Readmission Prevention Programs. Vice President, Strategy & Development June 6, 2017
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1 Readmission Prevention Programs Paul M. Vice President, Strategy & Development June 6, 2017
2 About Beacon Health Options Headquartered in Boston; more than 70 locations in the US and UK 5,000 employees nationally and in the UK serving 50 million people 200+ employer clients, including 45 Fortune 500 companies Programs serving Medicaid recipients in 27 states and the District of Columbia Serving 8.5 million military personnel, federal civilians and their families Partnerships with 100 health plans NCQA and URAC accredited 2
3 Readmissions Discussion Value Based Payments 3
4 Behavioral health is playing a very small role in the recent wave of value-based payments (VBP) Behavioral health s historical role has minimized participation to date A majority of ACO-like entities and energy are related to Medicare, where BH spending is lowest as a percent of total spending BH as a second class citizen in VBPs is not limited to Medicare. Same goes for Commercial; and we have no scaled Medicaid example (excluded from Oregon and Colorado) and Massachusetts and New York have yet to determine their approach. Data and evidence are thin Lack of strong outcomes measurement regimes that definitively identify best-in-class provision of BH services BH service provision lacks the diagnostic clarity and robust evidence base that physical health VBP has been built on in medical care (e.g. knee replacement) BH providers, while interested in VBP, have small balance sheets and most have no experience managing VBP risk, so the first project will be a leap of faith and an exercise in planning 4
5 Beacon has a number of large-scale VBP deals, but the total is still small Beacon has implemented ambitious value-based payment programs in Colorado, Texas, Florida, California, and more Colorado: Provider Partner Sub Cap Illinois: Complex mental illness case rate California: Case Management Bundle New Hampshire: Sub-cap for complex mental illness Florida: Provider Sub-cap Texas: Outpatient Case Rates 5
6 The emphasis on VBPs is unlikely to ebb any time soon RFPs and ensuing contracts include commitments to VBPs strategies, including numeric targets (even if they are not well thought out) NY glide path to having 85% of payments through VBP structures MA is ending its managed care program Oregon, Colorado, Alabama are all Medicaid programs organized around provider-led structures Those providers with real VBP experience actually like them Cash flow, predictability, flexibility, clinical innovation, etc. For BH specifically, lack of evidence notwithstanding, providers and payers both believe that more good than harm is occurring Washington remains a wildcard, but I would bet on continued growth of VBPs 6
7 VBPs are a spectrum of options; we must get the right mix of incentives and complexity to get desired outcomes VALUE-BASED PURCHASING OPTIONS Behavioral Health Capitation Risk for providers Full behavioral health payment Defined coverage set Total Health Outcomes Shared risk on total member experience COMPLEXITY Case Rate Group of services Combined payment Monthly/weekly payment Episode Bundle Group of services Combined payment Quality goals Defined time period Fee-for-service One service One payment Pay for Performance (P4P) Upside only Key process measures INCENTIVE-BASED TREATMENT RISK Overtreatment Under-treatment 7
8 More emphasis on PAYMENT than VALUE Value is defined as outcomes relative to the real costs Outcome improvement without understanding the true cost of care is unsustainable and does not help effective allocation of limited resources Cost reduction / revenue increase without regard to outcomes is not value VALUE = HEALTH OUTCOMES COST Negotiations are overly focused on the financial envelope (bottom half of the value equation) VBPs without changing outcomes is a very expensive way to lower cost Too often in healthcare organizations, the clinical leads are not well coordinated with the contracting leads (both payers and providers) Leads to an organizational disconnect: Price changed, but things aren t really going to be that different Proprietary and Confidential 8
9 Beacon Readmission Prevention Collaboration Intervention Component and Approach In-hospital care processes Risk stratification (use of clinical risk score) and measurement based care (routine use of validated BH outcome measures) Structured discharge planning (structured summary, planning meeting with all parties, family involvement, communication of plan to community caregivers) Medication management (reconciliation, education, coordination with community providers) Assessment of medical or BH needs (medical team or medical consults in psych units, psych in person or tele-consults in ERs or medical units Evidence Base Models predicting BH readmission risk validated but not widely tested in practice; routine use of validated BH outcome measures to guide care improved outcomes in some settings Reduces readmission & improves aftercare adherence (11 studies); mixed effect (1/3 studies); no effect among high utilizers (1 study) Borderline significant; reduces medication discrepancies when supported by electronic tool Adding primary care clinician to psychiatric team can improve processes of care More evidence Current Status Routine assessment with validated BH outcome measures; data not used in systematic way to guide care Narrative discharge plan; no systematic implementation process across hospitals Medications assessed on admission and discharge; some hospitals have medication management education Pilot psychiatrist tele-consult service for ER patients in some hospitals; process for medical referrals varies widely Bridging transition to community Telephone outreach calls (efforts to ensure timely follow-up, identify aftercare problems) Transition managers (regular follow-up, home visits, problem solving, psychoeducation, peer support) Patient and family skills training (psychoeducation, coping skills, living skills) Inpatient-outpatient provider communication (scheduling, timely communication of plan) Can be effective, especially when used with transition manager and with 90-day post-discharge outreach Mixed significance, but significant with home visits or peer support Consistently significant Weak significance Nurse outreach call and assessment within 72 hours Some hospitals have peer navigator program, but no systematic use of transition managers Used in several hospital settings, but no systematic approach No systematic approach, varies by hospital and setting 9
10 Partners in Data-Driven Care Management The success of organizations responsible for managing chronic / complex conditions is dependent on their ability to: 1. Identify those most likely to benefit from more intensive care management 2. Secure resources required to keep members healthy 3. Maintain enrollment of members after their health has been stabilized. Cyft uses machine learning and natural language processing to leverage all the information in both clinical and administrative healthcare data, including HRAs and notes. Machine Learning Care Management with a focus on SMI Rather than using risk scores or past TME, focus on hidden data Health risk assessments Care management notes 10
11 11
12 7 days and 30 days Follow-up After Hospitalization for Mental Illness (FUH) 12
13 To-Do s 1. Develop your program focused on hospitals readmissions. 2. Partner / Pilot with local hospital. 3. Partner with specialty managed care company. 4. Measure. 5. Measure. 6. Measure. 7. If you build it they will come is NOT a business plan! 13
14 Thank you Paul M. Duck Vice President, Strategy & Development (813) 14
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