From Impact to Payment: BHT Impact's Value Based Care Toolkit for Innovators
- Anjlee Joshi
- 3 days ago
- 7 min read
Over the years, I have had so many conversations with innovators who dream of value based contracts. They spend months and sometimes years spinning on how to achieve getting these contracts without fully understanding who is actually defining value in this situation and what it looks like to them.
As a result, I’ve seen repeated failure cycles where innovators don’t end up getting contracts because:
The solution’s metrics don’t directly impact the plan’s costs or savings
The solution does impact cost and savings but not enough to warrant this level of special contracting
The company doesn’t have enough time in the market or enough customers for early results to be considered a sustainable proof point
The company’s measurement, data, and reporting infrastructure is not complete enough to prove the value they are delivering
The savings can’t be directly attributed to the solution
The innovator struggles to tell a value story that health plans and states care about
And many more
The goal of our Value Based Care series isn’t just to explain VBC to you but to focus it exclusively on youth mental health AND to give you a set of decision guiding resources to see if your solution would qualify and if it does, to guide you through the realistic possibilities, common pitfalls, and how to build this for yourself at each step of the way.
That said, there are plenty of amazing general VBC resources alongside great tips and tricks. Here are just a few below:
Value Based Care is predominantly a form of contracting for providers or like solutions. But any innovator in this space has someone they need to prove value to and typically what you consider impact and value is usually different than what they do. Our materials may speak directly to the first group but they house key lessons on where the impact to youth dramatically differs from the impact to those who have power and control funding and payment.
Common Models of Value Based Care
Value-based care is very simply and broadly defined as paying for outcomes (value) rather than volume (a fee per service). In theory, providers are rewarded for improving mental health and reducing unnecessary costs. However, in practice, this shows up as a wide range of activities and, as you can image, faces limitations based on how well improvement and cost reduction can actually be measured and attributed to the provider.
Below is a high level and overly simplified visual of common models of value based care. Within a few months, we will have covered all of these, some in much more detail than others because of how often each does or does not occur within youth mental health.
Two important call-outs
Within each of these models there are several programs, opportunities, and contract types that exist both at the state and health plan level. In later resources we will dive into the details of each one to cover these measures, waivers, funded care models, programs, demonstrations, and more.
These programs can look dramatically different depending on the level of care – outpatient, intensive outpatient, inpatient, etc.
What VBC Actually Looks Like in Youth Mental Health
In youth mental health in Medicaid, models are not implemented equally. While the image looks like a straight path, VBC mostly operates like a Mt. Everest sized mountain with the tiniest number of providers getting to risk arrangements and the rest of us stuck at the volume and value based base camps.
In practice, most innovators will see higher FFS rates or a set of additional payments on top of their FFS arrangement. These fall into the same few patterns:
Pay-for-performance programs or small incentives based on screening, medication management metrics, quality measures, etc.
Per-member-per-month payments for specific models at the state level that treat high cost high need patient populations
State-led pilots or waivers testing more integrated approaches
If you haven’t already, you can start piecing together that value is defined as value to the measurable costs of the system not value experienced by the patient. As a result, “value” is still largely considered as what is easiest to measure (e.g., visits, assessments, short-term indicators) and realized in the short-term vs. what actually shapes long-term outcomes for youth and their families.
As innovators, it's essential for us to both/and this situation. What are the solutions that drive improvements and impact for youth and their families AND how do those solutions also drive the right changes for the stakeholders who hold power and payment control?
Key Differences for VBC for Youth
A lot of what we have discussed so far applies to youth and adult mental health when it comes to value based care. So where do assumptions break down even further specifically for youth mental health? We covered a lot of this in our “Not Just Tiny Adults” quick guide, but repetition is the best educator so here are some key reminders:
Unlike adults patients, youth patients involve more than just one person: impact, progress, and outcomes are shaped by caregivers, schools, and other systems. Treating youth as an isolated unit underestimates what drives impact and undervalues when impact actually happens. What does this mean for innovators? How many of these systems do you or do you not need to touch to drive that value? How do you know your solution can be attributed to the value?
Outcomes are developmental, not episodic: progress shows up over time through stability, functioning, involvement and more. Short-term symptom change is not the best predictor of improvement, value, or sustained change (true in adults but especially true in youth).
Consistent and appropriate retention is crucial: Initial engagement is great, but sustained retention is one of the strongest predictors of improvement for youth. Yet, this is rarely treated as a core outcome because measuring its impact on costs and savings does not exist in a robust way (yet!). Additionally, time and time again I have seen innovators not define this appropriately for their models either which only further adds to the confusion of what value it drives.
Note: for some solutions this curve looks different. Appropriate retention can be where youth use the solution when they need it, drop off if they don’t, and are able to re-engage with trusted solutions and people when they do.
Right now, many value based care models do not and cannot account for all these realities because they are so difficult to measure and tie to an ROI. That means that as an innovator your model needs to live in both worlds: strive for meaningful progress and be able to measure specific activities, work towards functional improvement but be sure to also measure short-term episodic improvement, know when your locus of influence and control is too small to take on risk that does not live within your boundaries.
The Divergence: Domains of Youth Mental Health and the Levers of Value Based Care
We could use this section to talk about how value based care needs to design more effective models and honestly, that is very true. But plenty of brilliant folks have already talked about it (see Nature’s new piece) so we’re going to focus this series on what is happening now, what you can realistically achieve, and where there may be wiggle room if and only if your model can deliver outsized value.
If you haven’t yet, check out “Youth Mental Health is Multi-Dimensional,” a quick reference guide on all the domains of measurement that encompass youth mental health. These domains are critical to understand and measure for but unfortunately when it comes to value based care, many of those domains are not yet integrated into these models because their measurable financial ROI is unclear or they are considered to be separate from the health care system.
Within a state or health plan model, levers of VBC are:
System navigation and coordination: Helping youth get timely and appropriate access to care they need and successful transitions between levels of care
Engagement and continuity: Ongoing and appropriate participation with solutions and care when needed and autonomously re-engaging when needed or being prompted to do so by the solution
Clinical outcomes: Symptom improvement, stabilization, appropriate treatment or subclinical support.
Cost or savings outcomes: Revenue generated by meeting quality measures, reduction in high cost inappropriate utilization (e.g., ER and IP visits), medical loss ratio improvement, and more.
**Notice what isn’t pictured? prevention, well-being, resilience, functional outcomes (e.g., academic, interpersonal, sleep, etc.), and physical health.
Most current models emphasize the first layer, partially address engagement and clinical outcomes through existing quality measures and assessments, and naturally strongly index cost and savings opportunities that can be attributed (there’s that word again). This is where domains of change for youth and levers of financial contracts begin to diverge.
BHT Impact’s Value Based Care Toolkit
This is just the start. Over the next few months we will be releasing detailing articles, toolkits, primers, and interactive media that will dive into the world of value based care including (but of course not limited to):
Financial Metrics: what these are at the health plan, state, and federal levels and how that impacts an innovation’s measurement of cost and savings
Quality Measures: what the established programs are and how they drive opportunities
VBC Model Deep Dive: how these models show up in the real world, the constraints, the opportunities, and the relevant innovations
Attribution: what value can actually be assigned to the innovation vs. other factors?
Level of Care and Acuity Considerations: how setting and severity favorably shift the tides of VBC
Risk and Capitation: what risk, capitation, and actuarial evidence all mean and what needs to be true to step into this arena
Contracting Reality: what actually matters, what variables need to be carefully considered, and where opportunities are in negotiations
Choose Your Own Adventure: are you actually a VBC innovation? Our decision tree will help simplify your decision making process
Comments