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Payers, SUD, and VBC: 'There's a Lot of Meat on This Bone'

Analysis  |  By Laura Beerman  
   April 11, 2024

MCO collaboration and value creation were a focus of the second annual Inspire Recovery conference.

"When you are addicted to fentanyl, you want it seven times more than you want water when you're hydrated." This hard reality is but one story of substance use disorder (SUD), spotlighted at the 2024 Inspire Recovery conference on Apr. 3 in Nashville. 

Addiction amplifies everything that is already hard about being human: knowing our worth, respecting it in others, and relating to one another from a place of similarity versus difference.

What role does managed care have to play in the SUD epidemic? Especially for Medicaid members in particular, for whom low income, social needs, and addiction are nothing less than a perfect storm?

"Medicaid MCOs are faced with trying to balance the continued push for greater treatment access and fast-rising behavioral health costs that can negatively affect Medical Loss Ratios, notes Carter Paine, CEO of Wayspring, presenter of the Inspire Recovery conference.

"This type of environment makes it increasingly ripe for value-based providers to work with health plans."

Or as one conference panelist put it: "Have you called your managed care company today? Anytime there is a barrier or obstacle to remove, please tap into managed care. Please use the resources available."

When a provider or patient does call their managed care company, what are they likely to hear?

Money and stigma

There was a common refrain at Inspire Recovery: The only way is reimbursement.

"Even if you can deliver the help people need, do you have the money to pay for it?" asked Jeremy Carpenter, VP-National Partnerships for Groups Recover Together — a conference supporting sponsor with Going Digital: Behavioral Health Tech.

Carpenter helmed a session on the role of criminal justice partnerships to support SUD needs.

"Giving providers the flexibility to help drive recovery is important. Different reimbursement structures with payers are what can help that happen," said Collen Nicewicz, CEO of Groups.

This linked to another important conference theme: the need for payer "co-opetition," the cooperation and competition that payers must demonstrate to meet the industry's biggest challenges.

Conference panelists identified three factors that strengthen both payer co-opetition and proprietary considerations: the importance of the public health lens, a market's maturity, and — again — the role of reimbursement.

"When there are quality withholds, you have to have MCO collaboration," noted Dr. Madelyn Meyn, Executive Director and Regional CMO for Aetna, a CVS Health Company. "If there are repercussions, then everyone stands to benefit."

So when is it not about the money in SUD? When people don't take it.

"Medicaid expansion has been a godsend to people who need access to benefits and treatment," said Wayspring CEO Paine. He marveled at the states that do not take advantage of this "90% funded insurance pool from the federal government."

There are risks to making progress and innovation dependent on reimbursement. Similar dependencies impact the stigma around SUD patients and treatment.

"In this day and age, saying we can't do something because of stigma just isn't good enough."

This from Dr. Tom McLellan, founder of the Treatment Research Institute.

McLellan's statement is especially true where stigma is not only perpetuated but codified.

"The industry tends to create policies that actually create stigma," noted Aetna's Meyn, who cited practices around Medication Assisted Treatment (MAT) for substance use.

MCO collaboration and value creation in SUD

The challenge with SUD progress is that everything is the key.

With SUD, SDOH and medical needs must come first noted Dr. Chirag Patel, CMO-WellCare of Kentucky, a subsidiary of Centene Corporation.

"When we're not managing SUD well, it spills back into physical health. Utilization creeps up because we don't have all the levers we need to manage the continuum of care."

Corey Ewing, CEO-WellCare of Kentucky, added: "If you're not addressing a member's immediate needs, you can't engage in a discussion about SUD treatment."

Dr. Meyn with Aetna noted another important first.

"Patient identification is the most important thing, with provider assessment and support."

Providers are the next "first."

"Providers are the key to engagement, innovation, and reimbursement," Meyn added, acknowledging that SUD progress is "multifactorial, also involving payers and SDOH."

The last "firsts" combine all of the others: the importance of integrated care — medical, behavioral, SUD, and social — and of incentives to drive stakeholder engagement.

"The goal is to reward providers for creating better access, outcomes and value," noted Wayspring's Paine. 

'There's a lot of meat on this bone'

What is true for SUD progress is true for value-based care (VBC): everything is key.

But how do you deliver value when you don't know how to define it or measure it, how to declare success or identify needed improvements? These questions — and the lack of evidence-based medicine (EBM) and common metrics — led to a common refrain on VBC in the SUD field: "There's a lot of meat on this bone."

"It is possible to weed out the bad actors in a fee-for-service system." This from Beth Mason, Chief Customer Officer at Wayspring. "But it's also difficult to define an SUD episode, to define success from the data, and to define SUD VBC measures and outcomes."

"You really have to measure success one member at a time," added WellCare's Patel, noting that flexibility, variability, and support are also important.

So is the role of utilization management, provided it helps not hinders.

"Without prior authorization, there is no forced conversation between the provider and the payer," said Mason.

Patel added: "We want to see utilization can come down, but not all utilization is the same. A patient has to settle down neurologically before peer support can work."

The CMO termed this the "sequencing of treatment": see the person, stabilize the person, support the person. "That's what we look for in a value-based model."

Defining traditional VBC in terms of episodic, primary care-based metrics, Patel stressed: "That can't work for SUD. We're trying to enable teams to think more broadly. It's not just about length of stay. Are patients maintaining their care or relapsing?"

"You have to look at the big picture. Success doesn't come in the first year of a VBC agreement."

Perhaps the best summary of stakeholder roles in SUD treatment came from Dr. Jim Casey, Statewide Director of Behavioral Health Services, Tennessee Department of Correction.

"We're going to get there, just not as fast as we'd like."

Laura Beerman is a contributing writer for HealthLeaders.


"Solutions on my left, problems on my right" — This was one of the many ways that healthcare stakeholders described the struggle to advance substance use disorder treatment.

In addition to patients and providers, managed care organizations have a role to play.

What is that role — and how is it unique when SUD meets value-based care?

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