On January 11th of this year, three key officials of the Centers for Medicare and Medicaid Services (CMS), Meena Seshamani1 Elizabeth Fowler2 and Chiquita Brooks-LaSure3 wrote in Health Affairs Forefront highlighting efforts to build on CMS’ strategic vision for a stronger Medicare through advancing health equity.4 The article was noteworthy on many fronts and focused on Medicare’s continued commitment to health equity and accomplishments from its 2015 Equity Plan5 for improving quality in Medicare, but also on the need to increase the clinician workforce in underserved communities, efforts to enhance culturally appropriate communication around services, and the tremendous opportunity to address health-related social needs in the community through expansion of accountable care organizations and value-based reimbursement. The authors acknowledged the need to address how social determinants of health (“SDOH”) create barriers to accessing care and increase risk for chronic health conditions.6 Equally important, CMS also has recently provided additional support and flexibility to improve patient access to health care services via telehealth and particularly telebehavioral health services, via telehealth policy updates in the 2022 Physician Fee Schedule Final Rule.7
For those working to transform care through value-based care delivery and value-based reimbursement models, these statements and policy updates from one of the largest national payers are important and signal the continued intention and commitment of CMS to transform from a fee-for- service reimbursement approach to a valuebased reimbursement approach, and to support greater access to and integration of behavioral and physical health to achieve whole person care. These actions are also consistent with CMS’s recent Innovation Center Strategy Refresh.8
A coordinated strategy that incorporates extraordinary value-based care delivery, behavioral health integration with physical health, and SDOH has the opportunity to truly further the Triple Aim.9 Behavioral health providers face unique challenges above and beyond those faced by physical health providers in value-based care delivery. All providers being paid under a value-based care reimbursement model must be able to access and integrate claims and practice data; report on quality metrics; use clinical and business analytics systems to identify care gaps, inform intervention strategies and real-time patient engagement; and manage population health and align clinician compensation to drive objectives. Behavioral health providers have additional challenges with regard to consensus on meaningful quality and outcome metrics10interoperability of data11 and clinical integration with physical health,12 to highlight just a few. In addition, while the data is clear on the role of behavioral health conditions in increasing the costs of chronic physical health conditions,13 bilateral integration of behavioral and physical health historically has been rare in care delivery and reimbursement of the same.
CMS’ current focus on health and greater access, together with an increasing willingness from federal, state and commercial payers to reimburse for integrated behavioral health services delivered under innovative care models,1415th signal progress toward rewarding providers for whole person care. One such model, the Collaborative Care Model, is an evidence-based model used to identify and treat patients with mental illness in primary care settings with an emphasis on targeted outcomes and a patientcentered approach.16 The Collaborative Care team is led by a primary care provider and comprised of behavioral health care managers, psychiatrists, and other mental health professionals who together a measurement-guided care plan with particular attention to implement accountability and quality improvement.17 Some providers rely heavily on telebehavioral health services to ease both the patient access burden and clinician workforce shortage when integrating behavioral health and physical health care using this model.18
With its intense focus on evidence-based tools and measurement of clinical outcomes, providers delivering behavioral health services via the Collaborative Care Model also are analyzing how addressing SDOHs could impact the treatment plans for their patient populations.19 One leading state payer takes the position that “whole person health care and health equity cannot be achieved without proactively addressing SDOH for all members of HCA [Washington State Health Care Authority] purchasing programs.”20 Some behavioral health providers who routinely incorporate engagement with community social service providers to support their patient populations may have an advantage in addressing SDOH on a patient by patient basis. At the same time, developing and using standardized SDOH metrics to measure outcomes is still evolving. For example, the Oregon Health Authority has been working since 2015 to develop measures of SDOH and incorporate the use of those metrics with its Medicaid population through its coordinated care contracting model.21
Achieving whole person care that incorporates value-based reimbursement for integrated physical and health care and that addresses the role of SDOH will require continued diligence and incremental progress to achieve. Leveraging partnerships to integrate behavioral health services and offer services via telehealth, while also collecting and analyzing data regarding SDOH, may better enable providers to improve health care outcomes, increase patient satisfaction and quality, and control costs. Participants in the Collaborative Care Model or other coordinated care delivery models with these capabilities may find participation in such programs a meaningful step in their value-based care journey.
1 Meena Seshamani, MD, Ph.D., is the Deputy Administrator and Director, Centers for Medicare and Medicaid Services.
2 Elizabeth Fowler, Ph.D., JD, is the Deputy Administrator and Director of the Center for Medicare and Medicaid Innovation (CMS Innovation Center).
3 Chiquita Brooks-LaSure is the Administrator for the Centers for Medicare and Medicaid Services.
4 Meena Seshamani, Elizabeth Fowler, and Chiquita Brooks-LaSure, Building On The CMS Strategic Vision: Working Together For A Stronger Medicare¸ Health Affairs (January 11, 2022), https://www.healthaffairs.org/do/10.1377/ forefront.20220110.198444.
5 See also Paving the Way to Equity: A Progress Report (2015-2021), CMS (2021), https://www.cms.gov/files/document/paving-way-equity-cms-omh-progressreport.pdf .
6 See Meena Seshamani, Elizabeth Fowler, and Chiquita Brooks-LaSure, Building On The CMS Strategic Vision: Working Together For A Stronger Medicare, Health Affairs (January 11, 2022), https://www.healthaffairs.org/do/10.1377 /forefront.20220110.198444 (“Overall, we will help those who live in rural areas; cannot afford broadband access; lack increased access to reliable transportation; have risk of COVID-19 infection due to disability, ESRD, or other chronic health conditions; or may experience other barriers to accessing the care they need.”).
7 86 Fed. Reg. 64996 (Nov. 19, 2021); see also Laura Little, Lori Oliver and Paul Gomez, CMS Greenlights Certain Telebehavioral Health Services Beyond the Public Health Emergency and Provides Important Incentives for Further Investment, Polsinelli (Nov. 8, 2021), https://www.natlawreview.com/article /cms-greenlights-certain-telebehavioral-health-services-beyond-public-health
8 Innovation Strategy Center Refresh, CMS, https://innovation.cms.gov/strategic-direction-whitepaper (last visited Feb. 4, 2022).
9 The IHI Triple Aim, Institute for Healthcare Improvement http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx (last visited Feb. 4, 2022). The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance, the “Triple Aim”: Improving the patient experience of care (including quality and satisfaction); Improving the health of populations; and Reducing the per capita cost of health care.
10 Lauren Niles and Serene Olin, Behavioral Health Quality Framework: A Roadmap for Using Measurement to Promote Joint Accountability and Whole-Person Care, The National Committee for Quality Assurance (NCQA) (May 2021), https://www.ncqa.org /wp-content/uploads/2021/07/20210701_Behavioral_Health_Quality_ Framework_NCQA_White_Paper.pdf.
11 Integrating Clinical Care through Greater Use of Electronic Health Records for Behavioral Health (Chapter 4), MACPAC (June 2021), https://www.macpac.gov/ publication/integrating-clinical-care-through-greater-use-of -electronic-health-records-for-behavioral-health/.
13 Behavioral health crisis in the United States: The fallout from the COVID-19 pandemic, McKinsey & Company, https://www.mckinsey.com/featured-insights/ mckinsey-live/webinars/americas-behavioral-health-crisis- the-fallout-from-the-covid-19-pandemic (last visited Feb. 4, 2022).
14 Getting Paid in the Collaborative Care Model, American Psychiatric Association, https://www.psychiatry.org/psychiatrists/practice/professional-interests/ integrated-care/get-paid (last visited Feb. 4, 2022).
15 Behavioral Health Integration Services, Medicare Learning Network (March 2021), https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/….
16 Collaborative Care, AIMS Center, Advancing Integrated Mental Health Solutions, https://aims.uw.edu/collaborative-care (last visited Feb. 4, 2022).
17 Learn About the Collaborative Care Model, American Psychiatric Association, https://www.psychiatry.org/psychiatrists/practice/professional-interests/ integrated-care/learn (last visited Feb. 4, 2022).
18 Practice-Based and Telemedicine-Based Collaborative Care, AIMS Center, Advancing Integrated Mental Health Solutions, https://aims.uw.edu/practice-basedand-telemedicine-based-collaborative-care (last visited Feb. 4, 2022) .
19 Melissa Farzam, A Look At Social Determinants Of Health In Collaborative Care, Concert Health (November 2021), https://concerthealth.io/a-look-at-socialdeterminants-of-health-in-collaborative-care/.
20 Paying for Health and Value, Health Care Authority’s Long Term Value-based Purchasing Roadmap (2022-2025), Washington State Health Care Authority (August 2020), at 15, https://www.hca.wa.gov/assets/ program/vbp-roadmap.pdf. The Washington Health Care Authority purchases health care through three state programs that serve Medicaid, employee, and school employee beneficiaries.
21 Social Determinants of Health Measurement Work Group Final Report, Oregon Health Authority (February 2021), https://www.oregon.gov/oha/HPA/ANALYTICS/ SDOH%20Page%20Documents/3.%20SDOH%20measurement%20work% 20group%20final%20report.pdf; see also Health Equity, Massachusetts Health Policy Commission, https://www.mass.gov/info-details/health-equity (last visited Feb. 4, 2022) (describing Massachusetts health equity activities); and Elizabeth Hinton and Lina Stolyar, Medicaid Authorities and Options to Address Social Determinants of Health (SDOH), KFF (Aug. 5, 2021), https://www.kff.org/medicaid/issue-brief/medicaid-authorities- and-options-to-address-social-determinants-of-health-sdoh/ (summarizing strategies to identify and address enrollee social needs within Medicaid’s regulatory authority).
© Polsinelli PC, Polsinelli LLP in CaliforniaNational Law Review, Volume XII, Number 63