Last week, OPEN MINDS Vice President Paul Block, Ph.D. talked about the challenges of getting health plan contracts – especially in a value-based market. His solution was to document your program’s clinical outcomes and financial impact – and then be assertive about proposing those models to health plans (see Have ‘The Best’ Services, But No Health Plan Contracts?). I agree with Paul’s recommendations – but for organizations operating within a payer landscape that hasn’t yet made the move to pay-for-value, this can be a challenge.
My recommendation (and the path that my organization, Grafton Integrated Health Network, has pursued) is to build a strategy for defining your own value by looking at what success means to your organization and the consumers you serve.
First, you need to look at your current market and how major payers for your services are defining value. In many states, Medicaid programs are moving forward with alternative payment models and establishing clear performance metrics with new value-based reimbursement models (see State-By-State Analysis Of Medicaid MCO Requirements For Provider Alternative Payment Reimbursement). How your state is, or is planning to define value is how your organization should be defining value.
However, in other states, there hasn’t yet been a move towards adopting value-based care. In my home state of Virginia for example, the state Medicaid program hasn’t made many moves towards value-based payment models. Grafton is primarily a Medicaid shop, which means that right now, our reimbursements aren’t tied to value.
This leads me to my second, long-term recommendation for your organization. You need to start thinking about how to define and demonstrate value on your own.
We operate in a system where there is no consensus on the definition of value. Successful outcomes are defined differently across the board – from state to state and payer to payer, making it difficult to compare provider organizations to each other. If uniform standards were set and enforced at the federal level, that might serve to define value, but that’s not the structure we’ve had, nor is it a panacea.
So where to start when we operate in a system where there is no consensus on the definition of value? Right now, I think the system judges provider organizations by cost instead of value. For example, in our current system, a great outcome is getting someone out of the hospital and back into the community. But that is a focus on cost, not value. It doesn’t tell us if the consumer is getting the services and supports they need to improve their health in the long term; it just tells us that for the present, they aren’t in the hospital. The “value perspective” of that situation would be deciding what the true indicators are that someone is ready to return to the community and the outcomes that demonstrate improved health. Therein lies the problem.
But what is the alternative? What constitutes a “successful” result in treating a complex consumer who has behavioral health issues? Is it that they can live out a somewhat independent and productive life with long-term care and supervision, or is it simply that they aren’t readmitted to the hospital or clinic within a month? What specifically represents the desired outcome? These kinds of questions might seem rhetorical, but they get at what we are ultimately striving for in our health care system: better, and better defined, results post-treatment.
We know that the ultimate goal in our system is towards the triple aim of reduced costs, better outcomes, and a better consumer experience – so consider what that looks like for your organization and your consumers and find a way to measure your results.
For now, until our industry comes up with some consensus on what value means, at Grafton we’re looking at the broader question of how we define value and putting the staffing and training in place to support that definition. We hope to bring payers and others into our definition of value over the long-term by showing results that others aren’t able to achieve, thus gaining increased market share and positioning our organization for value-based reimbursement in the future.
At Grafton, we’ve had internal KPIs for over a decade. Those are related to maintaining and improving our goal mastery rates, family satisfaction survey results, the “Grafton Model” scores (seclusion, restraint, trauma-informed care, which comes from performing the assessment we use on our external consultations on our own business lines), and safety rates as defined by VA DBHDS. The last one, and a new one for this year, is a “readiness for value-based contracting.” Of those KPIs, I would hope the goals and objectives identified on the IEP and the TxPlan would be part of the reason for value of our services under definitions from payers — specifically, if they are tied to the reason for the referrals. We have identified about 10 reasons a child has been referred to Grafton’s residential or education system, which include reductions in:
- Physical aggression towards others
- Physical aggression towards self
- Elopement (Bolting)
- Lack of safety awareness (possibly to include PICA)
- Lack of communication skills
- Lack of minimal skills for self-care
- Extreme inattention/impulsiveness
- Extreme oppositional or conduct disordered behavior (possibly to include property destruction)
- Sexual acting out
It is our belief that while there may be other goals a child may have, if we address and are able to document change in those areas, we will be able to more quickly transition the child back to the community-based level of care if proper supports are in place. So, we are trying to design our services and documentation around that model and tie value to it.
For more on how we define value and how you can prepare your organization to move forward, follow our live coverage of The 2017 OPEN MINDS Performance Management Institute on February 16-17, 2017. Registrations for the institute are sold-out, but our team will be reporting live from all the sessions at #OMPerformance.