Value Based Payment WHAT IS THIS ALL ABOUT?

Transcription

1 Value Based Payment WHAT IS THIS ALL ABOUT? 1 1

2 Agenda Welcome and Introductions RPC Introduction New York State s Vision Population Impacted What Does VBP Mean to Me as a BH Provider in NYS? What is Value Based Payment in New York State? Follow the Money VBP Arrangements and Payment Principles What Do I Do Now? State Overview of VBP Readiness funds 2

3 RPC Introduction March 30,

4 Value Based Payment Readiness Program Communication to the field March 30,

5 5 New York State s Vision

6 6 Background In 2011, Governor Cuomo created the Medicaid Redesign Team (MRT) MRT BH workgroup developed principles for moving BH services into managed care Recommended BH savings related to Managed Care be reinvested for the benefit of the BH population NYS adopted this recommendation into law $110 M is available through declining premiums $60 M will be reinvested to support the transition to Value Based Payment (VBP) The remainder will support new ACT teams and OASAS priorities

7 7 Why did we move Behavioral Health into Managed Care?

8 8 Improve Integrated Health Outcomes In NYS, Medicaid members with a BH diagnosis account for 20.9% of the population but 60% of Medicaid expenditures 53.5% of hospital admissions 45.1% of ED visits 82% of all readmissions within 30 days of the original admission 59% of those readmissions were for a medical condition The average length of stay per admission for BH Medicaid users is 30% longer than for the overall Medicaid population People with a BH conditions experience poor inpatient to outpatient connection Source: Measuring Physical and Behavioral Health Integration in the Context of Value-Based Purchasing. Greg Allen, December 7, based on 2014 Medicaid claims data

9 14 Integrated Care: In BHO Phase I, how often did behavioral health inpatient providers identify general medical conditions requiring follow-up, and did they arrange aftercare appointments? Based upon 56,167 statewide behavioral health community discharges (all service types) January 2012 June 2013

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11 10 Substance Use Comorbidity and Hospitalization 12% of all reported non-crisis SUD admissions in 2016 were for individuals who had been hospitalized in the past 6 months 8% of admissions were associated with medical hospitalizations 4% of admissions were associated with psychiatric hospitalizations Source: NYS OASAS Client Data System

12 11 Criminal Justice Involvement 40% of all SUD admissions into OASAS certified programs in 2016 reported that the client had some involvement with the criminal justice system at time of admission Source: NYS OASAS Client Data System

13 12 Homelessness 17% of all SUD admissions into OASAS certified programs in 2016 were reported to be homeless at time of admission 10.3% reported as homeless with no shelter 6.6% reported as homeless in shelter Source: NYS OASAS Client Data System

14 13 OASAS System of Care Continuity of Care from Inpatient Detox to appropriate AOD specialty treatment (inpatient, residential, or ambulatory) within 14 days of discharge ~26% (CY 2015) Continuity from Inpatient Rehab to appropriate AOD specialty treatment (residential or outpatient) within 14 days of discharge ~24% (CY 2015) Source: NYS Medicaid FFS and Encounter Claims (MDW)

15 15 Goals of Medicaid Managed Care Better Care Better Health Lower Cost Greater Access

16 16 Transformation Challenges

17 17 Transformation Challenges BH benefits just moved into managed care. Adult BH Home and Community Based Services are slow getting started There are currently few incentives to support integration within behavioral health (inpatient-ambulatory-rehabilitation) and across behavioral/general medical health care There is limited capacity to share information within and between the behavioral health and other systems Providers must achieve a certain critical mass of referrals to reduce the business risks and the competitive disadvantages small agencies face in the current environment Lack of nationally validated BH rehabilitation and recovery quality measures

18 18 How we define value affects what we pay for We need to define value as helping people lead meaningful lives in the community

19 19 HEDIS measures for Behavioral Health Available HEDIS Measures: o o o o o Follow-Up After Hospitalization for Mental Illness within 7 Days and 30 Day Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Identification of alcohol and other drug services (IAD) Initiation and engagement of alcohol and other drug dependence treatment (IET) Follow-up (7- and 30-day) after emergency department visit for alcohol and other drug dependence (HEDIS 2017)

20 20 Clinical Advisory Groups NYS VBP Clinical Advisory Groups (CAG) made recommendations to NYS on quality measures, data, and support required for providers to be successful VBP Workgroup members nominated BH subject matter experts to participate on the CAG Behavioral Health specific CAG reports Behavioral Health Chronic Conditions pgs HARP pgs

21 21 Transformation Challenges (Continued) BH providers face significant challenges such as: Revenue and reimbursement Staff recruitment and retention Lack of capital to acquire necessary IT/EMR/EHR systems Increasing costs of compliance Complex and changing regulatory, policy, and market environments The Affordable Care Act (ACA) provided incentives to physical health providers to address these challenges

22 22 Transformation Challenges (Continued) Healthcare Mergers and Consolidations Managed Care is increasingly dominated by large players. Hospital and primary care consolidation is increasing Affecting communities across New York State, including: o Rochester Regional Health System (Rochester) o Northwell Health (Long Island) o Mount Sinai Health System (NYC) o St. Peters Health Partners (Capital District) Smaller providers are at risk of being left behind

23 23 Where We Are Headed Achieving the NYS vision for improved care, recovery, and community integration requires a change in care delivery Increasingly, value is placed on providing services and supports that address the whole person (person-centered) Behavioral and physical health care integration is critical to achieving positive population health outcomes Under VBP providers are rewarded for achieving cross-system quality outcomes, at or below expected costs, rather than for volume

24 24 Getting to the Right Size and Value Collaboration is key Organizational (i.e. IPAs, ACOs) Networked looser affiliations of providers committed to achieving shared quality targets at or below a shared per-attributed-member budget Stakeholders must work together to measure, report, and respond to behavioral health quality metrics Providers should weigh advantages and challenges before committing to a particular approach

25 VBP in New York State For Behavioral Health Providers 25

26 Populations Impacted by VBP VBP discussed today only applies to the populations covered by Medicaid Managed Care. Do you know the populations you serve? How much of the care you deliver is impacted by VBP? 26

27 Does it mean a change in focus from volume to value? Yes! 27

28 Does it mean an emphasis on data demonstrating outcomes? Yes! 28

29 Does this mean participating in partnerships and networks with other providers, not just behavioral health providers? Yes! 29

30 Does this require communication and integration across all healthcare sectors? Yes! 30

31 Are there are opportunities for behavioral health providers? Yes! 31

32 Will this change how I get paid? Maybe 32

33 Are there resources out there to help? Yes! More to come 33

34 How BH Providers Get Paid (Medicaid/Medicaid Managed Care Only) Now Fee for service through Medicaid Fee for service through Medicaid Managed Care Plan In Near Future Fee for service Medicaid Fee for Service Medicaid Managed Care You might also get paid by ACO/IPA on Fee for Service Basis Medicaid Managed Care and/or ACO/IPA can pay you additional funds as: Incentives Pay for Performance Shared Savings Subcapitation 34

35 Value Based Defined A way of reimbursing providers focusing on value instead of volume Focus on Quality Outcome Driven Service Goals (the Triple Aim): Improving Quality Reducing Costs Improving the member s experience Source: VBP Bootcamp #1 35

36 Quality Measures VBP arrangements are based on meeting quality outcomes or targets**: Pay for Reporting Process measures Some examples include SBIRT Screening and screening for clinical depression Medication adherence Internal and partnership measures Outcome measures Some examples include: reducing preventable inpatient hospitalizations and readmissions, Follow-up After Hospitalizations for Mental Illnesses (within 7 and 30 days) **There is a lack of good BH rehab measures 36

37 Level 0 VBP* Level 1 VBP Level 2 VBP Level 3 VBP (feasible after experience with Level 2; requires mature contractors) FFS with bonus and/or withhold based on quality scores FFS with upside-only shared savings available when outcome scores are sufficient (For PCMH/IPC, FFS may be complemented with PMPM subsidy) FFS with risk sharing (upside available when outcome scores are sufficient) Prospective capitation PMPM or Bundle (with outcomebased component) FFS Payments FFS Payments FFS Payments Prospective total budget payments No Risk Sharing Upside Risk Only Upside & Downside Risk Upside & Downside Risk *Level 0 is not considered to be a sufficient move away from traditional fee-for-service incentives to be counted as value based payment in the terms of the NYS VBPRoadmap. Source: VBP Bootcamp #1 37

38 Consider Possible Contract Options in VBP Independent Practice Associations (IPA) Accountable Care Organizations (ACO) Individual Providers Hospital Systems FQHCs and large medical groups Smaller providers including community based organizations (CBOs) Individual provider could either assume all responsibility and upside/downside risk or make arrangements with other providers; or MCOs may want to create a VBP arrangement through individual contracts with these providers 38

39 Example of Contracting Options in VBP Note: ACO refers to a NYS Medicaid ACO as defined under PHL 2999-p Health Plan contracts with an ACO or IPA ACO or IPA is responsible for the total cost of care and outcomes for the specific population Source: VBP Bootcamp #1 39

40 Example of Contracting Options in VBP oripa Health Plan contracts with an ACO or IPA Note: ACO refers to a NYS Medicaid ACO as defined under PHL 2999-p ACO or IPA is responsible for thetotal cost of care and outcomes for the specific population Source: VBP Bootcamp#1 40

41 Example of Contracting Options in VBP Health Plan contracts separately with a hospital and a clinic Note: In practice, this is ordinarily only feasible for a Level 1 VBP Arrangement and is often a temporary step during IPA/ACO formation. While the contracts are separate, the providers performance is seen as a whole for total cost of care and outcomes for a specific population Source: VBP Bootcamp #1 41

42 Shared Savings/Risk Arrangements (Level 1 & 2 VBP) State Pays Plan Plan continues to pay providers on Fee for Services Basis Partnerships/Providers performance is evaluated by the plan as a whole and depending on the arrangement providers share in savings only (Level 1) or savings and risk (Level 2) 42

43 Capitation Arrangement (Level 3) State Pays Plan Plan pays monthly subcapitation rate to a contracted entity such as IPA/ACO (covers some or all services) Contracted entity such as IPA/ACO pays providers Fee for Service or in some other manner Partnerships/Providers performance is evaluated by the IPA/ACO as whole and depending on the arrangement providers share in savings or risk. 43

44 Types of VBP Arrangements Source: VBP Bootcamp #2 44

45 Takeaways All VBP Arrangement can be upside risk only, upside and downside risk or capitation Contracted entity takes responsibility for all associated needs/cost, including emergency room and inpatient cost. It is expected that BH Providers will predominately be downstream providers with the following possible financial arrangements with the contracted entity (e.g. Hospital, ACO, etc.) Bundle Payments Primary Integrated Care Fee For- Service with or without incentive payments 45

46 Myths and Truths 46

47 Myths 1. Everyone must eventually contract at Level 3 (capitation, sub-capitation) 2. A Payer can only reimburse innovative services if provider is in a Level 3 contract 3. FFS and government rates are incompatible with VBP 4. You are supposed to do more with less 5. VBP is about reducing the Medicaid Global Cap spend 6. Only PPSs can contract VBP arrangements 7. VBP is about reducing services offered to Medicaid members 47

48 Truths 1. MCOs will be penalized if the Roadmap goals are not achieved (MCOs may pass penalties onto providers) 2. The State will be providing analytical support to the VBP stakeholders 3. VBP provides flexibility in contracting - it is not a 'one size fits all' 4. The goal of VBP is to improve the quality of care and shift spending to keep members as healthy as possible and integrated in their community 5. VBP implementation is an iterative process - the State will keep learning as the process moves forward (pilots will play an important role in this learning) 6. VBP is focused on transparency around costs 7. Providers can continue to be paid FFS while participating in larger VBP arrangements. 48

49 What Do I Do Now? 49

50 Your Role as a Provider Behavioral health providers bring an expertise to the primary health care system that is needed to treat the whole person Purpose of affiliating is to increase your power and influence, not reduce. 50

51 What Can You Do? Determine what VBP approach(es) make sense for your agency Understand your costs to deliver care Know your population Identify the landscape Develop strategic marketing and communication plan Demonstrate your value Positioning and affiliating Consider Partnerships 51

52 Upcoming VBP Technical Assistance Offerings What is this all about What is VBP? What Does VBP Mean to Me as a BH Provider in NYS? How do you get paid? Marketing Plans: Marketing Research Develop a pitch Why am I groovy? What s my place in the world? Community scan Customer needs Needs assessment Analytics/Data-Driven Decision Making Metrics Self-Assessment Cost Population served (LOS, services provided) Partnership Arrangements Clinical Practice Change: Change management Contracting VBP contract Revenue Cycle Management in VBP Workforce development 52

53 3 key sentences that we want you to walk out of the room with: You will be able to get paid Make friends! Technical and financial assistance is available to help you! 53

54 Resources NYS DOH Value Based Payment Bootcamps: Session #1 Session # 2 Session #3 NYS DOH VBP Roadmap September 2016 NYS MCTAC VBP Conference NYS DOH VBP HARP Subpopulation VBP Recommendations April 2016 Report: contains recommended CAG Measures Care Transitions Network Please send any additional questions : MCTAC.info@nyu.edu 54

55 55 NYS BH VBP Readiness Program

56 56 Outline Overview Program Goals Funding Behavioral Health Care Collaboratives (BHCC) Program Participation Program Activities Ensuring Adequate Networks Evaluative Criteria

57 57 Overview NYS will make funding available through MCOs to support qualified groups of community based BH providers that form Behavioral Health Care Collaboratives (BHCC) Partnerships will be organized around improving Health outcomes, Managing member costs, and Participating in VBP arrangements

58 58 Program Goals Enhance BH Provider readiness to participate in VBP arrangements Attribute value to BH Rehabilitation and Recovery in the VBP environment Promote strategic formation and further development of BHCC partnerships Promote development of health data collection, reporting, and analytics infrastructures to support: o o Quality improvement across a continuum of providers with measurable standards Achievement of clinical and quality outcome targets for BH populations

59 59 Funding Approximately $60M will be available over 3 years Subject to budget approval There will be two funding levels available: Planning funds Implementation funds Applications may be for either or both, with an expectation that planning funds will be used to position the applicant to qualify for implementation funds No funds can be used to reimburse previous effort

60 60 Behavioral Health Care Collaboratives (BHCC) BHCCs must be able to provide the full spectrum of BH services available in a region o o BHCCs must include peer certified services Include CCBHCs, as available Promote social determinants of health (SDH) and prevention through community partnerships, including with peer-run organizations BHCCs may take on a variety of forms ranging from loosely structured to incorporated entities o A BHCC may or may not choose to legally incorporate as an IPA

61 61 Behavioral Health Care Collaboratives (BHCC) BHCCs should be organized around a collective goal to set and meet or exceed shared health outcome targets for a population of attributed members at or below a shared per-member budget Outcomes and expenditures apply to both behavioral and physical health BHCCs will need to develop the capacity to monitor and dynamically manage both fiscal and quality performance

62 BHCCs must: 62 Work together to improve access and coordination in order to meet cost containment and quality goals to attain value Provide person-centered care Significantly address the health care needs of their communities Enhance quality care through clinical integration and community-based recovery supports

63 63 BHCCs must: Increase cost-effectiveness Use data to manage quality and risk Support compliance with all clinical and network standards of care Commit, as a system, to continuous quality and performance improvement

64 64 Program Participation Open to creative proposals that address the needs of the service area NYS will work with Plans and providers to facilitate program implementation Participation is voluntary NYS will determine program participants and standards Will consider likelihood of sustainability beyond the program Funding will be available to applicants throughout NYS Will be evaluated on ability to meet deliverables, such as shared quality metrics & cost management Participating providers must commit substantial time and resources to the success of the partnership and eventual participation in VBP arrangements

65 65 Program Activities 1. Activities to develop joint program goals and objectives, including but not limited to: Market and feasibility studies Networking Organizing meetings Determining the value you bring to the market 2. Development of formal agreements and governance structures 3. Development of strategic plan and budget 4. Workforce preparation for VBP environment

66 66 Program Activities (cont.) 5. Funding niche and/or specialty provider participation in incorporated networks 6. Legal costs 7. IT support and data analytics for BH quality and financial management 8. Development of quality standards 9. Process design that supports continuous quality improvement 10.Consulting to support above activities

67 67 Ensuring Adequate Networks NYS will evaluate the proposed coverage area and assumed covered lives NYS may adjust funding requests based on: Data validation Network adequacy Number of Medicaid Managed Care covered lives Meeting application milestones, and/or The degree to which the funding request meets the goals of the program

68 68 Ensuring Adequate Networks (cont.) Where BHCCs do not cover the entirety of a service area, or multiple emerging BHCCs propose to serve the same individuals, providers should consider consolidation or collaboration to better serve the population The state reserves the right to deny applications or facilitate collaborations where necessary

69 69 Available BH Service Types State Plan Services HCBS State Funded Providers OMH & OASAS Outpatient Clinics OASAS Inpatient Withdrawal and Stabilization OASAS Inpatient Rehabilitation ACT Teams PROS Partial Hospital CDT Opioid Treatment Program (OTP) OASAS Residential Redesign - crisis stabilization - rehabilitation - community reintegration CPST PSR Family Support & Training Crisis Respite Habilitation Education Employment Services Peer Agencies Rehab Providers Housing Providers

70 70 Evaluative Criteria OMH and OASAS are developing criteria for reviewing applications The standards will address: Market Share Service Area Provider Expertise & Financial Solvency Qualifications Applicable MMC Small Provider statutory and Participation regulatory requirements

71 71 Proposed Timeline for Implementation Application Comment Period Application Period Letters of Intent to Participate Due FINAL Application Posted to Web First Round of ApplicantsApproved May Jun Jul Aug Sep 2017 The State reserves the right to facilitate collaborations and ensure appropriate regional distribution of readiness funds

72 72 Open Discussion