Although healthcare leaders agree behavioral health conditions are chronic illnesses that need to be treated as such, outdated reimbursement models put financial strain on systems that lag behind other sectors of care. Compounding the issue, grant funding is facing reductions in the near future.
Stuart Archer, CEO of Plano, Texas-based Oceans Healthcare, told Becker’s reimbursement models tend to focus on one level of care instead of understanding the need for a continuum of services throughout a patient’s life.
He said outdated reimbursement models, particularly in Medicare, create a disconnect and do not reflect the clinical capabilities of today’s behavioral health system.
“We enter into this period of examination and cuts are already behind our peers. So when you look at Medicare and you look at Medicaid again, we’re not starting at the same level,” Mr. Archer said. “We’re already, many times, way behind other [healthcare sectors] and so cuts — whether they’re intentional or not to this space — really threaten our sustainability as we move forward.”
Today’s models, he said, are designed primarily to benefit payers and health plans. He added that the industry should focus on the fundamental levels of care and include value-based care in the same conversation. Models such as value-based care can prove sustainable. But for this to happen, three stakeholders must be satisfied: the payer, the patient and the provider.
At Oceans, Mr. Archer said, many of the states in which the health system operates do not include outpatient programs and partial hospitalization in their Medicaid fee schedule. Without those downstream intermediate levels of care, it is difficult to have a credible conversation about value-based care.
Mr. Archer said health systems should take a step back and look at the journey of a patient and their families, as chronic conditions require a continuum of care. He said hospitals have been used as triage centers for mental health — the most expensive care setting — due to insufficient funding for outpatient services.
He added that legislation often fails to account for the impact on behavioral health.
“The [One] Big Beautiful Bill [Act] really isn’t directly focused on behavioral health, but you know, as we like to say, even if an elephant doesn’t mean to step on you and it does, you’re just as dead. So I think that it’s the unintended consequences.”
He warned that the progress behavioral health systems have made to gain funding is at risk of being undone in many states, making it increasingly difficult to provide sustainable services and reimbursement.
