Based on my work the past six months, I would describe the “path” to value-based reimbursement (VBR) for provider organizations as bumpy. I hear lots of frustrations from health plan managers about provider organization lack of ability to commit to a specific program, rates, and performance measures—and concerns about the contract management capabilities of those provider organizations. On the flip side, provider organization managers are concerned about the lack of data for developing value-based rates and the long lag times between discussions and moving ahead with actual VBR contracts.
I view these as “bumps in the road” on path to value-based reimbursement. The health and human service field has moved down that path—as we have reported on (see Where Are We On The Path To Value-Based Reimbursement?, Taking A Functional Approach To Succeeding With Value-Based Reimbursement, and The 2017 OPEN MINDS Performance Management Executive Survey: Where Are We On The Road To Value?). But there is obviously a long way to go in terms of the percent of spend covered by VBR—and the amount of “financial risk” related to performance in those agreements.
So how do we get past these bumps in the road? I turned to my friend and colleague Carole Matyas, Vice President, Behavioral Health Operations, WellCare Health Plans, Inc., to get her perspectives. WellCare providers government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to more than 4.3 million Americans across the country. Carole is a leader on WellCare’s team addressing integrated care delivery models in their health plans—moving ahead with a whole-person care model that integrates medical, behavioral health, pharmacy and social determinant needs of members, which is adapted to each state and community where WellCare operates. (For our previous coverage of Ms. Matyas’ work, check out Payer, Provider, Partner.)
WellCare has moved far down the path in moving its relationships with its provider networks to gainsharing arrangements. Ms. Matyas’ said:
“At WellCare, Expanding value-based care is a strategic priority. Over the past 3 years, we have grown both the percentage of our payments aligned to value as well as the number of provider practices in shared-risk arrangements in a meaningful way, including behavioral health.”
In that transition, the WellCare team has learned some interesting lessons in making VBR work. My takeaway was that the keys to success include local design, a phased-in approach and provider technical assistance. Ms. Matyas said:
“At WellCare, we understand health care is local. It’s about working with provider communities and finding the value-based strategy that works best for that community. We’ve learned we have to implement value-based reimbursement in phases as we don’t want to overwhelm our provider organizations, so we start small and grow their experience. We have started the process of applying a phased approach with claims-based measures while establishing a HEDIS baseline. In year two, we want to focus on the process of the HEDIS measures. In year three, our goal is to transition providers to focusing on outcomes. And we are providing the tools and resources to move provider organizations along that continuum. We are also creating partnerships. For example, WellCare now has quality practice advisors who deliver data that shows providers information such as member care gaps. It’s not just how to pay a claim anymore, but actually looking at, using—and caring—about data to show providers what is needed to achieve better outcomes and get rewarded through a VBP arrangement.”
But I was interested in Carole’s experience as she moves from working with primary care practices to behavioral health practices. She said WellCare is looking at different models of integration and expanding the range of “outcomes measures.” Her comments:
One of our key challenges is determining the right definition of integration. There are models out there that work and that are different strategies to integration. Sometimes an organization can get a model to work that another organization can’t. At times, behavioral health providers are behind the curve when it comes to this strategy. Sometimes it’s the state requirements and the structure of the Medicaid programs that are contributing to that. We look for viable process outcome measures that are behavioral health outcome-related. We aren’t looking to silo outcomes measurements into behavioral health and physical health separately. Because our care model is predominately focused on integration, we are looking for the right combination of care coordination, service delivery and social determinants outcome measures to use. And we have a big portion of our program wrapped around the community impact.
For more on these first-hand perspectives on value-based reimbursement, I’m pleased that Carole will be kicking off the second day (February 16) of the 2018 OPEN MINDS Performance Management Institute in Clearwater Beach, Florida with her keynote address, Overcoming The Impediments To Value-Based Reimbursement. In addition, Carole and I will hold a thought-leader session on that day for an interactive discussion about WellCare and the state of value-based reimbursement. I hope you can join us.