How do psychological services fit into a Value Based Care payment model?

[beginner2011]

Value Based Care (VBC) is a topic that has come up several times in various threads and is in contrast to the predominant Fee For Service (FFS) model. In an FFS model, each covered medical service or procedure is paid a set fee after it has occurred.

Instead of rewarding volume (FFS), new value-based payment models (VBC) reward better results in terms of cost, quality, and outcome measures. @Ollie123 shared this useful material describing the shift in another thread: https://www2.deloitte.com/content/d.../DUP-1063_Value-based-care_vFINAL_5.11.15.pdf

Some examples of VBC are:

Shared savings

• Paid under FFS until year-end reconciliation
• Shared savings bonuses are paid if expenditures do not exceed cost-containment goals
• Bonuses given if quality goals are achieved
• No financial risk if cost or quality goals are not met

Bundles

• Episode-based payment
• Payment for all services across multiple providers and care settings for a treatment or condition during a defined time period

Shared risk

• Paid under FFS until year-end reconciliation
• Savings bonuses if cost containment and quality goals (upside) are achieved
• At risk for a portion of spending that exceeds a cost containment target (downside)

Global capitation

• Single, comprehensive payment for a person over a period of time
• Intended to account for all of the expected costs of care for a patient or group of patients for a defined time period

Personally, I'm preparing to start a new position where I'll be working with an inter-professional team to treat folks experiencing chronic pain, and I see pain treatment as an area where the value of psychological services is beginning to be recognized more and more. I think pain treatment is an area where the value of psychosocial interventions is substantial in a VBC model. To illustrate: I attended a CE this afternoon presented by a physician that highlighted the significantly reduced effectiveness of a costly medical procedure to treat pain for those with BDI>16, compared to those with BDI<16, who also need substantial ongoing health care services to treat pain relapse. A clear question coming from this is whether or not psychosocial intervention for those BDI>16 would improve outcomes, and potentially significantly reduce costs to the system. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3229738/pdf/586_2011_Article_1891.pdf

I'm curious what psychologists think about the likelihood of an eventual shift from FFS to VBC in your practice context.
How do you believe this would affect your practice?
What are you doing to prepare?
What do you think psychologists are/ought to be doing as a field to be appropriately valued and incorporated in the context of a shift toward value-based payment models?

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[psych.meout]

I can't speak to all of this, but for pain specifically, there's some really good research on presurgical and pre-procedure (e.g., spinal surgery, spinal cord stimulator and intrathecal pump) assessment and the psychosocial factors affecting outcomes. Andrew Block has some good books on it and I attended a CE a few years ago where he gave a talk.

I used to do these evals at a previous adult-focused practicum and they were highly valued by the surgeons, who eventually would require the evals before doing any of these pain procedures, though I don't know if VBC was a factor in it. Conversely, for peds pain, I've never seen them require any evals and my supervisors said that this is consistent with their experience at this AMC, though this may be just a quirk of this AMC or a matter of these procedures just being so rare in peds populations.

 

[Ollie123]

A little pressed for time but did want to respond.

I think there are really two related but distinct questions in play - how this will impact day-to-day clinical activities and how this will impact the profession.

RE: day-to-day activities I think the impact will be modest and most changes are relatively obvious.
- PP taking insurance is going to get more complicated. I expect the current trend of independent medical practices being absorbed into large hospital systems to continue and expand to us. The infrastructure and paperwork needed in such a system seems cumbersome. Than again, this is still new and hasn't <really> hit yet so I wouldn't be surprised if people innovate around this.
- Increased positions like yours. More partnering with psychiatry departments. More mental health clinicians directly employed in other departments.
- Increased emphasis on routine outcome monitoring. Many of us (myself included) are lazier about this than we should be. That has to change. Related to this - expect increased bean counter involvement in this process. You'll be pressured to use the "How crazy are you?" facebook quiz by a glorified secretary with a chip on her shoulder because they need to monitor outcomes and she took this one and really liked it.

RE: the field, I actually think this is the bigger issue. I don't know. Right now I actually see little changing because I just don't see anyone actually attending to this. So we remain bottom rung and let medicine tell us what to do. What I'd like to see happen:
- Increased GOOD and TIME-EFFICIENT outcome monitoring research. Give me a flexible battery with clear links to diagnoses and verifiable constructs, not a 100 item measure of personality and general functioning. See if it helps. I posted about my < 100 item research battery that covers a wide spectrum about a year ago that I sadly have not had time to do research on (though hopefully after an upcoming move...). This was half-assed on my part and is FAR from ready for prime-time, but it was put together in part with this in mind.
- Increased pairing with health economists to run cost-effectiveness studies. This is standard for a lot of primary care things (smoking cessation, weight loss, etc.) but uncommon in many areas of mental health. I see a lot more internal chatter about how cost-effective we are than I see science that backs that up. This needs to be interdisciplinary. If we improve post-surgical outcomes for XYZ, we need to know by how much and what it saves the system.
- Most importantly, we need to use this as an opportunity to reposition ourselves in the healthcare system. We need to be innovating and trying stuff inside and outside our department. For goodness sakes: 1) We are a field covering patients who are notoriously high health-system-utilizers; 2) Existing evidence (though not enough of it) suggests mental health treatment improves outcomes for darn near everything; 3) We're dirt cheap compared to surgery; 4) We're the ONLY clinical field with required extensive research experience as part of their education.

I think point #4 is particularly key and often overlooked in these discussions. MDs, DOs, PAs, NPs etc. aren't typically doing dissertations. We're better qualified to be leading initiatives on largescale outcome monitoring and program evaluation than virtually any other clinical field. This is not about showing off what great scientists we are...this gets psychology face-time with key decision makers and (potentially) a seat at the table moving forward. Don't know about you, but I think it would be fantastic for the field if even 1/4 hospitals ended up with psychologists on the executive team and having regular meetings with hospital system leadership.

 

[AcronymAllergy]

A little pressed for time but did want to respond.

I think there are really two related but distinct questions in play - how this will impact day-to-day clinical activities and how this will impact the profession.

RE: day-to-day activities I think the impact will be modest and most changes are relatively obvious.
- PP taking insurance is going to get more complicated. I expect the current trend of independent medical practices being absorbed into large hospital systems to continue and expand to us. The infrastructure and paperwork needed in such a system seems cumbersome. Than again, this is still new and hasn't <really> hit yet so I wouldn't be surprised if people innovate around this.
- Increased positions like yours. More partnering with psychiatry departments. More mental health clinicians directly employed in other departments.
- Increased emphasis on routine outcome monitoring. Many of us (myself included) are lazier about this than we should be. That has to change. Related to this - expect increased bean counter involvement in this process. You'll be pressured to use the "How crazy are you?" facebook quiz by a glorified secretary with a chip on her shoulder because they need to monitor outcomes and she took this one and really liked it.

RE: the field, I actually think this is the bigger issue. I don't know. Right now I actually see little changing because I just don't see anyone actually attending to this. So we remain bottom rung and let medicine tell us what to do. What I'd like to see happen:
- Increased GOOD and TIME-EFFICIENT outcome monitoring research. Give me a flexible battery with clear links to diagnoses and verifiable constructs, not a 100 item measure of personality and general functioning. See if it helps. I posted about my < 100 item research battery that covers a wide spectrum about a year ago that I sadly have not had time to do research on (though hopefully after an upcoming move...). This was half-assed on my part and is FAR from ready for prime-time, but it was put together in part with this in mind.
- Increased pairing with health economists to run cost-effectiveness studies. This is standard for a lot of primary care things (smoking cessation, weight loss, etc.) but uncommon in many areas of mental health. I see a lot more internal chatter about how cost-effective we are than I see science that backs that up. This needs to be interdisciplinary. If we improve post-surgical outcomes for XYZ, we need to know by how much and what it saves the system.
- Most importantly, we need to use this as an opportunity to reposition ourselves in the healthcare system. We need to be innovating and trying stuff inside and outside our department. For goodness sakes: 1) We are a field covering patients who are notoriously high health-system-utilizers; 2) Existing evidence (though not enough of it) suggests mental health treatment improves outcomes for darn near everything; 3) We're dirt cheap compared to surgery; 4) We're the ONLY clinical field with required extensive research experience as part of their education.

I think point #4 is particularly key and often overlooked in these discussions. MDs, DOs, PAs, NPs etc. aren't typically doing dissertations. We're better qualified to be leading initiatives on largescale outcome monitoring and program evaluation than virtually any other clinical field. This is not about showing off what great scientists we are...this gets psychology face-time with key decision makers and (potentially) a seat at the table moving forward. Don't know about you, but I think it would be fantastic for the field if even 1/4 hospitals ended up with psychologists on the executive team and having regular meetings with hospital system leadership.

Just to quickly add to this--if you have PhD/PsyD after your name and work in a hospital/medical center, and someone is wanting to setup a research study, there's a chance they'll ask you to be involved without knowing anything other than that you have a doctorate and that you therefore know how to "do science." Particularly if your hospital/MC doesn't already have a strong academic affiliation or many PhDs on staff. This is obviously a bit of an oversimplification, but still. Be willing to collaborate.

And on the opposite end, consider branching out and conducting some clinically-oriented research across specialties. I could probably walk down the hall to cardiology and the cardiologist would be thrilled to participate in a quick and "simple" outcomes-based research study, especially if there were little extra work involved for him.