A Game Plan for Building a Sustainable Certified Community Behavioral Health Clinic (CCBHC)

The goal of the Certified Community Behavioral Health Clinics (CCBHC) is to improve patient care across the healthcare spectrum, serving highly complex patients while avoiding the use of high-cost, low-return care models though community-based alternatives that improve care management. Based on the success of the first wave of CCHBC’s, Congress has acted five times to extend the demonstration project and has allocated $450 million (to date) for CCBHC expansion grants. The number of CCBHC’s have expanded from 66 in 2015, to 166 in 2020.  The Substance Abuse and Mental Health Services Administration (SAMHSA) has embraced the CCBHC concept of integrated care and behavioral health providers, who have long supported integrated care, are now looking to the CCBHC model as an economically viable way to support this model of care.

Indeed, CCBHC’s have an excellent opportunity to be leaders in the new integrated healthcare system if they can display the following specific values:

  1. Accessibility: All needed services – mental health, substance abuse treatment, and physical health care – are provided in-house or quickly, in proximity, within the community.
  2. Efficiency: Multiple services can be provided daily, with one patient visit instead of multiple visits.
  3. Connection: Electronic Health Records (EHR) are used across service lines to produce and track clinical and quality metrics.
  4. Accountability: A commitment to producing the array of quality metrics required for quarterly reporting, in nearly real time.
  5. Adaptability: A commitment to using bundled payment arrangements that help clinics adopt and utilize alternative payment models instead of fee-for-service.

To meet these core values, provider organizations, in many cases, have had to update their organization’s service lines, hire new staff, and implement or update Electronic Health Record systems (EHRs). These changes represent substantial economic and human resource expenses. While enhanced reimbursement and up-front grant dollars have helped to offset the expense, it still begs the question: “How does an organization sustain the model beyond the grant period?” (https://vbcforbh.com/are-you-really-ready-for-value-based-payment/)

Thinking Beyond Grant Funding

The recipients of the 2020 CCBHC Expansion Grant the funding stream are only guaranteed funding for two years. A few considerations are important. The first is that funding may not be renewed. Considering potential fiscal deficits expected from the COVID epidemic, there is a distinct possibility that additional funding will not be there. A second possibility is that state funding may supplant federal funding. As states grapple with the aftermath of a pandemic, fewer state dollars will be available.  Already, Nevada has made a 6% cut to Medicaid dollars (https://vbcforbh.com/nevada-moves-forward-with-6-medicaid-fee-for-service-rate-cut/).

SAMSHA was abundantly clear that grant participants should not expect more federal support. The newest round of grantees were given the task to: “Develop and implement plans for sustainability to ensure delivery of services once federal funding ends. Recipients should not anticipate the continued renewal of federal funding to support this effort. Federal funding is subject to funding availability and is also subject to a competitive grant award process. Recipients must develop and implement sustainability plans to ensure continued service once the grant ends. Recipients will be asked to report on sustainability plans” (https://www.samhsa.gov/sites/default/files/grants/pdf/fy-2020-ccbhc-foa.pdf).

The long-term sustainability of CCBHC programming requires a strategic response.

Community Behavioral Health Clinic (CCBHC) Sustainability and Value-Based Reimbursement

The CCBHC’s with an eye toward a future will be looking for alternative revenue streams immediately. The good news is that the CCBHC infrastructure of data driven health care focused on improved outcomes and diminished costs is an ideal match for payers who are looking for lower cost interventions and improved population health, and are using Value Based Reimbursement (VBR) to meet these goals.

The organizational readiness for CCBHC implementation has laid the groundwork for Value Based Programming.  The development of Evidenced Based Practices, addition of service lines, hiring new staff, affiliations with emergency care, adoption enhanced payment processes, and implementing and updating you Electronic Health Records (EHR) to capture clinical and quality data has positioned CCBHC to think about working with both private and public payers.

A Growing Value Based Culture

The OPEN MINDS 2019 State-By-State Update found that 28 of the 40 states with Medicaid managed care require health plans to implement alternative payment arrangements (APMs) with provider organizations. This is up from 22 states out of 39 states in 2017. And Value-Based processes are at the center of the trend. Organizational readiness for VBR follows a defined path:

(See OPEN MINDS Are You Really Ready for Value-Based Payment?)

The CCBHC is already this path, developing a VBR infrastructure. The next step is to define the unique value proposition of the CCBHC.

Defining the Unique Value Proposition to New Payors

A successful sustainability plan keeps the following goals in mind:

  • Have the Data: Understand internal unit costs and key performance indicators (KPI). Fortunately, the data needed to do this can be found in your CCBHC data. Use this to data to develop a picture of what the CCBHC does well, and where there are opportunities for improvement. Knowing strengths and possible risks will be important guides in rate negotiations.
  • Know the Customer: Research the payers in the market. For the health plans and accountable care organizations, know their structure and customers, their current service delivery network, executive teams, and their enrollment in your service areas. A CCBHC plan has flexibility to meet the changing needs of the marketplace. Alignment with those needs will make a CCBHC more attractive to payers that need services.  (See What Are Health Plans Actually Doing? and Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System).
  • Prepare for the End-Game. Think about future meetings with health plan executives to discuss current contracts and proposed services as the CCBHC plan is developed. Be prepared with a proposal and assess readiness for newer payment models (Use the Value-Based Reimbursement Readiness Assessment).

Build Relationships Now

Avoid scrambling at the last moment for new funding streams. Remember, payers know that mental health and substance use disorders are the leading causes of disease burden in America.  This is further exacerbated by co-morbidities faced by people with mental health and substance use disorders who also suffer from cardiovascular disease, and diabetes, and other chronic diseases. The CCBHC is addressing this issue head on and that needs to be highlighted. To do this you can start by doing the following:

  • Build relationships with payers immediately: Reach as high into the payer organization as possible to develop those relationships. Then attempt to establish formal touchpoints. A scorecard with quarterly data will provide updates on key points that may be of value to the health plan. These interactions need to be succinct and to the point.
  • Develop a Pitch Deck: Prepare a brief (one or two slide) value story that describes how the CCBHC’s programs are differentiated in terms of quality and costs, and how they contribute to health care cost savings for the payer.
  • Leverage Informal Meetings: Attend conferences and industry meetings with target payers. These less formal venues allow for additional touchpoints to reiterate the value the CCBHC brings to the table, and the differentiating strengths.

Finally, connecting with health plans comes down to persistence.  Provider organizations need to find the right contact in network management, or whoever is leading their local plan and continue to reach out. In the end, relationship-building is still based on quality communication. The CCBHC model is the perfect framework to build relationships with payer organizations.

COVID-19 and Value-Based Reimbursement: What Do We Know? Where Will it Go?

The impacts of COVID-19 on health care continue to unfold, and one area of uncertainty is the impact COVID will have on Value Based Reimbursements (VBR). Regardless of this uncertainty it appears that VBR is still trending upwards in behavioral health care.  Surveys conducted by OPEN MINDS demonstrate more use of episodic payments, case rates, and bundled rates. In one health plan survey, the number of health plans using bundled payments or case rates rose from 39% to 59% from 2017 to 2019 (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System and What Are The Health Plans Doing About VBR?). And, a more recent survey of specialty provider organizations found that 24% of those organizations have some bundled rate contracts (see 2020 OPEN MINDS Performance Management Executive Survey: Where Are We On The Road To Value). A similar trend is noted in the public payer market, where a recent state-by-state analysis found that 28 of the 40 states with Medicaid managed care require health plans to implement alternative payment arrangements (APMs) with provider organizations. This is up from 22 states out of 39 states in 2017

With the continued growth of VBR, many questions about how the pandemic will change VBR processes remain. Some current trends shed light on this question. These trends also give providers clues about areas of focus moving forward in this ‘next normal’.

Shift to Telehealth

One of the astonishing developments of the pandemic is the phenomenal growth of telehealth utilization in behavioral health care. Telehealth has become ubiquitous during the pandemic. Some interesting results of a recent survey by Qualifacts and the National Council for Behavioral Health include:

  • Pre-pandemic, telehealth utilization in behavioral health care was relatively low, only 2% of organizations were providing 80% or more of their care virtually
  • Policy changes during the COVID-19 pandemic have reduced barriers to telehealth. Now, 60% of behavioral health organizations are providing 80% or more virtual care.
  • Behavioral health care executives expect the higher utilization of virtual services to continue, with a majority believing 40 % to 60% of their overall services will be provide in virtual platforms.

In the public sector, there have been sweeping changes in regulation and reimbursement for telehealth services. While the permanence of the changes in the public payer space has not been determined, it’s evident a system-wide reevaluation is occurring.  Some states have enacted new legislation already. For instance, On July 6, 2020, the Colorado legislature passed Senate Bill 212 to expand access to Medicaid telehealth services. The bill expands Medicaid coverage for telehealth services to include reimbursement at parity with in-person services at rural health clinics, federally qualified health centers (FQHC’s), and the Indian Health Service facilities.

Furthermore, the shift to telehealth is also be reinforced by the recent recognition by the National Committee for Quality Assurance (NCQA) revision of HEDIS Quality Measures associated with Telehealth utilization during the pandemic. https://bhmpc.com/2016/10/hedis-success-value-based-care/

New NCQA HEDIS Telehealth Rules

NCQA  adjusted 40 Healthcare Effectiveness Data and Information Set (HEDIS) measures—in response to the surge in telehealth during the pandemic (see NCQA HEDIS Quality Measures Adjusted For Increased Telehealth Use In Pandemic Crisis). The adjustments, published July 1, will go into effect in 2020 and include eight measures related to behavioral health—medication adherence, follow-up care after hospitalization or emergency department visits, and monitoring of co-occurring medical conditions in consumers with serious mental illness. For each measure, the updated guidance specifies how telehealth visits can be used and what will be included and excluded in the measure’s denominator and numerator. Most importantly, NCQA removed restrictions on video visits and now recognizes a video visit as the same as an in-person visit. Eight of the adjustments affect behavioral health measures (NCQA.org/COVID):

  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 implication of the of the updated HEDIS measures is that telehealth coverage will carry forward to the post-crisis future. As noted by the NCQA, they cannot drive quality improvement “if their measures don’t take into account what has quickly become the fastest-growing modality for providing health care services.” For behavioral health providers who see telehealth as significant portion of outpatient services this is good news. It will also allow for more flexibility in designing programming to address VBR processes, especially when access to in person care is a major obstacle. https://www.ncqa.org/covid/

Payers are aware of the increase in utilization of telehealth and will build VBR programs around the assumption that provider are utilizing telehealth as part of their service array. Providers with fully integrated telehealth programming will be at a distinct advantage when it comes to VBR readiness in the post crisis era.

The use of telehealth is just one tool in a provider’s service array. Some COVID-19 other trends provide insight into post pandemic behavioral health utilization needs and potential cost drivers that may stimulate VBR development.

Systemic Impact of COVID-19

One interesting trend is the current underutilization of behavioral health services.  Many behavioral health providers have experienced significant decreases in utilization and revenue streams due to COVID-19, in large part due to increased unemployment from COVID-19 and the transition time of shifting benefits from private to public payer sources.

Juxtaposed against underutilization is the increase level of mental health conditions associated with the pandemic. It is expected that there will increase in levels of trauma, depression, and anxiety occurring as a result of the pandemic. The April 2020 Johns Hopkins COVID-19 Civic Life and Public Health Survey Wave 1 demonstrated a 10% increase in adults reporting serious psychological distress over 2019 reports. These results showed an exacerbation for adults with household income of less than $35,000 per year, 19% of whom reported serious psychological distress. There is also expected to be an increase in suicide rates. Unemployment is highly correlated with deaths by suicide, which has led experts to speculate that suicides will increase in 2020/2021. One model, based upon previous suicide and unemployment data, projects 3,235 to 8,164 additional deaths by suicide in the United States in 2020/20212

For payers and providers these trends will, at some point, create an increased demand for behavioral health services. Behavioral health providers with services that align to these needs, like expertise in areas of trauma informed care and crisis intervention programming, will be positioned to better serve these population health needs and meet the needs of payers who are looking for better outcomes for their consumers.

A second area of concern for all providers is the increase in opioid utilization. Due to increased opioid usage during COVID, mortality rates are expected to climb due opioid-related deaths. The American Medical Association (AMA) recently released a statement of concern about reports of increased levels of addiction and opioid-related mortality.

Value-based programs around addiction treatment have been on the rise since before COVID, both Cigna and Anthem have developed VBR programs that look at claims data in their private and public plan, tied that data consumer satisfaction surveys and outcomes. (See OPEN MINDS Addiction by the Numbers.) With the rise in opioid utilization it is reasonable to expect continued development of this treatment programming.

A Final Thought on Integrations

What is also interesting about VBR moving forward is the focus on screening, prevention, and integration of physical health care and behavioral health. Many states and national measures have incentivized screening for depression or substance abuse in primary care settings. And many plans are incentivizing referrals to co-located services and warm hand-offs where co-located services are not available. For forward-thinking behavioral health providers, the need for strong relationships with physical health care providers will present another opportunity for expanding their footprint and enhancing their revenue cycle through VBR arrangements. (See How VBR Prioritizes Primary Care as the Center of Integration.)

 

Learn more about Value Based Reimbursement with these resources from the VBCforBH.com Library.

  1. There Is No “Plan B” Alternative to Value Creating A Value-Focused Competitive Strategy in A Changing Market
  2. How to Develop Alternative Payment Models: A Guide to Building Effective Bundled Payment Models
  3. Care Delivery in A Value-Based Era – Evidence-Based, Practice-Based, Standardized & Measurement-Based
  4. Developing Case Rates? Better Find Your ‘Single Source of Truth’
  5. Adjust Your Strategic Sails!
  6. When the Competition Succeeds at Pay-For-Performance, What Will You Do?
  7. Options for Alternative Payment Models for Behavioral Health
  8. Using Your Performance Metrics to Build A Value Proposition for Health Plans

From Fee-For-Service To Episode-Based Payments: The Shift Continues

As the prolonged pandemic continues, every executive in every industry is asking the question, “what’s next?” The health care sector has been completely upended by the pandemic crisis. From our analysis, it appears that the “next normal” holds more focus on “whole person” health management models, “hybrid” service programs with a mix of telehealth and face-to-face services, more leverage of technology, and more focus on value (see my recent presentation, Navigating From Challenge To Opportunity: The Best Of The 2020 OPEN MINDS Management Best Practices Institute).

That last piece—the focus on value—will be a move away from fee-for-service (FFS) reimbursement to some type of non-FFS alternative payment methodology (APM): bundled rates, case rates, episodic payments, and capitation reimbursement. I’m not certain what exactly that will look like and there will likely be significant variance by payer, consumer typology, and service models. Skeptics will say that we’ve been inching toward widespread acceptance of value-based reimbursement (VBR) for a decade or more with limited adoption. In 2018, 39% of payments were FFS, and another 25% were FFS with some link to quality and/or value, such as pay-for-reporting and pay-for-performance (see Entering The Next Phase Of Value-Based Payment Reform).

But that was before the pandemic. Moving to non-FFS APMs addresses multiple issues for payers and health plans. APMs support integrated care models. They allow health plans to address the growing prevalence of behavioral health conditions. They provide steady income for provider organizations. They address the likely budget compression that lies ahead by getting more alignment with provider organizations by increasing their downside financial risk—and shifting some administrative costs to them as well.

Immediately prior to the pandemic, the Centers for Medicare and Medicaid Services (CMS) implemented Patient Driven Groupings Model (PDGM) for home health agencies (HHAs) on January 1, 2020. PDGM was the most significant change to HHA reimbursement in 20 years, tying payment to an individual’s overall health condition rather than to therapy visits. Prior to implementation, there was widespread “the sky is falling” fear of the financial impact. The sky didn’t fall. There was the expected interruption in cash flow, but overall documentation, coding accuracy, and timeliness of claims submission have all improved, and reimbursement rates are better than projected. In some ways, PDGM helped HHAs prepare for the very sudden drop in utilization with the onset of COVID-19. That too, is turning around. Skilled nursing facilities (SNFs) had similar experiences with its new payment model, the Patient Driven Payment Model (PDPM). SNF utilization is declining, as expected, as the industry shifts to right person, right treatment, right setting with home being the preferred care delivery location.

And in anticipation of the “next normal,” on Tuesday, September 15, 2020, CMS released new guidance to help state Medicaid plans continue their shift towards VBR (see Value-Based Care State Medicaid Directors Letter). And, the CMS’ innovation center is about to roll out new risk-based model for those dually eligible for Medicare and Medicaid (see CMS Innovation Agency To Launch Risk-Based Model For Dual Eligibles). The model will allow Medicaid health plans to take on financial risk for a consumer’s FFS Medicare services.

In addition to CMS, health plans are also increasing their use of APMs. On September 14, 2020, Humana announced it was adding two more episode-based payment models—the Coronary Artery Bypass Grafting (CABG) model and the Total Shoulder Specialist Reward Program. These two episode-based models are in addition to Humana’s Maternity Episode-Based Model and Oncology Model of Care. Humana now offers a total of six specialty care payment models, with more than 2.6 million individual Medicare Advantage (MA) and commercial members receiving care through 1,000 value-based relationships across 43 states and Puerto Rico (see Humana Launches Two More Value-Based Programs for Specialty Care).

The implications are clear. More health and human service reimbursement is moving to non-fee-for-service payment models. And the provider organizations that are best prepared to accept value-based contracts with managed care plans are the organizations with a competitive edge. To get your team up to speed, these are some of the best OPEN MINDS resources on VBR models.

Assessments & Educational Programs

Managed Care Competencies Assessment

OPEN MINDS has developed a Managed Care Competencies Assessment, focused on the organizational and technical competencies needed to make the transition successful. This online self-assessment helps to evaluate and identify improvements in 12 domains.

Value-Based Readiness Assessment

To help provider organizations navigate the management challenges of transition to VBR, OPEN MINDS has developed a web-based readiness self-assessment for value-based reimbursement readiness, focused on scoring organizational and technical competencies needed for the transition. This tool was designed to evaluate and identify improvements in six domains.

Succeeding With Value-Based Reimbursement: An OPEN MINDS Executive Seminar On Organizational Competencies & Management Best Practices For Value-Based Contracting

The evolution of health and human services away from a focus on cost-based/volume-based reimbursement—and the growing expectations of consumers, caregivers, and health plans—are changing both the successful business model and the market role of many service provider organizations. This evolution is one that will (like in retail, banking, and publishing) create new winners.

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

In this presentation at the 2020 OPEN MINDS Management Best Practices Institute, OPEN MINDS Senior Associate Paul 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 programs and services with their goals, and provide data to show that how service lines can deliver quality outcomes with lower costs.

Strategic Implications Of VBR

VBR: Are You Walking In Your Customers 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).

Why Value-Based Purchasing For Medications Matters

On June 17, CMS issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based payment (VBP) arrangements with drug manufacturers. The rule’s definition of VBP is an arrangement intended to align payments to therapeutic or clinical value in a population, such as evidence-based measures. The cost should be linked to existing evidence of the effectiveness and/or outcomes-based measures. Or payment should be linked to the drug’s actual performance in a consumer or a population—such as reduction in medical expenses.

Collect The Data, Connect The Dots Value

One key tool for executive teams planning for recovery after this crisis period is having the metrics to make the right decisions. I tend to think of this data in three domains. There is financial data for short-term cash management strategy. There is strategic market information for planning long-term post-recovery strategy (this includes both external and internal data). And there is service performance data to optimize value.

Show Me The Value, Show Me The Money

This year, what has been top of mind for many executives attending the Institute is how to adapt your strategy in the current crisis—and how to use innovation to succeed in an altered health and human service landscape. But one question keeps coming up—where do “value” and “value-based” reimbursement fit in all of this?

The Blues Move To Value—Will Others Follow?

In the past two weeks, we’ve covered two initiatives sponsored by Blues plans to move behavioral health to some value-based arrangement. Blue Cross and Blue Shield of North Carolina launched a new value-based purchasing model, Blue Premier Behavioral Health, which allows behavioral health professionals who either meet or exceed quality benchmarks to earn higher reimbursement rates. In New York, BlueCross BlueShield of Western New York announced that it entered into a value-based reimbursement arrangement with Value Network.

Bundled Rates – Opioid Treatment & More

We’re seeing more use of episodic payments, case rates, and bundled rates. Our recent health plan survey found the number of health plans using bundled payments or case rates rose from 39% to 59% from 2017 to 2019 (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System and What Are The Health Plans Doing About VBR?). And, our recent survey of specialty provider organizations found that 24% of those organizations have some bundled rate contracts (see 2020 OPEN MINDS Performance Management Executive Survey: Where Are We On The Road To Value).

VBR – Where’s The Beef?

Greetings from Florida and the opening day of The 2020 OPEN MINDS Performance Management Institute. It’s a power-packed agenda full of sessions focused on optimizing performance and sustainability in the complex consumer market. I opened the institute with results from our 4th annual survey on the state of value-based reimbursement (VBR) in the market (see Where Are We On The Road To Value? The 2020 OPEN MINDS Performance Management Survey). The findings reminded me of the 1980s advertisement for Wendy’s with the woman, the insistent Clara Peller, asking, “Where’s The Beef?” (see Where’s The Beef) – and saying “I don’t think there is anybody back there…”

Access Matters: Payer Provider Partnerships & Shared Vision

This presentation was delivered on August 26, 2020 at The 2020 OPEN MINDS Management Best Practices Institute. Speakers discuss how the problem of access in behavioral health requires new partnerships, integrated care, collaboration, and a shared vision between payers and provider organizations; and how each payer is working to solve the access problem.

Getting Paid More For What You Do – Tactics To Increase Fees & Rates From Payers & Moving To New Reimbursement Models

OPEN MINDS hosted an executive web forum for executives of health and human service organizations. Led by OPEN MINDS Senior Associate Paul M. Duck, the forum took a deeper dive into different tactics and strategies provider organizations can leverage with payers to negotiate optimal fees and reimbursement rates.

VBR Updates

Alternative Payment Methods For Behavioral Health Associated With Lower Utilization & Spending

Alternative payment methods (APMs) for mental health and addiction disorder treatment are associated with 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.

CMS Unveils APM Strategy For Rural Health Care

On August 11, 2020, the Centers for Medicare & Medicaid Services (CMS) announced an alternative payment methodology (APM) for rural health care services. The APM is called the Community Health Access and Rural Transformation (CHART) Model. CHART has two value-based payment models: the Community Transformation model and the Accountable Care Organization (ACO) Transformation model.

Blue Cross Blue Shield of Massachusetts Launches New Value-Based Payment Model For Small Practices

On July 15, 2020, Blue Cross Blue Shield of Massachusetts (BCBSMA) announced plans to pilot a new value-based payment model for small practices that provides financial support through a global payment, upside risk incentives, and an immediate support payment.

Medicare ACOs Generated Savings Of 1% To 2%

Medicare accountable care organizations (ACOs) have generated 1% to 2% reductions in Medicare program spending, according to a review of ACO evaluations between 2012 and 2016. The savings estimates were consistent for ACOs participating in the Medicare Shared Savings Program (MSSP) and for those participating in the Next Generation (NextGen) ACO model. The Medicare ACO savings stem from small reductions in hospital inpatient, hospital outpatient, and post-acute care use compared to what would have been spent if the ACO program did not exist.

The Medicare savings estimate is before shared savings payments to those ACOs that earned savings. For NextGen ACOs, after the shared savings payment, the NextGen ACOs generated net savings of 1% in the first year. The second-year evaluation compared the NextGen model against all other FFS Medicare, including other ACOs, but found no net savings.

The review was conducted by the Medicare Payment and Access Commission (MedPAC). MedPAC noted that although ACO savings are relatively small, they are greater than savings generated by most Medicare care coordination models. About 11.2 million Medicare beneficiaries are assigned to one of the 517 ACOs participating in 2020. They represent about 23% of all Medicare fee-for-service (FFS) Part A and Part B beneficiaries. The Centers for Medicare & Medicaid Services assigns FFS beneficiaries to an ACO if the beneficiary has a plurality of visits with clinical professionals who participate in the ACO. The majority of beneficiaries are assigned to an ACO participating in the Medicare Shared Savings Program (MSSP). During 2016, 500,000 beneficiaries were assigned to one of the 18 NextGen ACOs.

MedPAC also considered the findings of evaluations of a commercial ACO, the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC). The ACQ evaluations found material gross savings and modest net savings after accounting for incentive payments. The savings were primarily due to reduced laboratory testing, imaging, and emergency department visits. About 29% of AQC savings in the early years of the model were due to the use of lower cost provider organizations, not lower service volume. MedPAC determined that savings reported by commercial ACOs may be difficult to replicate in the Medicare ACO models in part because Medicare sets prices administratively. Additionally, the larger ACQ gross savings should be expected because the model is housed in a health maintenance organization, which can use prior authorizations to restrict service use and steer members to lower-priced provider organizations.

These findings were included in MedPAC’s “June 2020 Report To The Congress: Medicare & The Health Care Delivery System,” in the second chapter titled “Challenges In Maintaining And Increasing Savings From Accountable Care Organizations.” The Commission evaluated past ACO savings evaluations, examined strategies to increase savings, and recommended a technical change that will reduce the risk that program vulnerabilities might result in unwarranted shared savings payments to ACOs.

The technical change pertains to the risk that an ACO might disproportionately shift high-cost beneficiaries out of the ACO during the performance year, although the high-cost beneficiaries were included in the baseline year. An ACO that engaged in this behavior would show a spending decrease relative to the ACO benchmark. To counter this risk, MedPAC recommended that CMS determine an ACO’s historical baseline spending using the same national provider identifiers (NPIs) that are used to compute the ACO’s performance-year spending.

A link to the full text of “MedPAC June 2020 Report To The Congress: Medicare & The Health Care Delivery System” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/061520medpacreport.htm. The chapter, “Challenges In Maintaining And Increasing Savings From Accountable Care Organizations,” starts on PDF page 31.

OPEN MINDS last reported on this topic in the following articles:

For more information, contact: Press Office, The Medicare Payment Advisory Commission, 425 I Street NW, Suite 701, Washington, District of Columbia 20001; 202-220-3700; Website: http://www.medpac.gov/

Nevada Cuts Medicaid Fee-For-Service Rate By 6%; Expects Annual Savings Of $53 Million

On August 15, 2020, the Nevada Medicaid program implemented a 6% rate cut to fee-for-service (FFS) rates. The Medicaid rate reduction is expected to save the state about $53 million over the coming fiscal year. The rate cut was directed by Assembly Bill 3 enacted by the Nevada Legislature during a Special Session to address a budget shortfall due to the coronavirus disease 2019 (COVID-19) pandemic and its subsequent economic impact. The state was facing a budget shortfall of nearly $1 billion. Assembly Bill 3 made a total of $130 million in cuts to the Medicaid program.

The state’s Medicaid managed care capitation rates will be amended by Nevada’s Actuary to include the impact of the 6% reduction to the FFS Fee Schedules, with an effective date of August 15, 2020. The total Medicaid caseload as of July 2020 is 716,981. About 27% (196,256 people) of these recipients are served through the fee-for-service program.

The 6% rate reduction affects behavioral health outpatient treatment, special clinic-addiction treatment agency model, psychologist, behavioral health rehabilitative treatment, applied behavior analysis, and inpatient psychiatric/substance abuse treatment services provided by a general acute hospital. However, rates will not be cut for the following behavioral health provider types and services:

  • Freestanding psychiatric hospital
  • Certified community behavioral health center
  • Residential treatment center
  • Federally Qualified Health Center

On August 14, 2020, the Nevada Department of Health and Human Services (DHHS) Division of Health Care Financing and Policy (DHCFP) notified provider organizations that it was also amending the application for the Home- and Community-Based (HCBS) Frail Elderly (FE) and Physical Disability (PD) Waiver to reflect the rate reduction. All FE and PD Waiver services will remain the same. The amendment must be submitted to the Center for Medicare and Medicaid Services (CMS) for approval. Comments will be accepted through September 14, 2020.

A link to the full text of “Nevada Medicaid Draft Home- and Community-Based Frail Elderly Waiver Amendment” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/081520nvdrafthcbsfewaiveramend.htm.

A link to the full text of “Nevada Medicaid Draft Amendment For Home &Community Based Waiver For Persons With Physical Disabilities” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/081520nvdrafthcbspdwaiveramend.htm

A link to the full text of “Nevada Assembly Bill #3: An Act Relating To State  Financial Administration” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/071920nvassemblybill3.htm.

For more information, contact:

  • Division of Health Care Financing and Policy, Nevada Department of Health and Human Services, 1100 East William Street, Suite 101, Carson City, Nevada 89701; 775-684-3676; Fax: 775-687-3893; Email: dhcfp@dhcfp.nv.gov; Website: http://dhcfp.nv.gov/Contact/Contact_Home/
  • Submit comments on the draft waiver amendment to: Nevada Division of Health Care Financing and Policy, ATTN: LTSS – FE/PD Waiver Amendment, 1050 E William Street, Suite 435, Carson City, Nevada 89701; Fax: 775-687-8724; Email: hcbs@dhcfp.nv.gov

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 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2768565 (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: andrew.carlo@nm.org; Website: https://www.uwmedicine.org/school-of-medicine.

Colorado Expands Medicaid Telehealth Access

On July 6, 2020, the Colorado legislature passed Senate Bill (SB) 212 to expand access to Medicaid telehealth services. The bill expands Medicaid coverage for telehealth services to include reimbursement at parity with in-person services at rural health clinics (RHCs), federally qualified health centers (FQHCs), and the Indian Health Service facilities. The list of covered Medicaid telehealth services is expanded from health care and mental health care services to include speech therapy, physical therapy, occupational therapy, hospice care, home health care, and pediatric behavioral health care. Additionally, home health care provider organizations will be able manage telehealth services for Medicaid beneficiaries.

Mental health centers and addiction treatment centers are not listed among the provider organization types affected by the legislation. However, community mental health centers are among the types of provider organizations that are eligible to provide Medicaid fee schedule medical and other professional services for Colorado’s Medicaid program. Publicly funded telemedicine is covered for behavioral health provider organizations under the capitated behavioral health benefit administered by the Regional Accountable Entities (RAEs).

SB 212 also prohibits private payers from requiring an in-person exam before a physician can treat a new consumer via telehealth. Private payers cannot impose limitations on location, certification, or training as a condition of reimbursement. Additionally, SB 212 prohibits private payers from imposing any requirement or limitations on the use of HIPAA-compliant technologies to deliver telehealth.

The definition of telehealth was expanded from being synchronous (real-time) interaction-only between a consumer at an originating site and a health care professional located at a distant site to include remote monitoring technologies and store-and-forward transfers. Remote monitoring is defined as “the use of synchronous or asynchronous technologies to collect or monitor medical and other forms of health data for individuals at an originating site and electronically transmit that information to clinical professionals at a distant site so providers can assess, diagnose, consult, treat, educate, provide care management, suggest self-management, or make recommendations regarding a covered consumer’s health care.” The state will post data on telehealth use by August 6, 2020.

A link to the full text of “Colorado Senate Bill 212: Reimbursement For Telehealth Services” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/070620coSB212.htm.

A link to the full text of “Telehealth Utilization In Health First Colorado From July 1, 2019 Through May 16, 2020” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/072920cotelehealthstats.htm.

For more information, contact: Marc Williams, Public Information Officer, Colorado Department of Health Care Policy & Financing, 1570 Grant Street, Denver, Colorado 80203; 303- 866-2993; Fax: 303-866-2803; Email: marc.williams@state.co.us; Website: https://www.colorado.gov/pacific/hcpf/telemedicine.

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

Respiratory

  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

Diabetes

  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

Utilization

  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 https://www.ncqa.org/covid/ (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: reynolds@ncqa.org; Website: https://www.ncqa.org/
  • 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: brock@ncqa.org; Website: https://www.ncqa.org/