Among the top 10 takeaways I shared from The 2020 OPEN MINDS Strategy & Innovation Institute last week (see The Recovery Formula: Strategy + Innovation + Preparing For (Some) Failure), a key one was “Provider organizations and payers CAN work together. Payers are looking for creative ways to meet consumer needs in times of crisis and beyond and welcome ideas and negotiation.”
This was reiterated in the Institute’s Open Forum On Health Plan Measures Of Treatment Efficacy, with Andy K. Kelly, director of provider value optimization at Optum Behavioral Health; Brian Smock, vice president of Magellan Health; Sharon Hicks, senior associate at OPEN MINDS and former chief information officer of Community Behavioral Health; and Joseph P. Naughton-Travers, senior associate at OPEN MINDS. The insights shared by the four panelists reveal what payers are looking for and how they are prepared to negotiate in three key areas—whole person care, outcomes data, and program innovation.
Payers Are Looking For Whole Person Care
Mr. Kelly explained that Optum’s models are centered around improving the delivery of person-centered care. Optum is focused on how to treat the whole person and how to engage and support individuals in the community after service delivery. How to accomplish this? The discussion that followed included two types of models. The first model is focused on co-location of services—behavioral health services in primary care organizations or primary care services in behavioral health organizations. Mr. Smock talked about the opportunity to leverage embedding primary care in specialty care for value-based purchasing—provider organizations can make the case by showing shared savings from treating chronic conditions on the behavioral health side. And Mr. Kelly emphasized that health plan managers appreciate the economies of scale, the efficiencies, and the better outcomes that can be achieved when the “primary care professional can walk down the hallway and talk to the psychiatrist.”
The second model of integrated care is through collaboration. Health plans want to see the full array of services covered under one agreement. But provider organizations don’t have to deliver the full array of services as long as they can work with others across the service delivery system to ensure and coordinate access to care for their consumers. This type of collaboration demands a technology infrastructure that allows for centralized care coordination—and interoperability with all collaborating service organizations. Mr. Smock pointed out that Magellan’s desired outcome with high-need, high-utilization consumers is to reduce inpatient readmissions—and if a collaborative model can get them closer to that outcome, it is welcomed. “We are open to negotiation with provider organizations if there is collaboration,” he said.
Evolving Performance Measures For Evolving Payer VBR Arrangements
The discussion of models for delivering integrated services moved to the discussion of value-based reimbursement (VBR), incentives, and measures. Two emerging issues in VBR performance incentives were raised. The first was how to develop reimbursement arrangements that take into account the period of time required to realize “savings.” The second was the issue of social determinants and how to determine “performance.”
Ms. Hicks pointed out that for the move to managed long-term services and supports programs, for incentivizing consumer quality of life and increases in consumer functional abilities, the measurement period needs to be longer than a year. “You have to be able to look at long-term conditions over a number of years but our rating systems don’t typically allow that. I can find ways to keep a consumer out of the hospital for one year. But that does not mean I am actually addressing their service needs.”
Mr. Kelly admitted that a one-year construct is fairly arbitrary for consumers with chronic conditions. At Optum, he said, “We are assimilating experiences from our state-mandated health homes to build our own measures. We are taking pieces from several state plan amendments—about what worked and what didn’t—to create a 36-month program. Twelve months does not cut it for high-risk populations that need wraparound services. One-year results go away quickly. We are looking for year-to-year progression and attribution—and plan to create pilot programs that cover performance over a three-year period.”
Mr. Smock explained that Magellan is looking at longer-term results in their contracting for Assertive Community Treatment (ACT) teams. “It’s been iterative. Programs are not static. We look at gains and what didn’t pan out. We know consumers can make substantial gains and move to less-intensive services but it takes time. We take a longer-term view and look not only at ACT team costs, but also at costs for other levels of care such as medical and emergency department visits. The longer we go, the more robust the data gets to help us figure out how to modify the models in future.”
A question from one of the executive attendees, Chris Wolf, executive vice president at I Am Boundless, shifted the discussion to social determinants of health (SDOH). He asked how SDOH are being incorporated in VBR reimbursement and in performance measurement systems. Ms. Hicks said some payers are giving bonus payments if provider organizations submit descriptors of SDOH in claim forms—payers are collecting SDOH information as diagnoses. (For more on how this is happening in Medicare Advantage plans, see a recording of the Institute keynote address by Allison Rizer, MHP, MBA, former vice president of strategy and health policy of UnitedHealthcare (Emerging Models & New Benefits For Individuals Dually Eligible For Medicare & Medicaid).
Mr. Kelly admitted that health plans are struggling with how to measure SDOH consistently and what to do with the data. “Value-based purchasing programs are based on what we can pull from claims data but that’s a limited view. We don’t know what better looks like on our own. We need provider organizations to make the case to us for additional reimbursement for SDOH,” he said. On the flip side, he said that health plans need to make the claims data available to provider organizations in a more useful form, “Here’s what we’re seeing with your population, help us out. We have to help providers determine the programs they can offer to address SDOH.”
Payers Will Collaborate For The Right Innovation
Payers are looking for provider organizations to come to them with creative programs ideas, said Mr. Smock and Mr. Kelly. If the potential outcomes align with a health plan’s overall goals for treatment, and if the provider organizations are willing to be flexible, they will find a way to make it work. But what about the financial risk? Mr. Naughton-Travers said to the panel, “A provider organization with an innovative model has fears about the downside risk of a model with substantial financial risk. They may want to know if they can get a year of protection before they move to a significant risk-based model. They want to know if they have time to ramp up to collect more data and establish better outcomes.”
All three of the health plan executives said that, for the right program model and proposed reimbursement, they are willing to work with provider organizations on a graduated financial risk model. “Some of these programs do not yield financial savings on day one and you have to find ways to get there. It’s a transformational process,” said Mr. Smock. He explained how Magellan gave a certified community behavioral health center (CCBHC) in Texas a “foundational payment” to help them develop infrastructure, ramp up, get a new program started, and get some reporting in place. Magellan’s desired outcome in supporting the program—a one-stop shop to help consumers get the full array of Medicaid services under one roof—was to reduce inpatient readmissions. If the CCBHC could follow up with consumers within seven days of discharge from inpatient and reduce readmissions, they could earn a monthly bonus based on percentage of reduction.
The strategic takeaways for executives of provider organizations are simple—think like a health plan and understand their goals for consumer care, develop a solid financial model and expected performance estimates for any proposed program, and be willing to collaborate in getting that program launched. As Mr. Naughton-Travers summarized, “Payers are partnering with providers to come up with solutions for better outcomes, to control costs, and get the data to build the model.”
For more on both integrated care and performance measures, check out these resources in The OPEN MINDS Industry Library:
- Reducing The Cost Of Reporting 558 Unique Performance Measures
- Proving Your Unique Value To Payers: Data Speaks Louder Than Words
- Performance Management Is Never ‘Done’
- Are You Ready For Whole-Person Care? Know The Performance Measures That Matter
- Does Your Organization Stack Up On Key Performance Measures?
- Ten Integration Models Reshaping Specialty Service Delivery
- The Path From Behavioral Health Carve-Out To Integration
- Developing Strategies To Address Integration—The Key Is Market Math & Innovative Value Propositions
- Making The Many Models Of Integration Work
- Integration—Strategic Threat (& Opportunity) For Specialists
And for the deeper dive on health plan strategy and new program development, browse the recordings and slides from 35+ sessions at The 2020 OPEN MINDS Strategy & Innovation Institute at https://www.openminds.com/live/sessions/.