A Systematic Review of Blended Payment Financing Strategies for Behavioral Healthcare

Background and Purpose

Blending two or more healthcare financing strategies has incentivized improvements in care quality, access and equity for a variety of chronic health conditions. As public mental health and substance use treatment programs continue to struggle with providing high quality care within limited budgets, these blended payment models may be effective strategies for incentivizing quality improvement in behavioral health. However, there is little knowledge of the extent to which blended payment models have been implemented for behavioral health care or their impact on behavioral healthcare provision. This systematic review synthesizes current evidence of the impact of blended payment models on behavioral healthcare provision, addressing a gap in the literature.

Methods

This review followed PROSPERO and PRISMA guidelines. Included studies used quantitative methods, mixed methods, or a case study approach to evaluate outcomes related to behavioral healthcare quality, access, cost or service utilization after initiating a blended payment model. Blended payment models were defined as combinations of the following financing mechanisms: capitated per-member per-month payments, fee-for-service payments, global budgets, pay-for-coordination, pay-for-performance and diagnosis related groups. Exclusion criteria included: articles on singular payment models, articles published prior to the year 2000 and purely qualitative reports. A broad search was conducted in PubMed, Web of Science, Embase, PsycInfo and SocINDEX using terminology related to behavioral health, blended payment methods, and behavioral health diagnoses. Two reviewers screened abstracts, with a third resolving conflicts. Two authors conducted a full text review, with disagreements resolved by discussion until reaching consensus. Two reviewers assessed study quality using Joanna Briggs Institute Critical Appraisal Tools. Findings were synthesized.

Results

After screening 188 abstracts and conducting full text review, 13 studies were included in the final synthesis. Eleven studies used quantitative methods, of which nine were quasi-experimental, three were randomized controlled trials, and two were mixed methods. Seven studies originated from the United States and six were international. Ten studies focused on pay-for-performance mechanisms blended with traditional financing, while three studies focused on blended capitation and fee-for-service models. Behavioral health topics included substance use (N=5), serious mental illness (N=4), depression/anxiety (N=3)and suicide (N=1). Across studies, impacts on behavioral health quality of care were mixed. Several showed improvements in clinical outcomes. Service utilization patterns shifted under incentive models, with some studies reporting increased outpatient engagement and reduced inpatient use, reducing some costs.

Conclusions and Implications

Blended payment systems have the potential to improve behavioral healthcare delivery. While service utilization, access, cost, and quality outcomes were frequently assessed, none of the included studies explicitly addressed equity, despite the potential of blended payments to incentivize care targeting health disparities. Very few studies of blended payment models focus on behavioral health. A continued deficit of research on these financing strategies limits financing innovation that may lead to more equitable and accessible care. The evidence base on blended payment models would benefit from improved study quality to support practical policy recommendations.