quality mental health care in a value-based environment

1© 2015. All Rights Reserved.

www.openminds.com163 York Street, Gettysburg, Pennsylvania 17325Phone: 717-334-1329 - Email: [email protected]

June 2, 2016

Presented by:Robert Teitt, Vice President of Technology & Business Development, Askesis Monica E. Oss, Chief Executive Officer, OPEN MINDS

Quality Mental Health CareIn A Value-Based Environment: Keeping The Vision Beyond Mental Health Month


Reorganization Of The “Value Chain” Of Health & Human Services Is Underway

Health Care Reform & Parity

Legislation

New Science

Focus On “Super-Utilizer”

Outcomes & Cost

Value-Based Contracting

Reorganization of the financing and delivery of health

and human services – with

many implications for consumers with mental disorders, addictions, and

cognitive disabilities…


The Regulatory & Policy Effects Of PPACA & Parity. . .

Drop in the uninsured population

Parity legislation provides financial equity in mental health and addiction treatment benefits for almost all Americans with health insurance

The Affordable Care Act -Over 80 provisions Effective Between 2010 & 2014

Expanded consumer access --expanded Medicaid coverage, health insurance exchange, and essential health benefits

Insurance coverage reform --minimum medical loss ratios (MLR) for insurers; pre-existing condition exclusions and lifetime limits prohibited

Integrated care coordination models -- Medicaid health homes and accountable care organizations in Medicare

Pay-for-performance --Medicare value-based purchasing initiatives and penalties for high rates of hospital readmissions


Medicaid & Medicare Are Now Larger Payer Than Commercial Insurance – With More Managed Care

Medicaid: 16% ($480 billion)12 of total U.S. health care spending. 55 million Americans on Medicaid13, or 19.5% of total insured populations14.

Medicare: 20% ($618.7 billion)15 of total U.S. health care spending. 54 million beneficiaries16, 16% of total insured population17.

Insurance Category20 Total Enrollment (Millions)

In Managed Care(Millions) % Managed Care

Medicare, 65+ 43.3 15.7 30%Medicare, Dual 9.6 2.9 30%

Medicaid 54.9 40.7 74%Commercial Insurance 172.7 171.0 99%

Military Insurance* 6.3 4.3 68%Uninsured* 33.9 N/A N/A

Total U.S. Population: 320,769,714


PPACA & Market Price Pressure Set The Course Toward Pay-For-Value

Compensation Continuum By Level Of Financial Risk

Capitation + Performance

-Based Contracting

CapitationShared Risk

Shared Savings

Bundled & Episodic

Payments

Performance-Based

Contracting

Fee-for-service

Small % of financial risk Moderate % of financial risk Large % 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


Moving To Pay-For-Value Across All Payers

Commercial health plans

State Medicaid plans

MedicareGovernment social service

agencies


Medicare Pay-For-Value InitiativesMedicare Advantage

Optional consumer health plan enrollment (instead of FFS)

Medicare ACOs Assignment of Medicare FFS beneficiaries into ACOs for the purpose of population health management

Medicare Bundled Rate Program

Range of case rates

Medicare FFS Realignment

Reduced volume of FFS payments to providers


“Next Gen” ACOs


Current Medicare ACO ModelsMedicare Shared Savings Program (MSSP) Under this program, ACOs have the choice of three different risk tracks. The MSSP is one of two ACO models that CMS is still accepting new ACOs.

Next Generation ACO Model The Next Generation ACO is similar to the pioneer model ACO and requires ACOs to take on a greater amount of risk than the MSSP program. 21 ACOs under this model begin operating January 1, 2016. A second round of ACOs will begin operation on January 1, 2017.

Telehealth expansion permitted: ACOs may provide telehealth services to all beneficiaries regardless of where they reside. Currently, CMS only allows telehealth to be provided to beneficiaries who live in rural areas.

Post-discharge home visits permitted: Within 10 days of beneficiary discharge from an inpatient facility, providers under the general supervision of the ACO may bill for “incident to” services provided at the beneficiary’s home.

SNF 3-day waiver rule: Beneficiaries may be directly admitted to a SNF without a 3-day inpatient stay, as currently required by Medicare.

ACOs Started In Medicare But Widely Adopted By

Health Plans

There are now over 800 public and private ACOs in all 50 states

• 436 Medicare ACOs • 316 Commercial ACOs• 62 Medicaid ACOs

67% of Americans live in an area with ACO coverage

25-31 million Americans (17% of the population) receive care through ACOs

• 2.4 million in Medicare ACOs

• 15 million non-Medicare patients in Medicare ACOs

• 8-14 million patients of non-Medicare ACOs


Medicaid Pay-For-Value InitiativesMedicaidManaged Care

For health care and long-term services/supports

Medicaid ACOs Assignment of Medicaidbeneficiaries into ACOs

Medicaid Health Home Program

PMPM for care coordination services

Medicaid WaiverProgram

Reduced volume of FFS payments to institutional provider organizations


Medicaid ACOs By State State Beneficiaries

Colorado 609,051

Illinois N/A

Iowa 35,000

Maine 30,000

Minnesota 175,000

New Jersey 122,782

Oregon 853,897

Utah 238,255

Vermont 64,515

http://www.chcs.org/project/medicaid-accountable-care-organization-learning-collaborative-phase-iii/


Medicaid Health Homes 19 states have health home

amendments to their Medicaid state plan

1,000,000+ enrollees

Use Of Medical Homes & Health Homes In MedicaidMedical homes/health homes manage the health of a population, typically receiving PMPM reimbursement with performance incentives. Medical Home, aka patient-centered

medical home (PCMH), coordinates the overall health care needs of a broad population

Health Home, defined in Section 2703 of ACA, offer coordinated, team-based care to individuals within a specific population – usually with multiple chronic health conditions including mental health and substance use disorders. * Alabama, District Of Columbia, Idaho, Iowa, Kansas, Maine,

Maryland, Michigan, Missouri, New Jersey, New York, North Carolina, Ohio, Oklahoma, Rhode Island, South Dakota, Vermont, Washington, West Virginia, Wisconsin.


13 states have implemented (9 in planning phase), most with a capitated model

Two states (Colorado and Washington) have MFFS model One state (Minnesota) with alternative model

States Participating in Medicare/Medicaid Financial Integration Via Managed Long-Term Services & Supports


Focus On “Superutilizer” Care Coordination To Increase Value Of Health Expenditures

• $43,212 average expenditure per person per year

5% of U.S. population

account for half (49%) of health care spending

• $253 average expenditure per person per year

50% of U.S. population

account for only 3% of health care

spending

“Superutilizers”

Shorthand term for people with

complex physical health, behavioral health, and social issues who have

high rates of utilization for ER

and hospital services2


Adoption Of Coordinated Care Models Across Medical, Behavioral, & Social Systems

Social

Behavioral

Medical

Social

Behavioral

MedicalNew service

model: single “vertical” care coordination program for

each consumer

New service model: behavioral

health services “imbedded” in

primary care for mild/moderate

conditions


New Bioscience

Genomics and ‘personalized medicine’

Epigenetics

Diagnostic tools

Treatment tools

Cheap & Ubiquitous Technology

Consumer connectivity

Web tools

Data exchange

“Big data”

The Synergistic Effects Of New Science & Technology


Payer & Consumer Expectations Changed By Technology = Expectation Of ‘Consumer Sovereignty’

The synergy of new technologies allows. . .

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

Interoperable electronic record-keeping systems capture health

information

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


The First Big Question – What Does This System Change Mean For Quality? We’ve redefined quality. . . quality of value-based reimbursement is monitoring access/underutilization, experience, and health outcomes1. Consumer sovereignty in an era of rising

consumer payments2. The trickle down effect of health plan ratings

–NCQA HEDIS–CMS Stars

3. Transparency – both curated and open source


Consumer Sovereignty. . . .a policy which assumes that the best profit will come from providing customers with the best products and best customer service at the lowest possible price. . . How do health and human service organizations use “consumer sovereignty” to remake their services?

– The first step is to understand who the consumers are.

– Then, how they use services and why.– And, finally, to understand what they value

and what they don’t.

All about metrics. . . .


Health Plan Quality - NCQA’s HEDIS MeasuresEffectiveness of Care Measures

– Antidepressant medication management

– Follow-up care for children prescribed ADHD medication

– Follow-up after hospitalization for mental illness

– Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications

– Diabetes monitoring for people with diabetes and schizophrenia

– Cardiovascular monitoring for people with cardiovascular disease and schizophrenia

– Adherence to antipsychotic medications for individuals with schizophrenia

– Metabolic monitoring for children and adolescents on antipsychotics

– Use of multiple concurrent antipsychotics in children and adolescents

Access/Availability/Utilization Of Care Measures

– Initiation and engagement of alcohol and other drug dependence treatment

– Use of first-line psychosocial care for children and adolescents on antipsychotics

– Utilization of the PHQ-9 to monitor depression symptoms for adolescents and adults

– Identification of alcohol and other drug services

– Mental health utilization


21

Health Plan Quality - CMS Star Health Plan Ratings: Based On 49 Total Measures

Domain Number Of MeasuresStaying healthy: screenings, tests, and vaccines 13

Managing chronic (long term) conditions 10

Drug plan customer service 7

Ratings of health plan responsiveness and care 6

Health plan member complaints, appeals 4Drug pricing and patient safety 4

Health plan telephone customer service 3

Drug plan member complaints, members who choose to leave, and Medicare audit findings

3

Member experience with drug plan 3

22© 2015. All Rights Reserved.© 2015 OPEN MINDS. All

rights reser ed22


23


No Stakeholder

Unaffected By Restructuring Of The Value

Chain

Consumers

Provider Organizations

& Systems

Health Plans

FQHCs & CMHCs

Professionals

CountiesThe ‘effects’ are different in states that

have expanded Medicaid

versus those that have

not

The Second Big Question – What Does This Mean For Stakeholders In The System?


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


Issues For County Planning Changing ‘safety net’ role in states that have expanded

MedicaidMore demand for uncompensated services in states that have

not expanded services Challenges for units of government that deliver direct

consumer services – collaboration, consumer experience, risk assumption, technology investments, unit cost management, etc. Need to develop preferred models for collaboration – with

‘defined boundaries’ -- between health (medical/behavioral) and social service systems


Considerations For CMHCs & FQHCs1. Creating model for participation in vertically integrated health

systems -- both delivering and financing care

2. Creating model for delivering ‘seamless’ consumer experience for integrated behavioral/primary care experience – that meets consumer convenience expectations

3. Capitalizing expenditures for new technology and systems

4. Privatization of the medical home/health home role

5. Effects of possible assumption of targeted case management role by Medicaid health plans

6. Effects of the creation of new primary care models by Medicaid health plans

7. Disruptive effects of widespread telehealth – for both behavioral consultation and for primary care

8. Diminishing ‘direct’ funding as more of the population is insured

More unpaid

demand for

services in states that have not expanded Medicaid


Professional Practice Options ChangingUse of clinical

decision support tools in population health management


Business Model Transition For Provider Organizations

Payer Policy = Pay For Cost Or Volume

Payer Policy = Pay For Value

What is paid for is good for the consumer -

- and doing more is the

business model

Giving the consumer (and

their payer) what they want and need is the business model

Good outcome at low cost –

conveniently

A revolution in performance management

required


New Strategic & Management Considerations For Provider OrganizationsAssume risk in caring for defined populations

Integrate behavioral health and medical care

Develop wellness programs that improve health and reduce medical costs

Engage increasingly value-conscious consumers

Accelerate the adoption of innovations that improve the value of health care and reengineering the delivery of services

Explore the capital models required to finance this transition

Identify change management skills and competencies that leaders need to make this happen


Closing Thoughts. . .

“Opportunity is missed by most people because it is dressed in overalls and looks like work.”

- Thomas Edison

“It is not the strongest of the species that survives… It is the one that is most adaptable to change.”

- Charles Darwin

www.openminds.com163 York Street, Gettysburg, Pennsylvania 17325Phone: 717-334-1329 - Email: [email protected]

Chronic Care Management ▪ Disability Supports & Long-Term Care ▪ Mental Health Services ▪Addiction Treatment ▪ Social Services ▪ Intellectual & Developmental Disability Supports ▪Child & Family Services ▪ Juvenile Justice ▪ Adult Corrections Health Care

quality mental health care in a value-based environment

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