I had a chance to talk to William Lopez, M.D., CPE, Senior Medical Director for Behavioral Health at Cigna last week—and learned a lot about Cigna’s strategies to better serve customers with the most complex needs. My takeaway? Success with managing “complexity” is less about expertise with specific conditions and more about a care delivery model. His response to my question about the issue:
I think traditionally the most complicated medical conditions are those for which customers need the most support. In general, that is diabetes, hypertension, coronary heart disease, especially when there is a co-morbid psychiatric condition present. That being said, when managing complex cases we don’t focus on addressing specific conditions. We look at the care delivery model, the use of evidence-based practices and making sure that health care professionals are addressing customers in a holistic way. In other words, we don’t focus on a specific number of conditions, but instead, we are trying to be more comprehensive about the whole care of each customer. The goal for our value-based relationships is to improve the quality overall, which lowers medical costs, and improves the customer’s health and satisfaction.
And, performance evaluation of programs to manage consumers with complex needs is straightforward. He said, “In general, we are looking at emergency room use, readmissions, total medical cost, and at areas where the customers’ care can be improved.”
One program Cigna is evaluating is the Advancing Integrated Mental Health Solutions (AIMS) model, that was developed at the University of Washington AIMS Center. It is a model of behavioral health integration that enhances “usual” primary care by adding two key services: care management support for patients receiving behavioral health treatment; and regular psychiatric inter-specialty consultation to the primary care team, particularly regarding patients whose conditions are not improving (see AIMS Center).
One specific program we are piloting based on the AIMS model is the Psychiatric Collaborative Care Model (CoCM) rolled out by CMS. Cigna is enabling provider organizations to have behavioral health services in office to target customers with chronic conditions and comorbid mental health diagnosis. The goal is to find the customers with the highest need for medical and behavioral health. We are basing reimbursement on the CPT codes CMS released last year to support the CoCM model (see Medicare To Reimburse For Integrated Behavioral Health Services In 2017). Currently, Cigna is not reimbursing these codes across the board because there are specific activities related to the code, and we are trying to figure out how to attest those activities. We are testing them with a selected number of Cigna’s collaborative care partner practices (ACO) and helping the health care providers build the structure required around the codes. In addition to that, we are looking at population health analytics and helping providers target those customers that are at the highest risk.
But for executives of specialty provider organizations, the interview with Dr. Lopez left me thinking there are new market threats and market opportunities in this approach. The opportunity is for specialist provider organizations to move beyond “traditional” consumer segments with “whole person” care coordination. There is room for innovation. Dr. Lopez said, “Determining what health plans want isn’t strictly a known quantity, and there is room to innovate as long as that innovation can be attached to a delivery care model that offers an integrated, holistic approach to services.”
At the same time, the threat is that acute care and primary care organizations will develop and perfect those same models. Want to know how prepared your organization is for developing and delivering a value-based care coordination model? Check out these resources from the OPEN MINDS Industry Library:
- Getting That ‘Preferred’ Role With Health Plans
- Tackling The Thorny Issue Of Behavioral Health ‘Value’
- The Value Challenge, Again
- The Problem With Risk – Not Everyone Can Be Above Average
- The Value Train Has Left The Station
- Value-Based Reimbursement: 3 Steps To Go From Idea To Action
- Preparing For Value-Based Reimbursement-Even Before The Contracts Are Signed.
Or, try our web-based readiness self-assessment for value-based reimbursement, focused on the scoring organizational and technical competencies. This new tool, Value-Based Reimbursement Readiness Assessment, can be purchased in the OPEN MINDS Shop-and is available free for all Elite members of the OPEN MINDS Circle.
And don’t miss for Dr. Lopez’s upcoming session on September 18 at The 2018 OPEN MINDS Executive Leadership Retreat, “Key Issues Shaping The Market For Complex Consumers: The Health Plan Perspective On What Executives Need To Know To Succeed.”