11/16/2012. Preparing for change, and what this means for organizations and providers. Healthcare Reform. Local Level Healthcare Readiness Assessment

Transcription

1 MCOs and Providers Working Together: Shared Rate/Risk Models David R. Swann, MA, LCAS, CCS, LPC, NCC Chief Clinical Officer Partners Behavioral Health Management Mark Rosenberg President BHM Healthcare Solutions Healthcare Reform Local Level Healthcare Readiness Assessment Evolution of Healthcare Payment Models Transitional Strategies for Payment Reform Value Based Purchasing Agreements Medicaid Waivers Question and Answer Session 2 Preparing for change, and what this means for organizations and providers 3 1

2 As parity and national healthcare reform are implemented, more people than ever before will have access to treatment for mental health and addiction services through expanded public and private insurance coverage. Specialty behavioral healthcare organizations must expand capacity to meet increased demand and offer measurable, high-performing prevention, early intervention, recovery, and wellness services and supports. 4 We must also be ready to work with the expanded Medicaid systems and be able to bill through the new health insurance exchanges, Accountable Care Organizations (ACOs), Primary Care Medical Homes, Person- Centered Medical Homes and other funding sources. Medical Homes or Health Homes are becoming the primary focus of integration of care connecting the head back to the body Significant movement to One Stop Shops integrated healthcare service delivery models. 5 Reducing Readmissions -more than half of readmits did not see a psychiatrist prior to discharge -failure to follow-up with prescriber or therapist is most common cause of readmits 1 Reducing Future Medical Costs of a Population -more than half of inpatient admissions had minimal to no engagement with behavioral health delivery system in prior year 1 Informing Consumer Choice -25% of consumers who are given more information about treatment options choose a less intensive option or service 3 Managing Behavioral Health Crisis -More than 40% of mental health cases in an Emergency Dept. are admitted vs. less than 5% of medical cases 2 1. Commercial Insured Population Analysis, Owens, P. HCUP MH and SU Related ED visits in Adults, AHRQ Olfson, Dropout from Outpatient MH Care, Psych. Services, July Fenton, WS Medication Nonadherence in Schizophrenia Schizophrenia Bulletin 1997 Treatment Adherence % drop out of psychotherapy prematurely 3.75 times the risk of psychiatric relapse with medication non-compliance 4 6 2

3 Fraud is defined as an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. It includes any act that constitutes fraud under applicable federal or state law. Abuse is defined as practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary costs, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs. A Primary Objective of Healthcare Reform is the elimination of waste, fraud, and abuse 7 Failure to coordinate Failure in process for the delivery of service - (infections, pressure sores) steps of care were not successful Overtreatment or prescribing tests or procedures that are not required Excessive administrative costs Inappropriate pricing Fraud/abuse 8 Waste In US Healthcare System 12% 17% 6% 6% 19% 40% Fraud Unnecessary Care Administrative Inefficiency Healthcare Provider Error Preventable Conditions 9 3

4 Cuts have been quick, and there are more to come Cuts are immediate and very predictable Quality is not quick It takes trust and confidence Today s presentation outlines options to build quality with both short term results and most importantly, long term standing 10 Prevention Integrated Horizontal Care Delivery System Accountable Care Organizations Medical Homes/Healthcare Homes 11 Payment Reform Primarily shared risk models with incentive payments to providers for meeting quality outcome indicators Lean Thinking- Modernization of of care through Information Technology, Data Sharing, and other Technologies (such as tele-monitoring and seamless care delivery) 12 4

5 Unsustainable Costs Pressure from stakeholders (providers, patients, etc.) Shrinking Revenue Calls for accountability 11/16/2012 Health care reform offers the opportunity to build from local strengths to meet the challenges Health Homes and Accountable Care Organizations are tools permitted to achieve the goals of reform 13 Under a Managed Care (MCO) or Accountable Care Organization (ACO) Model the Value of Behavioral Health Services will depend upon our ability to: Be Accessible (Fast Access to all Needed Services) Be Efficient (Provide High Quality Services at Lowest Possible Cost) Utilize Electronic Health Records capacity to connect with other providers Focus on Episodic Care Needs/Bundled Payments Produce Outcomes! Engaged Clients and Natural Support Networks Help Clients Self Manage Their Wellness and Recovery Greatly Reduce Need for Disruptive/ High Cost Services 14 Measuring CBHOs value as a Healthcare Partner 15 5

6 Access to treatment processes and costs and level of redundant collection of information and process variances Centralized Schedule Management with clinic/program wide and individual clinician Back Fill management using the Will Call procedure No Show/Cancellation management principles and practices using an Engagement Specialist to provide qualitative support Re-engagement/transition procedures for current cases not actively in treatment 16 Internal levels of care/benefit package designs to support appropriate utilization levels for all consumers Outcome Assessment Capacity (i.e., PHQ-9, DLA-20, 10 X 10 Wellness Indicators, etc.). Level of key performance indicators for all staff including cost-based direct service standards and ability to measure KPIs Use of Collaborative Concurrent Documentation 17 Current level of internal utilization management functions including: Pre-Certs, authorizations and re-authorizations Referrals to clinicians credentialed on the appropriate third party/aco panels Co-Pay Collections Timely/accurate claim submission to support payment for services provided Payer mix enhancements including third party payers 18 6

7 Revenue Cycle Management including co-pay collection processes Public information and collaboration with medical providers in the community through an Image Building and Customer Service plan Integrated physical and behavioral healthcare service delivery capacity Change management history on time to change and effective implementation 19 New and existing reimbursement models 20 Among leading strategies to reform health care is the development and implementation of new payment models The goal of these models is to change the way physicians, hospitals, and other providers are paid in order to emphasize quality care at lower costs Although a variety of payment reforms have been proposed, many either do too little to address the problems caused by the current system, or make changes so radical that they are difficult for providers to easily implement 21 7

8 Fee For Service Episode of Care Payment Bundled Payments Pay for Coordination Pay for Performance Traditional Capitation Comprehensive Care/Total Cost 22 Fee for Service Low Moderate High Performance Based Contract Level of Financial Risk Bundled & Episodic Payments Shared Savings Level of Accountability No Moderate Full Capitation Capitation AND Performanc e Based Contracting Provider less engaged Provider engaged Provider actively engaged Provider fully accountable 23 Fee for service is the most common way of paying for healthcare services today A predetermined amount is paid for each discrete service provided The provider is at risk for the number and cost of processes within each service, but there is no limit on the number of services Providers receive payment regardless of outcomes 24 8

9 Paying a single price for all services needed by a patient during an entire episode of care (also called case rate) Provider has responsibility for the number and types of services provided for an episode Example: if a patient has a heart attack a provider is given a single payment for all care needed by the patient for treatment Amount of payment is adjusted for severity Providers decide which services are provided within and episode Incentivizes eliminating unnecessary care within an episode If services of multiple providers are covered by the episode of care payment (bundling) care coordination is encouraged 25 Single payments for a group of services related to a treatment or condition that may involve multiple providers across varied settings Potential to improve coordination across multiple caregivers, provides flexibility in provision of care, incentivizes effective management of episodes Limitations include the difficulty in defining an episode, potential barriers to choice of provider, and lack of incentive to reduce unnecessary episodes 26 Payment for specified care coordination services to specific types of providers Example: medical homes- medical home receives a monthly payment in exchange for the delivery of care coordination services not otherwise provided Payment for support services not traditionally covered under a fee-for-service model, and therefore would not be provided Potential benefits: Enhanced patient physician communication Enhanced family involvement Improved flexibility for where care can be provided Reduction of unnecessary/inefficient care 27 9

10 Payment or financial incentives for achieving defined and measurable goals related to care processes, and outcomes Offers potential to improve quality of care, encourage collaboration, and enhance efficiency of care Limitations include single condition focused measures that do not reflect the complexity of caring for patients with complex cases May incentivize physicians to avoid high risk patients 28 Capitation models are designed to control the number of episodes, as well as the cost of individual episodes Provider receives a single payment to cover all services needed by a patient during a set period of time regardless of the number of episodes Payment amount is the same no matter how sick or healthy a patient is Incentivizes providers to avoid those with chronic or costly conditions 29 Involves providing a single risk-adjusted payment for the full range of health care services needed by a specified group of people for a fixed period of time Example: Per Member Per Month Similar to capitation, however there are additional risk adjustment methodologies utilized, limits on risk exposure, and incorporation of quality measures Benefits include flexibility for providers in terms of care delivery, incentive for efficient are, and improved emphasis on maximizing health Limitations include decrease in patient choice of provider, at risk structure for involved entities, and geographic challenges for the provision of care 30 10

11 Navigating Payment Reform and Proactively Planning for Change 31 Payment reforms are inevitable, however an overnight transition from fee for service, to alternative payment models can be devastating for providers and organizations when not appropriately planned for 32 Transitional strategies can be useful for both providers and organizations, provided that they keep both the starting point and the end goal in site Transitional strategies should deliver improvements in cost and quality for payers and patients as providers build the capacity to transition to more comprehensive payment reforms in a feasible way 33 11

12 Paying Hospitals on a case rate basis for all patients i.e. using DRG-type payments in place of per diem and charge based payments for all patients Paying all physicians on a case rate basis for acute care episodes Making a singe payment to a physician for all services during an entire patient stay Bundling payments to hospitals and physicians Making a single payment for both hospital and physician services Providing and inpatient warranty Having hospitals and/or physicians agree not to charge more for services to correct errors, infection, and other hospitalacquired complications 34 Bundling Payments for inpatient and post acute care Paying a single amount to cover both inpatient care and services after discharge such as inpatient rehabilitation and home health care Providing a warranty for post-discharge complications and readmission Having hospitals/providers agree not to charge more for preventable readmissions to the hospital Paying based on diagnosis instead of treatment Defining DRGs and physician case rates based on patient diagnoses, rather than on the specific procedure or treatments preformed 35 Paying Primary Care Practices with Care Management Payments and Utilization Based Performance Incentives Care management payment given to providers for each patient to support patient education and self management support aimed at reducing over-utilization Paying Specialists with Care Management Payments and Utilization Based Performance Incentives Specialists paid more to better manage and coordinate patient care with targets for reducing utilization of costly care such as hospital visits Paying Physician Practices with Condition-Specific Partial Comprehensive Care Payments Group of providers, or single practice paid a single amount for most or all services a patient will need for a health condition over a fixed amount of time 36 12

13 All Transitional strategies should have the following goals in mind: Establishment of appropriate payment amount Limiting the financial risk associated with unusually expensive patients, or with costs that the provider cannot control Condition/severity adjustment Outlier payments Risk corridors Exclusions and risk sharing between providers Maintaining or improving quality of care for patients as cost is controlled 37 Providers Purchasers/Payers Consumers Payment change should be manageable in care process and investment, without putting provider at significant risk Should produce financial savings; require modest claim changes; should yield return in less than one year to manage annual healthcare budgets Should improve quality and affordability; improve access to services 38 Best Opportunity for High Impact Short Term Success Conditions affect many patients Willing and able clinical leadership Overutilized services Low cost intervention 39 13

14 Focus on conditions which affect large numbers of consumers Small efficiency improvements can have aggregate impact in these areas Even small providers can participate in care/payment changes affecting common conditions Examples: Common Diseases such as diabetes, or common mental health conditions such as depression, or ADHD 40 14