CCBHCs Part 1: Managing Service Mix and Clinical Workflows Under a PPS Tim Swinfard President, Compass Health CEO, Pathways Community Health Virna Little, PsyD, LCSW-R, SAP Senior Vice President, Psychosocial Services and Community Affairs, The Institute for Family Health Rebecca Farley, MPH Vice President, Policy & Advocacy, National Council for Behavioral Health
PPS: A Refresher PPS is not cost reimbursement Bears a rational relationship to the provider s costs May not equal costs for a given year and is not subject to cost settlement Ability to thrive under PPS requires strategic consideration of: Allowable costs Qualifying visits Service mix
What goes into the numerator? Total number of daily or monthly visits each year Payment rate for each daily or monthly visit Allowable costs for the entire year Direct costs related to anticipated CCBHC services and activities (e.g. staff salaries, care coordination activities, costs of services provided under agreement/contract, medical supplies, professional liability insurance, etc.) Overhead, indirect costs Does NOT include non-ccbhc services
What goes into the denominator? Total number of daily or monthly visits each year Payment rate for each daily or monthly visit Important note for CCBHCs: your state defines what constitutes a visit E.g. in-person encounter with clinician, Telehealth encounter? Call to crisis line? Other?
When is a payment triggered? Total number of daily or monthly visits each year Payment rate for each daily or monthly visit In a Medicaid PPS, payment is only received for patients who are covered under Medicaid When that patient has a qualifying visit (incl. at DCO) Note distinction between allowable costs and qualifying visits!
Qualifying visit, or not? Can a CCBHC draw down a payment for: Med check with psychiatrist? Phone call from nurse care manager to primary care doctor to discuss patient s increased blood pressure? 45-minute counseling session with licensed clinical social worker? Case manager meets with patient to identify needs related to employment, housing, child care? Intake worker screens individual for behavioral health needs at jail booking? Patient calls crisis hotline (a DCO)? Patient receives psychiatric rehabilitation services from DCO?
What could this look like? Date & type of service FFS $ Actual cost CCBHC visit triggered? March 24: Diagnostic assessment with LCSW March 30: 60-min psychotherapy for crisis with psychiatrist April 7: 45-min psychotherapy by LCSW April 7: 15-min. clinical care consultation by psychiatrist April 7: Face-to-face case management PPS-1 $ PPS-2 $ $123 $127 Yes $344 $516 $102 $300 Yes $344 n/a $102 $150 Yes $344 $516 $30 $75 Yes n/a n/a $416 (per month) $380 (per month) No n/a n/a Total $773 $1,032 $1,032 $1,032
Generally, for BH providers under FFS Psychiatrist is typically the loss leader Difficult to give patients as much access to psychiatrists as needed Case management, services by mid-level professionals tend to have a better margin (or less loss) Rely more heavily on these services in the treatment plan Service mix often driven by financial constraints
Under PPS Cost-related rate captures actual cost of staff salaries Psychiatry, etc. no longer loss leader The revenue supports clinical care decisions driven by patient need Key services (care coordination, case management) typically no longer billable Wrapped into daily or monthly rate CCBHCs should beware of business as usual when it comes to service mix PPS-2 states should monitor monthly service utilization for alignment with predictions; consider whether rebasing is needed
Now you re a CCBHC so how does that change services? Program Budgets just changed substantially Services Rates versus Cost Value based Events Quality Outcomes
Services Rates versus Cost 1988 Counseling Rate = $48 1988 Psychiatry Rate = $8 per changed once to $12.50 1999 Psychiatric Rehab = $96 2010 Health Home Rate = PMPM Evidence Based Practice = No rate differential Can you hire a Psychiatrist for $60,000 per year?
Cost Equalizer When the rate was developed has historically determined your ability to deliver the service More Psychiatrist & Counselors do not mean bigger losses as rates were built off cost- If you are delivering evidence based practice the cost is included in your PPS rate Be careful- don t stop doing something that cost more for short term profit as rates my be rebased or material change in scope could trigger rebasing
Patient Centered- Value Based Events What will have biggest impact on increased access to care What will have biggest impact on consumer outcomes What services are consumers demanding when they seek access to care? Will improved use of technology to support evidence based practice & care management tools?
Enhanced Access Quicker Access means more value to the consumer in distress and increases probability of visit Offer same day if they cannot schedule within 7 days For hospital discharges utilized assertive outreach and engagement Time versus Value Functional Assessment & Screens versus exhaustive Psychosocial Report
What does new customer want? Access & Answers They don t want long psychosocial history They do want to see a mental health professional aka a Psychiatrist A place to call after hours when they are in distress
Consumer Outcomes Evidence Based Practices IDDT, DBT, PCIT - use the alphabet soup Children & Youth- Improve Assessment Technology Addictions- Chronic repeat need to changed the paradigm from Acute care to Chronic Care Serious Mental Illness- Reduce reduction in hospital visits and improve or prevent chronic health conditions, MOVING TOWARDS versus MOVING AGAINST VIEWEG STUDY
Technology Continued work in progress Need to move towards mobile technology GPS Tracking is a compliance and safety tool Self Help applications are good for general population more difficult for the chronic populations Our highest cost just like the health insurance market is the 5 percent are the 50 percent cost (patient engagement)
LIFE WITH PPS Virna Little, PsyD, LCSW-R, MBA, SAP, CCM
1. Developing a sustainability plan 2.Identify performance indicators 3.Learn optimize systems to support sustainability Objectives
The Front End and the Back End!
Considerations for Sustainability Staffing Productivity/Volume Direct Revenue Indirect Revenue Coding Contracting Optimization ( concurrent doc) Back end-denials, Dashboard development
Don t Forget PPS Not The Only One! Medicare Individual and Case Rates Third Party
Embrace Technology! How can the system help solve this problem? Quality and value measures Decision supports Portals
Contracts What does the payer care about? Why we love quality dollars! Care Management dollars Bill aboves Pass through visits
Coding Code what you do!! Why code for things we cant bill for? Some fun codes to know 96127, 96110 90839 Advanced Directives Case Conferencing Screening for substances Social determinants
You Cant Get Paid If you don t see enough patients Know the ratios Productivity needs to support sustainability
Quantifying Efficiency EFFICIENCY PERFORMANCE INDICATORS Capacity: % of Face-to-Face time spent with patients producing visits out of the total time available for patient care Productivity: Count of Visits Provided related through Rate of Production: Visits per given time (e.g. hour, standard work day) THE P WORD IS ONLY ONE COLOR!
Enhancing Efficiency SCHEDULING PERFORMANCE INDICATORS Scheduling Days Out: Count of days between the date on which an appointment was made and the date for which it is scheduled No-Show Rate: % of scheduled appointments for which a patient does not present, or that a patient cancels within 24 hours OPEN SLOTS ARE WHAT COUNTS!! YOU CANT TREAT A SEAT!!
Enhancing Efficiency SCHEDULING PERFORMANCE INDICATORS Necessary Data Points: Date Appointment was Made Date of Appointment Appointment Outcome Cancellation Date ( when is a no show)
Decrease Days Out--Intakes Pull Forward Currently Scheduled Intakes 1. Identify high areas of no shows-predictive modeling 2. Create strategic overbooking slots in the times of frequent no shows- we call them access slots 3. Take appointments scheduled furthest out and pull them forward into new slots 4. As show rate increase, adjust number of access slots 5. HOTSPOTTING
Identify days with high open slots
Identify times with high open slots
Time Monday Tuesday Wednesday Thursday Friday Saturday 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM Slot Create Strategic Access Schedule Slot Dr. Whatt s Schedule *shadow schedule: not a real provider Slot Slot Slot
Defining Benchmarks What is your ideal maximum number of days out? Same day next day..
Decrease Days Out--Ongoing Care Discontinue the habit of recurring individual therapy appointments, instead schedule weekto-week. What is average length Of care?
Decrease Days Out--Ongoing Care Consider walk-in only medication management follow-ups. 1. Psychiatrist tells patient at end of visit to walk-in the week of and provides available hours 2. Reminders based on who has been instructed to come in the week of
Maintain Quick Access Identify a right-sized number of intake slots How many ongoing cases can you clinic support at a time given current staffing? What is your average length of treatment? What percentage of intake convert into careas opposed to case closure? What is your no-show rates on intakes now? Use data to tell your story!
Open Access start slow and small
start with one provider Open Access
start with one population Open Access
start with one session Open Access
Dashboard Development Where do we think your biggest holes are? What information would we need to know to patch the holes daily, weekly, monthly, quarterly? How would we get this information? Who would get this information and how would they share it?
Dashboard Beginnings What do I need to know? When do I need to know it? Where can I get this information?
THANK YOU!
CCBHC Community of Practice Join CCBHCs from across the country to explore common challenges, solutions and best practices Featuring access to consultants, technical experts and advice Ongoing networking and information sharing with fellow CCBHCs Mark your calendars for our orientation webinar May 3, 2:00 pm EST! www.thenationalcouncil.org/topics/certified-community-behavioral-health-clinics/