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.
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.
Knowledge Partner Session at The 2020 OPEN MINDS Performance Management Institute
Providers are becoming more aware of and involved in the changing reimbursement landscape. While many can build the internal talent and resources needed to win in the VBR world, technology often seems a barrier that can’t be hurdled. The executives, who often have no technical background, are faced with expensive choices that will require focus and effort to implement. In this session we will explore questions that providers have about their technology decisions:
• How can they determine if they can afford these options?
• What are alternative options if they can’t afford technology at this time?
• Which options will bring the best return?
• Are there some that can be delayed?
• How can they allocate internal resources to tech projects without overwhelming their staff?
In this session we will explore building a plan that helps executives make choices with confidence, manage them financially, and overcoming VBR’s most challenging task, the development of an EHR systems that can optimize results.
- Behavioral Health Is In Transition From Volume Based Care To Value Based Care
Healthcare reimbursement models have shifted away from volume-based care, sometimes called fee-for-service, where a provider is paid a fee for each service rendered. The current trend is toward value-based care, defined as reimbursement that is directly linked to performance on cost, quality, and the patient’s experience of care.
This transition is already well established in physical health where, for instance Medicare has shifted almost 90% of payments for hospital visits into value-based models. While the numbers are not as robust in behavioral health, the percentage of value-based reimbursed care does continue to grow. Despite this growth, there are still many within the behavioral healthcare continuum that have not fully embraced the model. However, the transition is inevitable and one way to prepare is to understand the basic language and models of value- based care. Let’s start with terminology.
- Know Your VBR Payment Model Terminology
Know your reimbursement structures and the associated level of risk assumed by the provider organization, listed below in ascending order from low risk to high risk:
- Performance-based Contracting-Contracts in which payment is linked to provider performance and require providers to undertake specific activities or meet certain benchmarks for services. These contracts may include incentives and penalties, caseloads and Pay for Performance.
- Bundled & Episodic Rates-A single bulk payment for all services rendered to treat an individual for an identified condition during a specific time period. These payments also include case rates.
- Shared Savings-Supplemental payments to providers if they successfully reduce health care spending for a defined patient population relative to a benchmark. The payment is a percentage of the net savings generated by the provider.
- Shared Risk-An arrangement of shared financial responsibility between payer and provider that allows for cost control, efficiency of service use and quality. In this arrangement, both financial savings and losses are shared.
- Capitation– A payment arrangement for health care service providers that pays a set amount for each enrolled person assigned to them, per time period, regardless of whether the person receives services during the period covered by the payment.
- Capitation + Performance-based Contracting-This payment arrangement adds performance-based contracting as a supplemental incentive to a capitation contract.
- Develop an Incremental Plan For Risk With Payers
As noted above, the type of payment arrangement you choose will assume a certain level of financial risk for the provider. That level of assumed risk can be small, medium, or high as illustrated below. The upside of assuming risk is a higher payout for the provider. Of course, the downside is the potential to lose money.
- Assess Your Organization Readiness
Carefully assess your organization and determine the gaps in value-based care. OPEN MINDS has developed an online readiness assessment tool, sponsored by Carelogic. This tool offers you recommendations in your planning process in the following domains:
- Provider Network Management – Strategies to enhance provider networks
- Clinical Management & Clinical Performance Optimization – Data analyzed to drive clinical decision making
- Consumer Access, Service Engagement – Processes to empower consumers and create engagement
- Financial Management – Revenue cycle management and accounting procedures to support contracts
- Technology & Reporting Infrastructure – Data leveraged to gain insight
- Leadership & Governance – Alignment of strategy with infrastructure and resources
By Joining the Value Based Care for Behavioral Health online community, you have free access to the VBR Readiness Assessment. The assessment is available now at https://vbcforbh.com/vbr-assessment/
- Prepare for Challenges During Your Transition
- Create a transition plan for your clinical and financial operations to support value-based care. Plan capital expenditures over time.
- Identify patient experience and clinical outcome indicators that align with the expectations of your payers.
- Establish evidence-based care, aligned with workflows, data entry and outcome reporting.
- Adopt interoperable electronic health record systems and effective data analytics tools.
- Eliminate waste, streamline workflows, rightsize staff, and align supplier contracts to reduce costs.
Even if Value Based Reimbursement (VBR) is not immediately imminent in your region, it is on the horizon. Prepare now by measuring and improving patient experience and patient outcomes. Begin to demonstrate improvement in the quality and efficiency of care that your organization provides. Your pathway to value-based care will improve the health and satisfaction of your consumers and the financial effectiveness to your organization.
Value-Based Reimbursement (VBR) is an opportunity for payers and providers to establish and build new relationships based on shared goals, outcomes and incentives. Ultimately, patient mental and physical health outcomes are improved. Financial leaders must reevaluate their strategies and system. They must consider the investment in the patient experience, as well as clinical outcomes. Both will likely be measured. Key steps to position the financial systems of the organization to support VBR are outlined.
Step 1. Discern the Goals of the New Paradigm and Investment Needs
A first step is to understand the investment of new service lines, support systems and their staffing implications, technologies and other expectations by payers to successfully meet value-based care expectations in your region. This may include chronic care management, improved care coordination, and integration of physical health. Accreditation could also be required, which is a significant expense for a smaller organization. The clinical and operations teams will specify the resources needed and the finance team will help develop pro-forma to accomplish clinical and operations objectives.
Step 2. Bridge the Gaps Between Finance, Operations and Clinical Leadership
Examine your leadership culture, skill sets and silos. Many behavioral health provider organizations are mission-driven and may be ‘allergic’ to a ‘bottom line’ business model. However, VBR is a more complex reimbursement process that marries quality outcomes with cost effectiveness and ultimately defines reimbursements.
Finance leaders need to understand the clinical outcome and patient experience requirements and how to resource staffing and technology to support them. They must be properly funded. Operations and Clinician Leaders need to learn to formulate and present the ROI on additional resource needs and clearly articulate those in financial terms.
The finance department will need the new skill of correlating service data to VBR contract terms and projecting short and long-term cash needs. Keep in mind the financial analysis is only as good as the encounter data feeding the system. In turn, quality improvement can only be realized when the feedback loops are accurate. The lack of good data will diminish outcomes and over time, drive down cash flow. The finance department can often identify red flags in billing practices. In many organizations this may be a new role for the finance department and necessitates a closer working relationship between finance and operational departments.
Step 3. Evaluate Baseline Costs to Deliver Services
In order to evaluate cost effectiveness, you need a baseline of current costs. The average cost per visit is a good start, and this can also be broken down by service line. Engage with your finance department and ensure you are accurately tracking direct costs like staffing costs, and administrative costs that include occupancy, technology, and infrastructure.
Step 4. Determine the Investments Required
Consider the goals and investment needs discerned from Step 1. The development of VBR processes can be expensive. For instance, implementing a new evidenced-based practice can include ongoing trainings, certifications, and continuing education expenses. More to the point, can you afford the VBR plan you are planning? Remember you may have many options such as incentive-based ‘withholds’ that lower your financial risk. Having a sound understanding of your financial bandwidth allows you to effectively negotiate with payers and set up programs that will meet the need of the individuals you serve. Also, carefully assess hidden costs such as workforce training to accommodate a new payment model.
Step 5. Consider Your Cost Strategy
A more in-depth breakdown of costs will help increase that value for the consumer and the organization alike. Key tools are cost-driver analysis, activity analysis, and performance analysis. By understanding these crucial concepts, the move to operational implementation, changes and improved outcomes become viable. A few concepts to consider:
- Activity-based costing—Identify the key activities of a service. Key activities need to be broken down into definable tasks. Then we can identify the resources needed to complete the task. In turn, changes in productivity can be monitored and addressed on a systemic basis.
- Target costing—With our initial analysis we can identify the cost of a service to hit a specific target market rate to realize the required profit margin. While this type of analysis is derived from manufacturing processes it can be thoughtfully implemented in the behavioral health setting where profit margins are often slim at best. In the end Target costing balances three areas – price (what the consumers will pay), quality (the acceptable level of quality expected), and functionality (the service components expected).
- Value engineering—Define the functional outcome and identify ways to improve the process of reaching your goals. For instance, a new technology may be added to a service activity that reduces time spent traveling and associated costs like mileage and insurance. The role of the finance team in identifying cost drivers will be a key step in seeking cross-functional input from service line, IT and quality teams and transforming this information into a holistic view that incorporates the different perspectives on the path to better productivity.
Step 6. Take A Systematic Approach to Payer Contracting
It is a critical step to develop, hire or outsource the talent to negotiate payer contracts effectively. Practices should take small steps when entering into VBR. Gain experience with a few select outcome performance areas before entering into a full risk agreement. As you get experience with payer expectations and they with your practice’s cabilities, you can then broaden the contract risk. Identify the diagnoses or procedures you can most easily impact. Consider what matters to your payer by finding two to three diagnoses that comprise the most potential spend for them. It is ill advised to blindly enter into the contracting process without understanding your costs, reporting capabilities and current performance. As provider organization must objectively demonstrate both the improved results and ‘cost effectiveness’ of their approach, it will make it possible to negotiate to thrive, not survive. Also prepare the payer contracting function with national and regional benchmark data. Closely examine the underpinnings of benchmarks such as HEDIS measures. It will come in handy to level-set realistic expectations.
Step 7. Refine Your Revenue Cycle Management
A clear understanding of the hard and soft costs will help to determine the transaction price; an organization’s ability to identify the payment terms for the services provided. While the transaction price was is relatively clear in the fee for service system, the uncertainty of VBR needs heightened attention. Remember, many VBR reimbursements are not determined until the results are obtained. While an agile Electronic Health Record (EHR) can shorten this turn around, there can still be a lag in reimbursement timing. Having the economic stability to deal with these fluctuations is key to the organization.
Another key area of input by the finance department is timing of payment. If an outcome goal is reached over two fiscal financial periods, what is the contract language on how that incentive should be paid out. Again, the generally tight profit margins in behavioral health require a clear understanding of the financial terms of the VBR contract, including payment cycles.
Step 8. Evaluate Supplier Contracts
Consider your vendors and suppliers to be your partners in the delivery of value-based care. Under HIPAA rules, you are required to have business associate agreements with vendors who handle your organization’s Protected Health Information (PHI), which protects your organizational risk. Likewise, build in shared accountability into vendor agreements, whenever possible, to ensure timely metrics, adherence to system uptime slas, and data availability to obtain target reimbursements in providing cost-effective care. Perhaps you outsource your chronic care management program. You should have clear performance expectations in your contract to mirror payer performance. Insist upon performance guarantees and financial penalties if the vendor doesn’t perform to established expectations. Routine rebid of vendor relationships help organizations contain costs and maximize their quality.
Step 9. Bring Your Board “On Board”
A financially savvy provider organization executive team understands the need to align strategies for organizational performance with their ability to manage financial risk. The board has a fiduciary duty to oversee the financial investment and return on value-based care. An important element of this process involves effective education of the board or bringing the ‘board on board’. This topic is often neglected in literature, yet some resources exist (see Get the Board of Directors on Board for Change, Getting A Board On Board, and A Chaotic Environment Demands Fluid Strategic Planning).
Step 10. Leverage Technology for Efficient Cost Reporting
Many organizations are drawn to the belief that the VBR processes will be managed with EHR software. The good news is that EHRs have become increasingly more agile in the ability to output quality and financial data. The bad news is that there are pitfalls with over reliance on software. George Braunstein has been Executive Director of numerous behavioral health care provider organizations and has seen the evolution of ever more sophisticated software. He notes, “EHR software should be seen as support for VBR” and not a substitute for substantial planning and process implementation. George also noted that without consistent feedback and ongoing education at all organizational levels, there will be little functional change within your organization. (see the Financial Thought Leader article for the complete interview with Mr. Braunstein).
Final Thoughts: You’re Not Alone
Fluency in the language of finance is uncommon in the world of behavioral healthcare. Even seasoned administrators may struggle with the intricacies of alternative payment arrangements and shared risk. The evolution of VBR has made it a need to become familiar with financial processes, however, it does not mean you need to be an expert. Identifying and utilizing your available staff subject matter experts is always a good starting point. Once you have a sense of your organizational financial capabilities you can then move to process planning. Again, finding good resources is critical. For instance, an organizational preparation guide (see https://vbcforbh.com/does-your-strategy-prepare-you-for-success-in-a-value-based-market/) can demystify and give direction to successful VBR implementation. Finally, the use of an agile EHR can give you the systemic support throughout the VBR process.
Making the new gainsharing, value-based partnerships between health plans and provider organizations work requires changes from both parties, and a clear understanding of what success requires. Yesterday, I touched on some suggestions for health plan executives to make that equation work (see Making VBR A Success: What Health Plans Can Do). This discussion, which echoes my presentation during the 2019 OPEN MINDS Executive Leadership Retreat (see The Complexity Challenge: How To Position Your Organization For Success In A New Era), was prompted by a new report from Harvard and UnitedHealthcare with a three-dimension framework for building these new payer/provider partnership relationships (see A 3D Model For Value-Based Care: The Next Frontier In Financial incentives And Relationship Support).
The framework is built on performance incentives for cost reduction, performance incentives for consumer outcomes improvement, and the provider infrastructure needed to make value-based reimbursement (VBR) work. For provider organization executives to succeed in these new relationships, that ‘provider infrastructure’ brings a few key requirements – shared data, increased care management capacity, collaborative and innovative program design, and organizational evolution and leadership.
In yesterday’s article, shared data was front and center along with providing care coordination tools for provider organization partners. But having the data and tools isn’t enough for success. Provider organizations need to develop care management skills to ensure access, improve consumer outcomes, and develop a value equation (the balance between performance improvement and cost reduction). While there is ongoing contention about the responsibility for care coordination, the more provider organizations are at financial risk, the more robust provider-led care coordination is essential.
Another issue is innovation. Most executives of provider organizations that have active risk-based (particularly case rates and sub-capitated arrangements) reimbursement arrangements cite the ability to do something new and creative to improve consumer outcomes as the greatest benefit of VBR. These new provider-payer organization relationships can facilitate innovative program development by providing financial upside through aligned goals (see How To Build Value-Based Payer Partnerships).
Finally, there is the issue of organizational change and the leadership required to implement it. Delivering on VBR requires an entirely different type of organization. Every detail of the day-to-day running of provider operations needs to be reconfigured to succeed with VBR, which is why a leadership commitment is so essential. My colleague, Richard Louis III, OPEN MINDS vice president, noted in a recent session that many health and human service organizations will need to add new team members – both clinical professionals and administrative staff. And, many times, new approaches to care are required along with an enhanced tech infrastructure to ensure that data can be tracked and used in actionable ways (see Using Data To Follow The Money & Stay True To The Mission). He advises executive teams to assess their capacity for success early on and ask about a range of organizational competencies – including intake and eligibility determination systems, care managers who can conduct concurrent reviews, and the ability to collect deductibles and copayments (see The OPEN MINDS Value-Based Reimbursement Readiness Assessment).
The move to value-based care is changing the relationship between health plans and provider organizations. Ultimately, the relationships that are most successful will have leaders (on both sides of the equation) who understand that the commodity-oriented network model of the past is (slowly) being replaced by mutually-dependent partnerships. To learn more about preparing for VBR, check out the following resources in the OPEN MINDS Circle Library:
- Making VBR A Success: What Health Plans Can Do
- 4 Lessons From ACOs For Managing Downside Financial Risk, VBR @ Scale—Changes Required
- Preparing For The Very Glacial VBR Rollout In Some Markets
- Proving Your Unique Value To Payers: Data Speaks Louder Than Words
- VBR @ Scale—Changes Required
- The New Directions VBR Model
- CFOs On The VBR Path
- Crawl, Walk, Run To VBR
- The Pace Of VBR Is Picking Up
- What Are Health Plans Doing About VBR?
And join us February 12 for the session “How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating & Contracting With Health Plans” during the 2020 OPEN MINDS Performance Management Institute.
Adoption of value-based reimbursement (VBR) models is glacial—slow to occur but changing the delivery system in its wake. It’s an issue we’ve written about before—4 Lessons From ACOs For Managing Downside Financial Risk, VBR @ Scale—Changes Required, and Preparing For The Very Glacial VBR Rollout In Some Markets and will continue to help health and human service organizations find their footing. In the field, what I find interesting is that two different conversations are happening: Health plan executives talk about the lack of readiness of provider organizations while managers of provider organizations talk about the difficulty in moving VBR proposals forward with health plan customers. How do we make these partnerships evolve more smoothly? I think observations and advice from Alyna T. Chien, M.D., MS, Harvard Medical School, and Professor Meredith B. Rosenthal, Harvard T.H. Chan School of Public Health in the report, A 3D Model For Value-Based Care: The Next Frontier In Financial incentives And Relationship Support) provide a great foundation for that discussion.
The authors present a three-part framework for considering the health plan shift to VBR – financial incentives for reduced spending, financial incentives for improving quality, and infrastructure support for their partner provider organizations. Their infrastructure support includes performance management information (both access to raw data and analyzed data), limitations on financial exposure from risk contracts, care coordination tools, technical assistance, and infrastructure payments.
What is interesting is that these were the very issues brought up by provider organization executives during my session at our 2019 OPEN MINDS Executive Leadership Retreat. Access to data and limitation on financial downside were high on the list.
To make this three-dimensional model for VBR a reality, there are some specific actions that managers in health plans, accountable care organizations, and state and county government can take. Two key issues stood out for me as potentially having the greatest impact: Increasing the amount of revenue tied to VBR and aligning performance measures across payer contracts.
One of the common concerns I hear from provider organization executives is that the upside in the value-based contracts is not enough to justify infrastructure expenses. This is a fiscal reality at two levels in any individual payer contract. Is the incremental increased revenue of quality-based performance bonuses or shared financial savings enough to justify new operating infrastructure? Second is the volume of consumers served great enough to warrant dedicated service capacity (it’s addressing that ‘one foot in two canoes’ issue that provider organization managers face).
In our recent survey of specialty provider organizations, we found that 16% had 20% or more of their revenue coming from VBR contracts (see Where Are We On The Road To Value?: The 2019 OPEN MINDS Performance Management Executive Survey). While these numbers represent growth, they still illustrate the challenge of scale.
OPEN MINDS Senior Associate Drew Digiovanni urges industry members to walk before they run with VBR contracts that include financial risk:
Establish a pathway for providers who are entering into VBR agreements for the first time. Assess their abilities and offer limited performance measures in the first year to help them ramp up for success, before entering into more robust risk contracts.
The other issue is one that comes up every year during the OPEN MINDS Performance Management Institute – can’t health plans get together and agree on the same performance measures? From the provider organization perspective, almost every VBR-based contract is a ‘one off’ with different measures that have different definitions.
Admittedly, the adoption of NCQA HEDIS and CMS STARS are starting to create some “standardization” of measures, but provider organization managers need very flexible (and very expensive to maintain) performance reporting tools that can be customized for each contract. Almost any initiative to standardize measures would be welcome on the service delivery side of this equation.
Moving forward, how do health plan executives make their provider partnerships a success, sooner rather than later? OPEN MINDS Senior Associate Paul M. Duck suggests that transparency and investments in technology need to be front and center in VBR discussions:
Provider and payer organizations benefit from technology implementation. If a tool like a telepsychiatry platform is implemented, the payer benefits by increasing access to care, which lowers costs and prevents emergency room admissions. Provider organizations benefit by delivering a new service, which opens the door for additional revenue. It expands access for a larger population and delivers services in places where a group might not have a physical presence, such as rural communities. In other words, it’s a win-win.
Tomorrow, we’ll look more specifically at the provider organization side of the VBR equation. But for now, for more on the path to VBR, check out:
- The OPEN MINDS Value-Based Reimbursement Readiness Assessment
- How To Build Value-Based Payer Partnerships
- Implementing Value-Based Care Through The Certified Community Behavioral Health Model
- Does Your Strategy Prepare You For Success In A Value-Based Market?
- Current Insights Into Population Health Management Value-Based Models In Managing High-Risk, High-Cost Patients
- Using Data To Follow The Money & Stay True To The Mission
- Structuring (& Budgeting For) Analytics
- Technology & Reporting Requirements For Population Health Management: Preparing For Value-Based Reimbursement
- Planning & Budgeting For Technology: How Much Is Enough?
- From Pain Point To Revenue
And for a deep dive, join us February 12 for the “How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating & Contracting With Health Plans” during the 2020 OPEN MINDS Performance Management Institute.
Preparing your organization for the shift to a Value Based Reimbursement (VBR) model is a unique challenge for behavioral health organizations. The conceptual underpinning of VBR is relatively simple: payment based on improved outcomes. However, the implementation of value-based programming presents a long list of competencies to manage care and population health in a new way. The challenge for leadership is to support providers in meeting these new market demands and yet maintain clinical integrity.
Drew Digiovanni is the former director of education with the Medical Group Management Association, where he served over 20,000 practice administrators in primary care, medical specialties and behavioral health. Drew also served as vice president of quality, supporting 150 health centers to provide value-based care for large employers. In his leadership and consulting roles, he has worked with hundreds of health systems around the county, assisting leadership and staff in developing VBR skills.
Drew noted that the first step in developing VBR within an organization is to, “assess the way we view leadership, clinical and staff competencies across the organization. Certainly, we’re having to shift from a focus on productivity to a focus on patient outcomes. And I think that people have been trained and have the skill sets for a productivity-based environment.” In doing this, it helps point of care providers to understand the market demands and the alignment of demands toward improved clinical outcomes.
A second challenge is shifting organizations to a data driven mindset. He noted that it is normal for organizations to resist this change. Noted Drew, “we’re trained to focus on people, not on data necessarily. And so we’ve got to step back and reduce the resistance to a data driven environment through competency development. Our competency development is as much based on attitudinal change as it is on gaining new knowledge and skills.“
Competencies of a CEO
A CEO doesn’t need to have the skills of their C-suite, but they do need to have enough skill to oversee those functions, including Finance, Operations, Human Resources, IT, Quality and Population Health, and Clinical Operations. Clinical leaders and business leaders often see the world through a different lens. The CEO who drives the leadership team to see through the lens of their counterpart helps the organization to support an outcomes-based culture.
Needs for Continuous Leadership Development
“A foundation for VBR, or any large initiative, is to provide leadership development and enhance conflict management skills.” Leaders can better facilitate change using leadership styles that engage clinicians and staff and empower them in the change process. Turf battles between legacy teams and new service line and care management teams may ensure, and conflict management is critical.
Clinician and Staff Development
Staff require education in five key areas: 1. A clear understanding of payer needs and demands; 2. Performance goals; 3. Evidence-based standards within the organization’s scope of behavioral health, clinical care and chronic care management; 4. Patient experience standards that will be measured and reported; 5. How to interpret key performance data. Drew further explains “in the old paradigm, we might hand a client or patient discharge instructions or other patient education information. In an outcome-based environment, staff competencies in working with patients with low literacy skills is essential to helping them comply and stay engaged to achieve our outcome goals.”
Staff education isn’t always focused on knowledge and skills. Changing attitude comes into play when shifting to an outcome focus. Clinicians and staff need to value the changes necessary to drive outcomes. Drew says, “attitude doesn’t change in one conversation and leaders should expect that multiple conversations happen to outline the benefits to organization sustainability and particularly to enhance patient care.”
Engagement with Data Monitoring Through Visual Management
Drew cautions that no program will work without a sound approach for data validation. There needs to be a process which establishes a standardized approach to care, and a focus on evidence-based practices. Said Drew, “I think that the leadership needs to think about what are the standards of care that are driving internal operations, and then looking at how we document and get data into our systems so that we have good data coming out of the system.” A key takeaway that Drew emphasized is that staff and leaders need to know how to configure the EMR to capture that data. The ability to update and customize the EMR will allow for agility to manage your value-based program.
A final thought is the need for investment. The first investment is in technology; however, the larger investment is in human resources. “We need to make an investment to move towards value-based care, and part of that investment needs to be in competency development to address the gaps of our leaders, our clinicians and our staff. There’s going to be cost. It may seem like non-productive time to conduct education and training, but there is a return on investment if we help our teams come up to speed to support this new paradigm.”, says Drew. In the end, the marriage of agile technology with a well-trained workforce bodes well for success in this new value-based world.
Organizations who want to position themselves for the future need to identify ways to leverage current technology to capture and analyze data and create a culture where staff use metrics to drive consistent, high-quality results. No matter where you are on the path to value, this session will give you insight into three key competencies:
Technology – from harnessing the right technology for organizational needs to integrating that technology to drive performance results – your technology choices are a key element to success in a value-based reimbursement environment.
Data – performance management, driven by data is crucial for value-based care because organizational growth, new contracts, and financial sustainability are all tied to delivering quality service results.
Culture – create a culture of performance where continuous improvement and optimization is embraced as the ultimate support to your overarching mission.
Roy Leitstein, CEO, at Legacy Treatment Services shared how his organization created a culture focused on using data and technology to drive organizational growth – in services, contracts and community impact.
Ken Carr, Senior Associate, OPEN MINDS facilitated the discussion and shared key competencies tied to positioning agencies for the technological, data-driven and cultural changes necessary to transition to Value-Based Reimbursement models.
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/