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DATE: May 25, 2026 at 09:38PM
SOURCE: PsychBilling Coach In the News by Susan Frager
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TITLE: Aetna/Alma, the Therapist Shortage, and Shifting Power Dynamics?

URL: https://psychbillingcoach.com/news/aetna-alma-therapist-shortage/

In the middle of a so-called “therapist shortage” combined with a wildly inflationary economy, you wouldn’t think that an insurance company could be dumb enough to actually lower clinician compensation. Or could they be? 

Ok, it wasn’t exactly an insurance company, but the next thing to it. On May 20th, the mental health tech platform Alma’s announcement of upcoming changes to Aetna’s reimbursement effective July 15th quickly went viral.

• “Extended” sessions lasting 53+ minutes (90837) will be reimbursed at the same rate as 90834 sessions.
•
• Psychologists will be reimbursed at the same rate as master-level clinicians.
•
• MD’s will be reimbursed at the same rate as nurse practitioners.
•
• 99215 procedures (High-complexity visits with a psychiatrist or nurse practitioner), will be reimbursed at the same rate as 99214 sessions (the next-lower level of complexity).
•

Are they insane!?

No comment.

What happens now!?

I don’t usually make public prophecies or speculations, but in this instance, I think it’s worth exploring some hypotheses.

Will this affect clinicians in-network with Aetna via the other platforms, or who contract independently?

You’ll notice that in the above screenshots, Alma is putting the blame on Aetna. Is that really the case, though?

So far, I’d have to say the answer is no. Other platforms were quick to reassure the clinicians utilizing them that they have no such similar policy changes forthcoming.  Nor do the reimbursement rate reductions affect practitioners who are independently-contracted, according to a statement made by Aetna.

And, given the volume of clinicians contacting me for consultations, reimbursement rate inquiries, and help with starting the process of independently contracting with Aetna, it seems like I’m not the only one who believes that Alma’s to blame here, rather than Aetna.

So why would Alma, now part of Spring Health, stick its corporate neck out and risk perpetuating the so-called “therapist shortage?” Spring Health is now easily the largest of the tech platforms, valued at an estimated $6-7 billion according to a paywalled article in the Wall Street Journal on January 29, 2026, just after the acquisition was announced.

Hypotheses

I’m going to float a few hypotheses. These are theories that cannot be substantiated with publicly-available documentation available today.

Given Spring Health’s dominance among the venture-capital platforms, they could be counting on any or all of the following:

• Future ability to negotiate substantially higher rates with payers other than Aetna.
•
• If this occurs, other payers’ significantly-higher rates could potentially rectify the Aetna “therapist shortage” on Spring’s platform. In other words, Spring could be hoping to deliver higher-than-average rates overall, even if Aetna’s rates are lower than average.

• If this is true, Spring might be counting on their size and market dominance to force member clinicians to take Aetna despite the reimbursement rate reductions, in a sort of carrot-and-stick arrangement.
•
•
• Currently, mental health clinicians working for Spring Health are a mix of 1099 and W2 clinicians. With the influx of Alma clinicians (all 1099), it’s possible that Spring might intentionally be hoping that a significant percentage of Alma clinicians will leave Alma altogether, as opposed to simply dropping Aetna but remaining with Alma. If enough clinicians leave Alma completely, Spring could then concentrate on a W2 model, which would allow them greater control over the clinicians who deliver their product.
•
• Although the exact purchase price of Alma wasn’t revealed, I’m sure it set Spring Health back by a few million or two, give or take. Shaving off “excess” reimbursement in the form of the differentials between 90837 and 90834, 99215 and 99214, psychologists and masters, and MD’s and nurses, might be a quick way for Spring to recoup some of Alma’s purchase price on the backs of the clinicians delivering their product. After all, they have to please their billionaire investors and quickly resume profitability, right?
•

None of these hypotheses are necessarily mutually exclusive. One, all, or none of them could be true. And I’ll reiterate – these are hypotheses. There is no publicly-available documentation at this time to support what I’m speculating.

But what does this mean for the so-called “therapist shortage”?

You’ll notice I’ve been referring to it as a so-called “therapist shortage.” This is because I personally don’t believe there’s a shortage of clinicians. Instead, the “therapist shortage” consists of mental health professionals of any discipline who are willing to accept insurance (whether through platforms or independently), if the reimbursement rates are unsustainably low.

And that leads me to one final, very “rock and a hard place” hypothesis:

• Spring/Alma could be making a gamble based on current economic conditions. Everyone’s feeling the pinch: not just the mental health professionals, but also their clients. Who, as long as the economy is in the toilet, will feel the need to stay in-network (assuming they retain insurance coverage). Spring may be gambling that a low fee is better than none, and therefore no significant “therapist shortage” will occur as a result of last week’s announcement.
•

No therapist shortage at Spring Health would only take place, though, if enough others followed Spring’s lead and reconfigured their reimbursement structure to match. However, if Headway, Rula, Grow, SonderMind and the rest don’t follow suit, to say nothing of Aetna itself and/or other payers, Spring will lose clinicians. Given my previous hypotheses, this might not be catastrophic for Spring.

But what’s NOT a hypothesis, in my opinion, is that the reactions of clinicians who currently accept Aetna through the Alma platform, will have broader implications. My belief is that all platforms, Aetna, and the other insurance payers, will be watching -closely!- to see what the Alma-Aetna clinicians do.

People’s business decisions in this regard will largely be based on their own individual circumstances. I certainly can’t and won’t advise anyone that they should leave, just based on a sense of outrage or hypotheses about the state of the industry, however strong my feelings on the matter might be. Not everyone has the same level of privilege, and I think it’s important that clinicians who are more economically privileged extend understanding to those who aren’t. We won’t get anywhere by continually fighting amongst ourselves.

What else could happen?

It’s been well-documented that there IS a therapist shortage on most insurance panels, despite the increasing prevalence of the platforms. It isn’t just a therapist shortage, though. Medical professionals of all disciplines -not just in behavioral health- are leaving for cash-based practices, for the same reasons mental health clinicians do.

IF the upcoming midterm elections result in a progressive majority, and result in meaningful healthcare reform in 2027 and beyond, then who knows?

As long as I’m fantasizing, I’ll mention that the abuses of payers and venture-capital entities largely persist because of a dangerously unequal balance of power, which has contributed over time to create the current “therapist shortage.” Collective bargaining, which could restore some balance, is an illegal act for most self-employed healthcare professionals. However, Texas has a modified legal form of collective bargaining with insurance companies, which occurs under the supervision of the Texas state Department of Insurance. This is a model I’d love to see adopted nationwide.

Are you in Texas? Get a good lawyer and consider it.

URL: https://psychbillingcoach.com/news/aetna-alma-therapist-shortage/

Articles can be found by scrolling down the page at https://psychbillingcoach.com/news/ under the title "In the News".

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DATE: May 7, 2026 at 03:25PM
SOURCE: PsychBilling Coach In the News by Susan Frager
-------------------------------------------------

TITLE: What’s this Medicare eligibility attestation demand?

URL: https://psychbillingcoach.com/news/medicare-eligibility-attestation/

Your clearinghouse may have been bugging you for the last month about a deadline on May 11, 2026, with respect to Medicare eligibility and something called HETS.  What the HECK is HETS? Will you get paid after Monday if you don’t get this done…whatever this is?

HETS stands for HIPAA Eligibility Transaction System, in other words the system Medicare uses when you inquire about the eligibility of an Original Medicare client.  I introduced HETS briefly last September when discussing “Death by 1,000 Cuts” –  a thousand onerous tasks continually placed onto clinicians by insurance payers or government Powers That Be.

Now, apparently, it’s 1,001.

What if I don’t make the May 11th deadline?

Good news: nothing terrible will happen if you don’t make Monday’s deadline.  You might be temporarily blocked from accessing Medicare eligibility via your EHR/clearinghouse connection, though, until you attest.

You will not be kicked off Medicare, and your claims will still be paid.

Does it apply to me?

If you’re enrolled to bill Original Medicare, then a HETS attestation is required if you’re going to be conducting eligibility inquiries via an EHR/clearinghouse connection.

Why is Medicare eligibility a good thing to have?

When accepting a Medicare client, I can’t think of anything more crucial than to verify their eligibility. And yet, mental health clinicians I consult with often don’t know this tool is available.

Medicare eligibility returns give you vital information:

• Date of eligibility for Medicare.
•
• Does the client have Part B? Not everyone enrolls in Part B at age 65.
•
• Date of last Coordination of Benefits update.
•
• Is Medicare the primary payer? If not, you’ll need the “MSP type code” for billing purposes and the eligibility inquiry will give that to you.
•
• Is the client enrolled in an “Advantage” or PACE plan?  If yes, the Medicare eligibility will tell you who the “Advantage” or PACE payer is.
•
• Is the client a Qualified Medicare Beneficiary (QMB)? You can’t collect any patient responsibility amounts (coinsurance or deductible) if your client is QMB-enrolled.
•
• Deductible status, for non-QMB clients.
•
• Is the client a Railroad Medicare beneficiary?
•
Can I get eligibility another way?

All Medicare Administrative Contractors (MACs) have online portals you can use to obtain eligibility. If you’re a portal user, the HETS attestation is contained within the registration process for the portal. At various intervals thereafter, the portal will make you re-attest before gaining eligibility information. So if you’re obtaining Medicare eligibility via a MAC portal rather than an EHR/clearinghouse, the May 11th deadline does not apply to you.

The only ways to obtain Medicare eligibility are via EHR/clearinghouse or MAC portal. CMS discontinued telephone eligibility inquiries as of March 31, 2025.

What are these rules of behavior?

One therapist I consulted with said it best: “Don’t be stupid.”

Click here to read the HETS Rules of Behavior, but it can be summarized in two words: Follow HIPAA!

There’s a bit more to it if you utilize an offshore individual or entity who has access to Medicare eligibility data.

Why is this such a big deal?

When a Medicare beneficiary’s ID number (MBI) is compromised, it can be used fraudulently. Identity theft and/or data breaches are common, and when this happens, CMS has to issue new MBI’s to all beneficiaries whose information was breached. Recently, this happened to about 1.3 million people with Medicare, who will now be receiving new ID numbers.

Wanna know how it happened? Apparently, it had something to do with Elon and DOGE. The story first broke in the Washington Post on April 30th. Here’s a link to the story, but there’s a subscriber-only paywall.

And the database DOGE apparently exposed, was a database of healthcare professionals! Which means not only was it your MBI which was disclosed, but also your social security number and, potentially other information about your practice which can be used to fraudulently submit Medicare claims under your provider number. If you think you might have been affected, click here to read what to do and how to protect yourself.

Tip for everyone: if a client’s Medicare claims all of a sudden deny stating that you used an invalid MBI, the first thing to do is ask your client if they were sent a new card. Clients may think that Medicare automatically updates you as to their new number but naturally, that would be too easy. Can’t have THAT!

Big Brother is watching…

From the Rules of Behavior:

“The Centers for Medicare & Medicaid Services (CMS) monitors inquiries in HETS, and we’ll contact you if we find discrepancies. For example, we’ll check if you submit a high ratio of eligibility inquiries compared to your Fee-for-Service (FFS) claims. If we suspect improper use or if you violate these rules of behavior, we may suspend you, place you on a corrective action plan, or refer you for investigation and you could be subject to other penalties, including civil or criminal actions.”

In other words, CMS will be using AI analytics to determine that a sufficient percentage of the Medicare eligibility inquiries you submit become actual claims for service to those beneficiaries.

What’s the “sufficient percentage?” No clue. CMS hasn’t shared that (to my knowledge). But my recommendation is that you not conduct any Medicare eligibility inquiries until a client has already scheduled an appointment. Don’t verify just based on a telephone inquiry from the client as to whether you can accept their insurance.

What if I do use an offshore vendor?

It’s not illegal, but it makes things more complex for you in terms of documenting compliance, both with the HETS Rules of Behavior and also HIPAA. And state law, if you happen to be located in Florida.

In general HIPAA terms, you as the “covered entity” are responsible for the conduct of your “business associate,” such as a biller or virtual assistant. Anyone who requires access to Protected Health Information (PHI) in order to carry out their job functions, is, by definition, a “business associate.”

If a business associate violates HIPAA, they can be held liable but you’re liable also! HIPAA mandates covered entities to carefully monitor their business associate’s compliance. Which is a lot harder to do if your business associate is located in a foreign country. And then there are legal considerations. Following US law may be the terms under which you engage this person or organization, but in reality, can there be any consequences to a foreign entity if something happens? That’s not a question I have adequate training to answer.

Making things even more snarled, some American billing / revenue cycle management entities employ offshore labor. So you might think you’re ok, not realizing that in fact there is offshoring going on. If you utilize a larger billing vendor, contact them to ask if any of their employees who view/utilize Medicare eligibility data are located outside the US and document their answer!

Getting back to your HETS attestation, CMS expects you to disclose any offshore arrangements in which foreign vendors/contractors view Medicare eligibility data and/or utilize HETS. If you have to answer “yes” to this question on the HETS attestation, I strongly recommend you utilize the services of a cybersecurity expert as well as a certified HIPAA auditor who can carefully investigate to ensure your compliance. If you utilize offshore help but obtain Medicare eligibility data via your MAC’s portal, I recommend the same actions. The HETS Rules of Behavior do apply to portal use; it’s only the attestation process which differs.

So how do I jump through this **** hoop?

By now, your EHR/clearinghouse should have sent you detailed instructions or else an alert may be on their website or when you log into your account.

This is the general workflow:

• Start by downloading your EHR/clearinghouse vendor’s instructions. You’ll need their “unique ID” in order to complete the attestation.
•
• Complete the CMS HETS Attestation via the process established by your MAC. You can find instructions for all MACs here.
•
• Notify your EHR/clearinghouse that you completed the attestation on [date].
•
• Your EHR/clearinghouse then does their part to ensure your access to HETS stays active, or is re-activated.
•

Simple Practice says they know nothing about this!

The Simple Practice EHR/clearinghouse doesn’t support Medicare eligibility transactions. If you’re a Simple Practice user, your only option for Medicare eligibility is the MAC portal, which means the May 11th deadline doesn’t apply to you.

Still running into trouble after following your clearinghouse’s instructions? You can schedule a short consultation here I’ve been churning out HETS attestations with clinicians for the last month or so!

It’s always SOMETHING, isn’t it?

URL: https://psychbillingcoach.com/news/medicare-eligibility-attestation/

Articles can be found by scrolling down the page at https://psychbillingcoach.com/news/ under the title "In the News".

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This robot is unaffiliated with PsychBilling Coach.

Private, vetted email list for mental health professionals: https://www.clinicians-exchange.org

Unofficial Psychology Today Xitter to toot feed at Psych Today Unofficial Bot @PTUnofficialBot

Psychology news and research articles at Psychology News Robot @PTUnofficialBot

NYU Information for Practice puts out 400-500 good quality health-related research posts per week but its too much for many people, so that bot is limited to just subscribers. You can read it or subscribe at @PsychResearchBot

Since 1991 The National Psychologist has focused on keeping practicing psychologists current with news, information and items of interest. Check them out for more free articles, resources, and subscription information: https://www.nationalpsychologist.com

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DATE: April 28, 2026 at 07:16AM
SOURCE: PsychBilling Coach by Susan Frager
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TITLE: Finding the value in value-based care

URL: https://psychbillingcoach.com/value-in-value-based-care/

If you’ve never heard about “value-based care,” it’s time to catch up, and fast! This July, Medicare will be premiering a 10-year pilot model called ACCESS: Advancing Chronic Care with Effective, Scalable Solutions.  While Medicare certainly has had other value-based innovations in the past, ACCESS is different because, for the first time, behavioral health is included.  

What is value-based care?

The short and sweet definition is when a payer (Medicare, Medicaid, or an insurance company) pays for population outcomes rather than procedures. While in theory that makes sense if you break your leg or have a heart attack, how realistic is this in practice for behavioral health?

Probably many of us would scoff, saying that it’s not. How do you measure outcomes in mental health at scale? And is a decreased score on the GAD or PHQ really indicative of a positive treatment outcome? (I’m not qualified to answer that question…)

Sure, practices can, and should, measure outcomes with their clients in whatever ways they feel are clinically appropriate. But unless you’re a huge group, you’re not measuring large numbers of clients. Nor is measuring outcomes the only definition of value-based care.

“Paying for outcomes” shows clearly that value-based care is also a financial arrangement. In private practice, you may reliably be demonstrating positive outcomes with your clients, but Medicare, BC/BS, etc., are still paying based on the CPT code billed. In other words, payment is based on claims that represent you as having delivered a session: 90837, 90834, 90847, etc.

The less short, and definitely not sweet, finances of value-based care

Value-based care involves financial capitation. Here’s how capitation works: the payer begins by determining a population to be covered. For example, let’s say that Aetna wants to contract with an entity to cover all behavioral health services for the 10,000 Aetna members living in a specific city.

Aetna decides how much they will pay per enrollee, or “per head” – hence the term “capitation,” which comes from the Latin term for “counting of heads.”  An easy way to remember capitation is to think about what “decapitate” means – to cut off someone’s head!

Gruesome joking aside, to continue with the example…

Aetna selects a provider entity who sub-contracts. In that contract, the provider entity agrees to provide all covered services to the members. Once done, Aetna simply pays the per-head (per-member) amount to the subcontractor/provider, and then washes their hands of responsibility thereafter to pay for care for any member in that group of 10,000 members. The subcontractor is now responsible for providing -and managing- all care.

Which places the subcontractor/provider financially at risk. Why? Because the more services are provided, the less profit they make. Their payment from Aetna is fixed. Aetna gets a great deal. The subcontractor/provider…who knows? Maybe it’s a great deal also. Maybe it’s not.

The clinical ethics of a value-based arrangement are usually enough to give most mental health professionals a sense of the “ickies.”

So capitation, the payment method for value-based care, requires scale. It isn’t going to be offered to even a group private practice, unless the group was seriously large (and probably financed by venture capital).

See where this is headed?

The Targets of ACCESS

Who provides mental health services at a scale large enough for a payer like Medicare to sit up, pay attention, and consider capitated reimbursement on the basis of outcomes rather than CPT codes?

Ah yes. Now we come to it. The platforms!

Sometimes morphed with, or looking like, national in-person or hybrid groups, because not all platforms hire clinicians as 1099’s. Then there’s a whole slew of AI, digital health, and apps.

Here’s a list of the platform entities which have signed up with Medicare as of April 23rd to participate in the behavioral health ACCESS program. (More may be forthcoming – Medicare’s deadline to sign up isn’t until May 15th).

• Headway

• Insurer investors: HCSC (BC/BS IL, MT, NM, OK, TX)
•

•

• Innerwell  (specializes in at-home ketamine tx, therapy platform)

• Venture capital, but no known insurer investment
•

•

• Isaac Health (specializes with dementia/caregivers)  

• Insurer investors: CareSource, Intermountain Healthcare
•

•

• SonderMind

• Insurer investors: Venture capital, but no known insurer investment
•

•

• Total Life 

• Insurer investor: GEHA
•

• Other investors of note: Google, Charm EHR
•

•

In Medicare’s own words, “The ACCESS Model will test whether an alternative payment methodology—Outcome-Aligned Payments (OAPs)—for technology-enabled chronic care reduces expenditures while preserving or enhancing quality of care for Medicare beneficiaries.”

Rules of ACCESS

For those who are interested in all the arcane details of ACCESS, Medicare’s 63-page description is here.

These are just a few highlights.

To participate in ACCESS, entities must enroll as an organization eligible to bill under Part B, have valid state licensure, comply with HIPAA, and appoint a Medicare-enrolled physician to act as Medical Director. (which nicely eliminates the platforms’ contention that they’re just billing/credentialing services!).

ACCESS will be available to both Original Medicare and Medicare-Medicaid dual-eligibles. Opting into a program under ACCESS will be the choice of the beneficiary, with no reduction in other Medicare services. Medicare beneficiaries enrolled in “Advantage” plans will not be allowed to participate. And, for any Medicare recipient who enrolls in an ACCESS track, the ACCESS organizational participant (Headway, etc) will be forbidden to receive fee-for-service Medicare part B payment for that individual during their 12 months of ACCESS enrollment.

The only qualifying behavioral health conditions for beneficiary enrollment in ACCESS are a diagnosis of either depressive and/or anxiety disorder. And the only “Outcome-Aligned Payment Measure” is listed as

• Control or minimum improvement in symptoms (assessed via PHQ-9 for depression and GAD-7 for anxiety)
•

Payment will be a fixed amount to ACCESS organizations, payable over a 12-month period, and the amount will be prorated up or down, depending on the reported outcomes.

Hmmmm….any potential for fraud here?

The idea is apparently for the ACCESS participant organizations to utilize some form of technology to achieve the goals. These are some of the listed AI/app technologies that have signed up to participate in ACCESS:

• Altitude Cares Inc  their website proudly trumpets that it was built by leaders from CVS, Devoted Health, and Optum (is this a GOOD thing?!?)
•

• Ciba Health
•

• Headspace
•

• Limbic Care, PC 
•

• M3 Information. An AI tool for primary care providers to asses mental health conditions
•

• Meomind AI    RECORDED ACTUAL SESSIONS TO LISTEN TO, via an app. Plus live chat. Seems like a sort of BetterHelp model. Their website claims that clients gave consent for their therapy sessions to be recorded and published.
•

• Mindset Health
•

• MyHealthTrack   
•

• NeuroTap Health, Inc
•

• Slingshot AI  -the Ash therapy chatbot
•

In the fall of 2024, it was reported by Behavioral Health Business that Headway, in conjunction with the National Quality Forum, has been engaged in an initiative called Aligned Innovation, to develop a patient self-reporting outcomes tool that, in theory, will one day replace all others, and become the standard of care – whether insurance is paying for care or not.

““Measures will become broadly adopted and used, not just by one payer saying that they want to use them…, but when multiple payers in a market all align and say, ‘We’re going to all hold you, providers in our network, accountable for this measure, and we’re all going to use the same measure and do it in the same way,”’ Dana Gelb Safran, president and CEO of NQF, told BHB.

I’m not making a clinical argument about the necessity for measurement of outcomes, which is important. But when entities with a financial stake control both the development of the outcome measure and then leverage their power to mandate its use, which in turn determines how much and what type of treatment they’ll cover, I smell a serious conflict of interest, if not outright abuse of power.

And what’s disheartening is that CMS, for all the recent exclamations in the news about stamping out fraud, seems as if they might be opening up Medicare to fraud in newer areas.

Time will tell. But even if no fraud results, I do have to wonder about where this leaves solo behavioral health clinicians and smaller groups. If fee for service payment is ultimately discarded in favor of value-based care, what happens to the clinician who can’t or doesn’t want to scale? I seem to recall from my graduate statistics classes that small sample sizes aren’t valid for determining conclusions – which means value-based care could never be offered to independent clinicians. Is this a signpost on the road to extinction, if the dominant method of payment for healthcare becomes value-based??

That’s only one question. It seems to me that another major potential flaw concerns co-occurring diagnoses, severe histories of trauma, and lack of client privilege/history of marginalization (whether racial, economic, occupational/educational, ability/disability, other social determinants of health, religious background, gender, LGBTQ+, employment, etc). Clients with any of these characteristics might predispose ACCESS organizations to subtly discourage their enrollment into the value-based ACCESS program. Enough “severe” clients – there go your stats, and whoops! Your money too…

All in all, it seems to me that Medicare’s ACCESS, while well-intentioned, raises a lot of unanswered questions, at least as it pertains to behavioral health.

URL: https://psychbillingcoach.com/value-in-value-based-care/

Articles can be found by scrolling down the page at https://psychbillingcoach.com/billing-blog/ under the title "The Billing Blog".

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Since 1991 The National Psychologist has focused on keeping practicing psychologists current with news, information and items of interest. Check them out for more free articles, resources, and subscription information: https://www.nationalpsychologist.com

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DATE: April 28, 2026 at 07:16AM
SOURCE: PsychBilling Coach Billing Blog by Susan Frager
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TITLE: Finding the value in value-based care

URL: https://psychbillingcoach.com/value-in-value-based-care/

If you’ve never heard about “value-based care,” it’s time to catch up, and fast! This July, Medicare will be premiering a 10-year pilot model called ACCESS: Advancing Chronic Care with Effective, Scalable Solutions.  While Medicare certainly has had other value-based innovations in the past, ACCESS is different because, for the first time, behavioral health is included.  

What is value-based care?

The short and sweet definition is when a payer (Medicare, Medicaid, or an insurance company) pays for population outcomes rather than procedures. While in theory that makes sense if you break your leg or have a heart attack, how realistic is this in practice for behavioral health?

Probably many of us would scoff, saying that it’s not. How do you measure outcomes in mental health at scale? And is a decreased score on the GAD or PHQ really indicative of a positive treatment outcome? (I’m not qualified to answer that question…)

Sure, practices can, and should, measure outcomes with their clients in whatever ways they feel are clinically appropriate. But unless you’re a huge group, you’re not measuring large numbers of clients. Nor is measuring outcomes the only definition of value-based care.

“Paying for outcomes” shows clearly that value-based care is also a financial arrangement. In private practice, you may reliably be demonstrating positive outcomes with your clients, but Medicare, BC/BS, etc., are still paying based on the CPT code billed. In other words, payment is based on claims that represent you as having delivered a session: 90837, 90834, 90847, etc.

The less short, and definitely not sweet, finances of value-based care

Value-based care involves financial capitation. Here’s how capitation works: the payer begins by determining a population to be covered. For example, let’s say that Aetna wants to contract with an entity to cover all behavioral health services for the 10,000 Aetna members living in a specific city.

Aetna decides how much they will pay per enrollee, or “per head” – hence the term “capitation,” which comes from the Latin term for “counting of heads.”  An easy way to remember capitation is to think about what “decapitate” means – to cut off someone’s head!

Gruesome joking aside, to continue with the example…

Aetna selects a provider entity who sub-contracts. In that contract, the provider entity agrees to provide all covered services to the members. Once done, Aetna simply pays the per-head (per-member) amount to the subcontractor/provider, and then washes their hands of responsibility thereafter to pay for care for any member in that group of 10,000 members. The subcontractor is now responsible for providing -and managing- all care.

Which places the subcontractor/provider financially at risk. Why? Because the more services are provided, the less profit they make. Their payment from Aetna is fixed. Aetna gets a great deal. The subcontractor/provider…who knows? Maybe it’s a great deal also. Maybe it’s not.

The clinical ethics of a value-based arrangement are usually enough to give most mental health professionals a sense of the “ickies.”

So capitation, the payment method for value-based care, requires scale. It isn’t going to be offered to even a group private practice, unless the group was seriously large (and probably financed by venture capital).

See where this is headed?

The Targets of ACCESS

Who provides mental health services at a scale large enough for a payer like Medicare to sit up, pay attention, and consider capitated reimbursement on the basis of outcomes rather than CPT codes?

Ah yes. Now we come to it. The platforms!

Sometimes morphed with, or looking like, national in-person or hybrid groups, because not all platforms hire clinicians as 1099’s. Then there’s a whole slew of AI, digital health, and apps.

Here’s a list of the platform entities which have signed up with Medicare as of April 23rd to participate in the behavioral health ACCESS program. (More may be forthcoming – Medicare’s deadline to sign up isn’t until May 15th).

• Headway

• Insurer investors: HCSC (BC/BS IL, MT, NM, OK, TX)
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• Innerwell  (specializes in at-home ketamine tx, therapy platform)

• Venture capital, but no known insurer investment
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• Isaac Health (specializes with dementia/caregivers)  

• Insurer investors: CareSource, Intermountain Healthcare
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• SonderMind

• Insurer investors: Venture capital, but no known insurer investment
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• Total Life 

• Insurer investor: GEHA
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• Other investors of note: Google, Charm EHR
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In Medicare’s own words, “The ACCESS Model will test whether an alternative payment methodology—Outcome-Aligned Payments (OAPs)—for technology-enabled chronic care reduces expenditures while preserving or enhancing quality of care for Medicare beneficiaries.”

Rules of ACCESS

For those who are interested in all the arcane details of ACCESS, Medicare’s 63-page description is here.

These are just a few highlights.

To participate in ACCESS, entities must enroll as an organization eligible to bill under Part B, have valid state licensure, comply with HIPAA, and appoint a Medicare-enrolled physician to act as Medical Director. (which nicely eliminates the platforms’ contention that they’re just billing/credentialing services!).

ACCESS will be available to both Original Medicare and Medicare-Medicaid dual-eligibles. Opting into a program under ACCESS will be the choice of the beneficiary, with no reduction in other Medicare services. Medicare beneficiaries enrolled in “Advantage” plans will not be allowed to participate. And, for any Medicare recipient who enrolls in an ACCESS track, the ACCESS organizational participant (Headway, etc) will be forbidden to receive fee-for-service Medicare part B payment for that individual during their 12 months of ACCESS enrollment.

The only qualifying behavioral health conditions for beneficiary enrollment in ACCESS are a diagnosis of either depressive and/or anxiety disorder. And the only “Outcome-Aligned Payment Measure” is listed as

• Control or minimum improvement in symptoms (assessed via PHQ-9 for depression and GAD-7 for anxiety)
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Payment will be a fixed amount to ACCESS organizations, payable over a 12-month period, and the amount will be prorated up or down, depending on the reported outcomes.

Hmmmm….any potential for fraud here?

The idea is apparently for the ACCESS participant organizations to utilize some form of technology to achieve the goals. These are some of the listed AI/app technologies that have signed up to participate in ACCESS:

• Altitude Cares Inc  their website proudly trumpets that it was built by leaders from CVS, Devoted Health, and Optum (is this a GOOD thing?!?)
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• Ciba Health
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• Headspace
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• Limbic Care, PC 
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• M3 Information. An AI tool for primary care providers to asses mental health conditions
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• Meomind AI    RECORDED ACTUAL SESSIONS TO LISTEN TO, via an app. Plus live chat. Seems like a sort of BetterHelp model. Their website claims that clients gave consent for their therapy sessions to be recorded and published.
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• Mindset Health
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• MyHealthTrack   
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• NeuroTap Health, Inc
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• Slingshot AI  -the Ash therapy chatbot
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In the fall of 2024, it was reported by Behavioral Health Business that Headway, in conjunction with the National Quality Forum, has been engaged in an initiative called Aligned Innovation, to develop a patient self-reporting outcomes tool that, in theory, will one day replace all others, and become the standard of care – whether insurance is paying for care or not.

““Measures will become broadly adopted and used, not just by one payer saying that they want to use them…, but when multiple payers in a market all align and say, ‘We’re going to all hold you, providers in our network, accountable for this measure, and we’re all going to use the same measure and do it in the same way,”’ Dana Gelb Safran, president and CEO of NQF, told BHB.

I’m not making a clinical argument about the necessity for measurement of outcomes, which is important. But when entities with a financial stake control both the development of the outcome measure and then leverage their power to mandate its use, which in turn determines how much and what type of treatment they’ll cover, I smell a serious conflict of interest, if not outright abuse of power.

And what’s disheartening is that CMS, for all the recent exclamations in the news about stamping out fraud, seems as if they might be opening up Medicare to fraud in newer areas.

Time will tell. But even if no fraud results, I do have to wonder about where this leaves solo behavioral health clinicians and smaller groups. If fee for service payment is ultimately discarded in favor of value-based care, what happens to the clinician who can’t or doesn’t want to scale? I seem to recall from my graduate statistics classes that small sample sizes aren’t valid for determining conclusions – which means value-based care could never be offered to independent clinicians. Is this a signpost on the road to extinction, if the dominant method of payment for healthcare becomes value-based??

That’s only one question. It seems to me that another major potential flaw concerns co-occurring diagnoses, severe histories of trauma, and lack of client privilege/history of marginalization (whether racial, economic, occupational/educational, ability/disability, other social determinants of health, religious background, gender, LGBTQ+, employment, etc). Clients with any of these characteristics might predispose ACCESS organizations to subtly discourage their enrollment into the value-based ACCESS program. Enough “severe” clients – there go your stats, and whoops! Your money too…

All in all, it seems to me that Medicare’s ACCESS, while well-intentioned, raises a lot of unanswered questions, at least as it pertains to behavioral health.

URL: https://psychbillingcoach.com/value-in-value-based-care/

Articles can be found by scrolling down the page at https://psychbillingcoach.com/billing-blog/ under the title "The Billing Blog".

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