preparing specialty provider organizations for value … nina marshall, msw senior director, policy...

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www.openminds.com15 Lincoln Square, Gettysburg, Pennsylvania 17325

Phone: 717-334-1329 - Email: [email protected]

The 2017 OPEN MINDS Executive Leadership RetreatSeptember 28, 2017 | 2:00 pm – 3:15 pm

Ken Carr, Senior Associate, OPEN MINDS

Preparing Specialty Provider Organizations For Value-Based Reimbursement: An Overview Of Competencies Required For Success


I. Why Value-Based Reimbursement Is So Important (& What You

Need To Do To Prepare)

II. Four Domains For Assessing Value-Based Reimbursement

Readiness

III. Value-Based Care In Action: Nina Marshall, Senior Director, Policy

and Practice Improvement, National Council for Behavioral Health

IV. Value-Based Care In Action: Pamela Mattel, LCSW, Chief

Operating Officer, Acacia Network

V. Questions & Discussion

Agenda

I. Why Value-Based Reimbursement Is So Important (& What To Do To Prepare)


The Transition From Pay-For-Volume to Pay-For-Value

About 40% of 2014 commercial health plan

reimbursements to provider organizations

linked to value-oriented initiatives;

compared to 11% in 2013

Encourages the use of new treatment

technologies and tech-enabled platforms for

service delivery

Fee-For-Service

Case Rates &

Bundled Payments

Capitation &

Population

Payments

Pay-For-

Performance (P4P)


Why More Value-Based Purchasing (Risk-Based Contracting & P4P Contracting)?

• Increase “pressure” for improvement

• Facilitate consumer-directed care

Increase 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


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 is

doing more

Business Model:

Giving the

consumer (and

their payer) good

outcomes at a low

cost, conveniently

A Revolution In

Performance

Management

Required

Four Domains For Assessing Value-Based Reimbursement Readiness


1. Financial Management & Leadership/Governance Structure

• Alignment of strategy with infrastructure and resources

2. Technology & Reporting Infrastructure Functionality

• Data leveraged to gain insight

3. Provider Network Management & Clinical Performance Optimization

• Data analyzed to drive clinical decision-making

4. Consumer Access, Customer Service, & Consumer Engagement

• Processes to empower consumers and create engagement

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


1. Seven Key Competencies Of Organizational Leadership, Infrastructure, & Financial Management

1. Strategic

Alignment Around

Population Health

2. Culture Of

Innovation

3. Workforce

Adequacy

4. Revenue Cycle

Effectiveness

5. Encounter

Reporting

6. Value-based

Payment

Capabilities

7. Financial

Performance

Monitoring

Domain #1


2. Seven Key Competencies Of Technology Infrastructure Functionality

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 Health

Care Information

5. Care

Management

Functionality

6. Consumer Portal

Functionality

7. IT Performance

Monitoring

Domain #2


3. Six Key Competencies Of Provider Network Management & Clinical Performance Optimization

1. Provider Organization

& Professional

Recruiting &

Credentialing

2. Care Coordination &

Care Management

3. Consumer Screening,

Care, Provider Referrals,

& Case Authorizations

4. Decision Support &

Care Standardization

5. Integration of

Physical Health,

Behavioral Health, &

Social Services

6. Clinical Performance

Tracking, Assessment, &

Optimization

Domain #3


4. Seven Key Competencies Of Consumer Access & Customer Service Functionality

1. Consumer-

Informed Access

To Services

2. Automated

Consumer Service

Functionality

3. Mobile Health

Applications

4. Consumer

Wellness Support

5. Appeals &

Grievance

Procedures

6. Customer

Satisfaction

Feedback

7. Consumer

Performance

Metrics

Domain #4

National Council for Behavioral Health

Nina Marshall, Senior Director, Policy and Practice Improvement,



Preparing Specialty Provider Organizations For Value-Based Reimbursement: An Overview Of Competencies Required For Success

Nina Marshall, MSW

Senior Director, Policy & Practice Improvement



In New York State:Care Transitions Network

for People with Serious Mental Illness

Goals:

• Increase readiness for VBPs

• Decrease readmission rates

29 Practice Transformation Networks

National Transforming Clinical Practice Initiative


Value-Based Payments –Steps & Change Framework

Set Aims

Use Data

to Drive

Care

Achieve

Progress

on Aims

Benchmar

k Status

Thrive as

a Pay-for-

Value

Business

Continuous,

Data-Driven

Quality

Improvement

Patient- and

Family-Centered

Care Design

Sustainable

Business

Operations


Where Do You Start: Practice Assessment Tool

Developed by CMS

Used to assess preparedness for VBP

arrangements

–22 milestones tied to VBP competencies

– Evaluates progression through the five phases of

transformation

Results:– Can inform organizational focus and priority sequencing


Most Common Gaps

Financial data transparency

Met targets and sustained improvements for one year

Reduced unnecessary tests

Developed a vision and plan with specific clinical and utilization aims

Reduced unnecessary hospitalizations

Built QI capacity and empowered staff to use it

Has an organized QI approach

Works with primary care to develop criteria for referrals and

communication


Breaking Down Milestone 1

Practice has met its targets and has sustained improvements in practice identified metrics for at least one year:

0. Practice has identified the metrics it will track and has collected baseline information on these metrics

1. Practice is monitoring the metrics but it is not yet showing improvement in all of them

2. Practice has shown improvement… but has not reached its targets or improvement in not yet sustained

3. Practice has met at least 75% of its targets and sustained improvements for at least one year


Organization A.

Reduced

unnecessary

hospitalizations

Formal approach

for patient and

family feedback

Criteria for referrals

with primary care

Use of evidence-

based protocols or

care maps

Build QI capacity

and empower staff

to innovate

Shares financial

data in a

transparent

manner


Tools to Accelerate Change

Practice Assessment Tool

Value-Based Payment Planning Guide

Risk Stratification Tool

Chronic Conditions Cost Calculator

Technical Assistance:

– Practice Transformation Academy

– Networks through the Transforming Clinical Practice Initiative

Available at www.CareTransitionsNetwork.org and via www.TheNationalCouncil.org

http://www.caretransitionsnetwork.org/

http://www.thenationalcouncil.org/


Bridge: Destination Unknown

Image source: Kelley Grayson, Envolve, 9/5/17 for

National Council’s Practice Transformation

Academy


Developmental

– Improvement of what is

Transitional

– Movement towards well-defined new

state

Transformational

– New state is largely unknown

Types of Change


Questions?

Nina Marshall Sr. Director, Policy & Practice

Improvement

[email protected]

g

mailto:[email protected]

Acacia Network

Pamela Mattel, LCSW, Chief Operating Officer, Acacia Network

VBP Readiness

Progress Report

Acacia Network

Pamela Mattel LCSW

Chief Operating Officer

AIM

Reduce readmissions by 25%

for high risk patients presenting at the detoxification unit

Comparison

Volume Value

• Units of Service

• 2016 628/month

• 2017 782/month

• Admissions

• 2016 1877/156 month

• 2017 1424/178 month

• Financial Performance

• 2016 (315,489) 12 months

• 2017 475,797 7 months

• Process metrics

• Outcome metrics

• Readmissions <5

• 2016 16 patients

• 2017 28 patients

• Quality Payment

Value

9/11/2017 Pilot 1 Pilot 2 Pilot 3

PCP Confirmed 56% 82% 74%

Against Medical Advice 35% 10% 14%

Decreased Dosage 31% 51% 47%

Rehab Admission 10% 13% 26%

All Confirmed Referral

Appointment Kept 46%

Risk Assessment Low 24% Low 27%

Medium 41% Medium 56%

High 12% High 16%

High Utilizers

Overview

Demographic CharacteristicsFACTOR P1 P2 P3 P4 P5

Age 43 62 37 46 61

Gender Male Male Male Male Male

Race Hispanic Hispanic Hispanic Hispanic Hispanic

Housing Status Homeless Lives with Family Homeless Homeless Lives alone

Age of Subst. Abuse

Initiation

16 21 15 12 25

Family Information -No children

-Unmarried

-No children

-Unmarried

-No children

-Unmarried

-1 Child 15 y/old

-Widow

-No children

-Unmarried

Current Care Coordination Health Home

(Enrolled)

Effc 7/1/2017

Not enrolled Not enrolled Health Home

(Enrolled)

Effc 9/1/2013

Table 1

8

9

78

7

5

3.8

4.5

3.8

3

0

2

4

6

8

10

P1 P2 P3 P4 P5

Detox Admissions Vs. Length of Stay

# Acacia DetoxAdmissions

Average Length ofDetox Stay (Days)

Integrated View Of All Inpatient Admissions

Past 12 month (Psyckes Data)

0

5

10

15

20

25

30

35

P1 P2 P3 P4 P5

8

16

6

17

1

1

10

2

9

0

8

9

7

8

7

Medical ER Visits Acacia Inpatient Detox

CLINICAL FINDINGS:

Co-occurring Medical conditions: The frequency of hospital admissions in the past 12 months

were very similar for patient 2 and 4, with an average of 34 inpatient admissions. Most

hospitalizations were for a mental or physical illness, not SUD treatment. For these medical

admissions the most co ocurring medical diagnoses among all 5 patients were: Hypertension and

Hepatitis. Some other chronic conditions identified: were Asthma for 3 patients and Acute

Kidney Failure for 2.

Co-ocurring Substance Abuse Diagnosis: Opiod Dependence was the common substance

abuse diagnosis present in all 5 patients.

Co-occurring Mental Health conditions: Our review shows a common mental health

diagnosis : Unspecified Depressive Disorder. This was true across all five patients. Aditionally 3

patients presented with a secondary Dx of :Unspecified Bipolar.

Social Determinants of Health: Significant lack of family and social support, homeless,

unemployed.

Data Driven Decision Making“Judgement Free”

• Project influences the data set

• Focus data collection

• Patient Outcome Focused

• Readmissions

• AMA

• Continuity of Care

• Analysis

• Avoid rush to consensus and solutions

• Rapid Cycle Changes

• Data Analyst Resource Investment

Payor Relationship

• Position as collaborative, motivated, acknowledgment of VBP learning curve

• Agree and Set the Pace

• Leverage MCO/MBHO expertise, data and resources for successful transformation to VBP adoption

• Align with their Financial and Patient Outcome Interest

• Reduce ER and re-admissions by 25%

• Agree on a Realistic Target Project

• Reduce readmissions by 25% for high risk patients presenting for detoxification

• Discuss variables that make up the project from both sides

• Patient demographics, current performance, financial models

• Review their data on the program to learn more about what they are measuring and care about

Payor Relationship, cont.

• Agree on initial set of metrics for pilot study

• AMA

• PCP identification and notification

• MAT dosage for stabilization

• Appointment kept at next level of care

• Schedule recurring calls/meetings to review

• Be bold with data and transparency

• Ask for technical assistance

• CMO dialogue with Program Medical Director

Clinical Pathways and Risk Stratification

• Be fearless discovering inefficiencies and poor outcomes

• Initial AMA rate 36% 38/104 Pilot #2 10% 7/82

• Initial referral rate 27% 28/104 40% 33/82

• Listen to patients, and then listen to them again and again

• Listen to staff about pain points

• Look for other areas to improve

• Use formal health risk assessments inform clinical pathway redesign

• Low Medium High

Lessons Learned

• Team based approach with diverse group

• Follow the data

• Support staff to be inquisitive first

• Delay solutions until confident

• Test quickly and keep high degree of urgency

• Find the right payor, the right person and develop a trusting partnership

Next Steps

• Deep Dive into Financial Performance

• Cost drivers

• Cost reduction strategies

• Cost per patient

• Financial Management System

• Advanced Data Collection and Analysis

• Shadow Risk Arrangement

• Program Cultural Shift

• Significant Investment in Professional Technical Assistance on HIT, Financial Systems, Clinical Pathways

Questions & Discussion

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preparing specialty provider organizations for value … nina marshall, msw senior director, policy...

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