Dispatch No. 8

Site Design 2.0!, The Challenges of "Value-Based" Reimbursement

Welcome to Holbemn 2.0! Much thanks to K.Q. Dreger of Audacious Fox for the site design and for coaching me through this blogging experience. If you haven’t read AF before, pay Dreger a visit and treat yourself to the one of the best privately written columns on the internet. Both in person and on the web, Dreger is one of the sharpest and most thoughtful people I’ve come across, and best of all, he writes with the intent of being respectful of your time. I could stand to take more than one leaf out of his book…

On Mondays I come into the office, and attempt to be here at least 15 minutes before anything I’ve scheduled that morning. I sit down and on a blank 8.5”x11” sheet of paper, meticulously folded in half to be able to flip like a book, I copy the neglected, strike-through-less items from last week’s to-do list.

As I go through this process, I cope with pangs of guilt for calls I haven’t made, documents and charts which have gone unreviewed, dozens of housekeeping tasks that will likely never affect client care in any meaningful or outcome modifying way.

Herein lies my deeper frustration. A significant portion of my down-time is spent doing things which have no direct impact on the well-being of my clients.

But there are also the items which have travelled from list to list over the course of months, as opposed to a week or two. These are the tasks and pursuits that would enable me to be a better clinician: Trainings to look into and receive, books to read, ideas and proposals to develop for new services to offer our clients.

But sadly, those fall to the background of my day-to-day, and I find myself beginning each week on a frustrating note as I compile a large list of menial tasks.

Unfortunately these administrative tasks are multiplying as behavioral health organizations face increasing pressure to conform to insurance companies’ push to integrate “Value-Based Reimbursement,” an initiative mandated by the Affordable Care Act. Insurers, including Medicaid and Medicare, are beginning to require measurable results and outcomes documented on a regular basis to prove that care is working to reduce impairment. If progress is not being made, they won’t pay after a certain point. They will cease to offer their reimbursement to those providers and send the client to another agency or provider.

This theoretically makes complete sense. Healthcare providers should be accountable, data-driven, and intentional in their treatment, not simply seeing clients for years on end with no significant progress.

But therapy doesn’t always work on a schedule, and to ascribe a certain expected timeline to someone’s healing process seems to me to be just one more way that capitalism requires systems to place a dollar value on truly unquantifiable processes. For an insurance provider to hypothetically say in essence that under a provider’s care a client isn’t healing from a trauma quickly enough or demonstrating enough improvement in their ability to cope with an ongoing stressor such as an abusive spouse or family member seems to me to be cruel and uncaring toward the realities of the field.

Problems in living and the subsequent healing that people seek through therapy can hardly be quantified as one would a patient’s T-cell count in the course of HIV treatment. So to say that one’s response to treatment isn’t sufficient, and that the response will be to break a well-forged therapeutic relationship and force one to start over with another provider in the name of the bottom line strikes me as misguided and ignorant.

Meta-analyses of psychotherapy research routinely demonstrate that a client’s connection with the therapist is the number one determining factor for healing and growth to occur, surpassing therapeutic modality and all manner of demographic factors in influence. I believe this to be true and though my experience is anecdotal, I’ve personally rarely found much success in clients who I have not felt connected with. In fact, many times it takes months, or even greater than a year for a client to determine that I’m truly trustworthy enough for them to reveal the true issue that’s going on.

For insurance companies to place a required timeline on healing while ignoring the largest factors which drive it is at best, a misguided attempt at improving care outcomes, and at worst a shallow and transparent push for cost reduction.

Assuming the former and the best intentions of the insurers and policy-writers, it highlights how incredibly difficult it is to create and implement healthcare policy, especially for a system as fragmented as ours is in America. The system isn’t built in a way that values therapy for the hybrid of art and science that it is, and that it instead drives it to look more like a system to be streamlined, made more efficient, optimized. And if the internet and other “optimized systems” have taught us anything, it’s hard to preserve the human at the center of the process when you reduce them to data points.

I’ll get off of my soapbox now, but these are truly my thoughts as I write down the meticulous memos, assessment scores, and background documentation that I need to do to prove my efficacy as a counselor. I’ll continue to comment on this sort of thing from time to time, and hopefully provide some useful perspective from the behavioral health front lines.

As for my plan, I’ll be fighting for my clients however necessary. I’ll comply, rebel, do whatever I have to to protect the therapy that I know delivers results, however difficult and unquantifiable they may be.

The fight is at the top of my to-do list.