Succeeding With Value-Based Reimbursement: An OPEN MINDS ...€¦ · I. The Fee For Service...
Transcript of Succeeding With Value-Based Reimbursement: An OPEN MINDS ...€¦ · I. The Fee For Service...
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Succeeding With Value-Based Reimbursement: An OPEN MINDS
Executive Seminar On Organizational Competencies & Management Best
Practices For Value-Based Contracting
S t r a t e g y & I n n o v a t i o n I n s t i t u t eM o n d a y , J u n e 3 , 2 0 1 | 1 : 0 0 p m – 4 : 0 0 p m
K e n C a r r , S e n i o r A s s o c i a t e , O P E N M I N D S
© 2019 OPEN MINDS
AgendaI. The Fee For Service Business Model
II. The Value-Based Reimbursement Business Model
III. Becoming A Data-Driven Organization
IV. The Role Of Population Health Management In A Data-Driven
Organization
V. The Role of Technology In Value-Based Reimbursement
VI. The OPEN MINDS Value-Based Reimbursement Management
Readiness Assessment
2
© 2019 OPEN MINDS© 2019 OPEN MINDS
I. The Fee For Service Business Model
3
© 2019 OPEN MINDS
Financial Model – Fee For ServiceVariable Costs
Create Less Risk
Under FFS
© 2019 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
© 2019 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
© 2019 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
© 2019 OPEN MINDS
The Goal: Preferred & Exclusive
Being ‘Preferred’ Within A Payer Network
Having preferential referrals due to some
market differentiation
Need a demonstrable value proposition –
almost always involving P4P or value-based
payment
Gaining ‘Exclusivity’ Within A Payer System
Having a financial relationship (most often with
significant financial risk) that gives you
exclusivity by geography and/or consumer type
Your organization is the ‘narrow network’
© 2019 OPEN MINDS© 2019 OPEN MINDS
II. The Value-Based Reimbursement Business Model
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© 2019 OPEN MINDS
The Shifting Reimburse Market
A Change In Focus:
Reducing costs while delivering and
demonstrating value
A Change In Methods:
Managed Care & Value-Based Purchasing
© 2019 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
© 2019 OPEN MINDS
Why More Value-Based Purchasing (Risk-Based Contracting & P4P Contracting)?
• Increase “pressure” for improvement
• Facilitate consumer-directed careIncrease Transparency
Of Performance
• Improved access to care
• Increase care integration and coordination
• Person-centered planning and recovery focus
Link Professional, Service Provider
Organization, & Care Manager
Reimbursement To Desired Performance
• Financial incentives to help consumers become and remain healthy for longer periods of time
• Increase lower-cost interventions for “not yet seriously ill” population
• Reduce unnecessary use of high-cost services
Control Costs Of Care
© 2019 OPEN MINDS
Health Plan Reimbursement Moving From Volume To Value:Supporting “Integrated Care Coordination”
Compensation Continuum By Level Of Financial Risk
Capitation + Performance-
Based Contracting
CapitationShared RiskShared Savings
Bundled & Episodic
Payments
Performance-Based
Contracting
Fee-for-service
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
© 2019 OPEN MINDS
Changing Reimbursement Models
Provider Organizations With VBR Revenue
• 41% of primary care organizations
• 33% of behavioral health organizations
• 34% of child & family services organizations
• 14% of I/DD & LTSS organizations
© 2019 OPEN MINDS
What Are The Pay-For-Value Reimbursement Options?
Case Rates
& Bundled Rates
Medical Homes & Specialty Medical
Homes
Capitation &/Or Population Health
Gainsharing Arrangements
With P
ay-F
or-
Perf
orm
ance C
om
ponents
Specialist
positioning
Comprehensivist
positioning
© 2019 OPEN MINDS
Managed Fee-For-Service
Provider Paid An Established Fee For A
Defined Service
• Clearly defined package of services to be provided
• Quality standards can be established for defined services
Varying Degrees Of ‘Management’
• Preauthorization
• Concurrent review
• Retrospective review
© 2019 OPEN MINDS
Pay-For-Performance
A term that describes health care payment systems that offer financial rewards to providers who achieve, improve, or exceed their performance on specified quality, cost, and other benchmarks
Pay-for-Performance
(P4P)
© 2019 OPEN MINDS
Capitation In Population Health Arrangements
Arranged with the physician, hospital, or other health care provider or plan
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
Capitation/Sub capitation
• 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
Population Health Capitation
© 2019 OPEN MINDS
Example: Value-Based Payment Methodology
Goal for a pediatric practice is to immunize
80% of its patients by age 2, in accordance with the
nationally accepted immunization guidelines.
A provider that exceeds that goal and immunizes 90% of its patients would
receive bonuses in addition to the standard FFS reimbursement rate
from the payer.
© 2019 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.
© 2019 OPEN MINDS
Strategic Financial Implications Of Shifting Reimbursement Market
Develop competencies and internal culture to
compete in a performance-based
market
Develop infrastructure and information
technology and re-align processes
Improve understanding of cost drivers – manage and
reduce costs
© 2019 OPEN MINDS
Value-Based Reimbursement Here To Stay Because...
• Political and competitive pressure on payers – federal
government and employers
• Downward price pressure on health plans
• The success of ‘some’ ACOs
• The early findings of the Medicare bundled rate
initiative
• Pressure on health plan medical loss ratios
Consumerism
Technology
adoption
Value-based
reimbursement
“Integration” for
improved cost and
quality
© 2019 OPEN MINDS© 2019 OPEN MINDS
III. Becoming A Data-Driven Organization
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© 2019 OPEN MINDS
Tactical Data Focus
Data, No Outcomes
Focus
Data Driven
No Data Or
Outcomes
Outcomes Focus, No
Data
Data Management Discipline
Ou
tco
me
Focused In
tent
Tactical Orientation Grid
• Assesses organizations on tactical infrastructure to capture data, and cultural focus to use data to drive better outcomes
• Data-driven organizations must have data and an outcomes focused intent to use that data
© 2019 OPEN MINDS
Strategic Data Focus
Performance Tracking, But No
Adaptation Of Approach
Tracks Performance And Adapts Approach
No Performance Tracking Or Adaptation
Of Approach
Adapts Approach,
But No Performance
Tracking
Relate Efforts To OutcomesA
dju
stA
ppro
ach
Strategic Data Orientation Performance Domain
• Assesses organizations on their ability to adapt performance to improve outcomes
• Data-driven organizations must track and analyze services, and adapt performance to create social value
© 2019 OPEN MINDS
Program Impact Data Focus
Program Results, Not
Those Intended
Data Demonstrates
Intended Impact
No Intended Results Or Supporting
Data
Intended Results, But
No Supporting
Data
Program Impact DataC
ap
acity
To D
eliv
er S
erv
ices
/ Pro
gra
ms W
ith F
idelity
Program Value Performance Domain
• Assesses organizations on their ability to deliver intended outcomes
• Focus is on program data, not capacities and practices of the organization
© 2019 OPEN MINDS
Achieving Data-Driven Decision Making
Tactical Orientation
Grid
Program Value Grid
Strategic Orientation
Grid
Data Driven
© 2019 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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Focus On Four Types Of Outcomes
The New Value
Assessment
Contract-Specific Performance
Measures
Routine Services & Transactions
Great Customer Service
Cutting Edge Expertise
© 2019 OPEN MINDS
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
© 2019 OPEN MINDS
Follow-Up After Hospitalization & Readmission Rates Are The Most Popular Measures For Determining Performance
Top Five Performance Measures In Value-Based Contracts, %, 2019
22%
22%
23%
32%
36%
Access to caremeasures
Patient/consumersatisfaction
Emergency roomutilization
Readmission rates
Follow-up afterhospitalization
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Common HEDIS Measures Focused On Complex Populations
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© 2019 OPEN MINDS
CMS STAR Ratings
The use of CMS Star Ratings allows the Medicare program to determine the quality of all
Medicare-sponsored plans including Medicare Advantage and prescription drug MA plans.
Star Ratings for Medicare sponsored plans are determined using five major factors:
If Medicare beneficiaries remain healthy while on their plan
Management and improvement of beneficiary chronic conditions
Member experience with health plans
Customer service performance
Member complaints with health plans
Changes in overall health plan performance
Medicare collects quality data to determine a plan’s rating through regular monitoring of
health plan operations and beneficiary surveys that record consumer experiences.
Payers can achieve higher star ratings by investing in member engagement platforms and
developing strategic communications that build relationships with Medicare beneficiaries.
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© 2019 OPEN MINDS
CMS STARS Measures Focused on Complex Consumers
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© 2019 OPEN MINDS
2. Routine Services And 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.
Search engine ranking and optimization
scores
InquiriesInquiry
response time
Inquiry conversion
rates
Time to appointment
Service rates
© 2019 OPEN MINDS
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 scoreCustomer
satisfaction
Customer experience monitoring
(“mystery shopper”) results
Online reputation
© 2019 OPEN MINDS
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
© 2019 OPEN MINDS
Steps To Building An Effective KPI System
Identify performance measures – key measures for every domain
Set and communicate targets based on strategic and operational
success factors
Build a system to turn data into strategic insight
Communicate results through a dashboard
Drive results to targets through a system and culture of data analysis
and process improvement
© 2019 OPEN MINDS© 2019 OPEN MINDS
IV. The Role Of Population Health Management
In A Value-Driven Market
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© 2019 OPEN MINDS
“The health outcomes of a group
of individuals, including the
distribution of such outcomes within the
group”
Population health management seeks to
improve the health outcomes of a group by
monitoring and identifying individual
patients within that group...
A best-in-class PHM program brings
clinical, financial and operational data
together from across the enterprise and
provides actionable analytics for providers
to improve efficiency and patient care…
Population Health Management
© 2019 OPEN MINDS
Behavioral Health System Optimization Is Central To Successful Population Health Management
Consumers with behavioral disorders are often
‘superutilizers’ of health care resources
Undiagnosed and/or untreated behavioral health conditions
hinder the treatment of a wide range of medical conditions
Consumers with behavioral disorders and comorbid chronic medical conditions have higher
average costs than those consumers without comorbid
conditions
Lack of integrated care coordination – addressing the
medical, behavioral, and social needs of consumers - results in
poorer outcomes and higher cost per consumer
© 2019 OPEN MINDS
Key Components Of Population Health Management
Aggregation Of Health Data On A
Population Of Consumers
Analysis & Risk Stratification Of The
Health Data
Identification Of High-Risk
Consumers
Identification Of Optimal
Interventions For High-Risk
Consumers
Care Management & Follow-up
© 2019 OPEN MINDS© 2019 OPEN MINDS
V. The Role of Technology In Value-Based Reimbursement
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© 2019 OPEN MINDS
Shifting Role Of Technology In Health & Human Services
Administrative Tool
Compliance Requirement
Platform For Competitive Advantage
© 2019 OPEN MINDS
The Shift From The Functional To The Strategic
The result of compliance focus of the past ten years – 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
© 2019 OPEN MINDS
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
© 2019 OPEN MINDS
New Genetics, Pharma, & Neurotech:
The “What” of Service
Telehealth & Remote Services: The “Where” of Service
Web-Enabled Admin Tools:
The “How” of Service
Analytics & Decision Support:
The “Right” Service
New Service Delivery
Paradigm
A New Market Model Is Emerging
© 2019 OPEN MINDS
Technology Has Changed The Expectations Of Payers & Consumers
1. Personalization of consumer treatment through analytics-informed decision support
2. More efficient and effective coordination of consumer services across the service system
3. The measurement of “value” of services
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
consumer service planning
New treatment technologies have
changed the options for consumers
Leveraging Technology For Long-Term Sustainability
© 2019 OPEN MINDS
The Value Of Investing In Technology
© 2019 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
© 2019 OPEN MINDS
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
telemedicineRemote monitoring
Tech improving
admin efficiencies
Tech-enabled
treatment
© 2019 OPEN MINDS
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
© 2019 OPEN MINDS© 2019 OPEN MINDS
IV. The OPEN MINDS Value-Based Reimbursement
Management Readiness Assessment
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© 2019 OPEN MINDS
I. Provider Network Management
II. Clinical Management & Clinical Performance Optimization
III. Consumer Access, Service, and Engagement
IV. Financial Management
V. Technology & Reporting Infrastructure
VI. Leadership & Governance
Six Domains In OPEN MINDS Model For Assessing Value-Based Reimbursement Management Readiness
© 2019 OPEN MINDS
I. 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
© 2019 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
© 2019 OPEN MINDS
2. Care Coordination & Care Management
Focus:
Ability to identify care management needs,
obtain payer authorizations and refer to appropriate services
Key Competencies for Success
Processes in place to receive care
management referrals, assess needs
and refer consumers for services
Authorizations expertise
Focus on integration, follow-up and
communications
© 2019 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
Key Competencies for Success
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
© 2019 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
Key Competencies for Success
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
© 2019 OPEN MINDS
II. Two Key Competencies Of Clinical Management & Performance Optimization
1. Decision Support & Care Standardization
2. Clinical Performance Tracking, Assessment &
Optimization
© 2019 OPEN MINDS
1. Decision Support & Care Standardization
Focus:
Ability to use data to determine the most effective evidenced-
based practices
Key Competencies for Success
Standardized guide to care
management and treatment
Implementation of data-informed
planning, treatment and referral
Continuity of care planning and
transition between care settings
© 2019 OPEN MINDS
2. Clinical Performance Tracking, Assessment and Optimization
Focus:
Ability to track outcomes, assess how
to optimize services, and implement performance
improvements
Key Competencies for Success
Established KPIs
Ability to measure clinical outcomes
Process to assess outcomes against
KPIs and improve quality
© 2019 OPEN MINDS
III. 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
© 2019 OPEN MINDS
1. Consumer-Informed Access To Care
Focus:
Technology to improve consumer access to self-service tools for
both clinical and administrative services
Key Competencies for Success
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
© 2019 OPEN MINDS
2. Automated Consumer Service Functionality
Focus:
Ability for consumers to seek information and
self-refer to services in a timely fashion
Key Competencies for Success
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
© 2019 OPEN MINDS
3. Mobile Health Applications
Focus:
Ability to maximize consumer engagement
through the use of mobile health applications
Key Competencies for Success
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
© 2019 OPEN MINDS
4. Consumer Wellness Support
Focus:
Ability to educate, provide resources, and document effectiveness
related to wellness support
Key Competencies for Success
Processes and program to engage
consumers in ongoing wellness support
and self-management
© 2019 OPEN MINDS
5. Appeals & Grievance Procedures
Focus:
Ability to receive, investigate, and resolve consumer concerns in a fast, effective manner
Key Competencies for Success
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
© 2019 OPEN MINDS
6. Customer Satisfaction Feedback
Focus:
Assess ability to obtain frequent consumer
feedback through easy, non-obtrusive methods
Key Competencies for Success
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)
© 2019 OPEN MINDS
6. Clinical Performance Metrics
Focus:
Ability to track and analyze outcomes, identify options to
improve services, and quickly change
processes
Key Competencies for Success
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
© 2019 OPEN MINDS
IV. Four Key Competencies Of Financial Management
1. Revenue Cycle Effectiveness
2. Encounter Reporting
3. Value-Based
Payment Capabilities
4. Financial Performance Monitoring
© 2019 OPEN MINDS
1. Revenue Cycle Effectiveness
Focus:
Ability to align operational and financial
processes to assure adequate cash flow
Key Competencies for Success
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
© 2019 OPEN MINDS
2. Encounter Reporting
Focus:
Ability to capture, analyze, and report
granular utilization data to payers and to internal
teams for management
Key Competencies for Success
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
© 2019 OPEN MINDS
3. Value-Based Payment Capabilities
Focus: Ability to track manage contractual
outcomes and payments
Key Competencies for Success
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
© 2019 OPEN MINDS
4. Financial Performance Monitoring
Focus: Ability to monitor actual
financial results against contracts,
budgets, and forecasts
Key Competencies for Success
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
© 2019 OPEN MINDS
V. 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
© 2019 OPEN MINDS
1. Capacity To Collect Data
Focus:
Technology infrastructure to collect
data strategic in identifying health
needs of the population of
consumers served
Key Competencies for Success
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
© 2019 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
Key Competencies for Success
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
© 2019 OPEN MINDS
3. Ability To Manage Value-Based Contracts
Focus:
Ability to track performance metrics, submit invoices, and
maximize performance of value-based
contracts
Key Competencies for Success
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
© 2019 OPEN MINDS
4. Ability To Exchange Health Care Information
Focus:
Ability to exchange clinical and financial
information with other health care provider
organizations
Key Competencies for Success
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
© 2019 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
Key Competencies For Success
Automated risk assessment tools
Redesigned workflows to maximize
care management technology
Provider referral database to aid in care
matching and management
© 2019 OPEN MINDS
6. Consumer Portal Functionality
Focus: Ability to provide service data,
resources and interaction options with consumers through the
EHR
Key Competencies for Success
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
© 2019 OPEN MINDS
7. IT Performance Monitoring
Focus: Ability to monitor actual IT outcomes against established goals
Key Competencies for Success
Established key performance indicators
Ability to generate real-time reporting on
performance under value-based
reimbursement arrangements
© 2019 OPEN MINDS
VI. Three Key Competencies Of Leadership & Governance
1. Strategic Alignment Around Population Health
Management
2. Culture of Innovation
3. Workforce Adequacy
© 2019 OPEN MINDS
1. Strategic Alignment Around Population Health Management
Focus:
Alignment of leadership around population health
management and the ability to manage
financial risk
Key Competencies for Success
Resources and infrastructure to manage
clinical and financial risks of population
health management
© 2019 OPEN MINDS
2. Workforce Adequacy
Focus:
Ability to attract and retain the right staff to succeed at population health management
Key Competencies for Success
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
© 2019 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
Key Competencies for Success
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
© 2019 OPEN MINDS© 2019 OPEN MINDS
Questions & Discussion
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© 2019 OPEN MINDS
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