POPULATION HEALTH MANAGEMENT · BEHAVIORAL HEALTH


small proportion of someone’s practice. That doesn’t really allow providers to invest in the infrastructure that they need to run those models and build those codes. I think the same is true to some extent in Medicare’s newer, office-based Opioid Treatment Bundle. You need a lot of services and infrastructure to do that, and you need to ensure that the resources are there to fund that investment.” Workforce shortages are compounded


by low participation of mental health specialists in insurance networks, Huskamp added. “We need to reassess provider network requirements and the federal parity law’s role in guiding reimbursement for behavioral health specialists and other clinicians who are billing for these kinds of services. Obviously, reimbursement and coverage policy that would continue to facilitate the use of telehealth is an important way to get at these issues. Medicare has made a very strong statement saying we will continue to cover behavioral health via telemedicine, but how things play out with other payers is going to be really important, I think, in determining this way of accessing care and helping to reallocate providers across areas, even the providers that we have.” Werner noted that we talk about value-


based, purchasing a lot in other sectors of healthcare, yet it is lagging behind in men- tal healthcare and hasn’t been as widely adopted. She asked Huskamp whether she sees that as a potential solution for some of the payment-related challenges in mental health. Value-based payment is challenging


across the board, but it can be particularly challenging in mental health, Huskamp responded. “I do think there’s still a role for it. We still have a ways to go in terms of having a full set of mental health quality measures that clinicians and everyone will feel capture what we need to capture,” she said. “You have to worry about it anytime


you’re moving towards outcomes as opposed to just process measures of quality,” Huskamp said, adding that it poses concerns if risk adjustment isn’t adequately accounting for differences across patients. “Historically, our risk adjustment systems, while improving over time, haven’t done as well on behavioral health as they have on much of the rest of healthcare. That is an issue that certainly makes providers concerned about being rewarded or penalized on the basis of their


outcomes for things they may not have full control over.” Another issue involves what happens


to the outcomes you’re not rewarding, she added, because the outcomes that there has been agreement on in mental health focus on a narrow set of clinical areas. Also, the lack of capacity in the system creates challenges for this anyway. “There just isn’t much excess capacity, so it’s a little bit harder to implement systems with strong rewards and penalties for low qual- ity when we need everybody we have in the system. There are a lot of challenges, but I would like to see our field continue to move in that direction and try to counter those as we go.” Mai Pham, M.D., M.P.H, is president


of the Institute for Exceptional Care, a nonprofit organization dedicated to help- ing people with intellectual and develop- mental disabilities thrive by promoting radical, empathetic inclusion of IDD issues in healthcare, and for integration with other social supports. Previously she was vice president, provider alignment solutions at Anthem Inc., responsible for value-based care initiatives, and before that she served as chief innova- tion officer at the Center for Medicare and Medicaid Services. She stressed that there’s a desperate need to integrate not just physical and mental healthcare, but also with home and community-based service supports. “This is not something that the tradi-


tional professions are good at doing — one, because they’ve never been asked to do it; and two, they aren’t given the resources and the flexibility to do it,” Pham said. “It is not about the clinical side of the house solving every problem. It’s about them having access and knowing how to help patients reach those resources when they need them. For good or bad, primary care is going to be a major component of the mental healthcare delivery system, and for both those providers and for mental health providers, we need to think about some very different ways of paying. You need to get them off the fee-for-service wheel and give them more resources. I’m talking about at least a hybrid payment structure that is a little bit more majority capitation and less so fee for service, but capitation priced in a way that is significantly higher than what we have paid historically. That is what allows for the investment and the flexibility because you cannot address social drivers of health if you cannot reach out to those social service organizations


if you’re constantly watching the clock. People have a hard time connecting the dots from capitation higher pricing to the infrastructure but that’s what it is. You need the flexibility freed up from your revenue source to think about that.” In closing, Werner asked the panelists if


they had 10 minutes with a U.S. legislator, what would they identify as a must-do piece of federal legislation for improving the mental healthcare delivery system in this country? “I always am an advocate for expanded


mental health access housing,” Jha said. “I think it’s a true barrier to decreasing high utilization of primary and emer- gency care services for folks experiencing severe mental health crisis. People ask me ‘what do you see as a primary public mental health crisis’ and I say the hous- ing shortage is a primary mental health crisis. If somebody doesn’t have access to housing, there’s no way they can make an appointment. And yet then they get deemed by our system as a high utilizer. We use terrible phrases like frequent fliers, which I’ve heard so many times by various providers, and then they’re stigmatized and those things live on their medical records. My altruistic aim is always to say, give someone a place to live and think about their hierarchy of needs. And then appreciate that someone who might be a primary care provider can have a better space to understand those needs.” Dupuy said expanding the telehealth


provisions would be really important to maintaining access and then also expand- ing the interstate licensing provisions that can allow providers to reach underserved areas that are not in their state. Huskamp said she would push for a


bill that would expand system capacity in multiple different ways — funds for train- ing and recruitment of a diverse group of providers; expanding those telehealth policies to make sure that it’s accessible broadly; and pushing on network ade- quacy requirements, which would force reimbursement rates higher. “I would also address ways to help fund infrastructure development in primary care.” Pham said she would ask for two


things: robust primary care with partial capitation, and a nationwide investment in community health workers. who would go door to door and ask people how they’re doing and whether they would like to come to a place where they can be con- nected with others. HI


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