The Evolution of Financial Management to Support Value Based Care, an Interview with George Braunstein, FACHE

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.

Lessons Learned

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.

Implementing Value-Based Care Through The Certified Community Behavioral Health Model: A Value Based Care Community Interview With Chad Van Houten

Implementing innovative service changes with a focus on value-based care and reimbursement often involves identifying how to provide more effective service outcomes through coordination-of-care and integration of services – internally and with other community providers. A good model for this change in focus is the Certified Community Behavioral Health Clinic (CCBHC). The CCBHC service model was created and funded on a demonstration basis with the Excellence in Mental Health Act (EMHA). The EMHA created a new Medicaid provider type requiring participating organizations to provide, or contract for, essential services for individuals needing behavioral health and substance use disorder services to ensure accessibility, care coordination, and service integration. Eight states were selected for participation in the two year demonstration beginning in 2017 – Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon and Pennsylvania. We recently had the opportunity to talk with Chad Van Houten, Chief Financial Officer of Zumbro Valley Health Center, one of six CCBHCs that were created in Minnesota. Chad shared with us the opportunities and challenges of creating a new value-based service line.

Implementing a new innovative service creates challenges impacting culture, communications, and infrastructure. For Zumbro Valley Health Center, the model encompassed 60% of the program and 80% of clients across multiple programs, and involved almost all staff. A key requirement when reviewing current workflows was having open communication with staff, and continually asking the question, “Will this help improve client access?” Training sessions were implemented initially so that staff understood the new focus and requirement. Key consumer workflows were then redesigned, starting with intake and insurance coverage to determine whether consumers were covered by CCBHC services and funding, or another source. This caused therapists to begin to think about the services available to consumers based on their payer, and created more streamlined and better communication to maximize those services. Another challenge was keeping the state, as funder, in the loop with open communication. Pilot programs don’t always go as planned and unforeseen issues come up such as administrative bottlenecks, or conflict with other state mandates. Addressing these challenges required frequent pre-implementation and post-implementation meetings to identify unanticipated issues and collaborative work to identify solutions.

To address the significant shift in culture required by the new service model, leadership staff had to continually ask the question, “How does this impact staff?” This focus provided both an opportunity to identify issues, and engage staff in solutions to address those issues. Therefore, establishing a process for clear, open, and ongoing communication was critical. Helping staff understand how the design of the CCBHC would improve client outcomes created a common point for creating cultural and operational change.

Chad also described the changes in technology and data reporting necessary to create a focus on outcomes. The CCBHC reimbursement rate in Minnesota is a bundled rate based on the prospective (anticipated) cost of services and an estimate of potential consumers. A daily charge is created when a consumer receives one, or any number, of services in a day. Their EHR was already configured to work with bundled rates, however they engaged assistance to set up the new service and billing codes, ensuring that only one bill would be created daily per consumer. Getting the data needed to drive and report outcomes was the bigger part of the challenge of measuring quality outcomes. This entailed creating agreements and accepting data from other providers, and implementing a process for consumers to self-report information.

An important aspect of tracking data was having the right staff skills available. Zumbro Valley Health Center increased their resources in this area, hiring an analyst to work the clinical and financial data. This was critical in achieving their operational target since the reimbursement rate was based on anticipated costs, and tracking actual results to estimates ensured alignment with the operational plans. Precise plan execution was important to ensure that the estimated rate remained accurate for the future, for example, making sure that staff were hired when planned. Having a data analyst was helpful because that person had the knowledge and skills to manipulate large amounts of data to meaningfully inform staff about services and create the cost reporting required by the state.

To drive and monitor performance against contracted outcomes, the organization developed key metrics for each director of the organization. This involved a process of identifying outcome targets, determining data sources, and capturing and reporting data. Teams met bi-weekly, or monthly, as needed, to identify outcomes that were off course and collaborate on corrective actions. Chad came from a manufacturing background prior to behavioral health, so he was familiar with this focus on data. This focus was fairly new to the organization as a whole, so time was spent creating a data-driven culture – emphasizing the role of data to ensure the best outcomes – and the skills needed to work with data. These skills included capturing and analyzing the right data and sharing the results in a meaningful, informative dashboard for staff comprehension.

When asked to identify the two top lessons learned in implementing the CCBHC, Chad said, “When you implement, you think that you have a good process. But you need to stop periodically, and look at things from the consumer perspective. If something is cumbersome, then identify a new process. It’s all about access and making integrated services available when they are most needed.”

Because of the focus on consumer access – the services needed, when they are needed – along with care coordination, integration, and a focus on outcomes, Minnesota has committed resources, continued funding of the six CCBHC and plans to expanse the service model to two additional providers. For more on innovative value-based services, see:

Building An Infrastructure For Data-Driven Performance: An Executive Guide For Success In A Value-Based Market – https://vbcforbh.com/building-an-infrastructure-for-data-driven-performance-an-executive-guide-for-success-in-a-value-based-market/

Rate Setting For Value-Based Reimbursement: A Guide To Developing Capitated Payment Models – https://vbcforbh.com/021519ratesetting/

Value-Based Reimbursement: 3 Steps To Go From Idea To Action – https://vbcforbh.com/value-based-reimbursement-3-steps-go-idea-action/

Health Homes, Specialty Health Plans, CCBHCs. Oh My! – https://www.openminds.com/market-intelligence/executive-briefings/health-homes-specialty-health-plans-ccbhcs-oh-my/

Successfully Managing Bundled Rates—The Voice Of Experience – https://www.openminds.com/market-intelligence/executive-briefings/successfully-managing-bundled-rates-the-voice-of-experience/