Value-based care for behavioral health: A more measured approach to achieve true value

Abstract

This perspective calls behavioral healthcare leaders and providers to inform the direction and pace of value-based care (VBC). We recommend taking time to refocus on care quality metrics before payment models to engage providers and match current behavioral health system conditions. We review VBC, reasons why VBC is unique in behavioral healthcare, and key questions about VBC in behavioral health. We also feature youth behavioral health as particularly underdeveloped for VBC at this time. Finally, we propose a more gradual and inclusive approach to VBC in behavioral health, drawing on principles of quality improvement science. A stakeholder engaged process informed by the provider and patient community to identify appropriate care quality metrics in the short term may more productively drive value and facilitate innovation in the longer term.

Value-based care (VBC) is a healthcare reimbursement approach designed to contain costs and drive quality^1,2. In principle, VBC is a financial approach to prioritize quality over quantity based on predefined metrics believed to represent quality care. However, in practice, the emphasis on aggregate outcome reporting in behavioral healthcare has outpaced our field’s time to plan, build consensus on quality metrics, and develop capacity for data collection and reporting. In this perspective, we describe unique considerations of VBC in behavioral health and questions raised by the provider community that remain underrepresented in the literature or the current payor-led VBC movement. We are advocating for a more gradual and participatory approach to VBC in behavioral health that recognizes current system conditions and engages providers to define value and care quality prior to setting new payment models. Behavioral health refers to mental health inclusive of substance use disorders, and settings include outpatient specialty settings, inpatient psychiatric care, and primary care integration models across all public, private and grant funded models.

Broadly, VBC intends to structure health care services to promote value, defined as maximizing patient experience, clinical quality processes and achievable health outcomes at minimum cost². However, most VBC descriptions prioritize payment models and cost containment, placing care quality second. Indeed, VBC is typically defined as a payment model or type of contract between payors and providers^3–5 with several models designed to replace or augment fee-for-service reimbursement⁶. VBC models include performance-based payment, shared savings, per-member-per-month risk sharing, bundled payments, and capitation. Descriptions of each have been documented elsewhere^1–3. We advocate for a more explicit emphasis on care quality, as definitions of VBC focusing solely on financing models of cost containment or reduction is incomplete⁷ and may have unintended consequences. As VBC and cost reduction are increasingly conflated, the focus on patient experience and improving outcomes is getting lost⁷. Patient experience and improved outcomes through care quality are valuable regardless of cost implications and provider organizations are already oriented toward these care quality goals. However, once the focus on outcomes for cost containment purposes outpaces what is feasible in practice, or without time for quality improvement efforts to get there, VBC no longer sends the message that the true goal is patient care. The repercussions of over-emphasizing reimbursement models and cost containment for VBC in behavioral healthcare are substantial. Lessons learned from the Netherlands and UK demonstrate the risk of behavioral health care providers disliking or rejecting patient outcome monitoring when it is mandated for payment and accountability instead of clinical value^8–11.

VBC’s foundational vision is to transform healthcare delivery to one in which high-quality care, including optimal patient experience, centeredness, and outcomes, is valued and rewarded^6,7. For behavioral health, we have much work to do before achieving this vision. System gaps such as limited supply of behavioral healthcare providers, lack of usable technology solutions, electronic health record integration, care quality and outcome measurement problems, and lack of provider and patient engagement to define value must be addressed before value-based payment structures are realistic for behavioral health^6,12,13. Given these current behavioral healthcare system conditions, we agree with recent scholarship that encourages thinking about VBC as an approach to quality improvement¹.

We propose refocusing on VBC as an opportunity to create value and positive outcomes for patients through quality improvement for two reasons. First, we believe a care quality vision is more common ground to engage behavioral health providers in the VBC movement than a cost containment vision. Indeed, behavioral health is poorly reimbursed in comparison to other specialties where cost containment is paradoxically not as great a necessity. Second, there is a strong foundation of quality improvement literature to inform a more productive, sustainable, and stakeholder-engaged approach to system change. This perspective calls to action behavioral health providers and payors to work together to collaboratively inform the direction and pace of VBC in behavioral health by taking a stakeholder engaged quality improvement approach. See Table 1 for key terms.

Table 1.

Key terms

Key terms
Value-Based Care (VBC):	An approach to healthcare reimbursement to contain costs and improve quality
Benchmarks:	Predefined target outcomes or metrics set for incentives to be provided
Incentives:	Financial resources designed to reward target outcomes or performance goals
Patient-Reported Outcome Measures:	Standardized or individualized tools for patients to self-report their perception of their quality of life, functioning, symptoms, or other aspects of health and well-being
Quality Improvement:	A structured approach to system changes to achieve new levels of performance
Plan-Do-Study-Act Cycles (PDSAs):	A quality improvement science method to test change in an organization or system that is expected to lead to improvement. Also known as rapid cycle tests of change

Behavioral healthcare can pursue value and be tied to value-based reimbursement if permitted the necessary time and partnerships. We support this perspective by reviewing the current state of VBC in behavioral health, key questions to be addressed, and quality improvement principles to guide a more productive, realistic, provider- and patient-engaged system shift. Separating cost containment goals of VBC in the short term may allow for quality improvement-focused opportunities to gain momentum. Certainly, providers who have identified clear patient satisfaction and/or outcome metrics for their services and have the capacity to report them in aggregate could benefit now from shared savings and incentives. However, given the current state of the field with respect to diversity of services provided, patient populations, and settings with various infrastructure constraints, any financial incentives for value in the short term could more realistically target quality improvement processes and practices.

Current state of VBC in the U.S. behavioral health care system

The number of behavioral health care providers participating in VBC models - such as accountable care organizations and bundled Medicaid payment programs (e.g., Certified Community Behavioral Health Clinics or CCBHCs) - is steadily growing, yet remains low overall as compared to non-behavioral health providers^14,15. There are also early-stage alternative payment solutions proposed for integrated care models for children and adults as well as maternal health by the Centers for Medicare & Medicaid Services (CMS) Innovation Center¹⁶. VBC is currently further ahead in healthcare services outside of behavioral health¹ for several reasons. Behavioral healthcare has traditionally been siloed from other healthcare in the United States, resulting in infrastructure lags including technology, multidisciplinary care coordination, and communication which promote readiness for VBC¹⁷. These silos are rooted in a long history of behavioral health in separate “specialty” settings due to stigma and bias toward behavioral health not being sufficiently “medical”, as well as operational differences in financing and management, varied regulations, and reimbursement disparities^18,19. Collaborative care models with behavioral health integration are gaining momentum in the U.S. healthcare system which requires structural alignment at many levels. However, this effort often obscures important differences in behavioral health care compared to other areas of patient care. For example, there is poor consensus on behavioral health quality metrics among several hundred options, most of which are process measures from claims data that are not clearly linked to patient experience or outcomes^20,21. Patient-reported outcome measure development, refinement, research on their use in clinical care and consensus to identify the most relevant measures to care quality are necessary next steps in behavioral health before VBC can be truly realized^20,21. Indeed, some child and adolescent psychiatry scholars recommend advancing the use of quantitative progress measures in practice to promote parity and destigmatize behavioral health through transparency²². For instance, they highlight measurement-based care (i.e., the use of patient-reported outcome measures to monitor progress and collaboratively personalize care) as a practice to support the credibility of behavioral health care. Examples of practical patient-reported outcomes for children and adolescents include days absent from school and anxiety symptoms for a child with anxiety, homework completion for a child with Attention Deficit Hyperactivity Disorder, or number and length of temper tantrums for a child with disruptive behaviors.

When used, the impact of VBC models including pay for performance, accountable care organizations and bundled payments have been mixed on patient outcomes, and more innovation and rigorous evaluation is needed^23,24. Among a review of 15 empirical studies evaluating the effects of pay for performance across Maine, Delaware, Maryland, Massachusetts, and Washington, 12 had positive effects on process measures (e.g., service use, length of stay, follow-up, patient retention) and three had negative or null effects (e.g., gaming such as patient selection and dumping)²³. For example, VBC efforts in Maine focusing on quality improvement and systematic collection of behavioral outcome measures encountered barriers at behavioral health care system (e.g., workforce training and turnover) and policy (e.g., inflexible measurements; low reimbursement rate) levels²⁵. However, in Washington state, both incentivized and unincentivized quality targets such as systematic follow up, measurement-based care, and stepped care resulted in shorter time to patient outcomes within a collaborative care model²⁶. The authors discussed possible reasons for their positive results in contrast with other models typically showing limited effectiveness, owing their success to substantial training, consultation, a clinical tracking system, and focused clinical targets within one evidence-based model that are clinically meaningful. Bao and colleagues²⁶ also noted that existing VBC models driven by payor contracts typically do not come with adequate support systems such as theirs for quality improvement. VBC is also increasingly occurring in the public sector without evaluation of the effects of specific incentives, implementation levels, or unintended consequences for providers and patients²³.

VBC has faced mixed acceptance among behavioral health providers. There is significant ambiguity about what the purpose of VBC is, and a perception among behavioral healthcare providers that the principles of VBC as they perceive it do not match the realities of practice^27,28. We hypothesize that mixed acceptance of VBC among providers could also be related to structural differences and silos of behavioral health noted above and the history of the manualized evidence-based intervention movement and other “top-down” influences that have sensitized providers to feeling unheard, their expertise undervalued, and/or the realities of psychotherapy practice misunderstood. The VBC movement is currently very payor-led, limiting opportunity for provider partnership and expertise to inform the process. Further, proposed quality metrics selected for large groups of patients may not always capture meaningful changes in individual patients’ progress or functioning, and thus required outcome monitoring can be easily viewed by providers as evaluative instead of bringing value to patient care. For instance, “measurement-based care” (MBC) – the routine use of patient-reported outcome measures to adjust treatment – has sometimes been perceived as a way to track clinician performance and productivity²⁹. Yet, contemporary versions of MBC emphasize the patient-centered function of collecting and using patient-reported outcome measures to build provider buy-in for this clinical practice³⁰. Use of patient-reported outcome data for person-centered care has been suggested to improve work-related well-being and reduce behavioral health provider burnout^31,32. However, legitimate concerns remain when MBC is implemented primarily for aggregation across patients and reporting for VBC. In this way, VBC signals value for payors, not providers or patients, when aggregation of patient-reported outcomes for reimbursement is the primary goal.

Leading professional organizations, including the American Psychological Association, advocate for value-based payment models to align with healthcare partners³, signaling momentum and an opportunity for providers to join the VBC conversation. To align metrics with the diverse range of interventions, patient populations, and behavioral healthcare contexts, providers and patients must be actively involved to share their experiences and represent the heterogeneity of services. The first step is to ensure behavioral healthcare providers have a clearer understanding of VBC models. The next step is to include both providers and patients in defining relevant outcomes. Behavioral health professions, including child psychiatry, psychology, social work, and counseling bring robust literature bases with stakeholder-engaged, multi-level, mixed methods, and expertise to inform this work.

Although this perspective reviews literature across the age span, the necessity of partnership and quality improvement efforts are especially relevant in child and adolescent behavioral healthcare. Unique considerations include types of quality measures which are less developed for child populations, multiple respondents (e.g., caregiver, child self-report, teachers, pediatrician), natural developmental changes that intersect with treatment process and outcomes, and seasonal effects of the school and thus family calendar. Child psychotherapy is also reimbursed at lower rates than adult services. As a result, VBC is particularly complex and underdeveloped in youth behavioral healthcare due to financial disparities. This is especially true in the current context of the youth behavioral health crisis, which has been increasing over the past decade and amplified by the COVID-19 pandemic³³. The need for children’s behavioral health services significantly outpaces current capacity of the traditional behavioral health care workforce, and even when children and families do access treatment at a rate of 50% or less, retention in services and care coordination is severely lacking³⁴. Thus, the current focus within children’s behavioral health to improve quality care is concurrent with efforts to increase capacity through workforce initiatives, prevention, early intervention, and treatment in school and early childhood settings, and ensuring follow-up care following emergency department visits³⁵.

Key questions about VBC in behavioral health

Although we support the continued recognition of behavioral health as a medical specialty to reduce silos and stigma, traditional reimbursement approaches in the medical system to define relative value units (RVU) and other quality metrics are distinctly nuanced in behavioral health and may paradoxically constrain rather than clarify behavioral health practices. There are various key questions that warrant special attention and stakeholder-engaged guidance to advance VBC in behavioral health. Below are selected questions on measures, benchmarks, incentive structures, private practitioners, and the pace of VBC. They reflect the current research literature, content, and conversations at national behavioral health meetings and VBC learning events, gray literature from the practice community, and conversations with colleagues in academic medicine.

What measures will be used, and how do they represent quality care?

In VBC, target outcomes and associated measures must be prespecified³⁶. However, there is ample complexity associated with selecting measures of quality and value in behavioral healthcare. For example, treatment effectiveness based on patient outcomes is one of the least frequent measures in existing VBC models, which instead tend to focus on treatment process measures at the patient level (e.g., treatment dose, completion, length of stay, follow-up), clinician level (e.g., client retention, referrals), and organizational level (e.g., wait time, patients served, quality improvement efforts)²³. Among patient outcomes, symptom reduction is often the most obvious target measure, but symptoms and functioning may not progress or improve at the same rate or direction. For example, an adolescent with Attention Deficit Hyperactivity Disorder who has improved attention and concentration symptoms may still experience social relationship difficulties and an individual with substance use risk may be using marijuana daily yet attending school and/or work with little functional impairment. It is well documented in school refusal treatment research that symptom reduction and school attendance trend differently; when attendance improves, anxiety symptoms often increase due to gradual exposure but can be managed with successful distress tolerance skills³⁷. Symptom measures may also be sensitive to other conditions; an elevated PHQ-9 score could be a result of somatic health conditions or exposure to trauma unrelated to depression. Additional underrepresented yet clinically relevant outcomes include patient engagement, functioning, quality of life, goal attainment, and therapeutic alliance¹. There are also little to no measures available for clinical use on patient sense of self, insight development, or relationship quality within a family system². In behavioral health, progress and outcomes of psychotherapy are often patient-reported internal experiences based on many personal factors, in combination with some observable measures at times depending on patient age and condition. In contrast, physical health measures are slightly more objective and standardized, such as blood pressure readings.

When payors select measures and set targets quickly without clinician input, the result is undue administrative burden and clinician anxiety¹¹. Unfortunately, payors often lack incentives to ensure measures have value for patients, providers, or workflow integration^1,11. A stronger behavioral healthcare provider presence in the VBC movement could help select and test quality measures valued by clients and clinicians.

Part of the concern about VBC for behavioral healthcare is what measures will be used³⁸. Most behavioral health measures are narrow and condition specific³⁹, reflecting those endorsed by Centers for Medicare and Medicaid services (see Rothrock et al.¹). Underrepresented measures of interest to providers and patients include patient-reported therapeutic alliance, engagement, life functioning, quality of life, and goal attainment. Child providers, children, and families report value in individualized or idiographic, non-condition specific measures (e.g., school attendance, relationship quality, self-awareness, and goal-based outcomes)^40–42. Current behavioral health measures of symptoms, functioning and goal-based outcomes can tell different stories about progress⁴³ which has led some scholars to a call for more measure development³⁹, harmonization⁴⁴, and pragmatic use of existing measures to inform improvement⁴⁵.

The tension here is that broader and more clinically useful measures may not work well for aggregation and VBC. Patient-reported outcome measures on symptoms, functioning, and recovery are relatively poor for evaluating mental health care quality due to complexities with risk adjustment for individual variation, comorbidities, and sociodemographic risk factors outside provider control⁴⁶ (for a detailed justification of why process measures of care quality likely outweigh patient outcome measures, see Conrad²). A related issues is that behavioral healthcare providers inconsistently collect patient-reported outcome measures due to limited access to measures, data management infrastructure, clinician training, and leadership support^13,47.

Other candidate quality measures for behavioral healthcare reflect access or service processes, such as waitlist time, provision of preventive services, match of evidence-based interventions with patient goals, and patient safety. Yet, these areas lack validated measures developed with large and diverse samples^46,48. Some scholars advocate for exploring non-clinical VBC outcomes, such as clinician turnover³⁶. Clinician turnover and burnout has been a proposed care quality indicator for VBC, but only if disentangled from payment models^7,32.

Central to the topic of measurement in VBC is that behavioral health conditions often involve high burden and cost due to hospitalization and comorbidities with other medical conditions⁴⁹. Delays between care and outcomes, as well as variation in patient response, severity, access to related services, and care from other providers make outcomes-based payment complex and unreliable for behavioral health². A wider lens on creating value within the system is warranted—attending to metrics that represent alleviating behavioral health burden on patients, providers, and systems. Evaluating the appropriateness of various behavioral healthcare quality measures is a key area of inquiry for improvement science in behavioral health care and, subsequently, the foundational future of value-based behavioral healthcare.

What benchmarks—and adjustments—will be set and by whom?

As VBC expands, there are concerns about whether and how we can define and measure outcomes across populations^36,45. Benchmarks, or target outcomes, set on predefined improvement cutoffs, may need to be adjusted based on patient risk factors, acuity, comorbidities, and/or presenting concerns. Currently, payors are developing risk adjustment algorithms (i.e., expected variations in treatment trajectory by patient characteristics) and risk stratification (i.e., who may/may not be expected to show improvement). Some of the more successful value-based payment models have focused on a specific patient population or presenting concern, such as depression⁴⁶. Behavioral health providers must contribute their expertise at this decision-making table. For example, expected treatment recovery curves already exist in some measurement feedback systems, but may not account for all clinical and contextual variations. Behavioral health professionals are often trained as social scientists who understand confidence intervals, risk adjustment, and limitations in interpreting quantitative findings. This training affords ample expertise to participate in dialogues about aggregating individual measures to sample and population levels with appropriate scientific assumptions and limitations to interpretation.

Moreover, not all mental health therapies or conditions are good candidates for VBC³⁶. Payors may not understand case mix adjustments endogenous to specialty fields working with patients living with chronic conditions. Providers may request or propose that some conditions or service modalities be excluded from VBC, and would be positioned to provide examples and clinically-sound reasoning based on their expertise that payors may not be familiar with. Reorganizing healthcare around patient subgroups and medical conditions has been recommended as an important step toward comprehensive quality reform⁶. Teisberg, Wallace and O’Hara⁷ recommend a framework for implementing VBC organized around segments of patients with shared health needs instead of provider types to identify needs, integrate services, and start measuring costs and health outcomes. For a detailed interdisciplinary example, see Teisberg and colleagues’ work⁷.

What to incentivize in behavioral healthcare?

Prioritizing cost containment based on narrow symptom improvement benchmarks over time without adjustment raises several concerns. First, it may drive behavioral health professionals toward a moral dilemma of providing primarily ‘payable’ services to patients. These include short-term psychotherapy, services for conditions most readily tracked using symptom inventories and/or patients with fewer comorbid conditions or socioecological stressors. Second, incentive structure benchmarks and adjustments also raise equity concerns across payors, providers, and patient populations. Predetermined metrics of behavioral healthcare value with a one-size-fits-all approach could deepen inequities in affordable care accessibility. For instance, people living with behavioral health conditions are disproportionately of lower socioeconomic status, and youth with low socioeconomic status face higher mental health risks⁵⁰. Therefore, VBC incentives and benchmarks must account for intersecting risk factors through strategies such as capitated payments. However, until we can test appropriate metrics of clinical value for these populations and behavioral health is a healthcare system priority, value-based payment models for these populations are premature⁴.

So, what to incentivize and how? This is an open question that requires thoughtful and engaged planning. Behavioral economic research in medicine and psychology suggests that providing incentives for avoiding a loss or decline in health outcomes could be more motivating than improvement outcomes². Data like these might inform more appropriate incentive strategies for VBC that focus on maintaining stability in functioning or quality of life among chronic condition patients. Similarly, rewards have shown more supportive evidence than penalties to influence provider performance, so the introduction of penalties should be pursued cautiously².

Where will private practitioners land in this?

Small practices are unlikely to bear the financial risk of some VBC arrangements better suited to large hospital or organizational settings (e.g., bundled payments), as well as the administrative burden of measure collection and reporting cost. Thus, an emerging concern about VBC in behavioral health, predominantly led by third-party payors, is whether VBC will migrate providers toward private pay/sliding scale models or leave private practitioners with greater risk they cannot bear without the patient population size of larger group practices. A related concept articulated in the pay for performance literature is the risk of “crowding out” provider motivation toward care of complex or chronic conditions, a risk that some research has shown to be mitigated by involving providers in design, implementation and evaluation incentive arrangements^51,52. Rothrock and colleagues¹ give examples of what private practitioners or providers with small practices can do to engage in VBC. Smaller practices and/or providers with small caseloads may benefit from current fee-for-service payment arrangements with bonus incentives focused on individual risk adjustment, patient experience, and care coordination instead of larger caseload capitated models to offset the risk of some clients not meeting pre-defined improvement². Therefore, quality improvement initiatives to promote VBC infrastructure should be differentiated by organization size and represent providers and patients across the private to public healthcare continuum. This approach would generate needed recommendations about how to differentiate VBC to suit the vast heterogeneity of providers, clients, settings, and systems in behavioral healthcare, particularly for smaller clinics and those who desire to continue practicing independently.

How fast is VBC going?

Exact timelines and models for VBC in behavioral health care remain unclear, offering an opportunity to inform its pacing and direction. A phased approach to VBC is most appropriate given the current behavioral health system limitations and provider engagement needs. Open research and policy questions remain on aligning VBC models to different organizational structures, what payment incentives promote value and provider participation, and the feasibility of these strategies across stakeholders². We also have knowledge gaps in provider training and implementation support, usable information technology, effective policies, and field-specific barriers to VBC in behavioral health⁴⁶. Stakeholder engagement and shared learning are necessary before scaling up VBC across the field.

Given the very low fee-for-service reimbursement rates in the current behavioral health services market, comparing value-based payment strategies to this current strategy seems problematic. Due to the shortage of providers and need to expand systems and networks of care available to patients, payors should be motivated to offer a menu of contracts and incentives that offer sufficiently competitive financial gain by providers and organizations with a range of clinical skills and efficiency². Given the inherent complexity of payment strategies and incentives across behavioral health, proceeding rapidly with behavioral health VBC is both inconsistent with the field’s current readiness and risks unintended negative consequences.

Quality improvement principles for pacing VBC in behavioral health

We have outlined key questions that should be considered when implementing a financially-driven VBC model in behavioral health. However, we also advocate for VBC approaches to be pursued as quality improvement efforts in a broader system change process to articulate and prioritize care quality. Substantial behavioral healthcare system development is needed to support a valid, nuanced, and sustainable approach to VBC. For quality measurement to become a reality, core functions of a value-based delivery system include accessibility, efficiency, and coordination¹³. These basic conditions are still under development across the behavioral health field. For one, behavioral health outcomes have not been routinely measured due to infrastructure barriers, provider adoption, and biased symptom rating scales that are hard to collect without adequate training and implementation support¹³. To advance behavioral healthcare quality in terms of effectiveness, equity, patient centeredness, or any other quality metric⁵³, the field must leverage quality improvement principles and methods, along with appropriate time, supports, partnerships, and a culture of change. Continuous quality improvement (CQI) methods help bridge gaps between healthcare system goals and current practices. Rapid cycle tests of change and opportunities for peer learning across organizations, sites, and providers can stimulate innovation and clarify the path forward to realistic practice change. We briefly review three quality improvement principles that may facilitate momentum toward VBC with the support of behavioral health providers and patients.

First, having a focused aim and knowing why you have that aim is a primary principle in improvement science⁵⁴. While value is the aim in VBC, how value is defined varies, and whether the end goal is cost containment or care quality seems unclear. Improvement science would advise all stakeholders to leverage various expertise in developing a shared vision and aim. If driving care quality is the primary goal, the pace of cost containment models may need to slow down until after building consensus on quality metrics and methods.

Second, an improvement science lens would allow the VBC evolution to be part of a learning healthcare system. Discovery, creativity, and problem-solving would be necessary to develop and test VBC ideas while monitoring data feedback loops⁵⁵. The VBC movement would have to shift from a culture and climate of performance evaluation to that of a learning environment. In this shift, providers and payors would work together to explore measures, methods, systems, and workflows to discover how to operationalize and interpret value as defined by the collaborative aim. It is also notable that with this lens, variation is expected and observed during the learning process to monitor whether changes result in improvement. Thus, a sense of safety and vulnerability is essential to authentic and shared learning for discovery.

Third, a learning healthcare system approach to VBC would achieve the specified value aim by using the concept of small-scale change. This is a way to test and monitor low-risk improvement to learn about and gradually scale-up successful changes. Methods such as rapid cycle plan-do-study-act cycles (PDSAs) are used to test small-scale changes in day-to-day practice that front-line stakeholders, informed by recommendations and best practices, are empowered to pilot in their own practice settings. Quality improvement collaboratives using PDSA cycles and a shared learning network of leaders and front-line providers have effectively advanced healthcare quality processes and patient outcomes across a wide array of specialties. Examples include HIV care, asthma care, diabetes care, organ donation, lung cancer services, antidepressant prescribing, pain management, falls prevention, and infant mortality⁵⁶. Quality improvement collaboratives are also gaining popularity in behavioral healthcare⁵⁷, including child and adolescent service improvements, such as evidence-based treatment implementation, adolescent health and comprehensive school mental health services collaboratives^58–62. Like operating as a learning healthcare system, using small-scale changes would be a culture shift, as they are distinctly different from top-down decisions for system-wide rollout and provider compliance.

There are many opportunities to use CQI methods to establish the necessary preconditions for successful VBC in behavioral healthcare. As aforementioned, the risk of proceeding without a quality improvement framework is high, particularly for further alienating providers. For example, performance metrics should be established by an inclusive, data-informed CQI process. Driving value through mandatory behavioral health outcome measurement will only be achieved with adequate time, pacing, and provider and patient voice⁶. Pre-specification of outcomes and measures without adequate time to problem solve practical collection and reporting, or to explore which measures are most optimal to capture care quality, may result in blunt measures that are not well supported, sustained, or adopted by providers. Health information technology is also a core aspect of the behavioral health infrastructure needed to support the learning environment of VBC for providers, patients, and payors, which needs substantial development before VBC requirements². As one example, behavioral healthcare providers with low reimbursement rates are now investing in measurement feedback systems and other technology platforms to engage in VBC because often their current electronic health record platforms are insufficient.

Conclusion and future directions

In conclusion, we suggest that structural and systemic changes must occur before VBC models are appropriate for behavioral health. Second, behavioral health providers and patients must be active partners in transforming the field and promoting readiness for VBC. Cross-stakeholder conversations can generate opportunities for creative solutions that focus on striving toward true value for the breadth of care models and patients served. Strategies such as providers working with their local or national professional organizations, including patients on advisory boards, and ensuring provider and patient representation when payors pursue VBC changes are essential. We also envision opportunities for learning communities or pilot initiatives to promote practice-based feedback loops about candidate measures and care quality. Capitalizing on stakeholder-engaged processes and quality improvement methods would allow our field time to intentionally focus on the reform process instead of requiring submission of underdeveloped and potentially not useful patient outcome metrics.

Our concern is that if VBC applied to behavioral health does not reflect what is valued by patients and providers, it may widen the divide between payors and providers. Another unintended consequence could be provider migration toward uninsured private practice, which will further worsen behavioral healthcare access and disparities. Providers should feel empowered to assess existing performance measures and critically examine their meaningfulness, while simultaneously recommending and participating in piloting alternative metrics and systems. Indeed, best practices in quality improvement science encourage a low-risk learning environment supportive of testing innovative changes on a small scale, which may fail and thus generate data-driven learning and program evolution⁵⁴. The future of value-based behavioral healthcare depends on a partnered approach and true collaborative learning among patients, providers, and payors committed to promoting equitable access to high-quality services and supports.

Author contributions

L.M. and E.H.C. co-developed the idea, outline, and supporting references for the manuscript. E.H.C. led the initial drafting of the manuscript. L.M. revised the manuscript for important intellectual content.

Data availability

No datasets were generated or analysed during the current study.

Competing interests

All authors declare no financial competing interests. Author E.H.C. is Associate Editor of npj Mental Health Research and Guest Editor of Meeting the Need of Children’s Mental Health Collection. Author L.M. is Guest Editor of the Meeting the Need of Children’s Mental Health Collection. E.H.C. and L.M. were not involved in the journal’s review of, or decisions related to, this manuscript.