payment models and integrated care · payment models and integrated care confidential, unpublished...

Doug Nemecek, MD, MBA

Chief Medical Officer – Behavioral HealthJanuary 30, 2017

PAYMENT MODELS AND

INTEGRATED CARE

Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2015 Cigna

Agenda

The Case for Change

Pay for Performance and Value Based Reimbursement

Centers of Excellence and Network Tiering

Medical Integration

Telehealth


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A rapidly changing, dynamic environment


Demographic

shifts

Increasing

chronic

conditions

Rising health

care costs

Increased

demand for

transparency

Growth of

technology

and hyper

connectivity

Increased

regulation and

evolving social

safety net

Stakeholders:

• Individuals

• Employers

• Government

• Health care

providers

• Distribution

channels

Health care providers

Consolidating and moving

to a value-based system

Distribution channels

Traditional distribution

channels are consolidating,

while at the same time new

channels are emerging

Employers

Looking for greater

affordability, increased

predictability, improved

productivity

Individuals

Increased role and

seeking greater affordability

and personalization

Rapidly evolving market forces create

changing roles and responsibilities for all stakeholders

EVOLVING MARKET FORCES:

BEHAVIORAL HEALTH

Cost Trends

4Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna

• Costs for SUD treatment have outpaced other medical cost trends,

driven largely by OON unit cost.

2013: $4,900 INN vs. $26,500 OON 16% of Opioid Customers OON

2015: $5,700 INN vs. $36,500 OON 24% of Opioid Customers OON

• Higher medical spend for customers with chronic conditions and co-

morbid behavioral health conditions

• $429 PMPM difference – with severe mental health disorder

• $358 PMPM difference – with substance use/opioid disorder

• $190 PMPM difference – with general mental health disorder

P4P, Value Based Reimbursement, COE

NETWORK AND REIMBURSEMENT DEVELOPMENT


Cigna Collaborative Care behavioral health programs with hospitals


Reasons for changeCollaboration to achieve the Triple Aim:

Facilities

Metrics: Clinical, cost and satisfaction

Hospital compare

Traditional Model Collaborative Model

Contracting

Facilities:

Clinical metrics

Cost metrics

Quality metrics

Reimbursement for positive outcomes

More case rates; less fee for service

Rewards N/A Rate increases

Enhanced service level from Cigna

Fee-for-service

Better

quality

1

AffordabilityPatient

satisfaction

2 3

+ +

Cigna’s Response to the Opioid Epidemic


Reducing opioid

prescriptions by 25%

through advocating for

CDC guideline adoption

• Expand Narcotic Therapy Management Program

• Share with physicians their opioid prescribing profiles

• Provide just-in-time education to patients receiving opioid prescriptions

• Partner with Provider Partners in “Pledge” to follow CDC Guidelines

Pharmacy policy • Re-evaluate opioid dispensing quantity limits

• Provide feedback to physicians about their prescribing patterns in

comparison to CDC guidelines

• Update formulary and prior authorization guidelines

High risk customer

engagement

• Direct outreach to customers receiving hazardous levels

of opioid prescriptions

• Train Cigna staff interacting with customers at emerging or high risk

of Substance Use Disorder (SUD) in mental health first aid to improve

their SUD literacy

Community

comprehensive

Opioid Use Disorder

• Expand national designation program around high quality,

affordable intensive outpatient treatment programs including

medication assisted therapy

Comprehensive pain

management treatment

center network

• Identify and contract programs that provide a full range of

chronic pain management

Medication Assisted Treatment Network


Network Growth

Identify Providers

• Buprenorphine/naloxone preparations

• Vivitrol

• Methadone

1

2

3

Information Available to Physicians and Referral Sources

• Online search

• ACO and Primary Care

• Cigna Case Management Programs

Establish Reimbursement

• Fee for Service – Induction and Follow Up

• Outcomes and Value Based Contracts

Collaboration with the American Society

of Addiction Medicine (ASAM)


Rewarding health

care professionals

for using proven

therapies

Used to “test and validate” what’s

worked (and not) in substance

abuse prescribing

Provide ASAM with two years of

claims data

Used to develop guidelines for

treatment and prevention

Guidelines to Cigna Collaborative Care

doctors – incentives will shift from volume

to value, rewarding for using proven

therapies to improve patient outcomes

Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna 10

A facility in Cigna’s behavioral network that has earned a top ranking for patient

outcomes and cost-efficiency based on Cigna measures. Must be accredited by The

Joint Commission or Commission on Accreditation of Rehabilitation Facilities.

Designated Substance Use Treatment Provider

Capabilities

• Inpatient and residential,

detoxification

• Partial hospitalization program or

Intensive Outpatient program as an

optional level of care

Annual admissions

• Minimum of 25 unique treatment

episodes required for consideration

Total cost per episode

• Total dollars paid for services

Readmission rates

• Total admissions within 30, 90

and 180 calendar days of

original admission must be

10% or less

Seven-day ambulatory follow up

• Number of face-to-face

outpatient visits with licensed

behavioral practitioner within

seven days of discharge

Selected based on five health outcomes and cost-efficiency metrics:

INTEGRATION WITH MEDICAL CARE


Collaborating with large physician groups


Dedicated toll-free line

Release of information

GeoAccessreports

Claim and coverage validation

Integrating

behavioral

capabilities

Release behavioral

health information

• Get complete patient

information including

behavioral and

substance use

diagnoses

Dedicated 800 #

• Specially trained teams

of Cigna Behavioral

Health staff

• Patient’s benefit details

• Review patient care with

licensed clinical staff,

including psychiatrists

GeoAccess reports

• Identify in-network

behavioral professionals

• Maps of therapy,

psychiatry, and

behavioral health

services close to

practice

Claim and coverage

policy validation

• Receive current

policies according to

contracted services

and provider types

Integrating behavioral care with primary care means patient

is helped faster and costs are reduced

Making behavioral health integration financially viable


• G0502 Initial psych care mgmt, 70 min

• G0503 Subsequent psych care mgmt, 60 min

• G0504 Initial/subsequent psych care mgmt, additional 30 min

• G0507 Care mgmt. services, min 20 min

G codes can be billed by the treating primary care provider (PCP) and are intended to incorporate the services of all members of the collaborative care team as incident-to services of the PCP

Health & Behavior (H&B) codes: 96150-52:

Value Based arrangements:

• Reimburse for biopsychosocial assessment and brief intervention to address issues impairing a patient’s ability to manage a medical illness

• Reimbursable to behavioral providers who are not actively engaged in the diagnosis and treatment of behavioral health condition

• Activities performed by licensed behavioral staff that cannot be billed fee for service including high-acuity screening, psychosocial assessments, treatment plan coordination, family and caregiver support, educational groups, peer to peer consultation and education; medical and behavioral activities should be documented in a shared EMR

• Paid on a pmpm basis and based on performance metrics

Behavioral Telehealth

Reimbursement


> Telephonic: 99441, 99442, 99443: telephone services

provided by a physician to an established patient. The

patient must initiate the contact as these codes may not

be used for calls initiated by a provider

> Video: 99444: video services provided by a physician to

an established patient

CPT CODES

> 98966-98968: telephone services performed by qualified non-physician health

care professionals. Not covered by Medicare

> E/M 99201 to 99205: Codes for new patient encounters, require referral,

requires documentation of level of complexity

> E/M 99211 to 99215: Codes for established patients, requires documentation of

level of complexity

> Traditional BH CPT codes: 90832, 90792…

> GT, GQ, 95 modifiers

Virtual Healthcare - Headwinds


Barriers to HCP entry into Virtual Healthcare are too high (technology / payment)

HCP reimbursement

•72% of physicians and 45% of ACOs offering telehealth services are not reimbursed by any

commercial payer

Technology

•HIPPA

•No standard platform

•Ability to electronically share telehealth encounter information to HER

telehealth vendor networks - finding the right balance of services to extend

•Do we need to re-contract for minor medical conditions, or reimburse same rates as in person?

telehealth policy - Emerging and inconsistent regulation of telehealth services

•Lack of reciprocity in medical licensing across state lines

•Some states require an in-person encounter after a telemedicine encounter

•Drug prescription as a result of diagnosis via telehealth is regulated or prohibited in some states

Confidentiality and liability concerns of HCP offering services via telehealth

Cost-save or driver?

•Challenging to identify the cost of paying doctors for services they are providing gratis today (e.g.

prescription refill over the phone)


A TRANSFORMATIVE APPROACH

COST

QUALITY

SATISFACTION

COLLABORATION IS KEY.

CHANGE THE MODEL. IMPROVE VALUE.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company,

Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo,

and other Cigna marks are owned by Cigna Intellectual Property, Inc.

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