Succeeding In A Value-Based Health & Human Service Landscape · 2019-06-17 · n 15 Lincoln Square,...

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Succeeding In A Value-Based Health & Human Service Landscape:

Best Practices, Key Competencies & Strategies For Success

Ken Carr, Senior Associate, OPEN MINDS

June 13, 2019

2© 2018 OPEN MINDS© 2018 OPEN MINDS

Agenda

I. The Changing Health & Human Services Market Landscape, & The Drivers Shaping Value-Based Reimbursement

II. Strategic Implications Of The Market Changes & How Value-Based Reimbursement Is Being Implemented

III. Organizational Competencies & Management Best Practices For Value-Based Contracting

IV. Strategies For Engaging Payers In Value-Based Reimbursement Discussions

V. Six Key Strategies For Success In A Changing Market

Expertise

• Financial management of health and human service organizations

• Health information management and EHR selection and implementation

• Strategic planning and change management

• Strategic management and business process improvement

Highlights

• Chief Financial Officer, Elite DNA Therapy Services –Fort Myers, Florida

• Chief Financial Officer, The Centers – Ocala, Florida

• Chief Financial Officer, Guild Incorporated – St. Paul, Minnesota

• Administrative Director, American Red Cross National Testing Laboratory – St. Paul, Minnesota

Ken Carr, Senior Associate,

OPEN MINDS

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© 2018 OPEN MINDS© 2018 OPEN MINDS

I. The Changing Health & Human Services Market Landscape, & The

Drivers Shaping Value-Based Reimbursement

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Service Delivery System Is Evolving –The Market Results Are An Unpredictable Synergy Of Many Factors

Science & Technology

Policy & Politics

Demographics & Culture

Health & Human Service Financing & Delivery System

Services For Consumers – Access, Treatment Model, Professional Setting

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Executive Teams Are Challenged By A Few Key Drivers Of Change

Mental Health & SDoH Drive Integrated & Coordinated

Care

Changing Reimbursement

New Technologies

Emerging Consumerism

Changing Sustainability

Drives Consolidation

The Landscape

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© 2018 OPEN MINDS

Acute care

Post-acute care

Primary care

Long-term care

Social and

human services

Facility-based Community-based Home-based

Payers & Health Plans Looking To “Care Coordination” & “Integration” To Reduce Costs – By Shifting Service Model

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More Managed Care

Payer Type

2011, % Of

U.S.

Population

Covered

2016, % Of

U.S.

Population

Covered

2011, % Of

Population

Enrolled In

Managed

Care

2016, % Of

Population

Enrolled In

Managed

Care

2017, % Of

Population

Enrolled In

Managed

Care

Medicare,

non dual eligible 14% 15% 23% 32% N/AMedicare,

dual eligible 3% 3% 25% 38% N/A

Medicaid 18% 23% 50% 70% 80%

Commercial 52% 54% 93% 98% 99%

Military 3% 3% 57% 49% 100%

Uninsured 15% 9% N/A N/A 9%

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The New Lexicon Of Managed Care

Managed care organization

Managed behavioral health

organization

Managing entity

Minnesota Managed Care

The Landscape

8

Who is served by MCOs?

Families and children – 348,780

Adults with disabilities – 53,527

Seniors – 55,717

How much does it cost?

$5 billion annually

Federal law requires competitive procurement

State law requires re-procurement every five years

2019 procurement for 2020 contracts:

Greater Minnesota families and children with MinnesotaCare

Seniors

2020 procurement for 2021 contracts:

Metro families and children, including Next Generation IHP, and MinnesotaCare

Focus of re-procurement is quality care and best value

The next procurement will be open to for-profit MCOs

75% - DHS funding

through MCOs

25% - Fee for service

claims

© 2018 OPEN MINDS

ACO Overview, 2016

ACO

Contract

Payer

Number

Of ACOs

Number

Of

Contracts

Total

Beneficiaries

Percent Of

Attributed

Consumers

Medicare 412 485 14,615,007 41.7%

Medicaid 44 55 3,243,728 9.2%

Commercial 156 229 17,219,745 49.1%

Multiple

Contracts77 - - -

Total 689 769 35,078,480 100%

More ACOs

412

689

1011

2013

2016

2018Number Of ACOs

12.1%

2016

4.4%

2013

11.9

35.1 32.7

2013 2016 2018

Lives Covered (Millions)

U.S. Insured Population

Covered By An ACO

The Landscape

10.0%

2018

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The New Lexicon Of Accountable Care

Sustainability &

Infrastructure

Payment & Performance

on Cost

Members –Consumer

Assignment

Integration of Services

Quality & Patient

Outcomes Measurement

Accountable Care Organization

Independent Provider Associations

Patient Centered Medical Home

Total cost of care

Risk sharing

Upside risk

Downside risk

Minnesota Integrated Health Partnerships

The Landscape

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Key Decisions

2018 OPEN MINDS

Altair ACO

• Twelve disability service members

serving over 12,000 individuals

• Care coordination through “LifePlan

Model”

• Defines service outcome benchmarks

• Collaboration across multiple service

types:

• Disability services

• Behavioral health

• Primary care

• Public health

• Focus on developing improvement in

Health Information Technology/Health

Information Exchange

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Coordinates services for member

organizations serving individuals with

disabilities

Provides quality measurement and data

analytics to track outcomes

Facilitates information exchange

Implements alternate payment methods

ACO Advantages:

Better integration of services and consumer

choice through shared data and collaborative

relationships

2018 OPEN MINDS

The Changing World Of Health Plans

Medical loss ratio limitations

Smaller subsidies for plans on health exchanges

Downward pressure on rates and increased competition

(from each other and from ACOs)

Focus on human service coordination for consumers with

complex needs

Consolidation to gain scale in operating costs

Backward integration – via acquisitions and gainsharing

reimbursement arrangements with providers

Large investments in technological substitution

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Commercial Health Plans Using More VBR

95.4% of commercial health plans have P4P and FFS

payments for behavioral health organizations

40% of commercial health plan reimbursements to in-

network provider organizations in 2014 are linked to

value-oriented initiatives. . . up from 11% in 2013

There are 156 ACOs with commercial contracts serving

over 17 million consumers in 2016

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State Medicaid Plans & Medicaid Health Plans Using Value-Based Reimbursement

Value-based reimbursement and alternative payment models are being used in some form across 46 states, District of Columbia, and Puerto Rico. The states of Georgia, Indiana, Mississippi, and West Virginia are the only States not engaged

Episode of care programs have been implemented across 16 states

At least 22 states are using or planning to use ACO or ACO-like entities

There are 38 states that are pursing State Innovation Models Initiative (SIM) Grants

Comprehensive Primary Care Plus (CPC+) has been approved in 18 states

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2018 OPEN MINDS

Medicare & Medicare Health Plans Using Value-Based Reimbursement

In 2016, Medicare moved 30% of payments to alternative payment models with a goal

to hit 50% by the end of 2018

618 ACOs with more than 8.9 million Medicare beneficiaries

97% of Medicare Advantage plans have P4P and FFS payments for behavioral health

organizations

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2018 OPEN MINDS

All Types Of Services Moving To Pay-For-Value

Specialty medical homes for consumers with serious mental

illness (SMI), addictions, traumatic brain injury (TBI),

Alzheimer’s, and chronic health conditions – with all care

coordination services paid in per member per month (PMPM)

payment

Capitated contracts for Intellectual and Developmental

Disabilities (I/DD) services – Kansas Medicaid and 18 other

states to follow

Capitated contracts for senior services (including nursing

home care) planned for 19 state Medicaid plans

Case rates for children’s services in child welfare system

Case rates for TBI support services

Voluntary self-directed I/DD services with individuals

consumer budgets launching in California

Pay-for-value changes the rules for service reimbursement – and opens up opportunities for leveraging new science and technology to reduce costs and improve consumer convenience.

The Landscape

© 2018 OPEN MINDS

Changing Provider Reimbursement Models To Support “Integration”

Of the 38 states with Medicaid managed care, 22 require the Medicaid health plans to implement VBR with provider organizations At least 11 states have Medicaid ACOs

81% of Medicaid health plans have P4P FFS payments for behavioral health organizations

47% of Medicaid health plans have bundled payments for specific acute episodes

Nationally, specialty provider organizations with VBR revenue: 41% of primary care organizations

33% of behavioral health organizations

34% of child and family services organizations

14% of I/DD and LTSS organizations

The Landscape

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Value-Based Reimbursement Here To Stay Because...

Political and competitive pressure on payers –federal government and employers

Downward price pressure on health plans

Pressure on health plan medical loss ratios

The success of ‘some’ ACOs

The early findings of the Medicare bundled rate initiative

Return to fee-for-service not feasible – only “lever” in FFS is to reduce rates

Consumerism

Technology

adoption

Value-based

reimbursement

“Integration” for

improved cost and

quality

The Landscape

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Shifting Role Of Technology In Health & Human Services

Administrative Tool

Compliance Requirement

Platform For Competitive Advantage

Compliance focus the past ten years

– Result - less focus on usability and clinical effectiveness

From ‘cost’ to ‘investment’

From ‘administrative management’ to ‘imbedded in service lines’

– Essential for competitive advantage – and market positioning - over the next five years

The Landscape

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Optimizing Organizational

Performance, Care

Coordination & Population

Health Management

Getting The Necessary

Data

Technology Infrastructure To Support Performance Management

Electronic

health records

Health information exchange

and data aggregation

Care

coordination

platforms

Advanced population analytics

and clinical decision support

Performance

monitoring and

management tools

Consumer

segmentation

and health risk

stratification

Consumer referral trackingPatient registries

The Landscape

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Reducing Service Cost

Engaging Consumers

Technology Infrastructure To Optimize Value Of Consumer Care

Patient portals,

websites, and web-

based consumer tools

Automated

consumer outreach

Telehealth and

telemedicine

Remote

monitoring and

distributedservice platforms

Tech improving

admin efficiencies

of staff

Tech-enabled

treatment

services

The Landscape

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The Four-Stage Evolution Of Service Lines In Health & Human Services

Stage I: The Transition To (Semi) Competitive Market

Stage 2: The Integration Phase

Stage 3: The Value-Based Reimbursement Phase

Stage 4: The Tech Leverage Phase

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The Value Of Investing In Technology

Competitive Advantage Driven By Value To Payers &

Consumers

Product

BenefitBrand

Equity

Marketing

Benefit

Price= Value

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© 2018 OPEN MINDS

Strategic Quality Concept

Invest in “quality improvement” that differentiates you

from competitors – and customer is willing to pay for

the differential cost

Requires an understanding of:

Customer perceptions

Customer segmentation

Competitive offerings

Customer perceptions of competitive offerings

Price elasticity

Eight Dimensions Of “Quality”

Performance

Features

Reliability of service system

Conformance to standards

Durability and length of effect

Serviceability and customer experience

Aesthetics

Perceived quality

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New developments in many scientific domains are

reshaping health and human

services

Brain science

Augmented intelligence

Enhanced telecommunicatio

ns systems

The Landscape

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Leverage Of Technology To Reinvent Services Key To Long-Term Sustainability

1. Personalization of consumer treatment

2.More effective care coordination

3. Transparency in measurement of “value”

Telehealth and virtual

consultation changing

geographic market

boundaries for services

Smartphone and other

technologies for inexpensive consumer-

directed disease

management

Health information exchange provides data exchange and creates

‘big data’ for better consumer service

planning

New treatment technologies have

changed the options for consumers

Technologies permit task shifting to less expensive

staff

The Landscape

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The New Consumerism

Consumer Engagement

Consumer Transparency

Consumer Financial

Participation

Consumer Experience &

Consumer Choice

The Landscape

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© 2018 OPEN MINDS

The New Consumerism

Consumer Engagement


Consumer Financial

Participation


Consumer Choice

Consumer engagement =

Process to help individuals take action to improve their

health, make informed decisions, and engage

effectively and efficiently with the health care system

Expected results =

Improved health status, reduced costs, and better

access

The Landscape

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© 2018 OPEN MINDS

The New Consumerism

Consumer Engagement


Consumer Financial

Participation


Consumer Choice

Consumer transparency =

Making available, in a reliable, and understandable manner, information on the health care system's quality, efficiency and consumer experience with care, which includes price and quality

data

Expected results =

Improved service quality and reduced costs

The Landscape

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© 2018 OPEN MINDS

The New Consumerism

Consumer Engagement


Consumer Financial

Participation


Consumer Choice

Consumer financial participation =

Proportion of health care spending paid by the

consumer

Expected results =

Reduced costs by increasing engagement

and reducing unnecessary expenses

The Landscape

40% Of U.S.

adults can't

cover $400

unexpected

expense

Average

lifetime out-of-

pocket cost for

65+ person in

U.S. is $130,000

Average annual

out-of-pocket

cost for under

65 is ~$750)

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© 2018 OPEN MINDS

The New Consumerism

Consumer Engagement


Consumer Financial

Participation


Consumer Choice

Consumer experience =

How consumers perceive their interaction with an organization, evaluated as useful, usable, and

enjoyable - resulting in the consumer perception of an

organization’s brand

Expected results =

Improved consumer preference for certain provider

organizations – while improving their level of engagement

The Landscape

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© 2018 OPEN MINDS

The New Competition

“Consolidator companies” putting pressure on fee-

for-service rates by mergers/acquisitions that

increase size/scale of organization

“Disruptor organizations” are offering new service

models that are appealing to consumers, health

plans, and payers

The Landscape

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The New Lexicon Of MA&A

“Specialty care”

boundaries

Geographic service

boundaries

Virtual delivery systems

Health system function

expansion –payer,

provider, vendor

Health plan consolidation

and backward integration

Health plan merger

Health plan backward integration

Health system merger

National health systems evolution

Health systems acquiring specialty capabilities

Specialty provider organization merger

National ‘specialty’ delivery system evolution

Health plans/pharma combinations

Provider organizations/pharma combinations

Pharma/tech combinations

Tech-enabled service delivery

The ‘Melting’ Value Chain Driving

Mergers, Acquisitions, & Affiliations

The Landscape

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© 2018 OPEN MINDS

Consolidation Continues in Health Systems

Some Of The Largest Health Systems – Annual Revenue

Ascension Health – $22.6 Billion

Trinity Health – $17.6 Billion

Catholic Health Initiatives – $15.5 Billion

UPMC - $11.4 Billion

Dignity Health – $10.2 Billion

Atrium Health - $9.8 Billion

John Hopkins Medicine - $8 Billion

Mercy Bon Secours – $8 Billion

LifePoint Health - $6.3 Billion

Providence Health & Services - $6 Billion

Northwestern Memorial Healthcare - $4.6 Billion

Adventist Health System – $3.9 Billion

Prime Healthcare - $3.3 Billion

The Landscape

34

© 2018 OPEN MINDS

Consolidation Continues In Specialty Service Providers

Some Of The Largest Specialty Provider Organizations – Annual Revenue

Universal Health Services (UHS) – $10.4 Billion Elwyn - $276 Million

Kindred Healthcare – $6 Billion Mosaic – $232.3 Million

Acadia Healthcare – $2.8 Billion Bancroft – $146 Million

ResCare – $1.5 Billion Woods Services – $132 Million

Civitas Solutions – $1.4 Billion Public Health Management Corporation –

$155.5 Million

Sunrise Senior Living – $1.2 Billion Uplift – $118.1 Million

Merakey – $525 Million Atria Senior Living – $64.2 Million

Capital Senior Living – $463.6 Million Enlivant – $34 Million

Devereux – $429 Million Sequel – $33.5 Million

Centerstone – $400 Million Strategic Behavioral Health – $29.6 Million

American Addiction Centers – $318 Million KidsPeace – $28.5 Million

The Landscape

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© 2018 OPEN MINDS

New Competitors Form Disruptive Combinations

May 2018 – United Healthcare signs value-based

venture with Quest and LabCorp

January 2018 – Netsmart and American Well partner to

build telehealth network

2015 – Oscar health plan receives $165 M investment

from Alphabet (google)

May 2018 - ProMedica and Welltower partner to acquire

HCR ManorCare

December 2017 – Humana & TPG Capital acquire

Kindred Healthcare

December 2017 – CVS Health acquires Aetna

The Landscape

© 2018 OPEN MINDS

Virtual Behavioral Health Delivery Systems

The Landscape

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© 2018 OPEN MINDS

Private Equity Investments In The Complex Consumer Space Increasing

CareGiver - I/DD

ExpertCare - I/DD

Suncoast New Options – I/DD

Florida Autism Center - Autism

Community Psychiatric – Mental Health

Agape – Addiction Treatment

Haven Behavioral - Mental Health

InnerChange - Mental Health

Walden Behavioral – Mental Health

Sun Behavioral - Mental Health

Sequel Youth & Family – Children’s Residential

Center For Autism & Related Disorders – Autism

AdvoServ - I/DD

BrghtSpring - I/DD

The Landscape

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Strategies For Achieving “Scale”

Talent Contracting Technology Capital

Merger

Acquisition

Collaboration

Integrated Provider Association

Administrative Service

Organization (ASO)

For-profit/non-profit issues

Synergies

Why Is Scale Important?

The Landscape

39

Leveraging Resources For Scale


Questions & Discussion

40


II. Strategic Implications Of The Market Changes & How Value-Based

Reimbursement Is Being Implemented

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© 2018 OPEN MINDS

The Fee-For-Service Payer Network Contract

Most fundamental of all business relationships

for provider organizations in health and human services

Often need to begin with privileging professionals individually, rather than being privileged at the

organization level

Difficult market position but often necessary

No assurance of volume and no likelihood of

referrals

Often ‘commodity’ positioning

© 2018 OPEN MINDS

Key Challenges In A FFS Environment

Revenue Cycle

• Aligning internal operations to manage payer requirements

Market Positioning

• Position the organization in the market to maximize payer opportunities

© 2018 OPEN MINDS

Quality

• Member- and care-giver reported outcome measures

• Access to high quality services

• Provider Profiling

Cost Management

• Least restrictive setting

• Medical/service cost management

• Unit cost trends

Population Health

• Planning tied to population characteristics

• Interventions tied to better understanding of population health and desired outcomes

Evidence-Based Care

• New treatments and technologies

• Decisions based on clinical guidelines

Data-Driven

ACCESS, COST, QUALITY

Managed Care Principles

© 2018 OPEN MINDS

Triple Aim

High quality services in the least restrictive setting

Broad system of services, including natural supports

Consumers are empowered and engaged

Improved Outcomes

Population Health

Reduced Costs

Managed care and providers agree on the Triple Aim.

© 2018 OPEN MINDS

Tools To Improve Quality & Cost Outcomes

Provider-Focused Tools

• High-performance networks and providers, including

Centers of excellence

• Delivery system innovation, such as patient-

centered medical homes and accountable care

organizations (ACOs)

• Electronic medical records (EHRs), apply population

health characteristics

• Information exchanges and learning collaboratives

• Pre-service / concurrent / retrospective review and

physician education

• Outpatient, inpatient, and pharmacy utilization review

• Provider performance measurement and quality

improvement programs

• Value-based provider payments

Core Tools

• Benefit plan design

• Medical necessity clinical guidelines

and medical/service policies

• Coverage determination guidelines

• Appeals and grievances for members

and for providers

• Technology assessment

Provider & Member-Focused Tools

• Health care information technology

• Sophisticated clinical analytics to identify gaps in

care and in affordability

• Collaborative measurement projects, using multi-

payer claims databases

• Administrative simplification through automation

Member-Focused Tools

• Health and wellness programs

• Case management

• Disease or condition management

• Care coordination

• Transparency re: provider performance

• Consumer-directed incentives for healthier

behavior

• Value-based benefits, including tiered benefit

and rewards to seek services with high

value providers

© 2018 OPEN MINDS

Cost/Effectiveness Analysis Of MCO Interventions

10

100

0

Intervention Effectiveness

Intervention

Cost

• Effectiveness of typical interventions plotted against

the relative cost per consumer to implement

• For example, incentives may be effective an

intervention as benefit design is far more expensive

to implement

Peer

Comparisons Outcomes

Rating By

Case

Benefit

Structure

Provider

Newsletter

Mailed

Education

Materials

Provider

Letter

General

CEU

Session

Public

Recognition

Targeted

CEU

Session

Formal

Patient

Steerage

Provider

Transparency

Intensive

Case

Management

Feedback

Incentives

Provider

Detailing

Auditing

Against

Guidelines

Utilization

Review

© 2018 OPEN MINDS

Strategic Implications Of Managed Care Principles

• Develop positive payor relationships

• Evaluate measure collection and analysis against measures expected by payors/state

• Understand unit costs and improvement opportunities

• Review current workflows against managed care requirements (e.g., authorization rules, reports)

© 2018 OPEN MINDS

The Shifting Reimbursement Market

A Change In Focus:

Reducing Costs While Delivering &

Demonstrating Value

A Change In Methods:

Managed Care & Value-Based Purchasing

49

© 2018 OPEN MINDS

Business Model Transition For Provider Organizations

Payer Policy

Pay-For-Cost/Volume

Payer Policy Pay-For-Value

Business Model

What is paid for is

good for the

consumer and

doing more is the

business model

Business Model

Giving the

consumer (and

their payer) good

outcomes at a low

cost, conveniently

A revolution in

performance

management

required

Focus on achieving

outcomes and

managing risk

Focus on maximizing

price and managing

volume

50

© 2018 OPEN MINDS

Capitation + Performance

-Based Contracting

CapitationShared RiskShared Savings

Bundled & Episodic

Payments

Performance-Based

Contracting

Fee-for-service

Transition Of Payment To Provider Organizations From Volume To Value

Compensation Continuum By Level Of Financial Risk

No Financial Accountability Moderate Financial Accountability Full Financial Accountability

Passive Involvement Provider Engaged Provider Active In Management Providers Assumes Accountability

Management Via 100% Case By

Case External Review

Internal Ownership Of Performance

Using Internal Data Management

Small % Of Financial Risk Moderate % Of Financial Risk Large % Of Financial Risk

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© 2018 OPEN MINDS

Reimbursement Methods

52

Fee-for-service

Pay for performance

Case rate or bundled rate

Diagnosis Related Group (DRG)

Shared savings and shared risk

Capitation

1

2

3

4

5

6

© 2018 OPEN MINDS

• Payments match services

• Complete utilization data

• More transparency

• Provides audit trail

Pros

• Incentivizes over utilization

• Rigid and stands in the way of innovation

• Discourages efficiencies of integrated care

Cons

53

Definition: Separate payment to a health care

provider for each unbundled medical service

rendered to a patient

FFS Example

• “ABC” Health Plan pays a flat rate of $110

for CPT 90791 for a qualified, credentialed,

independent licensed provider

• “XYZ” Heath Plan pays a flat rate of $750

for Rev code 124 for acute inpatient level of

care after approved authorization

Fee-For-Service (FFS)

1

© 2018 OPEN MINDS

• Incentivizes behavior change

• Lead to improvement of quality measures

• Encourage more efficient coordination

Pros

• Provider only focused on care that affects measures, and ignore other factors - “manage to metric” or “cherry pick” member

• Incentive may not be large enough to promote behavior change

• Provider could see overall reduction in revenue if unable to fill vacancy

• Difficult to evaluate causality v. random fluctuation

Cons

54

Definition: Providers are financially rewarded for

meeting pre-established targets for delivery of

healthcare services

Pay For Performance Example

• “ABC” Health Plan pays an escalator of up

to 6% for rev code 124 (acute inpatient

level of care) based on achievement of

HEDIS 7-day ambulatory follow up

• “ABC” Plan pays a 1 time bonus of

$50,000 for achievement of key

performance measures included assuring

consumer compliance with annual dentist

visit

Pay For Performance

2

© 2018 OPEN MINDS

• May decrease need for authorization and concurrent review

• Controls cost per episode

• Incentivizes fewer re-admissions

• Can bundle multiple services and promote innovation

Pros

• Incentivizes shifting treatment to other settings or codes

• Increase oversight to manage quality

• Increases risk to providers

• Potential for double payment if member switches provider

• Encourages discharge once member passes breakeven point

• Incentivizes admissions

• Need to make many assumptions, e.g.. service mix, license mix, etc

• Requires system to support

Cons

55

Definition: A flat payment for a group of procedures

and/or servicesCase Rate Or Bundle Rate Example

• “ABC” Health Plan pays a monthly rate of

$1,200 for Medication Assisted Treatment

(MAT) to include medication management,

counseling services, and lab services

associated with treatment, excluding

medication costs

• “XYZ” Health Plan pays a case rate of $7,000

for acute inpatient episode to include all

services (e.g., physician fees, labs, etc.) for a

single treatment episode. A readmission

warranty includes a 10% withhold for any case

that is readmitted within 90 days of treatment

• “EFG” Health Plan pays a tiered case rate of

$800 for day 1 of treatment, $600 for days 3-5,

and $200 for Days 6 and 7 with no payment

after day 7 for acute inpatient treatment

Case Rate Or Bundled Rate

3

2018 OPEN MINDS

Minnesota Certified Community Behavioral Health Clinic

• Outpatient mental health and substance use

services

• Primary care screening and monitoring

• Screening, assessment and diagnosis,

including risk management

• Psychiatric rehabilitation services, including

ARMHS and CTSS

• Crisis mental health services, including 24-

mobile crisis teams, emergency crisis

Intervention services and crisis stabilization

• Patient-centered treatment planning

• Targeted case management

• Peer and family support

• Services for members of the armed forces

and veterans

• Connections with other providers and

systems

56

Service delivery model

Focused on integration of mental health and

substance use disorder treatment services

Integration is across all health and social

services

Improved access

Evidence-based protocols – to provide

specific, consistent outcomes

Alternate payment method:

Daily “bundled” encounter rate

© 2018 OPEN MINDS

• Single predictable payment allows provider to manage services

• Generally state of CMS-defined

Pros

• May not include outlier protocols for complex cases

• May be more medically driven

• May focus scrutiny on admission approval

Cons

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Definition: A flat payment for a bundled group of

procedures and/or services that are needed to treat a

particular disease

DRG Example

• “ABC” Health Plan pays 100% of the state-

defined DRG with no outlier methodology.

Diagnosis Related Group (DRG)

4

© 2018 OPEN MINDS

• Offer a reward split among those contributing to the success (e.g., payer supports analytics and member assignment and provider implements interventions to reduce costs

• Shared risk is a variation in which the provider is “at risk” for the service costs

• Good step toward capitation if successful

Pros

• “Shared” is not always a 50/50 share

• Achievement may result in little room for ongoing improvement—need to develop go-forward model of sustainability

Cons

58

Definition: Provider and payer share in the healthcare

savings pool generated by performance improvement

(e.g., reduced behavioral costs or total cost of care)

Shared Savings & Shared Risk Example

• A Core Service Agency (CSA) offers a full

continuum of care and has been assigned

500 seriously and emotionally disturbed

(SED) children to manage with a goal of

improving community tenure and reducing

out-of-state foster care placement.

Achievement of pre-defined target measures

(using baseline year of data) will result in the

Plan and the CSA splitting the savings

(generated from reduced higher level of care

costs) 50/50

• Variation – CSA is at risk for the

membership and splits any achievement

with the Plan, but must pay all services

and provide transparency into service

utilization and costs

Shared Savings & Shared Risk

5

© 2018 OPEN MINDS

• Rewards groups, and in turn those groups’ individual physicians, who deliver cost-efficient care

• Costs stable and predictable

• No billing

Pros

• Takes away from our value proposition, we lose control

• Selection incentives; promotes under-treatment

• Dependent on marketplace factors and a group’s negotiating prowess

• Difficult to reduce capitation payments

• Increase need for oversight

• Must ensure provider stays solvent

• Regulatory hurdles

• Requires system to support

Cons

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Definition: A set payment for each enrolled person

assigned to that physician or group of physicians,

whether or not that person seeks care, per period of

time

Capitation Example

• An outpatient provider is paid a per

member per month (PMPM) to support the

care coordination of an assigned cohort of

500 individuals that meet the state

definition of severe and persistently

mentally ill (SPMI). The provider can earn a

bonus on top of the PMPM if key

performance measures are achieved.

Capitation

6

© 2018 OPEN MINDS

Key Components Of Performance-Based Contracts

• Submit claims electronically with fast turn around time and/or have data sharing capabilities

• Participate in review and intervention discussion (e.g. once a month)

• Adhere to current managed care requirements and clinical guidelines

Entry Level Criteria

• Balance of Quality and Cost/Efficiency Measures with Social Determinants of Health tracking

• Emphasis on outcome vs treatment process measures

• Examples: PCP visit in past 12 months, #/% employed in integrated program, wages earned over 2 week in paid community job, national core indicators (NCI)

Measures

• Annual escalator

• Bonus payment

• Prorated based on performance to capped amount

Rewards

© 2018 OPEN MINDS

Most Commonly Used Performance Measures Of Specialty Provider Organizations, 2016-2018

Follow-up after hospitalization for

mental illness

Emergency room utilization

Readmission rates Patient or consumer

satisfactionPCP Engagement

Access to care measures

Diabetes screening for people with

Schizophrenia using an antipsychotic

Antidepressant medication

managementCommunity Tenure

Depression monitoring via

PHQ-9

Patient Reported Outcomes

Involvement of family/significant

other

Initiation/engagement of

alcohol and other drugs

Diabetes care –blood sugar controlled

Adherence to antipsychotic medication for

people with schizophrenia

Use of depression screening and follow-

upRisk adjusted ALOS

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The Intersection Of Value-Based Reimbursement (VBR) & Social Determinants Of Health (SDOH)

VBR – Ties reimbursement to quality and efficiency measures Facilitates the achievement of

the triple aim—improving population health, reducing the costs of health care and improving individual member outcomes

Supports provider engagement and payer/provider collaboration

Rewards provider performance on agreed upon measures of quality and utilization

SDOH– Environmental factors that influence a population’s health and functioning (e.g., socio-economic status, transportation, age) Provide important detail that can

guide interventions to achieve VBR goals

Increase understanding of population needs

Move VBR beyond easy-to-access measures that hold greater meaning

62

VBR SDOH

© 2018 OPEN MINDS

Population Health Drivers

10

100

0

Social

inclusion/

exclusion

Impact on Health

Ease of

Collection

What is the return on investment in collecting social

determinants of health?

Disabilty

Income

Age

Ethnicity

Education

Early

childhood

development

Social

Supports

Food

Insecurity

Housing

Access to

Health

Services Healthy

Behaviors

StressLiteracy

2018 OPEN MINDS

ICD-10-CM “Z” Codes For Social Determinants

• Z55 – Problems related to education and

literacy

• Z56 – Problems related to employment and

unemployment

• Z57 – Occupational exposure to risk factors

• Z59 – Problems related to housing and

economic circumstances

• Z60 – Problems related to social

environment

• Z62 – Problems related to upbringing

• Z63 – Other problems related to primary

support group, including family

circumstances

• Z64 – Problems related to certain

psychosocial circumstances

• Z65 – Problems related to other

psychosocial circumstances

64

Can be captures as part of ICD-10 coding

Potential health hazards related to

socioeconomic and psychosocial

circumstances

Requires an assessment at the time of primary

care or other health services

Focus of “Z” codes:

To better track the impact of social

determinants and create referrals by

healthcare professionals

© 2018 OPEN MINDS

What Are the Pay-For-Value Reimbursement Options?

Medical Homes & Specialty Medical Homes

Capitation And/Or Population Health Gainsharing Arrangements

With P

ay-F

or-

Perf

orm

ance C

om

ponents

Specialist

positioning

Comprehensivist

positioning

Case

Rates &

Bundled Rates

65

© 2018 OPEN MINDS

Case Rates, Bundled Rates, Episodic Payments

Based on:

Diagnosis or functional status

Other consumer characteristics

Package of services included

Length of time

Payment of a flat amount for a defined group of procedures and services

Per treatment episode Per time period

Case Rates

© 2018 OPEN MINDS

Capitation In Population Health Arrangements

A contracted rate for each member assigned, known as the "per-member-per-

month" (PMPM) rate

Regardless of the number or

nature of services provided

Contractual rates are usually

adjusted for age, gender, illness,

and regional differences

• PMPM for behavioral health treatment benefits (or other cognitive disability support services)

Behavioral Health Carve-Out Capitation

• PMPM to cover the cost of care coordination and preventative services

Medical Home/Health

Home Capitation

• PMPM for primary care services (assess, prescribe, refer)

Primary Care Capitation

• PMPM for cost of delivering all (or some) of the care for a group of consumers

Global Capitation

Capitation/Subcapitation Population Health Capitation

© 2018 OPEN MINDS

Key Effects Of Moving From FFS To Managed VBR

Focus On Outcomes

Create A Data-Driven Culture

Data, Analytics, Change

Management

Implement Effective

Technology

Manage Unit Costs &

Financial Risk

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© 2018 OPEN MINDS

22%

22%

23%

32%

36%

Access to caremeasures

Patient/consumersatisfaction

Emergency roomutilization

Readmission rates

Follow-up afterhospitalization

Follow-Up After Hospitalization & Readmission Rates Are The Most Popular Measures For Determining Performance

Top Five Performance Measures In Value-Based Contracts, %, 2019

69

© 2018 OPEN MINDS

Top Five Performance Measures In Value-Based Reimbursement Contracts With Specialty Provider Organizations, By Market, %, 2019

Top Five Performance Measures By Market, %, 2019

Behavioral Health Child Services I/DD & LTSS Primary Care

1. Follow-up after

hospitalization –

41%

2. Readmission rates

– 33%

3. Access to care

measures – 27%

4. Patient/consumer

satisfaction – 26%

5. Emergency room

utilization – 24%


– 19%

2. Follow-up after

hospitalization –

16%

3. Emergency room

utilization – 13%

4. Access to care

measures – 10%

5. Patient/consumer


1. Use of evidence-

based care

protocols – 24%

2. Follow-up after

hospitalization –

21%


– 21%

4. Patient/consumer


5. Emergency room

utilization – 14%


– 58%

2. Follow-up after

hospitalization –

54%

3. Emergency room

utilization – 46%

4. BMI assessment –

46%

5. Annual flu vaccine

– 42%

70

© 2018 OPEN MINDS

17%

19%

19%

23%

25%

39%

Risk management capabilities

Finding the experienced managers to manageperformance-based reimbursement

Managing care coordination for consumers

Lack of clarity about performance requirementsfrom payers

Building needed IT infrastructure

Data management and reporting

% of Organizations

Typ

es O

f C

ha

llen

ge

s

Top Five Challenges To Managing Value, %, 2019Specialty Provider Organization Executive Teams

71

© 2018 OPEN MINDS

Services Focused On Effective Outcomes & Value

Behavioral health service system sub-capitation

Specialty care coordination for consumers with

behavioral disorders

Specialty ‘center of excellence’ programs for

acute conditions

Behavioral health consultation in office-

based service locations –live or via telehealth

Management of specific acute episodes or chronic conditions via case rate or episodic/bundled payment

Management of short-term inpatient psychiatric and addiction treatment

programs

Psychiatric consultation –live or via telehealth – in

hospital emergency rooms

Behavioral health consultation program for inpatient programs – live or via telehealth

Hospital diversion programs

Specialty behavioral health ER/crisis

stabilization

Hospital readmission prevention programs

Community-based/mobile crisis

response

Home-based service delivery

Specialty primary care

72

2018 OPEN MINDS





acute conditions





programs






stabilization



response




Specialty care coordination for

consumers with behavioral

disorders


2018 OPEN MINDS





acute conditions





programs






stabilization



response




Hospital readmission

prevention programs

Specialty behavioral health

ER/crisis stabilizationHospital diversion programs


response

2018 OPEN MINDS





acute conditions





programs






stabilization



response




Specialty ‘center of excellence’

programs for acute conditions

Management of short-term

inpatient psychiatric and

addiction treatment programs

2018 OPEN MINDS






acute conditions





programs






stabilization



response



Behavioral health consultation

in office-based service

locations – live or via telehealth

Behavioral health service

system sub-capitation

76

2018 OPEN MINDS






acute conditions





programs






stabilization



response



Management of specific acute

episodes or chronic conditions

via case rate or

episodic/bundled payment

77

2018 OPEN MINDS






acute conditions





programs






stabilization



response




78

© 2018 OPEN MINDS

Provider Changes In A Value-Based Market

On The Increase Tech-enabled, hybrid service delivery –

BYOD in any location

Programs with superior consumer experience, including web-enabled organization interfaces

Professional “lifestyle” practices

“Top of practice” delivery models

Decision support and process excellence

Any service – medical, behavioral, social – with demonstrated ROI and VBP reimbursement

Case rate/bundled rate service programs for acute and chronic conditions

On The Decrease Provider organizations with poor

consumer interface (access, experience)

High unit cost services without ‘value’ equation

Long-term outpatient services except in EBP

Hospital and residential treatment, overall

Office-based services without tech-enabled consumer link

Solo practice, except for cash

79



80


III. Organizational Competencies & Management Best Practices For

Value-Based Contracting

81

© 2018 OPEN MINDS

I. Provider Network Management

II. Clinical Management & Clinical Performance Optimization

III. Consumer Access, Service, & Engagement

IV. Financial Management

V. Technology & Reporting Infrastructure

VI. Leadership & Governance

Six Domains In OPEN MINDS Model For Assessing Value-Based Reimbursement Management Readiness

82

© 2018 OPEN MINDS

Four Competencies Of Provider Network Management

1. Network Management & Credentialing

2. Care Coordination &

Care Management

3. Consumer Screening, Care,

Provider Referrals & Case Authorizations

4.Integration of Physical Health,

Behavioral Health & Social Services


83

© 2018 OPEN MINDS

1. Network Management & Credentialing

Focus:

Ability to negotiate contracts, manage

credentials of clinicians, and meet the requirements of payer

organizations

Key Competencies For Success

Accreditation in serving consumers

with complex needs

Payer relationship management

Identification of payer needs

Effective workflows for managing

clinician credentials


84

© 2018 OPEN MINDS

2. Care Coordination & Care Management

Focus:

Ability to identify care management needs,

obtain payer authorizations and refer to appropriate

services


Processes in place to receive care

management referrals, assess

needs and refer consumers for

services

Authorizations expertise

Focus on integration, follow-up and

communications


85

© 2018 OPEN MINDS

3. Consumer Screening, Care Provider Referrals & Case Authorizations

Focus:

Ability to identify high-risk and high-needs

individuals and ensure the more effective care management plan and

services


Ability to identify high-utilization

consumers

Process to screen, assess and refer

consumers to the appropriate level

of service

Systems to track usage of other

community providers


86

© 2018 OPEN MINDS

4. Integration Of Physical Health, Behavioral Health & Social Services

Focus:

Ability to ensure that chronic physical health issues are integrated

into the care plan


Established referral and data

sharing relationships with primary

care

Established protocols for referrals

and care transitions

Focus on identifying consumer

preferences when making primary

care referrals


87

© 2018 OPEN MINDS

Two Key Competencies Of Clinical Management & Performance Optimization

1. Decision Support & Care Standardization

2. Clinical Performance Tracking, Assessment &

Optimization


88

© 2018 OPEN MINDS

1. Decision Support & Care Standardization

Focus:

Ability to use data to determine the most effective evidenced-

based practices


Standardized guide to care

management and treatment

Implementation of data-informed

planning, treatment and referral

Continuity of care planning and

transition between care settings


89

© 2018 OPEN MINDS

2. Clinical Performance Tracking, Assessment & Optimization

Focus:

Ability to track outcomes, assess how to optimize services,

and implement performance

improvements


Established KPIs

Ability to measure clinical outcomes

Process to assess outcomes

against KPIs and improve quality


90

© 2018 OPEN MINDS

Seven Key Competencies Of Consumer Access, Service, & Engagement

1. Consumer-Informed Access

To Services

2. Automated Consumer

Service Functionality

3. Mobile Health Applications

4. Consumer Wellness Support

5. Appeals & Grievance

Procedures

6. Consumer Satisfaction Feedback

7. Consumer Performance

Metrics


91

© 2018 OPEN MINDS

1. Consumer-Informed Access To Care

Focus:

Technology to improve consumer access to self-service tools for

both clinical and administrative services


Access to online forms and

assessment tools

Centralized call center with 24/7

accessibility

Web-enabled provider network

access and self-referral process

Web-enabled follow-up care

processes


92

© 2018 OPEN MINDS

2. Automated Consumer Service Functionality

Focus:

Ability for consumers to seek information and

self-refer to services in a timely fashion


Focus on identifying and responding

to consumer access preferences

Identification and removal of

consumer barriers to health

information

Care and treatment approach that

involved consumers and family

members

Prompt availability of services


93

© 2018 OPEN MINDS

3. Mobile Health Applications

Focus:

Ability to maximize consumer engagement

through the use of mobile health applications


Availability of mobile technology that

assists with assessment, clinical

decision support, treatment, and

cognitive function restoration

Availability of mobile technology

supporting early detection of relapse

and relapse prevention

Availability of mobile technology that

makes treatment more accessible

Link of mobile technology to care

coordination functionality


94

© 2018 OPEN MINDS

4. Consumer Wellness Support

Focus:

Ability to educate, provide resources, and

document effectiveness related to

wellness support


Processes and program to engage

consumers in ongoing wellness

support and self-management


95

© 2018 OPEN MINDS

5. Appeals & Grievance Procedures

Focus:

Ability to receive, investigate, and resolve consumer concerns in a fast, effective manner


Function to notify consumers of

rights processes related to

grievances and appeals

Established processes for receiving,

tracking, investigating and resolving

consumers’ grievances

Process to inform systems of

provider organizations in system of

care of appeal and grievance

issues, with the focus on preventing

avoidable grievances


96

© 2018 OPEN MINDS

6. Customer Satisfaction Feedback

Focus:

Assess ability to obtain frequent consumer

feedback through easy, non-obtrusive methods


Survey tools and processes for

obtaining consumer feedback on the

consumer experience including: Access to care

Facilities

Interactions with staff

Effectiveness of treatment

Net promoter score (consumer

willingness to refer other for treatment)


97

© 2018 OPEN MINDS

7. Clinical Performance Metrics

Focus:

Ability to track and analyze outcomes, identify options to

improve services, and quickly change

processes


Systems in place to measure clinical

quality of care, patient experience

and service cost measures

Transparent process to publicly

report outcomes

Collaborative efforts to identify

performance improvement initiatives


98

© 2018 OPEN MINDS

Four Key Competencies Of Financial Management

1. Revenue Cycle Effectiveness

2. Encounter Reporting

3. Value-Based Payment

Capabilities

4. Financial Performance Monitoring


99

© 2018 OPEN MINDS

1. Revenue Cycle Effectiveness

Focus:

Ability to align operational and

financial processes to assure adequate cash

flow


Effective processes for

reconciliation of authorizations and

payment verification to credentialed

provider organizations

Ability to submit invoices to payers

for services delivered under value-

based reimbursement agreements


100

© 2018 OPEN MINDS

2. Encounter Reporting

Focus:

Ability to capture, analyze, and report

granular utilization data to payers and to internal teams for

management


Ability to electronically capture and

report reliable encounter data in the

format and in the timeframe

required by payers

Ability to analyze encounter data to

manage service outcomes and

utilization

Aggregation of encounter data to

manage value-based

reimbursement agreements


101

© 2018 OPEN MINDS

3. Value-Based Payment Capabilities

Focus:

Ability to track manage contractual outcomes

and payments


Ability to report on actual

performance data – outcomes and

financial performance – against

budget and against contractual

targets

Ability to bill for multiple types of

value-based reimbursement models


102

© 2018 OPEN MINDS

4. Financial Performance Monitoring

Focus:

Ability to monitor actual financial results against contracts, budgets, and

forecasts


Ability to report incurred but not

reported (IBNR) liabilities

Ability to monitor service utilization and

costs and reconcile to service and

revenue projections

System to link population health

management and value-based

contracting strategies to resources

planning and reporting

Comprehensive set of key performance

indicators for short-term and long-term

financial health


103

© 2018 OPEN MINDS

Seven Key Competencies Of Technology & Reporting Infrastructure

1. Capacity To Collect Data

2. Capacity To Analyze Data For Population Health

Management

3. Ability To Manage Value-

Based Contracts

4. Ability To Exchange Healthcare Information

5. Care Management Functionality

6. Consumer Portal

Functionality

7. IT Performance Monitoring

V. Technology & Reporting

104

© 2018 OPEN MINDS

1. Capacity To Collect Data

Focus:

Technology infrastructure to collect

data strategic in identifying health

needs of the population of consumers served


EHR core functionalities fully

implemented

Structured data collection around

assessments, diagnoses, and services

Workflows and processes to ensure

data integrity

Ability to collect data at the time and

source of service provision


105

© 2018 OPEN MINDS

2. Capacity To Analyze Data For Population Health Management

Focus:

Ability to perform strategic analysis of

data for risk stratification and care

management


Development of or access to consumer

data registries

Deployment of data analysis tools

Implementation of risk stratification

strategies

Ability to integrate multiple sources of

data


106

© 2018 OPEN MINDS

3. Ability To Manage Value-Based Contracts

Focus:

Ability to track performance metrics, submit invoices, and

maximize performance of value-based

contracts


EHR functionality that meets billing

requirements for value-based

purchasing models

Integration of clinical, operational and

financial data

Unit costing and cost accounting

capabilities

Predictive modeling and forecasting

capabilities


107

© 2018 OPEN MINDS

4. Ability To Exchange Health Care Information

Focus:

Ability to exchange clinical and financial

information with other health care provider

organizations


Health information exchange

agreements with key providers

Secure infrastructure, policies and

workflows that comply with HIPAA and

HITECH

Service notification agreements,

automation and processes with other

providers


108

© 2018 OPEN MINDS

5. Care Management Functionality

Focus:

Ability to manage eligibility, coordination

of benefits, inquiries/referrals,

decision support, care authorization, care coordination and

utilization management


Automated risk assessment tools

Redesigned workflows to maximize

care management technology

Provider referral database to aid in care

matching and management


109

© 2018 OPEN MINDS

6. Consumer Portal Functionality

Focus:

Ability to provide service data, resources and interaction options

with consumers through the EHR


Convenient, secure access to

personal health information through

the internet

Ability to access staff and services

through technology

Access to forms and account

payment functionality


110

© 2018 OPEN MINDS

7. IT Performance Monitoring

Focus:

Ability to monitor actual IT outcomes against

established goals


Established key performance

indicators

Ability to generate real-time

reporting on performance under

value-based reimbursement

arrangements


111

© 2018 OPEN MINDS

Three Key Competencies Of Leadership & Governance

1. Strategic Alignment Around Population Health

Management

2. Culture Of Innovation

3. Workforce Adequacy


112

© 2018 OPEN MINDS

1. Strategic Alignment Around Population Health Management

Focus:

Alignment of leadership around population

health management and the ability to

manage financial risk


Resources and infrastructure to

manage clinical and financial risks

of population health management


113

© 2018 OPEN MINDS

2. Workforce Adequacy

Focus:

Ability to attract and retain the right staff to succeed at population health management


Workforce culture, experience, and

capacity to innovate and adapt to

new service and business models

Ability to attract, develop, and retain

staff with expertise in clinical

innovation, technology. and financial

management

Compensation alignment with

performance outcomes and

strategic priorities


114

© 2018 OPEN MINDS

3. Culture Of Innovation

Focus:

Ability to adapt and realign current services

to meet the needs of population health

management – staff openness to change and ability to develop

new services


Established and effective quality

improvement processes in place –

Lean, Root Cause Analysis, Six

Sigma

Experience and expertise creating

new services lines

Blue Ocean Strategy

Three Box Solution


115



116


IV. Strategies For Engaging Payers In Value-Based Reimbursement

Discussions

117

© 2018 OPEN MINDS

Six Key Strategies For Engaging Payers In Value-Based Contracting Discussions

1• External Market Analysis

2• Internal Marketing & Business Development Planning

3• Payer-Focused Service Line Development

4• Health Plan Engagement & Contract Development

5• Payer Relationship Management

6• Performance Management: Delivering On Your Promises

© 2018 OPEN MINDS

Step 1

Assemble the Team

Step 2

Define the Goal

Step 3

Determine Metrics

Step 4

Approach Payer with Proposal, Metrics, Financial Arrangement

Step 5

Develop Reporting Structure

Step 6-10

Launch

• Collect

• Develop

• Monitor

• Review

• Maintain

The 10 Steps Of VBR With A Payer

119

The Value-Based Reimbursement Checklist

© 2018 OPEN MINDS

Assemble the TeamInclude leadership for awareness and those directly engaged in implementation and monitoring

Step 1: Assemble The Team

Example:A residential program seeking a VBC arrangement involved for awareness and buy in- CEO, COO, and clinical leaders. Payer

Relations & Finance Leader coordinated contract with payer review and approval of CFO/CEO. Achieving VBR reward required

workflow changes and technology changes which required engagement of care team across all shifts; CTO to support

availability of technology and discharge planner.

CFO: Name Clinical Leader: Name

CEO: Name Billing: Name

COO: Name Team/Unit Leaders: Name

Data/Reporting/Analytic

Support:

Name Others

(Direct control over implementation of

intervention or vested interest)

Name(s)


© 2018 OPEN MINDS

Define the Goal

Example:

a. Reduce out-of-state placement for foster care

b. Increase community tenure

c. Improve consumer reported health & wellness

d. Reduce readmissions

e. Improve medication adherence

Step 2: Define The Goal

Goal

Text here


© 2018 OPEN MINDS

Step 3: Determine Metrics

Example:

State offers incentive to improve 7 day follow up

and PCP engagement. MBHO is missing targets

on these measures.

Determine Metrics

a. Balance of Quality & Efficiency metrics

b. Obtain payer and/or State feedback/input

1. What measures is the State/Payer

endorsing or incentivizing

2. What pain points exist for payer/state

client

3. Consider social determinants of health

(SDOH)

Metrics List

Quality: Source:

a) Consumer participates in annual PCP visit.

b) Consumer health outcome score improves on SF-12. change pre and post.

a) Health plan claims

b) SF-12 collected by case based 12 months prior and 12 months

post program engagement

Efficiency:

a) HP Claims

Efficiency:

a) Community tenure

Determine data definition and

collection route

Quality:

Efficiency:

SDOH:

Quality:

Efficiency:

SDOH:


© 2018 OPEN MINDS

Step 4: Approach Payer With Proposal, Metrics, Financial Arrangement

Meet with Payer Pitch the Idea

1. Reach as high into organization as

possible – C-Suite

2. Learn payer pain points and objectives

3. Identify payer preferred provider

programs

4. Seek congruence across payers

1. Keep proposal succinct – goal. measurable,

objective, planned activities, return on investment

2. Illustrate this is a “win-win-win” for the payer,

provider, and consumer

3. Find the WIFM (What’s in it for me?)

Do Unit Cost Homework Finalize the Financial Arrangement

1. Map activities and processes

2. Determine cost of each activity process

3. Determine service level unit costs

• Costs per case

• Understand drivers of cost variation

• Cost per diagnosis and clinical path

• Population cost distribution

1. Consider an upside pay for performance as a 1st

step (e.g. bonus for achieving outcomes) prorated

against achievement

2. Risk share should aim for 50/50 split with

estimated return on investment (ROI)

3. Bundle payments may fit if you offer an array of

services each month – know your monthly costs.


© 2018 OPEN MINDS

Develop Reporting StructureIt all starts with Structure

Structure Process Outcome

Develop regular structure for reporting (e.g. scorecards), monitoring and evaluation to include intervention

development

a. Ideally, know your scores before the payer scorecard is released

b. Review case level detail weekly, monthly, and in aggregate

c. Capture root cause issues and interventions

d. Leverage EHR and SDOH data to avoid spreadsheet rainfall

Step 5: Develop Reporting Structure


© 2018 OPEN MINDS

Step 6-10: Launch

Launch

Collect and analyze data

Develop interventions based on analysis

Monitor intervention impact

Review interventions based on outcomes

Maintain monitoring and evaluation efforts.

Plan

Do

Check

Act


© 2018 OPEN MINDS

Revenue Cycle

Referral & Intake

Service Delivery

Billing & Collections

Monitoring & Process

Improvement

• Verifications

• Authorizations

• Credentials

• Documentation

• Claims Submission

• Denials Management

• Payment Receipt &

Posting

• Claims Analytics

• Process

Improvement

© 2018 OPEN MINDS

Strategic Financial Implications Of Shifting Reimbursement Market

Improve understanding of cost drivers – manage and reduce costs

Develop infrastructure,

information technology, and re-align processes

Develop competencies and internal

culture to compete in a performance-based market

© 2018 OPEN MINDS

How Does Activity Based Costing Work?

Determine and manage the cost of services

Evaluate outsourcing options

Develop “What if” scenarios for service expansion or reduction

Assist marketing staff in product design and service pricing

Develop budgets

Measure performance

Evaluate the cost benefits of alliances or mergers

Map Activities & Processes

Determine The Cost of Each

Activity & Process

Determine How Activities Relate

To Services

Select Measures To Track Each Activity & Its

Cost

© 2018 OPEN MINDS

Success Factors

1. Embrace Change

2. Develop Payor Relationships

3. Establish Or Revise Key Performance Indicators

4. Embrace Technology & Innovation

5. Think Collaboratively

© 2018 OPEN MINDS

Embrace Change

Key Principles

Success Factor #1

Be a change leader; create a culture that is able to flex and rewards flexibility.

Start at the top but involve every mind.

Address both the rational reason for the change and the emotional case - what’s in it for me (WIFM).

Identify and celebrate small wins; break the change into smaller components.

Assess and communicate, communicate, communicate.

Celebrate success.

© 2018 OPEN MINDS

Develop Payor Relationships

• Know what the payer needs and wants.

• Get to know key payer leaders/decision makers on a personal level.

• Pitch a pilot that resonates with the payer’s needs and the provider organization’s needs - Payer/Provider Pilot.

• Community Mental Health Center (CMHC) and payer concerned about medication adherence of high risk members

• Engaged vendor who specialized in co-located pharmacies that offer specialized adherence packaging, consults, alerts, member education, refill reminders, and reporting

• RESULT: $58 PMPM savings; Incentive payment for the CHMC.

Success Factor #2

© 2018 OPEN MINDS

Establish Or Revise Key Performance Indicators

Follow-up after hospitalization

Emergency room utilization

Readmission rates Consumer & caregiver

satisfaction

Use of evidence-based care protocols

Access to services measures

Diabetes screening Medication Adherence

Appropriate referrals to other providers

Depression monitoring via PHQ-9

Consumer employmentInvolvement of

family/significant other

Annual eye examConsumer reported

health measuresAnnual Dentist Visit

Annual Physical (PCP engagement)

Success Factor #3

© 2018 OPEN MINDS

Measure Performance With Defined Outcomes

Measuring treatment response is an effective quality measure.

• Depression screenings

• Initiation and maintenance of antidepressant medication therapy

• Depression remission

• Identification and treatment of substance use disorders

These typically illustrate provider or consumer adherence to care improvement processes and are substitutes when outcomes may be difficult to calculate.

• Scheduling appointments for 7-and 30-day follow-up after hospitalization for mental illness

• Treatment initiation and engagement benchmarks for substance use disorder

• Notification of inpatient admission

These are quantitative outcomes that demonstrate whether or not a targeted goal was achieved.

• Actual percentage for 7- and 30-day readmissions

• Actual percentage of “kept appointments” for 7-and 30-day follow-up after hospitalization for mental illness

Many behavioral health conditions contribute directly to deficits in social determinants of health. Measurements of social determinant outcomes can illustrate high quality behavioral health outcomes.

• Employment status

• Housing status

• Education status

• Quality of life

• Independent living

Measuring Treatment &

Service ResponseProcess Measures Outcome Measures

Social Determinants Of

Health Measures

Defining Outcomes

© 2018 OPEN MINDS

Diagnostics

• Tele-psychiatry using IronWorks™

• M3 (My Mood Monitor™)

• Brain scanning tech

Consumer Education/ Decision Support

• Video Doctor

• Common Ground

• Virtual Handheld Clinic

• PTSD Coach

• True Colours

• ChronoRecord

• Health Steps for Bipolar

• Biomarker: BDNF levels

• myStrength

Clinical Treatment

• TMS Therapy®

• Beating the Blues

• SilverCloud

Cognitive Function

Restoration

• My Mood Map

• eCBT Mood©

• MyBrain Solutions

Early Detection of

Relapse

• Automatic Trail Making Tests™

• fMRI

• ITAREPS

• MONARCA

• Actiwatch

• Health Buddy®

• OPTIMI

Relapse Prevention

• Technology Enhanced Recovery™

• REAC-CRM (REAC-lithium)

• PSYCHE

• Personalised Ambient Monitoring (PAM)

• MoodMapping

Remote Monitoring of

Patient Health

• ViTelCare™ T400

• SenseWear® Armband System

• MagneTrace

• ID-Cap

• Electronic Medication Management Assistant® (EMMA)

• Implantable RF Transceiver ZL70102

• Motionlogger Actigraph

• Helius™

• MOBUS

Treatment-Enabling Technologies Along The Service Continuum

Success Factor #4

© 2018 OPEN MINDS

The Human Support Factor

Coach-supported web-based

interventions

Are effective (ds=.56 – 1.08)

Patients are adherent (~9 logins)

Coaches do not need to be

mental health professionals

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Success Factor #4

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Collaborative Care Model (CoCM)

Primary Care

Practitioner

Behavioral Health

Care ManagerVirtual

Psychiatrist

Collaborative Care Model (CoCM)

Rewards PCP and multi-disciplinary treatment team to screen members for anxiety and depression

Virtual psychiatrist provides consultation to PCP for complex cases

Embedded care manager coordinates care and updates data register

Success Factor #5

© 2018 OPEN MINDS

Mental Health Case Study

• CMHC agrees to participate in monthly score card review

• Coordinate with Primary Care Physician (PCP) and other specialty providers to support medical Healthcare Effectiveness Data and Information Set (HEDIS) measure improvement (e.g. Dental appointments)

• Support collaborative care model by offering care coordination support and/or virtual prescriber access


• Follow up within 7 days post inpatient discharge and 7 days post Emergency Room (ER) visit.

• Diabetes screening

• Community tenure

Measures

• PMPM bonus payment prorated by outcome results

Rewards

© 2018 OPEN MINDS

Mental Health/Pharmacy Case Study

• CMHC, Pharmacy programs agree to report measures and meet monthly to review scorecard and implement intervention

• Agreed upon roles and responsibilities regarding consumer engagement workflows


• Rx adherence measures by percentages of days covered for anti-psychotic medication

• Rx adherence measures by percentages of days covered for anti-depressant medication

• Rx adherence measures by percentages of days covered for diabetes medication

• Rx adherence measures by percentages of days covered for hypertension medication

• Medication gaps

Measures

• PMPM bonus payment prorated by outcome results

Rewards


V. Six Key Strategies For Success In A Changing Market

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Six Key Strategies To Beat The Disruptive Competition

1• Best Practice Strategy Development & Sustainability – Driven Innovation

2• Adaptive Standardization

3• Market-Responsive Service Line Evolution

4• Metrics-Informed Performance Management

5• Nimble Tech Adoption & Deployment

6• Structure & Team To Manage Complexity

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Strategy For Sustainability Should Drive “Innovation”

1• Develop vision of future competitive advantage and market positioning – set objectives

2• External market analysis and internal portfolio analysis/performance benchmarking

3• Scenario-based strategic plan incorporating alternate future positioning options

4• Detailed plans – marketing, financial, operational, capital, HR, etc. – to implement strategy and future

vision

5• Key performance metrics and metrics-based management to track strategy implementation, and allow

for mid-course adjustments

6

• Optimization of current operations to keep current programs as competitive (and profitable) as possible as long as possible

7• New service line and service model development to support future vision

8• Collaborations and partnerships as needed to facilitate strategy implementation

Innovation

1. Market-Facing Strategy Driving Innovation

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Strategy Development Best Practices

Focused on mission, objectives, and sustainability

Market metrics-informed - tests strategy against

external market realities

Scenario-based (and scenario prepared)

Integrated into budgeting processTranslates strategy into tactics

and action items

Has measurable performance indicators – that allow metrics-

based, incremental implementation

Nimble and adjusted on an on-going basis based on market

metrics and performance metrics


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The Building Blocks Of Strategy Success

Market intelligence –understanding the

customers and competitors

Performance metrics – assessing your

performance relative to customer preferences and competitors ability

Strategy – plan for success and

sustainability that directs investment

Talent – leadership staff, technical staff, team communication

and cooperation

Strategy execution –make strategy a reality


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The Amazon Flywheel As

Strategic Investment Model

The Concept

A flywheel, when you feed any part of

it, naturally accelerates the entire loop.


Lower cost = more customers.

Better customer experience = more customers.

Better customer outcomes = more customers.

More customers = lower cost

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Structured Approach To Improving “Value”

Adaptive standardization –evidence-based standardization of routine care and services

Adaptive response for service line evolution –continual change of service portfolio based on both science and market

Effective performance management – continuous performance measurement ‘hardwired’ into all services

Standardization, Service Lines, & Continuous Improvement Need To Be Driven By

Improving Value Equation

2. Adaptive Standardization

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Standardization Of Clinical & Administrative Processes

Standardization - uniform standards and methods for

delivery of a service that assures maximize safety,

replicability, and performance

Elements of standardization:

Terminology

Processes, approaches, protocols

Personnel

Technical systems – technology, physical plant,

devices, etc.

Results

This is more than measuring ‘fidelity to the model’

Developing rates for value-based

reimbursement requires service

standardization

Business Management

Best Practices

“How we do it”

Clinical Services Best Practice

“What we do”

How Do You Assure That Consumers With The Same Problem Get

The Same Solution & The Same Experience Every Time?

2. Adaptive Standardization

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Continuous Service Line Evolution –Are Your Services Keeping Current With The Market?

Strategic Portfolio Review

Review Of Possible Service Options - New &

Refreshed

Review of New Science &

Technology

Clinical Standards

Review

Business Model Review

Go/No Go Decision &

Implementation Execution

Performance Monitoring & Continuous

Improvement

Continuous portfolio

management critical. . .

3. Responsive Service Line Development

© 2018 OPEN MINDS

The Blue Ocean Strategy Model

Blue ocean strategy

focuses not on beating the

competition - but making

the competition irrelevant

by creating new,

uncontested market space

Costs

Buyer Value

Value Creation

3. Responsive Service Line Development

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Metrics-Based Performance Management –How Services Compare To The Competition?

Metrics-based management is

the path from information to

action

Process Strategy

PeopleInformation

Technology

Performance

Metrics

Process Implementation

Process DesignP

rocess M

onito

ring &

Contro

lling

Pro

cess E

xecution

4. Metrics-Based Performance Management

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How To Select What Metrics To Manage?Employ The ‘Strategic Quality’ Concept

Invest in ‘performance improvement’ that

differentiates you from your competitors – and

customers are willing to pay for the differential cost

Part of the ‘market positioning’ of each service

Requires an understanding of:

Customer perceptions

Customer segmentation

Competitive offerings

Customer perceptions of competitive offerings

Price elasticity

Eight Dimensions Of “Strategic Quality”

Performance

Features

Reliability of service system

Conformance to standards

Durability and length of effect

Serviceability and customer experience

Aesthetics

“Perceived” quality


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Manage Performance In All Functions Of The Organization

Customer Experience

Clinical Performance

Compliance

Financial Sustainability

Marketing & Business

Development

Fundraising & Grants

Payer Contract

Performance

Employee Experience

Technology & Data

Analysis


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Focus On Four Types Of Outcomes For VBR Success

The New Value Assessment

1. Contract-Specific Performance

Measures

2. Routine Services and Transactions

3. Great Customer Service

4. Cutting Edge Expertise


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1. Contract-Specific Performance Measures

The floor for success

Requires a payer perspective and a consumer

perspective of ‘value’

Reflect outcomes that are the costliest to the

payer

Reflect outcomes that the payer is accountable

to achieve to receive maximum reimbursement

Mandated Health Home Performance

Measures

Adult body mass index assessment

Controlling high blood pressure

Screening for clinical depression and

follow-up plan

Follow-up after hospitalization for

mental illness (7 and 30 day)

Initiation and engagement of alcohol

and other drug (AOD) dependence

treatment

Plan all-cause readmissions

Prevention quality indicator (PQI) 92:

chronic conditions composite

Ambulatory care: emergency

department visits

Inpatient utilization

Nursing facility utilization

10 National Health Home

Measures

NCQA HEDIS Measures

CMS STARS Measures

Most Common Health Plan

Contract Measures

Your Specific Health Plan

Contract Measures


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2. Routine Services & Transactions

Consumer sovereignty – a business philosophy assuming the best profit will

come from providing customers with the best products and best customer

service at the lowest possible price

The Amazon

Doctrine –

above all else,

align with

customers.

“Win when they

win. Win only

when they win.”

Search Engine Ranking &

Optimization Scores

InquiriesInquiry

Response Time

Inquiry Conversion

Rates

Time To Appointment

Service Rates


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3. Customer Service

Providing service that creates ‘passionate advocates’ of your brand

Designing workflow from a consumer experience perspective –

preventing consumers from “feeling like they are simply another

transaction”

Developing a written

service strategy to

ensure consistency of

consumer experience

– and cultivate

consumer loyalty

Net Promoter Score

Customer Satisfaction

Customer Experience Monitoring (“Mystery

Shopper”) Results

Online Reputation


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4. Clinically Cutting Edge – A Consumer Advisor On Emerging Science

Can you be replaced by an online clinical decision support tool?

Understanding the new science in your area of specialization

Mastering the

new technologies

– and integrating

them into your

service array

(whether you

provide them or

not)

Consistency In ‘Treatment Model’ -

Lack Of Unexplained Variability

Time To Evaluation/Adoption Of

New Treatment Technology


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Top Five Key Performance Indicators

Domain Indicator Goal Review Parameters

Customer

ExperienceNet Promoter

Score

Assessment of customer

satisfaction and referral

development

Response to question about likelihood of

recommending our organization to friends and family

members; Monthly - Total, By Market, By Service

Line, YTD, Previous Year

Employee

ExperienceRevenue lost due

to vacancies

Identification of employee

satisfaction issues impacting

turnover and organizational

sustainability

Average revenue times time open for unfilled

positions; Monthly - Total, By Market, YTD, Previous

Year

Financial

SustainabilityA/R (days in

receivables)

Assessment of future cash flow and

identification of payer issuesTotal A/R divided by average daily charges; Monthly -

Total, By Market, By Service Line, YTD, Previous

Year

Clinical

Performance

ER utilization

(service lines

TBD)

Effectiveness in sustaining recovery

by providing timely, nonacute

services

Monthly - Total, By Market , By Service Line, YTD,

Previous Year – will require data sharing and/or

integration

Technology &

Data AnalysisNumber of report

requests and time

to complete

Organization use of analytics;

analytics resource adequacy and

effectiveness

Count of requests submitted and number of work

days from request to completion; Monthly - Total, By

Market, YTD, Year over year

Customer

ExperienceDays to

appointment

Assessment of customer

satisfaction and service quality

Monthly, Total, By Market, By Service Line, YTD,

Previous Year


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The Big Technology Problem –The Science To Service Gap In Health & Human Services

Adoption Of New

Technologies

New Service Models For

Health & Human

Services

15- to 20-year lag

between the

development of a

practice and its

common use at

the community

level

5. Nimble Tech Adoption


The Health & Human Service Organization Problem

For success with new tech adoption, health and

human service organizations need:

Metrics-based process improvement - and

competitive performance benchmarking – to

identify needs for strategic tech investment

(and estimate ROI)

Functionality-based technology selection with

ROI analysis

Ownership of technology implementation

Process (and resources) for on-going

technology process/performance curation

Moving beyond

compliance to strategy -

lack of formal process

link of technology to

strategy


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Both the technology company and the health and human service organization have to be focused on the same performance metrics –and the same ROI

Health and human service organization managers need to leverage the new processes that technologies create – and not focus on automation of current processes

The tech company and the provider organization partners need to plan ‘beyond the pilot’ for scalability – role in larger health system, on-going operating processes, data interoperability, financing, and more

Making Provider/Vendor Partnerships Work In Health & Human Service Field Requires. . .


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Health & Human Service Market Has Gone From Complicated To Complex

When things interact, they change one another in unexpected and

irreversible ways – creating unexpected innovations and outcomes – or

systems emergence.

Complicated systems may have many parts

but when the parts interact they do not change each other

The distinction between ‘‘complexity’’

and ‘‘complicated’’

Complexity is about rich interconnectivity

6. Complexity Management

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Leading In A Complex Environment Requires Adaptive Response

• Complex environments need structures and leaders that

enable adaptive response!


Adaptive space requires two systems – operational and entrepreneurial

Allows team members to take innovation to commercialization – and create a new business model

Provides an organizational construct to resist the “orthodoxy” from winning (allows change to happen)

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Entrepreneurial

Leadership

Enabling

Leadership

Operational

Leadership

Leadership For ChangeNew Leadership Model Needed For Innovation In A Changing Market


© 2018 OPEN MINDS

Value, Competitive Advantage, SustainabilityStrategy

Improved Performance

Reduced Cost

New Partnerships

New Service

New Population

New Tech

Sustainable Competitive

Service Model

Innovation

Sustainability In Health & Human Services Needs A Measured Approach To Respond to New (& Disruptive) Competition

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Succeeding In A Value-Based Health & Human Service Landscape · 2019-06-17 · n 15 Lincoln Square,...

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Transcript of Succeeding In A Value-Based Health & Human Service Landscape · 2019-06-17 · n 15 Lincoln Square,...