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.

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.