VBP Training for Tier 1 CBOs,

Primary Care Providers, and

Mental Health/Substance Use

Providers

Nassau Queens Performing

Provider System (NQP PPS)

Presented by McSilver Institute

Agenda

• VBP Overview/Reminders

• Provider performance requirements under

VBP levels 2 & 3

• Infrastructure needs to be effective in a

VBP environment

• Role of Tier 1 CBOs in Future VBP

Arrangements - Role of Social

Determinants of Health in VBP

2

Reminder: What Is Value Based

Payment (VBP)?According to CMS,

Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for. Value-based programs also support our three-part aim:

• Better care for individuals

• Better health for populations

• Lower cost

3

Provider Performance

Requirements under VBP

Levels 2 & 3

4

Financial Payment Models

Fee For Service

Managed Care

Incentive/Pay For

Performance (P4)

Upside Risk Only

Shared Savings

Upside and Downside

Risk

Capitation/

Per Member Per Month

(PMPM)

5

Level 0 VBP* Level 1 VBP Level 2 VBP Level 3 VBP

(feasible after experiencewith

Level 2; requires mature

contractors)

FFS with bonus

and/or withhold

based on quality

scores

FFS with upside-only shared

savings available when

outcome scores are sufficient

(For PCMH/IPC, FFS may be

complemented with PMPM

subsidy)

FFS with risk sharing

(upside available when

outcome scores are

sufficient)

Prospective capitation PMPM

or Bundle (with outcome-

based component)

FFS Payments FFS Payments FFS Payments Prospective total budget

payments

No Risk Sharing Upside Risk Only Upside & Downside Risk Upside & Downside Risk

*Level 0 is not considered to be a sufficient move away from traditional fee-for-service incentives to be counted

as value based payment in the terms of the NYS VBPRoadmap.Source: VBP Bootcamp #1

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Fundamentals of Partial and Full Risk

Arrangements

Orientation to Common Risk Sharing

and Gain Sharing Arrangements

Source: VBP Bootcamp #2

• Joint

Replacemen

t

• I/DD

Managed Care Through Shared

Risk

• Payment continues to be FFS

• Shared savings potential

– If savings and quality is achieved

• Upside and downside risk

• Lower shared savings in upside risk when

compared to upside and downside risk

8

Capitation/PMPM

• Providers take responsibility for a designated population

• Providers paid monthly even if services are provided or not

• Medical loss ratio (MLR) rules usually apply

• This model is used primarily by Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs)

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Performance Standards

Standards Will Vary

Based On Payer Needs

Change Overtime

Based On Government

Measures

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Achieving Savings thru Metrics

• To achieve savings, agreed upon metrics

must be met

• Providers would need to meet all metrics

to share in savings

• For example, if provider needs to meet 5

out of 8 agreed upon measures and only

achieves 4, provider would not be eligible

to share in savings.

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Intro to Stop Loss Insurance and

Transition Considerations Moving from

Level 1 to Levels 2 & 3 Contracts

• Stop Loss Insurance – Insurance purchased to help

manage your risk; covers losses passed a certain

amount. Different levels of stop loss insurance available,

can cover:

– An individual issue (i.e. inpatient admission)

– Aggregate (total cost incurred for a patient/member)

• Transition considerations moving from level 1 to level 2 &

3

– Potential to lose money, must have the funds to cover

that

– Substantial actuarial work as part of level 2 & 312

Infrastructure Needs in

Order to be Effective in a

VBP Environment

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Infrastructure Needs

• Flexible/Adaptable

• Responsive to agency needs

• Ability to connect finance and clinical data

• Beyond connection, multidimensional: able to

accommodate the nuances of how finance

and clinical data influence each other

• Ability to handle data from multiple platforms

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Discussion

• What are ways that your organization has

increased or could increase the flexibility

and interconnectedness of your

infrastructure?

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Infrastructure Areas• Ongoing IT support and development:

– Hardware

– Software

– Staffing

• Finance– New financial structure/reporting

– Budgeting/projections

– Staffing

• Human Resources:– Hiring and Promotion Practices

– Training and Development of Performance Driven Culture

– Job description/skills

• Ongoing quality improvement support and development:– Tool development

– Staffing

• Data and Analytics– Technology

– Staffing

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Data

• Common data set

• Standard data format

• Actionable

• Data dictionary

• Interoperability

• Comprehensive

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Data Considerations and Barriers

• Tangible Improvements

• Real time vs. Batch

• Visualization vs. Reports

• Data collection

– Direct staff

– Data entry

• Client identification across systems

• HIPPA/42 CFR protected information and consent

• Interoperability standards

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Discussion

• What types of data are you already

collecting?

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Data Sets

• Government/Grantor

– Demographics

– Reports

– Payment data

• Payer

– Demographics

– Medicaid

– Medicare

– Private/Commercial Insurance

– Utilization Management

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Data Sets Continues

• Regional Health Information Organizations (RHIO)

– Demographics

– Clinical

– Payer

• Provider

– Demographics

– Clinical

– Service/Billing

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Role of Tier 1 CBOs in Future VBP

Arrangements - Role of Social

Determinants of Health in VBP

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Social Determinants of Health

Those factors that impact upon health and well-

being: the circumstances into which we are born,

grow up, live, work, and age, including the health

system. World Health Organization: 2008.

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20January 2018

The 5 Domains of Social Determinants

of Health (SDH)

Education

Social and Community

Health and Health Care

Neighborhood and

Environment

Economic Stability

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Your ZIP code may be more

important to your overall health

than your genetic code

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Discrimination Persists

‣ Pairs of young, well-groomed, well-spoken college men

with identical resumes applied for 350 advertised entry-

level jobs in Milwaukee, Wisconsin.

‣ Two teams were black and two were white. In each team,

one said that he had served an 18-month prison sentence

for cocaine possession.

‣ The study found that it was easier for a white male with a

felony conviction to get a job than a black male with no

criminal record.

Source: Devan Pager; NYT March 20, 2004

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Behavioral Health Related Outcomes Associated with Poverty and Income

Inequality

‣Depressive disorders

‣Poor self-reported mental health

‣Drug overdose deaths

‣Juvenile homicides

‣Those involved or previously

Involved with the justice system

‣Anxiety disorders

‣PTSD

‣Increased arrests

‣Cognitive, behavioral,

and attention-related

problems in children

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Health Impact of Substandard Housing Conditions

‣Increased asthma

‣Increased lead poisoning

‣Injuries

•Radiator burns

•Window falls

•Fires from improper wiring, lack of smoke detectors, use

of space heaters

‣Increased infectious diseases

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Impact of Insufficient Access to

Food/Nutrition• Unhealthy diet due to lack of access to fresh fruits,

vegetables and other healthy food options

– Increases obesity, high blood pressure, heart disease and stroke, diabetes, and some cancers

– Increases stress, depression, and other mental illnesses

• Not having enough food to feed yourself and your family

– Children: negatively impacts their ability to learn and develop/grow properly which increases chronic illnesses (i.e. asthma) and behavioral problems and can have lifelong effects

• Education is another social determinant of health

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Discussion

• Have you witnessed the effects of Social

Determinants of Health in your work? In

what ways?

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Ineffective Practices

Despite the high rates of mental health problems manifested by

the underprivileged in the United States, people living in poverty

routinely underutilize counseling services and often prematurely

terminate counseling when they do access such services (Coiro,

2001; Gonzalez, 2005).

Not understanding client’s circumstances can lead to treatment

that is not relevant and/or meaningful to clients.

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Examine agency policies to

determine if they may be

inadvertently limiting access to

the disenfranchised

Policies

Do you recruit, retain, and promote a diverse group of

staff with knowledge, skills, and experience in

serving diverse populations?

Staffing

Has your agency identified and

articulated engagement

practices/standards for staff to utilize

when serving hard to reach populations?

Delivery

Awareness of SDH is Crucial to

Changing Health Outcomes

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Tier 1 CBOs in future VBP arrangements -

Role of social determinants of health in

VBP • Addressing social determinants of health can

improve outcomes– Many performance measures are impacted with

Social Determinants of Health

• Benefits of Tier 1 CBOs– Enmeshed in the community

• have built trust

• culturally competent

– Already involved in work to address social determinants of health (improve housing conditions, increase access to healthy food, increased access to resources)

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Resources

• New York State DOH

https://www.health.ny.gov/health_care/me

dicaid/redesign/dsrip

• VBP Arrangement Fact Sheet

https://www.health.ny.gov/health_care/medicaid/

redesign/dsrip/vbp_library/index.htm

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Questions?

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