic” nature of this system. Several branches in the healthcare system, outside of ABA, are further ahead in their adoption of VBHC and are demonstrating the results of the migration away from fee-for-service payment models. BMC Health Services Research cites that unfortunately, well-intentioned efforts to move to a more effective system are adding to the already substantial administrative and regulatory burden on physicians, hospitals, and other providers.The current administrative burden faced by providers diverts limited time and resources that could be better spent on patient care. In addition, physician practices spend a sizable amount of time and resources trying to get paid for the care they provide. This is a particular problem in the Medicaid program, where reimbursement rates often fail to cover the cost of care. Transitioning to a patient-centered and value-based health care payment and delivery system is a good idea. However, initiatives that divert physician time away from clinical care are not patient-centered, and investing precious resources on administrative and reporting requirements without any improvement in the quality of care is anything but value-based. “(https://www.healthaffairs.org/do/10.1377/forefront.20180927.405697/full/ [https://www.healthaffairs.org/do/10.1377/forefront.20180927.405697/full/])
They go on to critique multiple aspects of VBC which begins with specifying the rather narrow conception of ‘value’,and express concerns over how that narrow value definition starts to cause problems. VBHC conceives value in a merely economic way, for example ‘clinical outcomes divided by costs’, however “value'' in philosophy holds a much broader definition. BMC claims to show that VBHC holds a rather hierarchical conception of...
