How VBR Prioritizes Primary Care As The ‘Center’ Of Integration

In March the California Department of Health Care Services (DHCS) released draft value-based payment (VBP) performance measures for the state’s Medicaid managed care program (in California, the Medicaid program is called Medi-Cal—for more on the California Medicaid system, see California Medicaid System: An OPEN MINDS State Profile). The measures are grouped into four domains: behavioral health integration; chronic disease management; prenatal/post-partum care; and early childhood preventive care. Each domain has five performance measures. These measures will be tied to risk-based incentive payments and are aimed at improving care for certain high-cost or high-need populations (see California Releases Proposed Medi-Cal Value-Based Payment Program Measures).

What is interesting about the draft VBP measures is that DHCS focused the measures 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, but these measures go one step farther. The measures include an additional incentive payment to provider organizations per visit for services delivered in an environment that has co-located primary care with behavioral health care. (For a complete listing of the draft measures, see California Medi-Cal Value Based Payment Program Performance Measures, March 2019: Proposal For Comment.)

Why do these measures matter if you’re not serving consumers in the state of California? Just keep in mind the adage: “As California goes, so goes the nation.” California is the most populous state in the country and has the largest Medicaid population of any state by far, at about 10.5 million total enrollees—or about 16% of the total Medicaid population (see January 2019 Medicaid & CHIP Enrollment Data Highlights). While they are not alone in requiring their Medicaid health plans to utilize value-based reimbursement (VBR) models (see State-By-State Analysis Of Medicaid MCO Requirements For Provider Alternative Payment Models: The 2017 Update), with such a huge portion of the Medicaid population they are often a bellwether for innovation in Medicaid and the results of their program changes can provide a significant data set for other states to analyze when making their own program modifications.

What do these measures tell us? First, primary care-led integration will continue to be a priority for payers and health plans. In California and elsewhere, performance measures related to behavioral health tend to be aimed at primary care—not behavioral health care provider organizations. Measures like screening for depression or alcohol use are about improving behavioral health, but they are intended for the primary care setting. With California adding additional incentives for services to be delivered in an integrated care setting, we will see health plans give priority in referrals to co-located programs. If so, this presents an incentive for provider organizations to form new partnerships with primary care practices and health systems. In a co-located system of care, behavioral health screening measures are easier to meet. The right changes in workflow ensure that consumers who may screen positive can see the right clinical professionals on site as needed. (For a deep dive into integrated care models, check out the March edition of the OPEN MINDS Management Newsletter, including our cover story analysis on the state of primary care integration: Primary Care Isn’t What It Used To Be.)

Second, integration measures, particularly screening measures, are a new opportunity to use technology tools to streamline processes. Online or tech-based screening systems are a convenient and efficient way to ensure that every consumer has their screening either before they come into the office for their visit utilizing on online tool (for example, see Google Will Provide A Validated Mental Health Screening Tool Online) or in office while waiting for their appointment using a tablet device or kiosk (for example, see Al Pioneer Raiven Health Care Joins Forces With VPAC To Improve Mental Health Screening, Diagnostics & Treatment). Studies have shown that online screenings can be just as effective as in-person screening (see Computer-Based Suicide Risk-Assessment Tool As Accurate As In-Person Psychiatric Assessment and Online Autism Screening & Skill Assessment Tool As Accurate As In-Person Screening & Assessment), and with screening being such a huge part of VBR performance measures, we can expect the use of these tools to grow.

California was accepting comments on their draft performance measures through the end of March, with the final measures expected this year. We’ll continue to monitor the effectiveness of California’s new performance measures and how other states are utilizing VBR to prioritize integration. For more on how to partner with health plans in this integrated, value-based market, join us at Management Best Practices week in Long Beach, California for the seminar, How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating, & Contracting With Health Plan, on August 12, featuring Deb Adler, Senior Associate, OPEN MINDS.