For the past decade, healthcare leaders have talked a lot about value-based care (VBC). The idea was that by tying payment directly to outcomes, we’d make healthcare more effective, more affordable, and more accountable.
The reality has been a bit more complicated. While some areas (like Medicare Advantage) have genuinely embraced these models, adoption across physical healthcare as a whole has been slower and more uneven than originally expected.
And in behavioral health, progress has been slower still. We’re behind—not just because our data is fragmented and our systems siloed, but because we’ve often treated behavioral healthcare as something that’s incompatible with clear, standardized measurement. Too many of us still talk about our work as “more art than science.”
But that perspective won’t hold up much longer. Payers and policymakers are becoming less patient with processes that measure activity or service volume rather than real-world impact. Expectations around data, integration, and meaningful measurement are growing quickly.
The next few years will tell us a lot. Those who invest now in measurement-based care and integration with primary care will be in a stronger position for future sustainability. Those who resist or hesitate will eventually wake up to find the landscape has shifted—whether or not they were ready.
The VBC Gap in Behavioral Health
To have an honest discussion about why behavioral health is behind on value-based care, we have to:
- look at the structural issues that have plagued the field for years, and
- define what we mean by “value.”
Change-Resistant Payment Infrastructure
Structurally, we’ve been operating in a system that was never really built for this kind of accountability. Fee-for-service has been the dominant model, and everything from our funding streams to our documentation systems have been designed to support that. You get paid for the service you deliver—not the outcome it produces. And while there’s been a lot of talk about changing that, we haven’t seen those conversations consistently backed by real infrastructure or incentives.
Measurement-based care is still spotty. Even with the use of tools like the PHQ-9 and GAD-7 becoming more common, plenty of organizations struggle to make measurement a routine part of care. That’s partially because the tools themselves don’t always feel like a natural fit for the way behavioral health is practiced—and partially because payers haven’t always demanded it (or rewarded it) until recently.
The Quality Conundrum
The basic definition of value is quality divided by cost. (Or, as an old friend puts it, “What is the cost of a pound of cure?”)
Value = Quality ÷ Cost
We are pretty good at measuring the cost part of this equation, but quality is another matter. For many of the problems we address, tracking whether there has been symptom relief is sufficient—and when the symptoms have returned to baseline, the problem is considered resolved or cured. But what about problems for which there is no cure? How do we measure quality to determine value?
Tools like the PHQ-9 and GAD-7 are designed to measure symptoms—specifically, depression and anxiety. And like I said, these tools can work when symptom relief is the goal. But for people with serious mental illnesses like schizophrenia, functionality can be more important than symptoms—because ultimately, we want to know whether people are able to live their lives in the way they want. For chronic illnesses that have no cure, treatment is not time-limited. People with diabetes, hypertension, and asthma do not get “cured”—they learn to live with their illnesses and often receive life-long supports. And when there is no cure—no finish line—creating a definitive measure of quality becomes more challenging.
Measurement-Based Care as the Foundation for VBC
Despite these challenges, the simple truth is that behavioral health providers can’t get reimbursed in a value-based care model without measurement.
If you’re going to get paid for the outcomes you deliver instead of the services you bill, you have to be able to demonstrate those outcomes objectively. And right now, we still have work to do as a field when it comes to making measurement a standard part of care.
The measures we have at our disposal are not perfect, and they certainly don’t capture the full scope of what behavioral health providers are addressing with their clients. And a lot of times, they feel disconnected from the real work of therapy, like something you complete for the record—not because it’s changing what happens in the session.
Still, they are a place to start. If we wait until the perfect measure comes along before embracing VBC, we’ll be waiting a long time. In the meantime, payers are already tightening expectations around outcomes, and they increasingly expect to see data that’s solid and definitive. Providers who can’t demonstrate outcomes are going to have a hard time proving their value or keeping their seat at the table as these models evolve.
Good clinical care matters, but so does the business side of the house. Without measurement, providers are also going to struggle to compete in contracts that are tied to data. Measurement-based care isn’t optional when it becomes the price of entry for participating in VBC models.
Primary Care Integration as the VBC Accelerator
Further complicating the shift to value-based care in our industry is the historical divide between behavioral and physical health. The systems supporting these two realms of care were built and funded separately—and to this day, many of them still don’t talk to each other.
Yet, we’ve known for a long time that nearly half of all mental health care happens in primary care settings. That’s where most people show up first, and it’s where many of them prefer to stay. So, any value-based model that doesn’t connect behavioral health and primary care is missing the point, because you can’t manage whole-person health or costs if half the care is happening outside the system you’re working in.
The data backs this up. Models that integrate behavioral health into primary care—like Certified Community Behavioral Health Clinics (CCBHCs) and Accountable Care Organizations (ACOs)—see better outcomes and lower costs. The numbers are clear, and they’ve been clear for a while. Integrated care works.
Integration also speeds up the transition to VBC because it gives payers and providers access to the kind of data and coordination that these models depend on. When behavioral health is baked into primary care workflows, it’s easier to track outcomes, manage risk, and spot issues early—before they turn into higher-cost interventions. It’s also where payers are already focusing their VBC strategies, which means behavioral health organizations that can plug into those systems will have a faster path to participation.
What I see coming next is payers expecting proof. Not conversations and handshakes—but real, tangible proof of boots-on-the-ground collaboration between behavioral health and primary care. We’re past the point where integration is a talking point. From here on out, it’s going to show up in contracts, data, and network decisions.
What’s Already Changing
Behavioral health has been left out of value-based care models for a long time, but there are plenty of signals that change is happening:
- The Centers for Medicare & Medicaid Services (CMS) has introduced the Innovation in Behavioral Health (IBH) Model, which focuses on whole-person care outcomes and expects mental health and substance use treatment to be part of the core delivery system.
- Private payers are pushing bundled payments, especially for serious mental illness and substance use populations, where they expect providers to coordinate care across settings and show clear results.
- Technology is stepping up. Digital tools and AI are helping providers scale measurement-based care and finally close some of the data gaps that have made integration so hard.
These developments are the first sign that behavioral health is about to become a critical component of VBC initiatives. The infrastructure is being built, and the expectations are clear: integrate, measure, and demonstrate value.
For a long time, behavioral health has watched value-based care move forward from the sidelines. Sometimes that happened because the field chose to be cautious rather than proactive. Sometimes the system itself made it hard to participate. But value-based care is moving ahead, and the sidelines are getting crowded.
The organizations most likely to succeed will be the ones who treat measurement as a regular part of care. That means building connections with primary care, showing clear results, and integrating data capture into their everyday workflow. Assertions that measurement does not align with behavioral health are starting to wear thin as expectations rise.
Now is the time for leaders to make measurement-based care a standard part of clinical work. Measurement should support learning and improvement, not just compliance. When organizations put these pieces in place, they are better equipped to adapt, demonstrate real impact, and ensure financial stability as payment models change.
Want to dive deeper into trends like VBC and what they mean for your organization? Download my full Executive Report on the Future of Behavioral Healthcare.
