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NatCon16: Payers and providers can work together

March 10, 2016

While many behavioral health providers are taking increasingly combative positions when interacting with commercial payers, experts speaking at NatCon 2016 believe a mutually beneficial relationship is possible. What has united one provider and one payer in New Jersey—Care Plus NJ and Health Republic Insurance—is the common goal of population health.

It’s a story of two stakeholders working out a bundled payment model, but the story has rather unique circumstances as well.

Care Plus is a community-based behavioral health center providing integrated services. Meanwhile, Health Republic is one of the new co-op insurance plans created under the Affordable Care Act. The plan is small, member-focused and generally attracts a more vulnerable population because of its position in the market.

Plan leaders were looking for big-picture solutions because admissions related to behavioral health diagnoses represented 10% of the plan’s total admissions, which is high for a typical commercial plan.

Kathy Bianco, advocate leader of Care Plus, said the center had been working on a number of grant-based programs, such as health homes and SAMHSA integration projects, and saw an opportunity to do more for the members of Health Republic to help reduce ER visits and hospitalizations. For example, the center is able to engage clients in health management through technology tools, such as take-home tablet computers that are used for health improvement.

It certainly seemed like an opportunity to work together.

New payment model

After several meetings, the two struck an agreement that would allow for a bundled payment arrangement that paid day rates for a spectrum of services, many focused on in-person crisis care. Instead of paying code by code, the health plan paid a single rate that allowed the care teams to optimize services. Additionally, Care Plus agreed to provide high-touch care when patients in need were identified by Health Republic through its claims data.

By removing the limitations of fee for service, needed care and additional services could be delivered by Care Plus and reimbursed with the bundled dollars from Health Republic.

Bianco says the relationship is proving to help more people receive care and is improving patient outcomes. More such arrangements are needed in the industry, but where should providers begin?

She recommends that behavioral health leaders work to find a way to meet directly with health-plan decision makers, particularly the chief medical officers who speak the same language as the providers. Also the plan staff members who are responsible for patient advocacy can be helpful in understanding the issues providers face.

“And you need to have data and outcomes,” Bianco said. “The provider should get whatever they can out of their EHRs or even just through team meetings, start collecting stories. Take the stories of people who were well managed by your staff and start applying them to small groups. When you walk in with those stories, I think it makes a difference to the payers.”

Dina Melendez, vice president of Health Republic, recommends that providers stay open minded and communicate how the two entities can work together to meet individuals’ needs.

“I’ve worked on the provider end, and I know their struggles,” she said. “It’s always the strong arm tactics of saying ‘we’re the insurance company, this is how it is, take it or leave it.’ But we don’t believe in that. We meet the providers where they are.”

She also believes Health Republic Insurance—because of its unique model as a co-op—is less intimidating to providers because it’s specifically structured to be member/patient-centered.

Next steps

Now, Health Republic and Care Plus together are beginning to leverage a new statewide network of behavioral health homes. The network extends the high-touch model and helps Care Plus increase its reach, indirectly through integration, from five counties to the entire state of New Jersey.

Bianco says next up for Care Plus is becoming a Certified Community Behavioral Health Clinic under the Excellence in Mental Health Act.

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