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www.openminds.com n 15 Lincoln Square, Gettysburg, Pennsylvania 17325 n 717-334-1329 n info@openminds.com
Building An Infrastructure For Innovation: An Executive Guide For A Value-Based
Market
Ken Ca r r, Sen io r Assoc ia te , OPEN MINDS
© 2018 OPEN MINDS
CareLogic®Analytics
TransformYour Information Into Meaningful Insights andActions
Qualifacts is proud to partner with OPEN MINDS in support of today’s presentation.
The CareLogic EHR and CareLogic Analytics Suite provides multiple options for organizations to meet the clinical, financial, data,
and reporting needs necessary to thrive in a value based market.
Connect with a Qualifacts team member after the session to schedule a personal tour of CareLogic Analytics Suite.
© 2018 OPEN MINDS
I. The Drivers Shaping The Movement To Value-Based Contracting The
Value-Based Reimbursement Business Model
II. The Value-Based Reimbursement Business Model The Role Of
Population Health Management In A Data-Driven Organization
III. The Key To Value-Based Contracting Success Is Managing
Performance The OPEN MINDS Value-Based Reimbursement
Management Readiness Assessment
IV. Infrastructure Competencies To Success In Value-Based Contracting
3
© 2018 OPEN MINDS© 2018 OPEN MINDS
I. The Drivers Shaping The Movement To Value-Based Contracting
4
© 2018 OPEN MINDS
The Drivers Of The Changing Service Delivery Landscape
5
Mental Health & SDoH Drive Integrated & Coordinated
Care
Changing Reimbursement
New Technologies
Emerging Consumerism
Changing Sustainability
Drives Consolidation
The Landscape
© 2018 OPEN MINDS
Acute care
Post-acute care
Primary care
Long-term care
Social and
human services
Facility-based Community-based Home-based
Payers & Health Plans Looking To “Care Coordination” & “Integration” To Reduce Costs – By Shifting Service Model
6
The Landscape
© 2018 OPEN MINDS
Changing Provider Reimbursement Models To Support “Integration”
Of the 38 states with Medicaid managed care, 22 require the Medicaid health plans to implement VBR with provider organizations At least 11 states have Medicaid ACOs
81% of Medicaid health plans have P4P FFS payments for behavioral health organizations
47% of Medicaid health plans have bundled payments for specific acute episodes
Nationally, specialty provider organizations with VBR revenue: 41% of primary care organizations
33% of behavioral health organizations
34% of child and family services organizations
14% of I/DD and LTSS organizations
7
The Landscape
© 2018 OPEN MINDS
Value-Based Reimbursement Here To Stay Because...
Political and competitive pressure on payers –
federal government and employers
Downward price pressure on health plans
Pressure on health plan medical loss ratios
The success of ‘some’ ACOs
The early findings of the Medicare bundled rate
initiative
Return to fee-for-service not feasible –
only “lever” in FFS is to reduce rates
8
Consumerism
Technology
adoption
Value-based
reimbursement
“Integration” for
improved cost and
quality
The Landscape
© 2018 OPEN MINDS
Shifting Role Of Technology In Health & Human Services
Administrative Tool
Compliance Requirement
Platform For Competitive Advantage
Compliance focus the past ten years
– Result - less focus on usability and clinical effectiveness
From “cost” to “investment”
From “administrative management” to “imbedded in service lines”
– Essential for competitive advantage – and market positioning – over the next five years
9
The Landscape
© 2018 OPEN MINDS
The Four-Stage Evolution Of Service Lines In Health & Human Services
Stage I: The Transition To (Semi) Competitive Market
Stage 2: The Integration Phase
Stage 3: The Value-Based Reimbursement Phase
Stage 4: The Tech Leverage Phase
© 2018 OPEN MINDS
The Value Of Investing In Technology
Competitive Advantage Driven By Value To Payers &
Consumers
Product
BenefitBrand
Equity
Marketing
Benefit
Price= Value
© 2018 OPEN MINDS
Strategic Quality Concept
Invest in “quality improvement” that differentiates you
from competitors – and customer is willing to pay for
the differential cost
Requires an understanding of:
Customer perceptions
Customer segmentation
Competitive offerings
Customer perceptions of competitive offerings
Price elasticity
Eight Dimensions Of “Quality”
Performance
Features
Reliability of service system
Conformance to standards
Durability and length of effect
Serviceability and customer experience
Aesthetics
Perceived quality
© 2018 OPEN MINDS
Optimizing Organizational
Performance, Care
Coordination & Population
Health Management
Getting The Necessary
Data
Technology Infrastructure To Support Performance Management
Electronic
health records
Health information exchange
and data aggregation
Care
coordination
platforms
Advanced population analytics
and clinical decision support
Performance
monitoring and
management tools
Consumer
segmentation
and health risk
stratification
Consumer referral trackingPatient registries
13
© 2018 OPEN MINDS
Reducing Service Cost
Engaging Consumers
Technology Infrastructure To Optimize Value Of Consumer Care
Patient portals,
websites, and web-
based consumer tools
Automated
consumer outreach
Telehealth and
telemedicine
Remote
monitoring and
distributedservice platforms
Tech improving
admin efficiencies
of staff
Tech-enabled
treatment
services
14
© 2018 OPEN MINDS
Leverage Of Technology To Reinvent Services Key To Long-Term Sustainability
1. Personalization of consumer treatment
2.More effective care coordination
3. Transparency in measurement of “value”
Telehealth and virtual
consultation changing
geographic market
boundaries for services
Smartphone and other
technologies for inexpensive consumer-
directed disease
management
Health information exchange provides data exchange and creates
‘big data’ for better consumer service
planning
New treatment technologies have
changed the options for consumers
15
Technologies permit task shifting to less expensive
staff
© 2018 OPEN MINDS© 2018 OPEN MINDS
II. The Value-Based Reimbursement Business Model
16
© 2018 OPEN MINDS
The Shifting Reimbursement Market
A Change In Focus:
Reducing Costs While Delivering &
Demonstrating Value
A Change In Methods:
Managed Care & Value-Based Purchasing
© 2018 OPEN MINDS
Business Model Transition For Provider Organizations
Payer Policy
Pay-For-Cost/Volume
Payer Policy Pay-For-Value
Business Model
What is paid for is
good for the
consumer and
doing more is the
business model
Business Model
Giving the
consumer (and
their payer) good
outcomes at a low
cost, conveniently
A revolution in
performance
management
required
Focus on achieving
outcomes and
managing risk
Focus on maximizing
price and managing
volume
© 2018 OPEN MINDS
Capitation + Performance
-Based Contracting
CapitationShared RiskShared Savings
Bundled & Episodic
Payments
Performance-Based
Contracting
Fee-for-service
Transition Of Payment To Provider Organizations From Volume To Value
Compensation Continuum By Level Of Financial Risk
No Financial Accountability Moderate Financial Accountability Full Financial Accountability
Passive Involvement Provider Engaged Provider Active In Management Providers Assumes
Accountability
Management Via 100% Case By
Case External Review
Internal Ownership Of Performance
Using Internal Data Management
Small % Of Financial Risk Moderate % Of Financial Risk Large % Of Financial Risk
© 2018 OPEN MINDS
45%
30%
23%21%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
PFP FFS Capitation for specificservices
Capitation for carecoordination
Case rate or bundledrate
Distribution Of VBR Models Is Changing
20
*Note provider organizations could select that they were participating in more than one type of VBR arrangement
Provider Organizations Participating In APMs, By Model Type, %, 2019
© 2018 OPEN MINDS
Key Effects Of Moving From FFS To Managed VBR
Focus On Outcomes
Create A Data-Driven Culture
Data, Analytics, Change
Management
Implement Effective
Technology
Manage Unit Costs &
Financial Risk
21
© 2018 OPEN MINDS
22%
22%
23%
32%
36%
Access to caremeasures
Patient/consumersatisfaction
Emergency roomutilization
Readmission rates
Follow-up afterhospitalization
Follow-Up After Hospitalization & Readmission Rates Are The Most Popular Measures For Determining Performance
22
Top Five Performance Measures In Value-Based Contracts, %, 2019
© 2018 OPEN MINDS
Top Five Performance Measures In Value-Based Reimbursement Contracts With Specialty Provider Organizations, By Market, %, 2019
23
Top Five Performance Measures By Market, %, 2019
Behavioral Health Child Services I/DD & LTSS Primary Care
1. Follow-up after
hospitalization – 41%
2. Readmission rates –
33%
3. Access to care
measures – 27%
4. Patient/consumer
satisfaction – 26%
5. Emergency room
utilization – 24%
1. Readmission rates –
19%
2. Follow-up after
hospitalization – 16%
3. Emergency room
utilization – 13%
4. Access to care
measures – 10%
5. Patient/consumer
satisfaction – 10%
1. Use of evidence-
based care protocols
– 24%
2. Follow-up after
hospitalization – 21%
3. Readmission rates –
21%
4. Patient/consumer
satisfaction – 14%
5. Emergency room
utilization – 14%
1. Readmission rates –
58%
2. Follow-up after
hospitalization – 54%
3. Emergency room
utilization – 46%
4. BMI assessment –
46%
5. Annual flu vaccine –
42%
© 2018 OPEN MINDS 24
17%
19%
19%
23%
25%
39%
Risk management capabilities
Finding the experienced managers to manageperformance-based reimbursement
Managing care coordination for consumers
Lack of clarity about performance requirementsfrom payers
Building needed IT infrastructure
Data management and reporting
% of Organizations
Typ
es O
f C
ha
llen
ge
s
Top Five Challenges To Managing Value, %, 2019
Specialty Provider Organization Executive Teams
© 2018 OPEN MINDS© 2018 OPEN MINDS
III. The Key To Value-Based Contracting Success Is Managing
Performance
25
© 2018 OPEN MINDS
Manage Performance In All Functions Of The Organization
Customer Experience
Clinical Performance
Compliance
Financial Sustainability
Marketing & Business
Development
Fundraising & Grants
Payer Contract
Performance
Employee Experience
Technology & Data
Analysis
© 2018 OPEN MINDS
Focus On Four Types Of Outcomes For VBR Success
The New Value
Assessment
Contract-Specific Performance
Measures
Routine Services and Transactions
Great Customer Service
Cutting Edge Expertise
© 2018 OPEN MINDS
1. Contract-Specific Performance Measures
The floor for success
Requires a payer perspective and a consumer
perspective of ‘value’
Reflect outcomes that are the costliest to the
payer
Reflect outcomes that the payer is accountable
to achieve to receive maximum reimbursement
Mandated Health Home
Performance Measures
Adult body mass index assessment
Controlling high blood pressure
Screening for clinical depression
and follow-up plan
Follow-up after hospitalization for
mental illness (7 and 30 day)
Initiation and engagement of
alcohol and other drug (AOD)
dependence treatment
Plan all-cause readmissions
Prevention quality indicator (PQI)
92: chronic conditions composite
Ambulatory care: emergency
department visits
Inpatient utilization
Nursing facility utilization
10 National Health Home
Measures
NCQA HEDIS Measures
CMS STARS Measures
Most Common Health Plan
Contract Measures
Your Specific Health Plan
Contract Measures
© 2018 OPEN MINDS
2. Routine Services & Transactions
Consumer sovereignty – a business philosophy assuming the best profit will
come from providing customers with the best products and best customer
service at the lowest possible price
The Amazon
Doctrine –
above all else,
align with
customers.
“Win when they
win. Win only
when they win.”
Search Engine Ranking &
Optimization Scores
InquiriesInquiry
Response Time
Inquiry Conversion
Rates
Time To Appointment
Service Rates
© 2018 OPEN MINDS
3. Customer Service
Providing service that creates ‘passionate advocates’ of your brand
Designing workflow from a consumer experience perspective –
preventing consumers from “feeling like they are simply another
transaction”
Developing a written
service strategy to
ensure consistency of
consumer experience
– and cultivate
consumer loyalty
Net Promoter Score
Customer Satisfaction
Customer Experience Monitoring (“Mystery
Shopper”) Results
Online Reputation
© 2018 OPEN MINDS
4. Clinically Cutting Edge – A Consumer Advisor On Emerging Science
Can you be replaced by an online clinical decision support tool?
Understanding the new science in your area of specialization
Mastering the
new technologies
– and integrating
them into your
service array
(whether you
provide them or
not)
Consistency In ‘Treatment Model’ -Lack Of Unexplained
Variability
Time To Evaluation/Adoption Of
New Treatment Technology
© 2018 OPEN MINDS
Top Five Key Performance Indicators
32
Domain Indicator Goal Review Parameters
Customer
ExperienceNet Promoter
Score
Assessment of customer
satisfaction and referral
development
Response to question about likelihood of
recommending our organization to friends and family
members; Monthly - Total, By Market, By Service
Line, YTD, Previous Year
Employee
ExperienceRevenue lost due
to vacancies
Identification of employee
satisfaction issues impacting
turnover and organizational
sustainability
Average revenue times time open for unfilled
positions; Monthly - Total, By Market, YTD, Previous
Year
Financial
SustainabilityA/R (days in
receivables)
Assessment of future cash flow and
identification of payer issuesTotal A/R divided by average daily charges; Monthly -
Total, By Market, By Service Line, YTD, Previous
Year
Clinical
Performance
ER utilization
(service lines
TBD)
Effectiveness in sustaining recovery
by providing timely, nonacute
services
Monthly - Total, By Market , By Service Line, YTD,
Previous Year – will require data sharing and/or
integration
Technology &
Data AnalysisNumber of report
requests and time
to complete
Organization use of analytics;
analytics resource adequacy and
effectiveness
Count of requests submitted and number of work
days from request to completion; Monthly - Total, By
Market, YTD, Year over year
Customer
ExperienceDays to
appointment
Assessment of customer
satisfaction and service quality
Monthly, Total, By Market, By Service Line, YTD,
Previous Year
© 2018 OPEN MINDS© 2018 OPEN MINDS
IV. Infrastructure Competencies To Success In Value-Based Contracting
33
© 2018 OPEN MINDS
I. Provider Network Management
II. Clinical Management & Clinical Performance Optimization
III. Consumer Access, Service, & Engagement
IV. Financial Management
V. Technology & Reporting Infrastructure
VI. Leadership & Governance
Six Domains In OPEN MINDS Model For Assessing Value-Based Reimbursement Management Readiness
© 2018 OPEN MINDS
IV. Four Key Competencies Of Financial Management
1. Revenue Cycle Effectiveness
2. Encounter Reporting
3. Value-Based Payment
Capabilities
4. Financial Performance Monitoring
© 2018 OPEN MINDS
1. Revenue Cycle Effectiveness
Focus:
Ability to align operational and
financial processes to assure adequate cash
flow
Key Competencies For Success
Effective processes for
reconciliation of authorizations and
payment verification to credentialed
provider organizations
Ability to submit invoices to payers
for services delivered under value-
based reimbursement agreements
© 2018 OPEN MINDS
2. Encounter Reporting
Focus:
Ability to capture, analyze, and report
granular utilization data to payers and to internal teams for
management
Key Competencies For Success
Ability to electronically capture and
report reliable encounter data in the
format and in the timeframe
required by payers
Ability to analyze encounter data to
manage service outcomes and
utilization
Aggregation of encounter data to
manage value-based
reimbursement agreements
© 2018 OPEN MINDS
3. Value-Based Payment Capabilities
Focus:
Ability to track manage contractual outcomes
and payments
Key Competencies For Success
Ability to report on actual
performance data – outcomes and
financial performance – against
budget and against contractual
targets
Ability to bill for multiple types of
value-based reimbursement models
© 2018 OPEN MINDS
4. Financial Performance Monitoring
Focus:
Ability to monitor actual financial results against contracts, budgets, and
forecasts
Key Competencies For Success
Ability to report incurred but not
reported (IBNR) liabilities
Ability to monitor service utilization and
costs and reconcile to service and
revenue projections
System to link population health
management and value-based
contracting strategies to resources
planning and reporting
Comprehensive set of key performance
indicators for short-term and long-term
financial health
© 2018 OPEN MINDS
V. Seven Key Competencies Of Technology & Reporting Infrastructure
1. Capacity To Collect Data
2. Capacity To Analyze Data For Population Health
Management
3. Ability To Manage Value-
Based Contracts
4. Ability To Exchange Healthcare Information
5. Care Management Functionality
6. Consumer Portal
Functionality
7. IT Performance Monitoring
© 2018 OPEN MINDS
1. Capacity To Collect Data
Focus:
Technology infrastructure to collect
data strategic in identifying health
needs of the population of consumers served
Key Competencies For Success
EHR core functionalities fully
implemented
Structured data collection around
assessments, diagnoses, and services
Workflows and processes to ensure
data integrity
Ability to collect data at the time and
source of service provision
© 2018 OPEN MINDS
2. Capacity To Analyze Data For Population Health Management
Focus:
Ability to perform strategic analysis of
data for risk stratification and care
management
Key Competencies For Success
Development of or access to consumer
data registries
Deployment of data analysis tools
Implementation of risk stratification
strategies
Ability to integrate multiple sources of
data
© 2018 OPEN MINDS
3. Ability To Manage Value-Based Contracts
Focus:
Ability to track performance metrics, submit invoices, and
maximize performance of value-based
contracts
Key Competencies For Success
EHR functionality that meets billing
requirements for value-based
purchasing models
Integration of clinical, operational and
financial data
Unit costing and cost accounting
capabilities
Predictive modeling and forecasting
capabilities
© 2018 OPEN MINDS
4. Ability To Exchange Health Care Information
Focus:
Ability to exchange clinical and financial
information with other health care provider
organizations
Key Competencies For Success
Health information exchange
agreements with key providers
Secure infrastructure, policies and
workflows that comply with HIPAA and
HITECH
Service notification agreements,
automation and processes with other
providers
© 2018 OPEN MINDS
5. Care Management Functionality
Focus:
Ability to manage eligibility, coordination
of benefits, inquiries/referrals,
decision support, care authorization, care coordination and
utilization management
Key Competencies For Success
Automated risk assessment tools
Redesigned workflows to maximize
care management technology
Provider referral database to aid in care
matching and management
© 2018 OPEN MINDS
6. Consumer Portal Functionality
Focus:
Ability to provide service data, resources and interaction options
with consumers through the EHR
Key Competencies For Success
Convenient, secure access to
personal health information through
the internet
Ability to access staff and services
through technology
Access to forms and account
payment functionality
© 2018 OPEN MINDS
7. IT Performance Monitoring
Focus:
Ability to monitor actual IT outcomes against
established goals
Key Competencies For Success
Established key performance
indicators
Ability to generate real-time
reporting on performance under
value-based reimbursement
arrangements
© 2018 OPEN MINDS© 2018 OPEN MINDS
Questions & Discussion
48
© 2018 OPEN MINDS
CareLogic®Analytics
TransformYour Information Into Meaningful Insights andActions
Qualifacts is proud to partner with OPEN MINDS in support of today’s presentation.
The CareLogic EHR and CareLogic Analytics Suite provides multiple options for organizations to meet the clinical, financial, data,
and reporting needs necessary to thrive in a value based market.
Connect with a Qualifacts team member after the session to schedule a personal tour of CareLogic Analytics Suite.
Turning Market Intelligence
Into Business AdvantageOPEN MINDS market intelligence and technical assistance helps over 550,000+
industry executives tackle business challenges, improve decision-making, and
maximize organizational performance every day
www.openminds.com n 15 Lincoln Square, Gettysburg, Pennsylvania 17325 n 717-334-1329 n info@openminds.com
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