CONTINUING THE CONVERSATION ON VALUE BASED PURCHASING: The Health Plan Perspective

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1 CONTINUING THE CONVERSATION ON VALUE BASED PURCHASING: The Health Plan Perspective Monica Collins, Magellan Healthcare Kelly Champ, Optum Jeremy Hastings, Beacon Health Options Kelley Grayson, envolve

2 Value Based Purchasing Bridging the Gap QUALITY COST

3 THE PAYMENT/REIMBURSEMENT CONTINUUM

4 Examples Our work in the reimbursement continuum Small % of financial risk Moderate % of financial risk Large % of financial risk Fee-forservice Performancebased contracting Shared savings Bundled and episodic payments Shared risk Capitation Capitation + performancebased contracting Low accountability Moderate accountability Maximum accountability P4P/shared savings contracts with qualified facilities and outpatient providers SUDS medicationassisted therapy (MAT) providers DRG ACOs, medicalbehavioral integration in health homes 3

5 RISKS AND BARRIERS Reducing Risks, Breaking Down Barriers and Provider Competencies

6 Providers should think about the following competencies to be ready to participate with VBPs It s complicated; there are a lot of systemic and practice level changes that need to happen Stand up an internal UM function: As utilization management moves from payer-led to provider-led, providers will need to structure how to manage a bundled payment and stay within financial allowances Plan for case-rounding with payers: As prior-authorization steps down in a VBP, providers will have more frequent interactions with payers to stay connected on patient care case rounding, complex case management, transitions of care Invest in IT: Providers need to generate and monitor patient utilization reports, validation of encounter data submissions, financial utilization reports by member, quality performance targets Develop programs around payer needs: Most VBPs will ask for something extra clinically timely patient access, outcome accountability, process measures and providers should be building programs that a payer can then purchase Rethink Accounts Receivable: When you are no longer chasing claims but instead taking in dollars and then spending down that payment on patient care, accounts receivable (and payable) will need to be rebuilt

7 VBP FUTURE STATE Team Conjecture

8 VBP-Provider Expectations Practice and Payment Anticipate more focus on expanded services or risk stratification contracts to improve overall member outcomes Social and functional outcomes measures Treatment response measures Collaboration with other BH providers and other levels of care Joint metrics (i.e. IP and OP) incentivized for FUH targets. Increasing responsibility for BH providers to demonstrate their value to become active partners in VBP arrangements Bundled or case rate payments associated with risk stratified patient population that include measurable outcomes tied to improvement over baseline and shift towards community based services versus institutional services. ACO-like continuum of care service delivery models where providers are incentivized collectively based on meeting certain quality and efficiency targets.

9 VBP-Provider Expectations Integration Practice and Payment Anticipate more emphasis on physical health integration where BH quality/efficiency measures inclusive of physical health and risk associated with meeting these measures. CMHC working with PCP using quality and efficiency metrics along with Chronic Care Management (CCM) codes to support care management provided under PCP to drive positive health outcomes. CCBHC model where CMHC incentivized through an encounter rate for BH services, Physical Health screening and care coordination, in addition to Substance Use Disorder services *Member Attribution key to any value based contracting model. Anticipate ramp strategies leading towards taking risk EXAMPLES: Year 1 is FFS (No risk) additional incentive dollars can be earned by meeting quality/efficiency targets. Year 2 (Some Risk) capitation/bundled payment (possible risk stratification payments and/or expanded services) with quality/efficiency targets. Year 3 (Full Risk) capitation/bundled payment (with risk stratification and expanded services) Financial penalty if quality/efficiency targets not met. Cost savings tied to efficiencies realized are shared with Provider.