The slow, uneven shift from pay-for-volume to pay-for-value continues to dominate strategy in the health and human service market – for payer, health plan, and provider organization executive teams. The shift presents challenges – alignment of incentives, sustainability, consumer choice, infrastructure and capital requirements, and scale are just a few. Some of our coverage over the past few months illustrates the shifts in the market:
- 2020 Medicare Advantage Open Enrollment Features 3,148 Plans; Up 15% From 2019
- 8 Health Plans Earn Top NCQA Rating For 2019
- Illinois Medicaid Implementing Managed Care For Foster Care On February 1, 2020
- Humana Member Costs 20% Lower For Physicians In Value-Based Contracts Than For Fee-For-Service Medicare
- Optum Begins Contract As Maryland’s Public Behavioral Health ASO
- Blue Cross Blue Shield Of Michigan & Seven Health Organizations Will Share Financial Risk For Consumer Care & Health
- West Virginia Awards Aetna Better Health 3.5-Year $200 Million MCO Contract For Foster Care Population
Each year, we survey provider organizations in the field to see where they are at with the shifting reimbursement models – see Where Are We On The Road To Value?: The 2019 OPEN MINDS Performance Management Executive Survey. And, we also survey health plan executives to see how they are managing the care of the most complex consumers – 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System. We’ve published a great deal on succeeding with value-based reimbursement (VBR) as the industry shifts away from fee-for-service reimbursement models – The Complexity Challenge: How To Position Your Organization For Success In A New Era, Have You Mastered These 4 Financial Management Skills For VBR?, Success With VBR: What Provider Organization Execs Should Consider, and The 4-Part Checklist For VBR Success. And, through the sponsorship of Qualifacts and our collaborative on-line community – Value Based Care for Behavioral Health – any executive team can complete our assessment tool – The OPEN MINDS Value-Based Reimbursement Readiness Assessment – and see where they stand in preparing for this shift.
With this strategic focus on VBR, these resources are in high demand. And, in you case you missed them, these are our most-read resources on VBR in 2019:
On April 22, 2019, the Centers for Medicare & Medicaid Services (CMS) launched the “Primary Cares Initiative” to implement five new value-based primary care models for Medicare fee-for-service (FFS) beneficiaries. CMS projects that nearly 11 million Medicare beneficiaries (25% of the total Medicare FFS population) could be served through the five new models.
The relationship between health plans and provider organizations has traditionally been pretty straightforward: Health plans purchased services on behalf of consumers—if they were preauthorized—and provider organizations provided those services in commodity-like network arrangements. During the last decade, that relationship has changed due to shifts in the market and new competitive pressures on health plans. What are these market factors and what do they mean for provider organization contracting?
I’ve been thinking a lot about financial risk for health and human services over the past month. While the shift in “who is at risk” has been glacial, the effects on the service delivery landscape are becoming increasingly apparent. At the payer level, the shift of financial risk from employers, from Medicare, and from Medicaid plans continues. At last count, 77% of the U.S. population with health insurance was enrolled in managed care plans—including commercial (99%), Medicaid (68%), and Medicare (33%).
In March the California Department of Health Care Services (DHCS) released draft value-based payment (VBP) performance measures for the state’s Medicaid managed care program. The measures are grouped into four domains: behavioral health integration; chronic disease management; prenatal/post-partum care; and early childhood preventive care. Each domain has five performance measures. These measures will be tied to risk-based incentive payments and are aimed at improving care for certain high-cost or high-need populations.
All but four states—Georgia, Indiana, Mississippi, and West Virginia—are using value-based care (VBC) and alternative payment models. The remaining 46 states, the District of Columbia, and Puerto Rico are implementing some sort of value-based model. About 50% of those programs are multi-payer in scope.
I think managed long-term services and supports (MLTSS) is in the process of remaking the concept of managed care. This was my conclusion following the remarks of Leigh Davison, staff vice president, Medicaid and LTSS Specialty Organization at Anthem, during her keynote presentation, Innovative Collaborations & Partnerships For Long-Term Services: The Anthem Perspective, at The 2019 OPEN MINDS Performance Management Institute. MLTSS programs requiring taking the concept of “whole person care” and “integration” one step further. Why?
How does an organization create innovative, value-based partnerships with health plans? It starts with an understanding the broader market—including consumer needs and preferences and payer “pain points”. From there, you can design services that address the needs of health plans more efficiently, measure your results, and then build a contracting relationship leveraged on that performance data.
In creating proposed models for value-based reimbursement of specialty provider organizations, one of the goals of our team is to link specialty provider organization “performance” to the total cost of consumer care. This is a bigger goal—but also provides a bigger role for specialty provider organizations in the health care system since behavioral health and long-term care services together are only about 15% of the total health care spend.
During the last few years, the Centers for Medicare & Medicaid Services (CMS) has not so quietly been in the process of increasing its commitment to alternative 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.
Cerner and naviHealth recently announced a five-year partnership to launch a value-based care offering to support the Bundled Payments For Care Improvement Advanced Program (BPCI Advanced) for Medicare. Cerner and naviHealth work together to streamline electronic workflows for post-acute discharge services.
For more, sign up for our (free, but registration required) monthly digest on value-based care. If you’re already a member, go to your membership account, select email preferences, and select “Value-Based Reimbursement.” If you’re not a member, sign up for your free membership at https://www.openminds.com/free/. And for even more on VBR strategies, join me at The 2020 OPEN MINDS Performance Management Institute on 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, led by OPEN MINDS Senior Associate Paul Duck.