Open Letter to Behavioral Health Providers,

As an advocate and firm believer in the importance of mental health services and access to care, I want to weigh in on recent headlines in the behavioral health industry.

I'm sure you've recently seen the headlines or read about organizations such as Alma, Headway, Sondermind, and more. These organizations market the idea of enabling access to mental health services by taking on administrative burdens that often frustrate the provider, such as billing, credentialing, contract negotiations, marketing, technology barriers, and more.

One organization, Headway, promises to credential you within 4 to 8 weeks and negotiate higher pay rates with insurance companies when you sign up with them. Appealing since doing credentialing on your own can take up to or exceed 120 days and negotiating a contract with fair reimbursement may take even longer. Some insurances do not allow negotiations for first-time credentialing providers. Headway claims they are building a new mental healthcare system, all with software and venture capital funding from top investors, including Andreesen Horowitz, Accel, Thrive Capital, and GV (formerly Google Ventures). According to an article published in November 2020 by Axios, the administrative costs are placed back on the insurers instead of the clients or providers (Primack, 2020).

You might be asking, "Why is this a bad thing? If they encourage more providers to accept insurance, are paid better, and open doors to mental health access, how can this be bad?"

It is an excellent question with a complicated answer.

It begins with the belief that independent behavioral health professionals in solo practices, even group practices, are incapable of having their own infrastructure to support their business. Brian Wheeler, VP of Carefirst BlueCross BlueShield, stated, "If you're a solo behavioral health provider, you do not have a receptionist, and an office staff and a billing team," Wheeler said. "You probably don't have a website, and you probably don't have your own video conferencing, HIPAA-secure [system] and some of the things that consumers expect" (Lovett, 2022). He claims that the industry is fragmented, and by partnering with Headway, they are providing much-needed infrastructure support to in-network providers.

While the narrative is convincing, it is genuinely flawed.

The biggest hurdle independent behavioral health professionals face is insurance companies. Read that again – The problem is not lack of infrastructure. It is the health insurance industry. The health insurance industry makes it challenging to credential and contract with them. It lacks transparency in its fee schedules, lacks oversight for timely payments, and provides poor reimbursement to providers for services rendered.

Providers either do not take or stop taking insurance for several reasons, such as the length of time and complexity of credentialing and negotiating fair payment. Claims are arbitrarily denied without clear reasoning or glitches in the payor system, inability to reach a customer service agent geographically within the US promptly to combat denials, benefit verification issues, and other claim issues. Payments are clawed back, often due to insurance processing errors and audits, sometimes years after services are provided to a client leaving the provider no recourse except to be out thousands of dollars. 

The process is overwhelming to new & existing providers, but health insurance companies created the "fragmented Cottage industry," as described by VP Brain Wheeler. Andrew Adams, CEO of Headway, says that the defining problem in behavioral health services is access (Primack, 2020). While he is not entirely wrong, he partners with the very culprits that create the issue in the first place.

Technology, websites, HIPAA compliance, and the ability to schedule online for telehealth or in-person appointments are rarely access issues. The real problem is the insurance industry seeking to make a profit from those utilizing insurance benefits and the providers forced to accept their 'allowable' rates for services. Insurance makes it notoriously difficult to understand the red tape of receiving and accessing care. Clients do not receive an explanation of how much the insurance will 'allow' for services or which services are not covered so that they can calculate their financial burden for receiving care. Clients have excessive premiums, high deductibles, and co-insurance rates while insurance companies create barriers to access, such as limited numbers of visits for mental health issues, required pre-authorizations, and refusal to reimburse for services such as couples therapy, family therapy, group therapy, and extended sessions.  All of these ultimately become the patient’s responsibility.

Independent providers do not need insurance companies or Headway to create infrastructure or efficient business practices for their business. Solo clinicians in the behavioral health industry disclose their fees upfront, and most will tell you their fees have always been transparent. Session fees are part of the informed consent to psychotherapy and the provider's policies. Independent practices have websites, HIPAA-compliant technology, telehealth platforms, online scheduling, and more. 

So why are insurance companies like CareFirst BlueCross BlueShield really creating partnerships with Headway? According to Brian Wheeler, "What we were thinking is, … could we find someone who could organize these solo practitioners under a managed services organization (MSO) type of arrangement" (Lovett, 2022).

Historically, Managed Services Organizations aim to reduce the utilization of services through uniform standardization of care. They also aim to move from a fee-for-service payment model to a value-based payment model, such as alternative payment models (APMs) or pay-for-performance (PFP) arrangements. These models create incentives and disincentives for providers by tying their compensation to specific performance measures. 

How do the MSO and insurance companies determine the metrics for which a provider is successful and clients receive quality care? Through data mining. The recent partnership between Headway and Carefirst BlueCross Blue Shield enables "real-time data sharing between Headway and CareFirst in order for the payer to gain insights into the patient experience" (Lovett, 2022). This is an example of data mining and the beginning of these companies analyzing the data and translating it into metrics for future value-based payment arrangements.

The aim is to provide lower costs, better administrative oversight, and quality care to clients. However, it also invites potential fraud, and penalties for providers that do not meet 'quality scores,' leading to a worsening behavioral health system, not a better one. Just look at the Center for Medicare & Medicaid Services that created Medicare's pay-for-performance program – The Value-Based Payment Modifier. According to a 2018 study published in the Annals of Internal Medicine by the University of Pittsburgh and Harvard researchers, the potential for exacerbating healthcare disparities is considerable (Roberts et al.). Those struggling to find access to behavioral health providers and receive quality care will continue to experience struggles and disparities. 

V.P. Brian Wheeler states, "Through this initiative, we will further invest in mental health providers, and double down on our efforts to advance equitable care, leveraging data to direct more resources and providers to communities in need." (BlueShield).

Pretty yet deceptive words for a glaring future of insurance companies continuing to interfere in the mental health access between clients and providers. Mental health is not a one size fits all service. If Headway does act in the capacity of a Managed Services Organization partnered with Major health insurance companies, how will that affect and define quality care? How will it affect providers' ability to care for clients who do not fall within the parameters set forth by these partnerships? 

How much power will be taken away from independent behavioral health providers to provide care and negotiate contracts and fair rates separate from these partnerships? Will it drive smaller practices out of business if they refuse to participate? Serious questions need to be asked regarding the relationship between Headway and similar companies and major insurance companies before the influence of this "new healthcare system" transforms the mental healthcare industry detrimentally and permanently. 

This partnership is not about access… It's about power, control, and money…

Changes need to come from within the healthcare insurance industry. Not pigeonhole providers into a less desirable management arrangement; or that removes their autonomy as independent clinicians to do what is best for their clients and protect the privacy of client data. The industry needs to pay better reimbursement rates as an incentive for behavioral health providers instead of trying to force them to use companies such as Headway just to receive better rates. Simplify credentialing, be willing to negotiate contracts, utilize better customer service options, stop recoupments on insurance processing errors, allow providers to determine medical necessity of services without restricting the number of sessions a client can receive.

There are plenty of ways the industry can enable better access to behavioral health services that do not require questionable partnerships such as the one discussed here.

Kind Regards,

Mrs. Michelle Hidrogo, RHIT                             

Owner of Medical Management & Mentoring, LLC

©2022 Medical Management & Mentoring, LLC

References

1. BlueShield, CareFirst BlueCross. “CareFirst BlueCross BlueShield and Headway Announce Collaboration to Enhance Mental Healthcare System.” Member Information, CareFirst, 2 Aug. 2022, https://member.carefirst.com/members/news/2022/08/carefirst-bluecross-blueshield-and-headway-announc/. 
2. Lovett, Laura. “CareFirst BlueCross BlueShield Taps Headway to Help Patients Find Behavioral Health Care Providers in 'Fragmented Cottage Industry'.” Behavioral Health Business, 2 Aug. 2022, https://bhbusiness.com/2022/08/02/carefirst-bluecross-blueshield-is-teaming-up-with-headway-a-company-that-matches-patients-to-mental-health-clinicians-on-a-new-initiative-designed-to-help-members-more-easily-find-behavioral-health/. 
3. Primack, Dan. “Headway, Software to Help Therapists Match with Patients, Raises $26 Million.” Axios, 18 Nov. 2020, https://www.axios.com/2020/11/18/headway-therapy-software-fundraising.  
4. Roberts, Eric T., et al. “The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities.” Annals of Internal Medicine, https://www.acpjournals.org/doi/10.7326/M17-1740.