Technology Planning For Integrated Care & Value-Based Reimbursement

OPEN MINDS Senior Associate Ray Wolfe, J.D. and Chief Executive Officer Monica E. Oss delivered this executive web briefing on April 2nd, 2020.  In this session, we explored building a plan that helps executives make choices with confidence, manage them financially, and overcome VBR’s most challenging task: the development of an EHR system that can optimize results.

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2020 OPEN MINDS Performance Management Executive Survey: Where Are We On The Road To Value

The results are in! Download the 2020 OPEN MINDS Performance Management Executive Survey eBook: Where Are We On The Road To Value.

The survey was presented at The 2020 OPEN MINDS Performance Management Institute by OPEN MINDS Chief Executive Officer, Monica E. Oss.

In its fourth year, the survey tracks adoption of value-based reimbursement by specialty provider organizations, including the dominant models and performance measures used. The survey will provide direction on how to make sure your organization keeps pace with the rest of the field.

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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.

Health Plan Relationship Building Skills Key To VBR Success

As executive teams of specialty provider organizations look ahead to 2019, it appears that the shift to performance-based reimbursement will continue. The most recent change has been the new CMS rules that will move accountable care organizations (ACO) to full-risk reimbursement contracts (see CMS ‘Pathways To Success’ Medicare ACO Overhaul Limits ACO Time Without Risk). This is going to generate new and different relationships between health plans and provider organizations, as I discussed in Health System/Insurer Combos Gain Steam-& More To Come With ACO Changes. As a result, the OPEN MINDS senior team views value-based reimbursement (VBR) strategy as a key sustainability issue for provider organizations in 2019—The 2019 Health & Human Service Landscape: 2018 Legacy Sets Stage For Opportunities & Challenges and The Three Trends That Are ‘Top Of Mind’ In 2019 For The OPEN MINDS Team.

Deb Adler

If that is the case, the strategic question for executive teams is: How do you seize the opportunities and avoid market challenges in this landscape? That question will be the focus of the upcoming 2019 OPEN MINDS Health Plan Partnership Summit on February 13, 2019 at the Sheraton Sand Key Resort, in Clearwater Beach. The summit is led by my colleague and OPEN MINDS Senior Associate Deb Adler. Ms. Adler’s overarching advice for provider organization executive teams struggling with this question is focused on enhancing their skills with building relationships (and new programming) for health plans.

What is involved in that relationship building? Ms. Adler outlined four key items:

  1. Develop a brief (one or two slide) value story that describes how your organization’s programs are differentiated in terms of quality and costs, and how you contribute to health care cost savings for the payer
  2. Know the payer’s pain points and needs, as well as important performance metrics
  3. Know thyself and plan a formal negotiation strategy that identifies your “walk-away” position on pricing and service model elements
  4. Develop the relationship, at the highest level possible, and sustain that relationship intentionally

Develop a brief value story—When contact is made, and executives of a provider organization have gotten “in the door” for their initial meeting, the conversation needs to get to the point promptly. What value is your organization bringing to the table, and what are the strengths that differentiate you from the competition. Ms. Adler noted:

Provider organizations should have a short, one or two-slide value story presentation that illustrates what they bring to the health plan that is a cost and quality differentiator. Ideally it would include measurable results for the measures that the plan cares about—measures like ambulatory follow-up, readmission rates, health care cost savings, reduced emergency room visits, etc.

Know the payer’s pain points—It’s a mistake to walk in and attempt to describe the problem when the payer knows exactly what their problems already are. The key is for the provider organization’s executive team is to understand the problem from the health plans perspective and how they will measure success. Ms. Adler explained:

There is a high probability that the payer’s pain points largely center around three key areas: access to psychiatry services, addiction costs, and autism service access and costs. While I wouldn’t assume that any individual health plan has all three or even any of these pain points, the best approach is to ask. Get to know the health plan’s specific problems and devise a proposal that makes the health plan management team successful in terms of the quality or cost issues they have identified. Presenting a proposal that ultimately solves the health plan’s current challenge is the key—with a focus on the service, the cost, and measures of performance.

Know thyself and plan—When developing a relationship, and hopefully a contract, a provider organization’s executive team need to know when to compromise and when to hold firm. Walking that fine line is the focus of your negotiations, and requires an understanding of the market, the competition, and your organization’s capabilities and cost structure. Ms. Adler explained.

Provider organizations need to have a formal negotiation strategy-knowing what they want and how to negotiate towards that end. You need to understand your internal unit costs and key performance indicators (KPI) and your ability to manage risks and alternative reimbursement models. You should spend time preparing (and role playing if possible) all key contract terms (both language and reimbursement), thinking through various payer reactions and how you will respond. You need a clear idea of what things you will bend on, as well as those that would result in walking away.

Develop the relationship—Finally, Ms. Adler stressed the importance of pull-through on the new relationship. After the contract is in place, the executive team must be involved in maintaining and continuing to build the relationship to ensure that the partnership remains mutually beneficial. She noted:

Like any relationship, you need to find ways to develop and sustain it. I always recommend reaching as high into the payer organization as possible to develop those relationships—and the more relationships, the better. Then implement formal touchpoints (e.g., monthly or quarter scorecard reviews) or informal touchpoints (watch for conferences where the health plan leader is attending, and you can interact), where you can share industry updates that you think will be valuable to the health plan.

In summary, Ms. Adler explained that connecting with health plans on these (and other) topics comes down to persistence more times than not. Provider organizations need to find the right contact in network management, or whoever is leading their local plan and continue to reach out.

For more, be sure to mark your calendar for The 2019 OPEN MINDS Health Plan Partnership Summit on February 13, featuring Ms. Adler along with Kelly J. Champ, Vice President, Network Strategy & Innovation, Optum; Matt Miller, Senior Vice President, Public Sector, Magellan Healthcare; Charles Gross, Ph.D., Vice President, Behavioral Health, Anthem, Inc.; and Beth Rath, PMP, Vice President Network Operations, New Directions.

The Business Model Transition To Value-Based Care

Hello again from sunny Clearwater, where we are wrapping up The 2016 OPEN MINDS Performance Management Institute. It’s been a power-packed three days – with a focus on the evolution of pay-for-performance and value-based contracting. The discussion has left me with some new thoughts about the strategies needed for success in the decade ahead. Managed care and integrated service delivery models are definitely causing a “reordering” of the market value chain for the financing and delivering services for consumers with complex care needs. More specialty services are being delivered, and will be delivered, in primary care settings. The current role served by targeted case management will likely be assumed by new programs and players. To respond to the many new opportunities, provider organizations need more entrepreneurial service line development – and the access to capital to make that happen. And, all of this brings big advantages to organizations that have scale.

The fundamental change for health plans and provider organizations alike is the emergence of a new business model in this new value-focused environment. The traditional role of optimizing the volume of services delivered is being gradually replaced by a model that aligns organizational success with giving the consumer (and their payer) what they want and need (see Will Good, Cheap & Easy Win the Day?). This shift to consumer sovereignty as the driver of success (see Consumer Sovereignty As Success Strategy and The Key To Success With Integrated Service Delivery? A Seamless Consumer Experience) creates a new leadership and management challenge – making performance management a core competency.

Are You Really Ready For Value-Based Payment? Planning Your Move

So how do organizations accelerate their path to performance management excellence? There are three key steps:  measurement, metrics-based management, and developing a performance-driven culture.


Decide what to measure and measure it – The first step on the path is deciding on the measures that your executive team needs to navigate their way to performance excellence. There are the customer-facing metrics (HEDIS and SMS Stars measures for payers and consumer experience and web site analytics for consumers). And, there are the metrics you need to manage the enterprise – from cash on hand to productivity. Automate your measurements and measure routinely.

Establish a metrics-based management system – Metrics-based management is the path from information to action. It’s the system for knowing both your current performance on every measure and the performance you’re looking for – and the actions needed to bridge the gap.

Build a performance-driven culture – Performance measurement is only part of the equation. Using the data to change the organization is the key – and this requires a performance-driven culture. In short, an executive team and a management style that actually improves performance through talent management, goal alignment, and employee engagement.

So the question for most executives teams – is your culture a performance-driven culture? Can your organization thrive in the market environment where performance and value are the determinants of success? For more, check out my presentation, Are You Really Ready For Value-Based Payment?, from today’s institute. And, tomorrow, we’ll review the characteristics and competencies of the organization that is ready for results. And, in the meantime, check out our archived coverage of The 2016 OPEN MINDS Performance Management Institute on Twitter @openmindscircle#OMPerformance.