value-based purchasing in behavioral health · 2017-06-01 · value-based purchasing in behavioral...
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Value-Based Purchasing
in Behavioral Health
Office of Mental Health and Substance Abuse Services
Office of Medical Assistance Programs
May 25, 2017
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Today’s Goals
• Provide a point of reference and framework for value-
based purchasing (VBP).
• Gather stakeholder input for move to value-based
purchasing in behavioral health.
• Identify current value-based purchasing activities.
• Identify potential for value-based purchasing
activities.
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The Triple Aim
• Enhanced consumer experience and satisfaction.
• Better quality of care, consumer outcomes, and
population health.
• Lower per-capita cost of care.
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Source: DFS Report (http://www.dfs.ny.gov/reportpub/payment-reform-report.pdf)
Value-Based Payment Programs
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HealthChoices Physical Health
Managed Care Program
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2017 Agreement Language
• Setting specific targets for value-based purchasing.
• Increasing year over year value-based purchasing.
• Requiring patient-centered medical homes.
• Encouraging use of Accountable Care Organizations
(ACOs).
• Improving access to quality care.
• Improving the provider experience.
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VBP Model Strategy
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Value-Based Purchasing
MCO Contract Year Year 1 Year 2 Year 3
VBP Requirement 7.5% 15% 30%
Value-Based
Purchasing Models
1. Pay for Performance
7.5% may be
from any
combination of
models 1, 2, 3, 4
or 5
2. Patient Centered
Medical Home At least 50% of
the 15% must
be from any
combination of
models 2, 3, 4
or 5
3. Shared Savings At least 50% of
the 30% must
be from any
combination of
3, 4 or 5
4. Bundled Payments
5. Full Risk / Accountable
Care Organizations
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MCO Reporting Requirements
• January 1 - MCOs must submit VBP yearly plan.
• Quarterly - MCOs must report on their progress.
• June 30 of subsequent CY - MCOs must submit a report of
accomplishments from prior year to include:
o Explanation of purchasing arrangements by provider.
o Dollar amount spent for each arrangements.
• June 30 report will be used to determine compliance in
meeting Agreement goals for the subsequent year.
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Holdbacks/Financial Penalties
• Within 60 days after receipt of their report (August 30),
DHS will notify the MCO of their compliance or non-
compliance.
• MCO has 30 days to respond.
• If the Department finds an MCO noncompliant, there
will be a reduction in a future capitation payment.
• The reduction will be equivalent to one percent (1%) of
the prior December’s capitation.
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February 2017
VBP and Data Sharing
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Timely and actionable data to providers is critical to the success of VBP.
Expectations for data sharing:
• Identify high-risk patients.
• Care gaps, including those related to quality measures used in the VBP.
• Service utilization and claims data:
o Inpatient
o Short procedure unit
o Emergency department
o Radiology
o Lab
o Durable medical equipment and medical supplies
o Physician services
o Home health services
o Prescriptions
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February 2017
Patient-Centered Medical Homes (PCMH)
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The PCMH model of care includes these key components:
• Whole-person focus on behavioral health and physical health.
• Comprehensive focus on wellness, acute conditions, and
chronic conditions.
• Increased access to care.
• Improved quality of care.
• Team-based approach to care management/coordination.
• Use of electronic health records (EHR) and health information
technology to track and improve care.
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February 2017
Patient-Centered Medical Homes (continued)
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MCOs are expected to:
• Contract with high-volume providers in their network who
meet the requirements of a PCMH.
• Make payments to their contracted PCMHs.
• Collect quality, related data from the PCMHs.
• Reward PCMHs with quality-based enhanced payments.
• Develop a learning network that includes PCMHs and other
MCOs.
• Report annually on the clinical and financial outcomes of their
PCMH program.
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February 2017
PCMH and Data Sharing
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The MCO must provide timely and actionable data to its
PCMHs, including, but not limited to:
• Identification of high-risk patients.
• Comprehensive care gaps inclusive of gaps related to quality
metrics used in the value-based payment arrangement.
• Service utilization and claims data across clinical areas such
as inpatient admissions, outpatient facility (SPU/ASC),
emergency department, radiology services, lab services,
durable medical equipment and supplies, specialty physician
services, home health services, and prescriptions.
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Where to Begin
• Pay for Performance (P4P) Provider (or MCO)
payments for meeting or exceeding pre-established
benchmarks often paid in addition to FFS payments.
• Care Coordination Payment for a specific time period
to ensure coordination across multiple services.
• Episode of Care Payment (Bundled Payment or
Case Rate) Payment for all services to treat an
individual for an identified condition during a specific
period of time.
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Value-Based Payment
Individual consumers
Services included
Quality outcomes generated
Payment
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Opportunities within Behavioral Health
• Pay for Performance (P4P)
o Behavioral Health Specific P4P
• Care Coordination
o Centers of Excellence (COE)
o Certified Community Behavioral Health Clinics (CCBHC)
o Physical Health / Behavioral Health Integration
• Episode of Care Payment
o Assertive Community Treatment (ACT)
o Inpatient Psychiatric Case Rates
o First Episode Psychosis (FEP)
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Measuring Quality
• Process measures:
o Follow-up after in-patient stays
o Engagement in treatment
o Retention in treatment
• Change in health care usage:
o Readmission rates
o Inpatient stays
o ER utilization
• Social and functional measures:
o Employment
o Housing stability
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Contract Requirements Decisions
• Dates of implementation
o Percent required for each year
o What is included in the percent
o Required reporting
• Prior approval of MCO Plan
• Incentives or penalties to the MCOs
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QUESTIONS?