George Braunstein, FACHE has 40 years of experience in the health and human service industry, leading both private and public organizations – in institutional and ambulatory settings. He has worked as Executive Director of the Fairfax-Falls Church Community Services Board (CSB) in Fairfax, Virginia and also was the Executive Director of the Chesterfield County Community Services Board. Mr. Braunstein also served as the Executive Director of Behavioral Health for Aurora Health Care in Milwaukee – the largest integrated health care system in Wisconsin with 13 hospitals, 20,000 employees and $1.5 billion in annual revenues.
Ahead of His Time
Starting with in the early 1990s, before NCQA and EHRs were well developed to support Value Based Reimbursement (VBR), George Braunstein was directing an HMO in Milwaukee overseeing behavioral health care. As was the trend at that time for HMOs, cost savings were based on limiting all services across the board. Said Braunstein, “We were struggling with a policy which was a denial of care to attempt to make the bottom line look better.” Despite the reduced services, overall costs were not necessarily declining. When Mr. Braunstein looked at this trend, he had a different idea. Using only simple algorithms and rudimentary financial data, Mr. Braunstein and a nationally based work group quickly realized that there was a “missing piece”, which he described as “how do we create value out of behavioral health”.
The solution was to set up a “single integrated model’ where behavioral health providers were embedded in the primary healthcare system. And instead of strict limits on services, George and his team looked for the most cost-effective ways to reach desired results. One relatively simple strategy was to not limit outpatient behavioral health therapy which had the direct effect of reducing expensive inpatient readmission rates. Mr. Braunstein and his team closely monitored both costs and outcomes and developed a 10 percent withhold reimbursement to incentivize the staff to achieve desired clinical outcomes. As noted by Braunstein, he saw “the need for some kind of continuous quality improvement tool.” The program succeeded. In its first year, Mr. Braunstein noted a two percent pay out and seven percent payout in the second year.
This early success laid the groundwork for more sophisticated VBR processes that Mr. Braunstein would later develop in his career. For instance, the implementation of higher financial risk accountable care organizations and the implementation of case rates and bundled rates, to name a few. While these VBR models became more sophisticated, the underlying principles that needed to be in place for VBR to work remain the same. Some of the lessons learned include:
- Understand your baseline data, both clinical and financial, and make that data available at the “point of impact.” The front-line providers need to be in the loop.
- Stay on top of the data. Organizations can have a great deal of data but without built-in processes for sharing and accountability, VBR will fail.
- Be patient. Most behavioral healthcare providers are “mission driven” and may not see the ‘value’ in VBR. Mr. Braunstein noted that although changing organizational culture can take years, continuously providing clinical and financial updates on improvement to providers will help them develop a more “entrepreneurial approach” to their practices too.
When asked what he considered to be the largest barrier to creating a Value Based culture, Mr. Braunstein noted that an overly controlling corporate environment is often hard to overcome. As noted, the transition to VBR seldom occurs overnight and there can be failures. He recommends that you carefully work with your board to ensure that they are both mission-driven and entrepreneurial in their outlook. Finally, some bandwidth for program development and, occasionally, a failure is a necessity for overall success.
Technology and VBR
One of the biggest changes Mr. Braunstein has seen since the early days of Value Based Reimbursement is the development of Electronic Health Records. He noted, “the data can be organized, both performance and financial, to adapt and improve”, more efficiently and allow you “to act more proactively”. Importantly, these systems allow for timely analysis of revenue cycles. As noted by Mr. Braunstein, with ever shrinking budgets in behavioral healthcare, the ability to identify and contain costs is the best way to maximize revenue.