In Brief: Establishing trust between payers and providers is the first step in resolving the behavioral health crisis.
The pandemic pushed the US healthcare system to its limits, bringing long-standing problems—a workforce shortage and provider burnout chief among them—to a boiling point as clinicians and hospital staff struggled to keep up with overcrowded emergency rooms.
But it’s fair to say that no specialty was more uniquely affected than behavioral health.
Amid a climate of social isolation, economic stress, health concerns, and grief and loss, hospitals saw double-digit increases in mental health emergency visits in 2020. The pandemic exposed access issues as demand soared.
The public health emergency around COVID-19 has ended, but a crisis in behavioral health persists.
- 55% of US counties do not have a single practicing psychiatrist.
- 1 in 5 youths aged 13 to 18 live with a serious mental illness.
- Mental and behavioral health claims now make up 12% of all claims nationally—up from 5% in 2015.
But is there cause for optimism?
The toll that the pandemic took on people’s mental health shouldn’t be downplayed, but the events of 2020 also helped bring behavioral health care into the national conversation. What’s more, behavioral health suddenly found itself situated at the nexus of evolving technology and changing perceptions. “I think the pandemic opened people’s eyes to the fact that there are alternatives to in-person, face-to-face care,” says Tom Foley, a senior manager in ECG’s Managed Care Division. “Before the pandemic, telehealth was nice to have. Now it’s a must have, and it’s here to stay.”
And along with new modes of care delivery came an evolving understanding of mental illness. “Ten years ago, people didn’t really talk about their behavioral health struggles,” notes Katy Shropshire, a senior consultant with ECG. “At least in the younger population, it’s almost trendy to have a therapist [today]. I’m excited to see that continued acceptance and progression.”
Meanwhile, there are tangible examples that demonstrate the potential of an organizational commitment to behavioral health care. And recently enacted legislation is poised to expand increase the behavioral workforce and expand access to mental health care for Medicare beneficiaries.
That’s encouraging, but until the gulf between payers and behavioral health providers can be bridged, progress will remain elusive. In a recent survey conducted by the American Hospital Association, 78% of hospitals said their relationships with payers are getting worse. Reimbursement for mental health care has historically been inadequate, and the fragmented nature of the space has complicated efforts to create cohesive behavioral health networks. Clearly, there’s work to be done.
ECG’s Behavioral Health Team Adds Payer Expertise
Tom Foley and Katy Shropshire bring a payer’s mindset to ECG’s behavioral health managed care team. Tom has 30 years of payer experience and served as the director of ancillary and behavioral health contracting at Blue Cross Blue Shield of Massachusetts before joining ECG. Katy was previously a senior network contract manager with Optum Behavioral Health, where she led network contracting and reimbursement initiatives across the western US.
Here they talk about why they came to ECG and how they think payers and mental health providers can find common ground.
Strength in Numbers
Reimbursement for mental health services has historically been low, a notion Tom doesn’t dispute. “When you look at the behavioral health professional network as a whole and the freestanding behavioral health provider facilities, I would say [reimbursement is low], especially if you haven’t consistently attempted to renegotiate your contracts or if you’re a new market entrant with limited historical utilization with payers,” he says.
Of course, behavioral health providers can’t show up to the negotiating table empty handed. “There’s a lot of talk right now in the behavioral health space about needing to show up to conversations with payers with data,” Katy explains. “Providers need to demonstrate to payers that their outcomes are measurable and in line with what payers want to see to in order to get higher reimbursement rates.”
But behavioral health providers, especially individual providers, often struggle to capture and interpret the data that can improve their standing in a rate negotiation. “To get that data, there has to be an investment in technology,” Katy says. “But current reimbursement barely supports the clinicians, let alone an investment in technology. Payers don’t always include that in their calculations when they’re when looking at rates.”
Larger entities are better positioned to invest in those capabilities, and Tom sees that happening. “You’re starting to see formation of professional groups across multiple states. You need that so you can share data with a payer and take it to the next level,” he says.
Pathway to Partnership
Fixing behavioral health will require a coordinated effort among payers, providers, and communities. Tom believes providers are willing to make that effort. “I think behavioral health providers are looking to have partnerships with payers,” he says.
But are payers willing to be partners?
“Step one is building trust in the payer-provider relationship,” Tom says, while acknowledging that that’s “easier said than done.” He also suggests that payers should take note of the growing numbers of mental health provider groups. “They should be targeting provider organizations that they feel they can partner with, organizations that will use that increased investment in technology, like Katy mentioned.”
And if providers are willing to invest in technology to help them capture data about outcomes and access, payers need to establish solid goalposts. “Payers need to be able to clearly define what they’re looking for,” Katy says.
Payers also need to be open to innovative approaches to behavioral health care delivery—and simplifying processes wherever possible.
Primary Care
Furnishing behavioral health care in primary care offices, whether through medication management or by embedding therapists, is increasingly being viewed by health systems, CMS, and payers as an option for expanding access while providing care in a lower-cost setting. “There’s growing momentum toward that model,” Katy acknowledges, “but from a payment perspective, it’s very complicated.” The administrative difficulty of managing behavioral health claims in the primary care space is slowing adoption of the model. But if payers are willing to collaborate with providers to make it work, they may be able to keep patients from turning unnecessarily to emergency rooms for care.
Home Care
Tom emphasizes the growing trend of care moving outside of traditional settings. ”I think there will be more care in the home in general,” he says. “I also see a movement afoot where it becomes industry standard that reimbursement is based not just on ‘traditional services,’ but also nontraditional services. Peer coaching is something that’s being looked at for substance use disorder. It doesn’t sound very innovative, but it’s very important because someone may not have the ability to get to a medical appointment or have access to a laptop.”
There’s nothing to suggest any of this is easy—approving reimbursement for care under nontraditional circumstances involves operating within a complex environment of policies, regulations, politics, and inertia. But telehealth preceded the pandemic by decades, and its adoption was similarly stymied by administrative complexity as well as payer and provider skepticism. A public health emergency changed that, and now payers and providers need to approach the behavioral health crisis with the same sense of urgency.
Moving Forward Together
Fostering that sense of collaboration is what brought Tom to ECG. And he feels like his extensive payer experience will help. “I think our behavioral health managed care team is positioned to provide the expertise and feedback for clients to optimize their relationship with their payers,” he says. Tom knows that firsthand, having encountered ECG’s team from the other side of the negotiating table. “I had direct experience working with ECG, and it was really a partnership. That’s what I was interested in.”
Katy strikes a hopeful note as well. “I chose to work in the behavioral health space because there’s so much energy and innovation right now, and that makes it a really exciting space to work in.”
Let’s see if payers and providers can convert that energy into change.
Published May 10, 2023