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Value-Based Care Continues to Dominate Insurance Reimbursement Discussions

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at January 23, 2015

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Attached is a recent article from the Sarasota (FL) Herald-Tribune, regarding the signing of a new contract between Sarasota Memorial Hospital and insurance industry heavyweight United Healthcare.

Here is a short excerpt which I found the summarize where we are as we enter Year 5 of the Affordable Care Act:

While neither side released details about the new agreement, Clarkson’s reference to “valuebased care” is an indicator of what the contract likely holds, said Peter Young, a hospital industry consultant with HealthCare Strategic Issues, in Fort Myers. “ ‘Valuebased care’ is care that ties reimbursement rates to whether or not providers practice evidence based medicine,” Young said. “Going forward, insurers, and eventually Medicare, are going to pay for the best outcomes and the best clinical performance. They’ll pay less to people who don’t follow established performance standards.” United Healthcare has been a leader in pushing value-based contracts, and the insurer has dropped thousands of providers from its nationwide Medicare Advantage network in the last two years for being inefficient and “overutilizing” care.

My takeaways from the article are the following:

First, the most obvious – the allegation of “overutilization” is now being used both in reimbursement disputes (and has become the latest buzzword in clawback litigation) and has also become the allegation du jour from the Florida Office of Insurance Regulation relating to urinalysis testing.

Second, while we know that the Affordable Care Act itself has poised CMS (the Centers for Medicare & Medicaid Services) to steer away from the fee-for-service model and towards this outcome-based system, it has been difficult at best for behavioral health care providers to navigate such performance-based measurements without some modicum of generally acceptable guidelines. That said, I had thought that ASAM (the American Society of Addiction Medicine) had created this supposed benchmark one would assume had been adopted by the insurance industry, but alas, my optimism and assumptions get the best of me.

One potential dark outcome of this latest push towards “outcome based measurements” may be equating “performance” with achieving “sobriety” via medication-assisted treatment (“MAT”) alone (i.e., Naltrexone), which outcomes websites such as WebMD have called “one of the most exciting things to happen in the world of drug treatment, not only because it works so well, but because you don’t have to go to a drug treatment center or clinic to get it — any psychiatrist or even a regular family doctor can prescribe it.”

However, as astutely pointed out by a colleague of mine: “What are we going to do when all the kids we are treating are now ‘drug free’ but have not been given the tools to cope with their underlying behavioral and psychological infirmities because insurance will not pay for it? How many people are going to have to do something drastic, like commit suicide, before we realize the strategy of MAT didn’t work??”

A discussion to be continued…..

Read more here:
New Prescriptions for Addiction Treatment
Sarasota Memorial, United Healthcare sign deal over Value Based Care

SAMHSA – Naltrexone – MAT

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