Over the past few years, the federal Centers for Medicare and Medicaid Services (CMS) has not so quietly been in the process of increasing its commitment to alternate payment models (APMs). In 2017, CMS has six primary APM programs in play, which are currently serving 12.3 million Medicare and/or Medicaid beneficiaries (see Alternate Payment Models – Strategy Implications Of The CMS Roadmap and What are Alternative Payment Models (APMs)?).
In spite of the recent upheaval in the world of health care policy (see Changes Proposed For PPACA Via HHS Rule Change On CSR Payments & New Presidential Executive Order), the move towards value-based reimbursement and APMs isn’t something that we expect to see change. If anything, CMS has been reaffirming its commitment. Last month, CMS’ Center for Medicare & Medicaid Innovation (CMMI) “upped the ante” by discussing new potential behavioral health payment models at the Behavioral Health Payment and Care Delivery Innovation Summit (see Summit: Behavioral Health Payment and Care Delivery Innovation).
Though the summit didn’t result in any concrete action plans, the presentation that I found the most interesting identified 11 APMs that are currently under development for behavioral health (see Payment Reform and Opportunities for Behavioral Health: Alternative Payment Model Examples). Many of these models aren’t new, but are being applied to new services and new populations (i.e., case rates for substance use or serious mental illness)—while others take a totally different approach to managing care (i.e., accountable communities that address the physical, behavioral, and social needs of children and families).
These are the 11 program models that were identified by the Scattergood Foundation as potential payment reform options in behavioral health. These models are all in various stages of development, with some being piloted by a few organizations in individual contracts with specific payers, some just at the beginning stages of development, and others being utilized in test programs with CMS:
- Case rates for substance use disorders, in which a case rate is established for each level of care, including detoxification, rehabilitation, partial hospitalization, and intensive outpatient.
- Specialized case rate for serious mental illness, in which provider organizations are given a single rate that covers all mental health services, and the provider organizations are at financial risk for up to 30 days of psychiatric inpatient care.
- Value-based collaborative care, a Medicare payment model established in January 2017 in which Medicare reimburses for behavioral health services integrated into primary care settings via the Medicare psychiatric collaborative care model (CoCM) and other models. The psychiatric CoCM allows for inter-professional consultation between primary care physicians, a psychiatric consultant, and a case manager.
- Multi-Payer Collaborative Care strengthens the Medicare value-based collaborative care APM by extending it to more payers, both public and private. In addition to Medicare, Medicaid agencies from various states can reimburse for collaborative care.
- Patient-centered opioid addiction treatment payment (P-COAT), designed to improve outcomes and reduce spending for opioid addiction by expanding coverage of Medication Assisted Treatment (MAT) through the use of bundled payments that are depended on the consumer’s stage of care.
- Coordinated Specialty Care (CSC) for First-Episode Psychosis uses a case rate or bundled rate to cover the full array of services and supports delivered in evidence-based CSC programs.
- Telehealth can be enhanced through the use of APMs that incentivize the use of existing payment codes to promote the use of telehealth.
- Transitional Care Bundled Payments use bundled payments to cover the transition of care from the emergency department for consumers with behavioral health issues – with the main goal of reducing preventable hospital readmissions.
- CPC+ Behavioral Health-Add is a modification of the CMS Comprehensive Primary Care Plus (CPC+) program, which is an advanced primary care medical home model. Behavioral health services can be added to this model in a primary care setting, using risk adjustment, performance-based incentives, and partial capitation.
- Accountable communities for health for children and families, a concept that tests the use of an “integrator organization” to connect consumers with needed social services and address community-based social determinants of health.
- ACOs at Risk for Behavioral Health Care is a model that requires more accountable care organizations (ACO) to implement behavioral health performance metrics, such as depression screening and depression remission metrics (instead of just Medicare ACOs), putting some risk for these outcomes.
As we know, it’s a long way to take an APM from the “drawing board,” to proof of concept, to scale (see Where Are We On The Path To Value-Based Reimbursement? and State-By-State Analysis Of Medicaid MCO Requirements For Provider Alternative Payment Reimbursement). But, we’ll be covering those developments in the year ahead. For more on meeting these challenging value-based models, join OPEN MINDS Senior Associate, Ken Carr on November 7 for his session, “Technology & Reporting Requirements For Population Health Management: Preparing For Value-Based Reimbursement,” at The 2017 OPEN MINDS Technology & Informatics Institute.