Improving the Payer-Provider Relationship in Behavioral Health
By Sarah Fleury, LICSW, Managing Director of Behavioral Health, BCBSRI and Ellen Hallsworth, Director, Bradley REACH, Bradley Hospital
The payer-provider relationship can often be fraught with difficulty and distrust, even as mental health parity rules become established. But in Rhode Island, Bradley Hospital, the nation’s oldest specialist pediatric psychiatric hospital, and Blue Cross & Blue Shield of Rhode Island (BCBSRI), the state’s largest commercial health insurer, are finding common ground through collaboration.
With a shared focus on making it easier for children and families to get there care they need, we have worked together to build a unique continuum of care and strengthened the workforce in pediatric mental health.
At the recent Behavioral Health Tech Conference, we shared the lessons we’ve learned from this collaboration.
Trust
In 2018, BCBSRI made a trailblazing decision to remove prior authorization for in-network mental health and substance use disorder services, bucking a national trend.
This decision has had a profound impact. First, it has created an atmosphere of trust, demonstrating that BCBSRI has confidence in providers’ clinical judgement. Second, the administrative burden for both parties has reduced significantly. Third, and most importantly, it has enabled patients to get the care they need more quickly. When patients “board” in the emergency department waiting for inpatient care, it is costly for payers, operationally challenging for providers, and extremely stressful for families. Eliminating prior authorization has not only been the right thing to do, but also the efficient thing.
Innovation
Bradley Hospital’s Pediatric Anxiety Research Center (PARC) is a national leader in the treatment of childhood obsessive compulsive disorder (OCD). PARC has developed a unique team-based care model, where trained providers work under the supervision of licensed psychologists. Given the dramatic increase in childhood anxiety disorders and the workforce shortage in behavioral health in New England and nationally, this model has the potential to deliver quality, evidence-based treatment to many more children.
Initially, this work and its evaluation were funded by a PCORI grant to Bradley Hospital. Too often, government or philanthropic grant funding pays for the pilot phase of this type of innovation in care delivery, but then it withers on the vine due to a lack of sustainable ongoing funding.
Fortunately, BCBSRI saw the potential and agreed to start reimbursing for the program after its initial pilot phase. PCORI’s decision earlier this year to grant a further $11 million for the expansion and evaluation of different treatment modalities was driven in part by our ability to fund the program through insurance. By funding the program sustainably, BCBSRI has leveraged further funding for innovation in the state.
Education
We know that children and youth with autism spectrum disorder (ASD) and developmental disabilities often experience significant mental health challenges. This is a population with unique needs: evidence-based interventions for mental health may only work if they are modified taking neurodiversity into account. With nearly 3,000 children in RI with a diagnosis of ASD, we need to expand access to treatment that works.
The Verrecchia Clinic, part of Bradley Hospital’s Center for Autism and Developmental Disabilities, developed an 18-month training program for community providers to modify treatments for neurodiverse children and youth. Our partnership with BCBSRI is crucial to making this work. We know that for providers in private practice or community outpatient settings, time is money and it’s difficult to take time out of seeing patients for this type of training. That’s why BCBSRI is providing a $100 hourly stipend for providers to attend this training.
This investment demonstrates the value we jointly place on expanding access to quality care. It’s another example of how doing the right thing – expanding access to quality care close to home – may ultimately be the efficient thing – enabling more children to receive care in less acute, community settings.
Understanding that Health Doesn’t Just Happen in the Hospital
Child and adolescent mental health exists in a web of family, school, community and health care settings.
Over recent decades, with the support of BCBSRI and local Medicaid programs, Bradley has built up a system of partial hospitalization programs (PHPs) and intensive outpatient programs (IOPs). Since the COVID-19 pandemic, through our Bradley REACH program, we have provided a virtual PHP across New England, and, since 2023 in Florida as well, with planned expansion into more states. This virtual program allows for intensive, team-based treatment while children remain in their families and communities.
In Bradley’s full-day PHP, which runs for up to four weeks, the transition out of the program and back to school is an inflection point. Adolescents are typically offered a day where they trial returning to school a few days ahead of time, but then come back to the program to debrief and work through any challenges. This smooths the transition back to school and results in long-term gains in their mental health. Operationally, though, this has been challenging because doing the right thing for patients has resulted in a day of lost revenue.
Recently, BCBSRI agreed to reimburse for one school transition day as part of the program. This explicit and progressive acknowledgement of the interconnectedness of school and mental health will support Bradley’s efforts to improve the care of children, and, we believe, reduce the need for further intensive treatment.
Of course, there’s always more we can do. There is huge opportunity for future collaboration, especially in terms of sharing data and more sophisticated measurement of clinical outcomes that will allow us to refine our treatment approaches and our reimbursement policies. Acknowledging our shared focus on patient outcomes has built a strong foundation for us to innovate in other ways.
