Telehealth – What Will The Payers Change Post-COVID-19? Let’s Ask Them

This presentation was delivered on August 26, 2020 at The 2020 OPEN MINDS Management Best Practices Institute. In the presentation, the speakers discussed future reimbursement models and expected outcomes post-pandemic; how the payer focus on quality and performance will expand; and how you can collaborate with payers as they navigate a path to recovery.

The presentation speakers included:

  • Amy Pearlman, Vice President, Clinical Provider Strategy, Beacon Health Options
  • Roberta Montemayor, Regional Network Manager, OptumHealth Behavioral Solutions
  • Sean Schreiber, Executive Vice President, Network & Community Health, Alliance Health
  • Deb Adler, Senior Associate, OPEN MINDS

Navigating The Crisis – Best Leadership Practices To Survive A Crisis & Emerge As A Market Leader

This presentation was delivered by OPEN MINDS Chief Executive Officer Monica E. Oss on August 26, 2020 at The 2020 OPEN MINDS Management Best Practices Institute. In the presentation, Ms. Oss discussed best practices for managing the mechanics and the financials for reopening; how to manage uncertainty; and how to map out a strategy, a detailed operating plan, and good cash flow projections to make thinking differently a successful reality.

Download Resource

How To Build Value-Based Payer Partnerships: Best Practices In Marketing, Negotiating & Contracting With Health Plans

This presentation was delivered by OPEN MINDS Senior Associate Paul M. Duck on August 24, 2020 at The 2020 OPEN MINDS Management Best Practices Institute. In the presentation, Mr. Duck discussed how to develop relationships with the payers in your market, initiate strategic conversations, demonstrate value, and secure and optimize service agreements. He also discussed how to help payers meet their performance requirements, align your programs and services with their goals, and provide data to show that your service lines can deliver quality outcomes with lower costs.

Download Resource

Alternative Payment Methods For Behavioral Health Associated With Lower Utilization

Alternative payment methods (APMs) for mental health and addiction disorder treatment are associated lower behavioral health service utilization and lower spending, as well as improvements in process of care outcomes, according to a review of evaluations of 17 APM implementations. Of the 17 APM implementation evaluations, 11 assessed utilization changes and five found lower utilization. Eight evaluations assessed spending, and half found an association with lower spending. Fifteen evaluations assessed process of care, and 12 reported statistically significant improvements due to the APM.

Among the five APM evaluations that assessed clinical outcomes, three reported improvements. Although data on clinical outcomes was scarce in the APM evaluations, pay-for-performance APMs were associated with improved behavioral health outcomes. APMs with shared savings were not.

The 17 APMs spanned three broad types: fee-for-service (FFS) with links to quality and value, APMs built on FFS architecture, and population-based payments. Within each broad type, the implementations could take different approaches and serve different populations. Nine targeted people with addiction disorder, four targeted people with mental health disorders, and the remaining four targeted both mental health and addiction disorder. Eleven of the APM implementations specifically focused on adults, and two specifically targeted children and adolescents.

17 Alternative Payment Methods Focused On Behavioral Health

Implementation Type Population

Outcomes Evaluated

FFS With Link To Quality & Value

Sustaining Healthcare Across Integrated Primary Care Efforts Program Foundational payments for infrastructure and operations Medicare, Medicaid, and individuals with dual eligibility; all ages Mental health and addiction treatment, processes of care and spending
Adolescent Community Reinforcement Approach Pay-for-performance Publicly funded SUD programs; child and adolescent Addiction treatment, processes of care, clinical outcomes, and spending
Spectrum Addiction Services Pay-for-performance Medicaid and uninsured; adult Addiction treatment, processes of care
Outpatient Psychosocial Counseling Treatment Center In Maryland Pay-for-performance Publicly funded addiction treatment programs; adult Addiction treatment, processes of care, clinical outcomes, and adverse selection
Washington State Mental Health Integration Program Pay-for-performance Medicaid; adult Mental health, processes of care, clinical outcomes, and adverse selection
Connecticut’s Behavioral Health Partnership Pay-for-performance Medicaid; child and adolescent Mental health and addiction treatment, process of care

APMs Built On FFS Architecture

Medicare Shared Savings Program Accountable Care Organizations APMs with shared savings Medicare; adult Mental health and addiction treatment; processes of care, clinical outcomes, spending, utilization, and adverse selection
Maine Medicaid Accountable Communities Initiative APMs with shared savings Medicaid; adult Mental health and addiction treatment; processes of care, spending, and utilization
Vermont Medicaid Shared Savings Program APMs with shared savings Medicaid; all ages Mental health and addiction treatment; processes of care, utilization, and adverse selection
Medicare Pioneer Accountable Care Organizations APMs with shared saving and downside risk Medicare; adult Mental health; processes of care, clinical outcomes, spending, utilization, and adverse selection
Minnesota Integrated Health Partnerships Program APMs with shared saving and downside risk Medicaid; all ages Mental health and addiction treatment; processes of care, spending, and utilization

Population-Based Payment

Delaware Division of Substance Abuse and Mental Health–Outpatient Services APM Condition-specific population-based payment Publicly funded addiction treatment programs; adult Addiction treatment; processes of care, utilization, and adverse selection
Delaware Division of Substance Abuse and Mental Health–Detoxification Care Transition APM Condition-specific population-based payment Publicly funded addiction treatment programs; adult Addiction treatment; utilization, and adverse selection
Maine Addiction Treatment System, phase 1 of performance-based contracting Condition-specific population-based payment Publicly funded addiction treatment programs; adult Addiction treatment; clinical outcomes, utilization, and adverse selection
Maine Addiction Treatment System, phase 2 of performance-based contracting Condition-specific population-based payment Publicly funded addiction treatment programs; adult Addiction treatment; process, utilization, and adverse selection
BCBSMA Alternative Quality Contract Comprehensive population-based payment Commercial; adult Mental health; process of care, spending, and utilization
Oregon Coordinated Care Organizations Comprehensive population-based payment Medicaid; adult Addiction treatment; process of care

These findings were reported in “Association of Alternative Payment and Delivery Models With Outcomes for Mental Health and Substance Use Disorders; A Systematic Review” by Andrew D. Carlo, M.D., MPH; Nicole M. Benson, M.D.; Frances Chu, MSN, MLIS; et al. The researchers analyzed 27 articles published from January 1, 1997 to May 17, 2019, on 17 APM implementations in behavioral health care. The goal was to review and summarize the published literature on APMs for people with behavioral health conditions to evaluate the impact of the APM on behavioral health outcomes or changes in service delivery. The articles each assessed at least one mental health or addiction treatment outcome in comparison to a control group. The researchers concluded that their review identified some evidence for APM effectiveness for behavioral health care; however, more research is needed to identify successful program components and associations with clinical outcomes.

The full text of “Association of Alternative Payment and Delivery Models With Outcomes for Mental Health and Substance Use Disorders; A Systematic Review” was published July 23, 2020 by JAMA Network Open. A free copy is available online at (accessed August 17, 2020).

For more information, contact: Andrew D. Carlo, M.D., MPH, Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 446 East Ontario Street, #7-200, Chicago, Illinois 60611; Email:; Website:

VBR: Are You Walking In Your Customer’s Shoes?

Despite the significant upset to the health and human service system caused by the pandemic crisis, the move to value-based reimbursement (VBR) seems to be moving along. On June 3, The Centers for Medicare and Medicaid Services (CMS) announced adjustments to 16 value-based care (VBC) models, with goals of accounting for COVID-19-related changes in health care delivery (and the uptick in costs), as well as allowing more time for participating provider organizations to transition to VBC (see CMS Makes COVID-19-Related Changes To Value-Based Care Models). And, on June 19, CMS issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based payment (VBP) arrangements with drug manufacturers (see CMS Proposes Regulatory Changes To Promote Medicaid Value-Based Drug Purchasing).

At the health plan level, most recent was the launch of Blue Cross and Blue Shield of North Carolina’s “Accelerate to Value” program to help primary care practices deal with COVID-19-related financial challenges (see Blue Cross Of North Carolina Launches Program To Pay Primary Care Practices To Switch To Value-Based Model). The program, which requires primary care practices to commit to transitioning to VBC by the end of 2020, provides financial stabilization payments based on the practice’s 2019 revenue.

Over the past few months, we’ve seen similar initiatives emerge from BlueCross BlueShield of Western New York (BCBSWNY) (see BlueCross BlueShield & Value Network Partner To Start Behavioral Health Value-Based Payment In Western New York), the Pennsylvania Clinical Network with Geisinger Health Plan (see PA Clinical Network & Geisinger Health Plan Announce Value-Based Contract Agreement), and Aetna (see Pennsylvania Clinical Network Signs Value-Based Contract With Aetna Medicare Advantage Plan).

What this means for provider organization recovery strategy depends on the organization’s current market positioning. The likely impact of the impending payer budget crunch (both government and employer) is more managed care and more value-based reimbursement arrangements. But that will vary by specialty, by consumer type, and by geography. Many provider organization executive teams are not waiting to see what comes their way. They are using changing reimbursement as a market positioning advantage for their post-recovery strategy.

For example, Heal announced the launch of a new “health assurance” offering called “Heal Pass”—a monthly subscription of $49 dollars where enrollees receive eight physician house calls, annual physicals, and next-day shipping on medications prescribed by a Heal clinical professional (see Heal Launches New ‘Health Assurance’ Offering). And, Talkspace has a number of subscription options that consist of unlimited texting, live sessions, or therapy options geared toward specific populations including couples and adolescents—ranging from a rate of $260 per month to $396 per month (see How Much Does Talkspace Cost?).

The question for executive teams is to evaluate whether a proposed non-fee-for-service reimbursement model would be better for market positioning—with more revenue and/or greater profitability. To evaluate that question, executive teams need an external perspective—good customer perspectives on what they need and how they prefer to pay for those services. But equally as important, executive teams need to understand the costs of their services, not only by unit of service but by type of consumer over time.

Ken Carr, Senior Associate, OPEN MINDS

And my colleague and OPEN MINDS Senior Associate Ken Carr believes that our traditional view of VBR—reduced costs, focus on value, and consumer outcomes—needs to take on an additional dimension with the advent of models like Heal and Talkspace. Their approach to value is to identify what is important to the consumer—immediate access, price transparency, and consistent payment, with good service and outcomes implied. For provider organization managers, fee-for-service reimbursement has driven business models—filling the schedules of clinical professionals, ensuring required levels of productivity, and shaping consumer access around available office hours. And consumers have no idea how much the service costs until they receive a statement in the mail a month later. In contrast, as Mr. Carr explained, “The new approach to value must focus on ease of access—house calls, phone calls, and virtual services.” The consumer (or the health plan) doesn’t need to worry about the cost—the subscription can be worked into a monthly spending budget like a gym fee or even a Netflix subscription.

Moving to using VBR as a proactive market strategy requires setting aside past structures, and creating entirely new approaches. But how do provider organization managers begin to deal with the costs of a consumer-driven access model and set prices for these new models? Identifying the unit cost of a service and the related utilization is a starting point. But building a sustainable model will also require data on how consumers access the service, how often they use the service, and the intensity of their needs. “Provider organizations must create a structure to manage a new payment method that will lower their financial risks while better meeting consumer needs. For that, having timely data, and adjusting resource capacity is critical,” said Mr. Carr.

Mr. Carr had some more pointers for provider organizations gearing up for the shift to value in his seminar, Succeeding With Value-Based Reimbursement: An OPEN MINDS Executive Seminar On Organizational Competencies & Management Best Practices For Value-Based Contracting, at The 2020 OPEN MINDS Strategy & Innovation Institute:

At the end of the day, VBR is here to stay. As Mr. Carr explained, “Now is the time to start the transition. VBR isn’t going to be set aside or delayed as a result of the pandemic. If anything, it’s going to be adopted as a strategy to keep costs down during a time where budgets are increasingly strained.”

For more on value-based care, check out these resources in The OPEN MINDS Industry Library:

And for even more, join us at The 2020 OPEN MINDS Management Best Practices Institute for the session, Navigating Health Plans: Keys To Developing Long Term Relationships, with OPEN MINDS Senior Associate Paul Duck and OPEN MINDS Vice President Richard Louis, III.

Making Your Clinical Programs VBR-Ready

The adoption of value-based reimbursement (VBR) has been inconsistent over the past few years (see VBR – Where’s The Beef? And Where Are We On The Road To Value? The 2020 OPEN MINDS Performance Management Survey). But the consensus is that the recession that is upon us and the likely reduced federal/state budgets will drive more VBR and more financial risk transfers from managed care organizations to provider organizations (see Show Me The Value, Show Me The Money).

Dominick DiSalvo, MA, LPC, Corporate Director of Clinical Services, KidsPeace
Dominick DiSalvo, MA, LPC, Corporate Director of Clinical Services, KidsPeace

Our team does a lot of organizational assessments of ‘readiness’ for VBR—and we’ve developed a self-assessment tool to do just that. The tool (see The OPEN MINDS Value-Based Reimbursement Readiness Assessment) has several key domains including provider network management; consumer access and service engagement; financial management; leadership and governance; technology and reporting; and clinical management and performance optimization. But, readiness assessments tend to focus on the organizational management infrastructure. A big question for executive teams is whether clinical programs are ready for VBR. That was the focus of the session Creating & Managing The Clinical Models You Need For Value-Based Reimbursement, led by Dominick DiSalvo, MA, LPC, corporate director of clinical services at KidsPeace at The 2020 OPEN MINDS Strategy & Innovation Institute.

KidsPeace offers a full continuum of behavioral health care services for children and families, from serving youth in the foster care and child welfare system to providing residential treatment, accredited educational services, and a free standing psychiatric hospital. Headquartered in Pennsylvania, its services span 10 states and the District of Columbia. Between 2016 and 2017, the organization followed the state of Pennsylvania in its initial journey to VBR. Since then, KidsPeace has participated in performance-based contracting, including pay-for-performance, with payments linked to a specific set of benchmarked outcomes.

But success with VBR doesn’t come without its challenges—it requires a significant shift in both leadership mindset and organizational infrastructure. As Mr. DiSalvo discussed, “The most difficult task we have is to limit risk by finding the balance between person/family-centered care and structured programs that reduce variability in services and outcomes.” His advice? Focus on trauma-informed care; synthesize evidence-based clinical models; use data to drive clinical decisionmaking; and engage clinical professionals to engage consumers.

Focus on trauma-informed care—KidsPeace began the move to VBR by using the Trauma History Questionnaire (THQ), a 24-item self-report measure that examines an individual’s experience with possible traumatic events including crime, physical or sexual assault, and neglect. Mr. DiSalvo described this as a necessary first step in moving toward a value-based framework for care, because when trauma wasn’t factored in, the desired treatment outcomes were not being achieved. After it started to implement trauma-informed care, KidsPeace found that youth self-reported experiencing an average of 10 traumatic categories before entering the program. The new focus on trauma as an underlying cause required a considerable shift in how clinical professionals were supporting consumers—and how senior leaders were supporting clinical professionals. “This data really convinced our leadership team that we needed to have a complete change in focus—we needed to be family and youth driven, trauma-informed, and have data drive what is going on in our programs,” said Mr. DiSalvo. (For more on becoming trauma-informed, see Making Trauma-Informed Care A Scalable Reality and How ‘Trauma-Informed’ Is Your Organization?).

Synthesize evidence-based clinical models—After understanding the “value” of becoming trauma-informed to provide more effective treatment—and ultimately—more meaningful and measurable outcomes, KidsPeace completely restructured their clinical programming by synthesizing a core set of evidence-based practices within each program. The restructure allowed each individualized treatment plan to be guided by both the youth and their family—and driven by objective and relevant data—an essential part in defining “value” for each consumer. The organization adopted four clinical practice models—including trauma focused-cognitive behavioral therapy (with all clinical leadership becoming or in the process of becoming Nationally Certified Trauma Therapists); motivational interviewing (to increase motivation and engagement among youth); community living (to prepare adolescents for young adulthood and community inclusion); and individualized treatment planning. By using these four clinical models, the organization has the flexibility to provide individualized care as well as the consistency and structure to meet the needs of all youth and families that are served. (For more on evidence-based practices, see Care Delivery In A Value-Based Era – Evidence-Based, Practice-Based, Standardized & Measurement-Based and Behavioral Health Evidence-Based Practices As Population Health Management Tools).

Use data to drive clinical decisionmaking—Before they restructured clinical program models to focus on value, Mr. DiSalvo noted that KidsPeace had challenges with using data to drive treatment and decisionmaking processes. “When I had conversations with our foster care program in Indiana versus conversations with our residential program in Georgia, the way they captured data and assessed youth were very different.” To ensure consistency across all programs, no matter the location or service line, the organization moved to a corporate wide electronic health record and adopted the use of a data dashboard to visually track key metrics over time. Those metrics included discharge disposition and post-discharge follow up surveys, high risk behaviors (e.g. suicidal ideation), clinical treatment benchmarks, length of stay, and individualized score cards in graph format. The data is then broken down further by day, time of day, over time, and total score. “We’ve even gotten as granular as examining if there is a particular staff member that youth are struggling more with and if we need to provide more training.” The key quality indicators (in a simple, color-coded format) are reviewed quarterly with the senior leadership team to quickly identify any pain points and make changes to maximize program efficiency. Mr. DiSalvo explained, “Not only can we track youth individually but we are also able to track specific program progress from an aggregate level—and then make changes and help continuously improve that program.” (For more on using data to drive decisionmaking, see Don’t Underestimate The Culture Change In Becoming Data Drive and Proving Your Unique Value To Payers: Data Speaks Louder Than Words).

Engage clinical professionals to engage consumers—To truly drive optimal outcomes in value-based clinical programming, Mr. DiSalvo highlighted a final key component—engaging clinical professionals. “It’s impossible to succeed with risk-based payment models if staff aren’t engaged. If a child feels like a staff member is there simply to get a paycheck, they are not going to respond well.” Rather, a significant shift in mindset was necessary for many professionals to continuously find ways to improve the overall experience for youth, families, and staff. “Once we started to have the data inform practice, our clinicians started seeing clear, quantitative results. Once that happened, it was a ripple effect—our youth found more enjoyment in their experience. Ultimately, it’s the clinicians who then become the champions for change.” (For more on engagement, see Health Plans Invest In Consumer Engagement and Navigating The Performance Loop – Customer Service, Consumer Experience & Consumer Engagement).

Any significant transformation isn’t sustainable without embedding those changes within the organizational culture (see How Culture Makes Organizational Change Less Painful). Mr. DiSalvo discussed the importance of cultivating a cohesive culture to act as the foundation of any clinical program focused on providing value, “Our initiative at KidsPeace is to integrate all of our resources to improve safety, engagement, connection, clinical practice and outcomes for all staff, youth, and families but it doesn’t come naturally. It requires robust training and a strong understanding about what engagement actually looks like. Clinical professionals must move away from the mindset that ‘we are the ones who know best’ and understand that the family and youth are the experts. We are simply here to join them in their journey.”

My takeaway from the session is that it’s not enough to have your administrative and financial infrastructure “ready” for VBR. Making clinical programs VBR-ready is a critical aspect of strategy development for sustainability.

For more on finding and demonstrating your value, check out these resources in the OPEN MINDS Industry Library:

And for even more on best practices in establishing service standards and key performance measures, join us on October 8 at 1:00 pm EDT for the web briefing, Measuring & Improving Consumer Experience, Consumer Engagement & Consumer Performance – A Best Practice Approach, led by OPEN MINDS Executive Vice President Kimberly Bond. The web briefing is offered as part of The OPEN MINDS Executive Blueprint For Crisis Management: Building Organizational Sustainability & Success In A Disrupted Health & Human Service Market, a program designed to help executive teams prepare, respond, and navigate the disruption caused by a market in turbulence.

NCQA Adjusts HEDIS Quality Measures Due To COVID-19 Pandemic-Driven Telehealth Surge

On June 5, 2020, the National Committee for Quality Assurance (NCQA) announced adjustments to 40 Healthcare Effectiveness Data and Information Set (HEDIS) measures to support the use of telehealth during the coronavirus disease 2019 (COVID-19) pandemic and after. NCQA will apply the adjustment for measurement of health care quality starting in 2020. The adjustments align with guidance from the Centers for Medicare & Medicaid Services and other federal and state regulators.

NCQA is updating the measures in “HEDIS Volume 2 Technical Specifications,” which will be published on July 1, 2020. Telehealth revisions will be outlined in each measure specification’s “Summary of Changes” section. The guidance will specify how telehealth visits can be used, what will be included in the measure denominator and numerator, and what will be excluded. It will also specify what type of telehealth (e.g., synchronous telehealth visits, telephone visits or asynchronous e-visits or virtual check-ins) is permitted to meet the measure.

Eight of the adjustments affect behavioral health measures:

  1. Antidepressant Medication Management
  2. Follow-up Care for Children Prescribed ADHD Medication
  3. Follow-up After Hospitalization for Mental Illness
  4. Follow-up After Emergency Department Visit for Mental Illness
  5. Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medication
  6. Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia
  7. Diabetes Monitoring for People with Diabetes and Schizophrenia
  8. Adherence to Antipsychotic Medications for Individuals with Schizophrenia

The remaining measures with new telehealth accommodations concern prevention and screening, respiratory care, cardiovascular care, diabetes care, musculoskeletal conditions, care coordination, access and availability of care, utilization, and risk-adjusted utilization. The accommodations also affect measures reported using electronic clinical data systems. Within these remaining measures, some also affect behavioral health services.

Prevention and Screening

  1. Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
  2. Breast Cancer Screening
  3. Colorectal Cancer Screening
  4. Care for Older Adults


  1. Use of Spirometry Testing in the Assessment and Diagnosis of COPD
  2. Asthma Medication Ratio

Cardiovascular Conditions

  1. Controlling High Blood Pressure
  2. Persistence of Beta-Blocker Treatment After a Heart Attack
  3. Statin Therapy for Patients with Cardiovascular Disease
  4. Cardiac Rehabilitation


  1. Comprehensive Diabetes Care
  2. Kidney Health Evaluation for Patients with Diabetes
  3. Statin Therapy for Patients with Diabetes

Musculoskeletal Conditions

  1. Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis- Scheduled for Retirement
  2. Osteoporosis Management in Women Who Had a Fracture
  3. Osteoporosis Screening in Older Women

Care Coordination

  1. Transitions of Care
  2. Follow-up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions
  3. Access/Availability of Care

Access/Availability of Care

  1. Prenatal and Postpartum Care
  2. Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics


  1. Well-Child Visits in the First 30 Months of Life
  2. Child and Adolescent Well Care Visits
  3. Mental Health Utilization

Risk-Adjusted Utilization

  1. Plan All-Cause Readmissions
  2. Hospitalization Following Discharge from a Skilled Nursing Facility
  3. Acute Hospital Utilization
  4. Emergency Department Utilization
  5. Hospitalization for Potentially Preventable Complications

Measures Reported Using Electronic Clinical Data Systems

  1. Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
  2. Depression Screening and Follow-up for Adolescents and Adults
  3. Postpartum Depression Screening and Follow-up
  4. Prenatal Depression Screening and Follow-up
  5. Breast Cancer Screening
  6. Colorectal Cancer Screening
  7. Follow-up Care for Children Prescribed ADHD Medication

More information about the changes is posted at (accessed June 12, 2020).

For more information, contact:

  • Andy Reynolds, Assistant Vice President, Marketing And Communications, National Committee for Quality Assurance, 1100 13th Street Northwest, 3rd Floor, Washington, District of Columbia 20005; 202-955-3518; Email:; Website:
  • Matt Brock, Communications Director, National Committee for Quality Assurance, 1100 13th Street Northwest, 3rd Floor, Washington, District of Columbia 20005; 202-955-1739; Fax: 202-955-3599; Email:; Website:

Think Like A Health Plan

Among the top 10 takeaways I shared from The 2020 OPEN MINDS Strategy & Innovation Institute last week (see The Recovery Formula: Strategy + Innovation + Preparing For (Some) Failure), a key one was “Provider organizations and payers CAN work together. Payers are looking for creative ways to meet consumer needs in times of crisis and beyond and welcome ideas and negotiation.”

This was reiterated in the Institute’s Open Forum On Health Plan Measures Of Treatment Efficacy, with Andy K. Kelly, director of provider value optimization at Optum Behavioral Health; Brian Smock, vice president of Magellan Health; Sharon Hicks, senior associate at OPEN MINDS and former chief information officer of Community Behavioral Health; and Joseph P. Naughton-Travers, senior associate at OPEN MINDS. The insights shared by the four panelists reveal what payers are looking for and how they are prepared to negotiate in three key areas—whole person care, outcomes data, and program innovation.

Payers Are Looking For Whole Person Care

Mr. Kelly explained that Optum’s models are centered around improving the delivery of person-centered care. Optum is focused on how to treat the whole person and how to engage and support individuals in the community after service delivery. How to accomplish this? The discussion that followed included two types of models. The first model is focused on co-location of services—behavioral health services in primary care organizations or primary care services in behavioral health organizations. Mr. Smock talked about the opportunity to leverage embedding primary care in specialty care for value-based purchasing—provider organizations can make the case by showing shared savings from treating chronic conditions on the behavioral health side. And Mr. Kelly emphasized that health plan managers appreciate the economies of scale, the efficiencies, and the better outcomes that can be achieved when the “primary care professional can walk down the hallway and talk to the psychiatrist.”

The second model of integrated care is through collaboration. Health plans want to see the full array of services covered under one agreement. But provider organizations don’t have to deliver the full array of services as long as they can work with others across the service delivery system to ensure and coordinate access to care for their consumers. This type of collaboration demands a technology infrastructure that allows for centralized care coordination—and interoperability with all collaborating service organizations. Mr. Smock pointed out that Magellan’s desired outcome with high-need, high-utilization consumers is to reduce inpatient readmissions—and if a collaborative model can get them closer to that outcome, it is welcomed. “We are open to negotiation with provider organizations if there is collaboration,” he said.

Evolving Performance Measures For Evolving Payer VBR Arrangements 

The discussion of models for delivering integrated services moved to the discussion of value-based reimbursement (VBR), incentives, and measures. Two emerging issues in VBR performance incentives were raised. The first was how to develop reimbursement arrangements that take into account the period of time required to realize “savings.” The second was the issue of social determinants and how to determine “performance.”

Ms. Hicks pointed out that for the move to managed long-term services and supports programs, for incentivizing consumer quality of life and increases in consumer functional abilities, the measurement period needs to be longer than a year. “You have to be able to look at long-term conditions over a number of years but our rating systems don’t typically allow that. I can find ways to keep a consumer out of the hospital for one year. But that does not mean I am actually addressing their service needs.”

Mr. Kelly admitted that a one-year construct is fairly arbitrary for consumers with chronic conditions. At Optum, he said, “We are assimilating experiences from our state-mandated health homes to build our own measures. We are taking pieces from several state plan amendments—about what worked and what didn’t—to create a 36-month program. Twelve months does not cut it for high-risk populations that need wraparound services. One-year results go away quickly. We are looking for year-to-year progression and attribution—and plan to create pilot programs that cover performance over a three-year period.”

Mr. Smock explained that Magellan is looking at longer-term results in their contracting for Assertive Community Treatment (ACT) teams. “It’s been iterative. Programs are not static. We look at gains and what didn’t pan out. We know consumers can make substantial gains and move to less-intensive services but it takes time. We take a longer-term view and look not only at ACT team costs, but also at costs for other levels of care such as medical and emergency department visits. The longer we go, the more robust the data gets to help us figure out how to modify the models in future.”

A question from one of the executive attendees, Chris Wolf, executive vice president at I Am Boundless, shifted the discussion to social determinants of health (SDOH). He asked how SDOH are being incorporated in VBR reimbursement and in performance measurement systems. Ms. Hicks said some payers are giving bonus payments if provider organizations submit descriptors of SDOH in claim forms—payers are collecting SDOH information as diagnoses. (For more on how this is happening in Medicare Advantage plans, see a recording of the Institute keynote address by Allison Rizer, MHP, MBA, former vice president of strategy and health policy of UnitedHealthcare (Emerging Models & New Benefits For Individuals Dually Eligible For Medicare & Medicaid).

Mr. Kelly admitted that health plans are struggling with how to measure SDOH consistently and what to do with the data. “Value-based purchasing programs are based on what we can pull from claims data but that’s a limited view. We don’t know what better looks like on our own. We need provider organizations to make the case to us for additional reimbursement for SDOH,” he said. On the flip side, he said that health plans need to make the claims data available to provider organizations in a more useful form, “Here’s what we’re seeing with your population, help us out. We have to help providers determine the programs they can offer to address SDOH.”

Payers Will Collaborate For The Right Innovation

Payers are looking for provider organizations to come to them with creative programs ideas, said Mr. Smock and Mr. Kelly. If the potential outcomes align with a health plan’s overall goals for treatment, and if the provider organizations are willing to be flexible, they will find a way to make it work. But what about the financial risk? Mr. Naughton-Travers said to the panel, “A provider organization with an innovative model has fears about the downside risk of a model with substantial financial risk. They may want to know if they can get a year of protection before they move to a significant risk-based model. They want to know if they have time to ramp up to collect more data and establish better outcomes.”

All three of the health plan executives said that, for the right program model and proposed reimbursement, they are willing to work with provider organizations on a graduated financial risk model. “Some of these programs do not yield financial savings on day one and you have to find ways to get there. It’s a transformational process,” said Mr. Smock. He explained how Magellan gave a certified community behavioral health center (CCBHC) in Texas a “foundational payment” to help them develop infrastructure, ramp up, get a new program started, and get some reporting in place. Magellan’s desired outcome in supporting the program—a one-stop shop to help consumers get the full array of Medicaid services under one roof—was to reduce inpatient readmissions. If the CCBHC could follow up with consumers within seven days of discharge from inpatient and reduce readmissions, they could earn a monthly bonus based on percentage of reduction.

The strategic takeaways for executives of provider organizations are simple—think like a health plan and understand their goals for consumer care, develop a solid financial model and expected performance estimates for any proposed program, and be willing to collaborate in getting that program launched. As Mr. Naughton-Travers summarized, “Payers are partnering with providers to come up with solutions for better outcomes, to control costs, and get the data to build the model.”

For more on both integrated care and performance measures, check out these resources in The OPEN MINDS Industry Library:

  1. Reducing The Cost Of Reporting 558 Unique Performance Measures
  2. Proving Your Unique Value To Payers: Data Speaks Louder Than Words
  3. Performance Management Is Never ‘Done’
  4. Are You Ready For Whole-Person Care? Know The Performance Measures That Matter
  5. Does Your Organization Stack Up On Key Performance Measures?
  6. Ten Integration Models Reshaping Specialty Service Delivery
  7. The Path From Behavioral Health Carve-Out To Integration
  8. Developing Strategies To Address Integration—The Key Is Market Math & Innovative Value Propositions
  9. Making The Many Models Of Integration Work
  10. Integration—Strategic Threat (& Opportunity) For Specialists

And for the deeper dive on health plan strategy and new program development, browse the recordings and slides from 35+ sessions at The 2020 OPEN MINDS Strategy & Innovation Institute at

The Current Service & Financing Trends Affecting Children, Families & Provider Organizations

This presentation was delivered by Sean Klutinoty, MBA, Senior Associate, OPEN MINDS, on June 5, 2020 at The 2020 OPEN MINDS Strategy & Innovation Institute. In the presentation, Mr. Klutinoty discussed key data elements in the current service trends for children and families, health homes and value-based integrated models, as well as questions for the future of service delivery in our current landscape.

Download Resource