Delaware Releases RFP For Medicaid Managed Care Organizations

The Delaware Department of Health and Social Services (DHSS) is rebidding the Medicaid managed care organization (MCO) contracts for its Diamond State Health Plan (DSHP) and DSHP Plus. DSHP provides acute physical and behavioral health services, as well as pharmacy, for traditional Medicaid beneficiaries. DSHP Plus provides acute physical and behavioral services for people who need long-term services and supports (LTSS), including those dually eligible for Medicare and Medicaid, those receiving home- and community-based services (HCBS), and nursing facility residents. The state intends to select two or three MCOs. The request for proposals (RFP HSS-22-008) was released on December 15, 2021, and proposals are due by February 22, 2022.

For adults all traditional and specialty mental health services are included in the MCO capitation rate, unless an individual qualifies for Promoting Optimal Mental Health for Individuals through Supports and Empowerment (PROMISE) services. PROMISE services are for individuals with behavioral health needs and functional limitations. The services include an array of HCBS that are provided on a fee-for-service (FFS) basis. For children, the MCO capitation rate includes 30 outpatient visits. If that limit is exceeded behavioral health services are provided FFS by the state, along with all behavioral health inpatient services. The MCOs cover treatment for opioid use disorders, including office-based opioid treatment and opioid treatment programs.

The incumbents are AmeriHealth Caritas Delaware and Highmark BCBS Delaware Highmark Health Options; their contracts expire December 31, 2022. Awards announcements are anticipated by May 3, 2022. The new contracts are slated to go live on January 1, 2023.

The RFP includes provisions to achieve the following goals:

  • Member focus: The MCOs will help improve the quality of care and heath outcomes for members by providing whole person, person-centered care; engaging with communities; identifying and addressing health related-social need, and advancing health equity.
  • Accountability: The MCOs will be accountable for program costs, performance, and creativity.
  • Innovation: The MCOs will lead by example and drive innovation across the state’s health care system.
  • Alignment with other state initiatives: The MCOs will collaborate with efforts to align Medicaid initiatives with other DHSS programs and state health care initiatives.

The proposals will be evaluated based on seven criteria, as follows:

  • 10 points for qualifications and experience
  • 35 points for delivery and coordination of services
  • 10 points for community engagement, health equity, and health related social needs (HRSN)
  • 10 points for the provider organization network and provider services
  • 15 points for value-based purchasing strategies
  • 10 points for administration and operations
  • 10 points for case scenarios

The value-based purchasing strategies (VBPS) should address one or more of the following domains: primary care, maternal and child health, behavioral health , HRSN, health equity, and LTSS. The contractors’ value-based purchasing strategies must reach minimum payment threshold levels in each year of the contract, and a smaller percentage must take place through VBPS that have downside risk to the provider organization, such as bundled or episode payments, risk/capitation rates/total cost of care.

For calendar year 2023, at least 60% of all medical/service expenditures for all populations must be through VBPS. In addition, at least 45% of all expenditures must be through a VBPS with downside risk to the provider organizations. For calendar year 2024, at least 70% of all medical/service expenditures for all populations must be through the VBPS listed in the RFP, and at least 50% must be from a combination of VBPS with downside risk to the provider organizations. For calendar year 2025, and subsequent years the minimum level remains the same as for calendar year 2024.

Delaware’s mandatory Medicaid managed care program, comprised of DSHP and DSHP Plus, is authorized under a Medicaid 1115 waiver. About 86% of the 264,440 Delaware Medicaid beneficiaries are enrolled in one of the two Diamond State plans. The two programs serve different populations:

  • DSHP was implemented in 1996; it serves traditional Medicaid beneficiaries. Beneficiaries needing long-term services and supports are excluded, as are those dually eligible for Medicare. DSHP provides acute physical and behavioral health care services.
  • DSHP Plus was implemented in 2012; it serves people dually eligible for Medicare and Medicaid, people receiving home- and community-based services (HCBS), and nursing facility residents. The MCOs are also responsible for covering HCBS and custodial nursing facility services.

For more information about the RFP, contact: Kathleen Dougherty, Division of Medicaid and Medical Assistance, Delaware Department of Health and Social Services, 1901 North DuPont Highway, Lewis Building, New Castle, Delaware 19720; Email:; Website:

For more information about the state’s current Medicaid contracts, contact: Jill Fredel, Communications Director, Delaware Department of Health and Social Services, 1901 North DuPont Highway, Main Building, New Castle, Delaware 19720; 302-255-9047; Email:; Website:

Understanding Unit Costs & Why They Matter So Much In Value-Based Reimbursement

By Ken Carr

Many health and human service executives are under the impression that value-based reimbursement (VBR) models alleviate the need for organizations to worry about unit costs and productivity anymore. This is definitely not the case. In fact, managing unit cost is just as critical, if not more, in a value-based payment environment (see Value-Based Reimbursement: The Three Strategy Questions).

VBR models are focused on realigning incentives to provide high quality service while keeping the cost of services down. And now, more than 93% of health plans — including commercial plans, Medicaid, and Medicare — have implemented some type of pay-for-performance reimbursement models (see Trends In Behavioral Health: A Reference Guide On The U.S. Behavioral Health Financing & Delivery System). In addition, the use of episodic or bundled payments for specific acute care episodes is gaining traction, with 59% of plans using this model. While only 40% of commercial health plans use episodic payments, 71% of Medicare and 88% of Medicaid health plans use these payment arrangements for behavioral health. And, the Health Care Payment Learning & Action Network (LAN), a coalition of public and private health care provider organizations and health plans—working to accelerate the adoption of two-sided risk and alternative payment models—estimates that by 2025, 100% of Medicare and 50% of Medicaid and commercial payments will be value-based (see LAN Goal Statement FAQs). But even with all these shifts in payment models, unit costs still are a critical element in the evolving value equation – and controlling unit costs will remain an important strategic issue.

And for those organizations still working with legacy fee-for-service (FFS) reimbursements, our current market is making managing unit costs more vital than ever. A review of Medicare and Medicaid fee-for-service (FFS) payment rates show minor increases in FFS rates – certainly not enough to keep up with operating costs; especially with rising per-consumer costs due to the increase in volume of services, new technology, and the increasing number of consumers with multiple chronic conditions. Plus, many of these additional costs are passed on to consumers as out-of-pocket expenses to individuals are seeing their monthly incomes shrink under the weight of such pressures (see Medicare Raising Consumer Out-of-Pocket Costs for 2022).

The question for most executive teams is how to improve their unit cost management. The key is to “think about manufacturing around a particular price. It’s not just math – a lot of what we’re talking about is understanding the operations and the workflow, because you can’t do all of that without the pieces. There are four keys to best practice management of unit costs:

Service line-specific cost accounting The first component in the process is the ability to understand and measure costs in general (and unit costs in particular) by service line. More “global” measurement and management of costs is not useful as executive teams think more about the financial sustainability of specific services (see VBR & I/DD–The Wave Begins).

Target costing This is a pricing method to reengineer the cost of a service to hit a specific target market rate, or the maximum amount of cost for a service that can be incurred to earn the required profit margin. The key element is the ability to reengineer your costs so your price to the payer or consumer is within their “acceptable” range. After you determine the acceptable rate for the service, you determine what it costs your organization to deliver that unit of services — and if your costs exceed the rate, its time for “backwards engineering” to bring your costs in line. The reality is, there are only so many cost variables that you alter – including wages and benefits of direct care staff, staff productivity, volume of consumers served, administration/overhead, etc. (see How To Develop Your Next Big Thing: The OPEN MINDS Framework For New Service Line Design & Development). But this is a necessary step to be competitive in our value-driven market.

Automated process measurement (and management) systems Performance measurement needs to be automated with multiple systems connected to monitor unit costs in the real time. Electronic health record systems, financial management systems, human resource management systems, and customer relationship management systems all must be integrated and aligned to provide the real-time monitoring and reporting data you need to manage on a daily basis. Automated, up-to-date process measurement will allow you to make data-driven management decisions and take action quickly to address problems (see If You Can’t Keep Score, You Can’t Be In The Game).

Metrics-based business process management Metrics-based management is a model of managing processes, outcomes, and performance that relies on qualitative and quantitative measurement of the current performance, the desired performance, and the objectives and action plans to improve performance. Metrics-based management requires both strategic management to identify your performance goals, and business process management to optimize day-to-day organizational processes (see If You Don’t Measure It, You Won’t Implement It: Setting Strategic Plan Metrics). Metrics-based measures are also increasingly being used by payors as a way to measure the quality of care as much of the information already collected by providers through their electronic health records can be used to improve outcomes (see Using the Data You Already Collect to Measurably Improve Clinical Outcomes).

A big piece of the metrics-based management process is operational reengineering – driving operational change for the organization’s structure, staff/jobs, and technology. And in those areas, your goal is to “track the people and what they do” (including consumers, staff, and administration), and “track the paper and where it goes” (including consumer medical records, service delivery and billing, and routine financial workflows).

Reshaping Revenue Cycle Management For The Post-Pandemic Era

By Monica Oss

But what is revenue cycle management? In short, revenue cycle management is the set of administrative and clinical functions related to capturing client service revenue. It begins when a consumer schedules an appointment and continues through point-of-service registration, charge capture and coding, claims submission, remittance processing, payer follow-up, and analysis. Crucial to revenue cycle management is clearly articulated workflows, sufficient staffing, integrated technology, and regular oversight.

“The revenue cycle management process is not going to change, the tools and info and detail to manage revenue cycle management are going to change, said Mr. Wawrzynek. “So, when I talk with people, the key is to have the basics done and nailed now, because when you bring in another variable, like outcomes, then it is going to be difficult to be successful.”

Here are some of the key revenue cycle management changes organizations will need to make in our evolving post-pandemic, value-based world.

Easily configurable billing and EHR systems EHR and billing systems should be easily configurable to accommodate value-based contracting specifics. For example, a value-based contract may require outcomes data that is not currently collected in the EHR. A billing system may also need to collect additional discreet variables to identify individual projects or contracts at the payer level and the client level. Ms. Lane did caution that it is important to manage the changes and updates being done to your system to control the complex variables that go into billing. Don’t let your vendor make a change to the system without completely understanding what they are doing and how it will affect your systems (see Beefing Up Your EHR To Beat The Competition).

Adding the ability to suspend claims Mr. Wawrzynek explained that many billing systems can suspend claims from being sent for payments if they do not meet certain regulatory compliance standards. Organizations may need to enhance their systems to suspend claims based upon contract specific requirements. Ms. Lane also added that it is crucial to have a compliance system in place that regularly audits your billing processes. By catching wrongly billed claims earlier, not only can organizations prevent claw backs later in the year, they can build trust with payers by voluntarily offering refunds for incorrectly billed services (see More Data Means More Risk).

Directly access data stored in billing and EHR systems A major part of managing revenue cycle management in a value-based contracts, is actively managing performance data. Therefore, provider organizations should begin developing data warehouses and data models that can be used to manage performance. Ms. Lane explained that Grafton regularly pulls data and looks at their performance. In cases where their performance isn’t what they expected or they are in danger of missing the targets in their contract, they will speak with the payer. She also said that payers like to see that they are proactively reviewing their contracts and are willing to problem-solve. It goes a long way in managing their relationships (see Data-Driven Care: Using Population Health & High-Utilizer Data).

Ms. Lane explained that managers need to take a more holistic approach to the traditional revenue cycle management process. While having the correct systems in place is crucial, managers should be actively using market intelligence and monitoring the data payers are putting out. Additionally, different revenue cycle staff members should attend meetings and conferences to network with payers. People with different specialties, often have different perspectives and may find a new way to solve a problem for a payer (see Addressing Social Determinants As A Path To Revenue Growth).

Finally, it is important to communicate across different revenue cycle management teams and the organization as a whole. Ms. Lane explained that the head of your revenue cycle management team should take their position broadly and sit in on business development meetings and strategy meetings. Value-based reimbursement requires organizations to sell their services, not just fill out contracting forms. Revenue cycle management should understand the different processes and components that are expected. Across the revenue cycle management team, it’s important to communicate new enhanced rates, changes in procedures due to a new contract, etc. As contracts become more complicated and individualized, teams need to be in constant communication to ensure they are billing at or above the negotiated rate and meeting the specified requirements.

As specialty provider organizations look to re-tool their revenue management cycle process for value-based reimbursement, they should stop focusing on whether they are billing and start focusing on relationship management at every level – the C-suite, clinical, and contracting.

Merger & Acquisition Volume In The Health Services Sector Up 56% In 2021 Over 2020

The number of mergers and acquisitions in the health services sector for the 12 months ended November 15, 2021 was 56% higher than the previous year. Aggregate deal volume rose from 1,138 deals in 2020 to 1,773 for the 12 months ended May 15, 2021. Aggregate deal value in the health services sector rose 227%, from $62 billion in 2020 to $203 billion for the 12 months ended May 15, 2021. The share of “mega deals” valued at $5 billion or more rose from $11 billion in 2020 to $107 billion in 2021. In 2020, mega deals represented 18% of the total $62 billion deal volume. In 2021, mega deals represented 53% of the total $203 billion deal volume.

During 2021, the five subsectors with the highest deal volume were long-term care, physician medical groups, home health and hospice, behavioral health, and laboratory/imaging and dialysis. Additional details were as follows:

  1. Long-term care: There were 445 deals in the sector valued at $18.6 billion, representing 25% of total deal volume, and 9% of aggregate value.
  2. Physician medical groups: There were 407 deals in the sector valued at $5.5 billion, representing 23% of total deal volume, and 3% of aggregate value.
  3. Home health and hospice: There were 137 deals in the sector valued at $12.7 billion, representing 8% of total deal volume, and 6% of aggregate value.
  4. Behavioral health: There were 114 deals in the sector valued at $5.7 billion, representing 6% of total deal volume, and 3% of aggregate value.
  5. Laboratory/imaging and dialysis: There were 102 deals in the sector valued at $27.1 billion, representing 6% of total deal volume, and 13% of aggregate value.

Between 2020 and 2021, the deal volume doubled in three subsectors: rehabilitation, physician medical groups, and managed care.

  1. Rehabilitation: The 81 deals in 2021 represented a 145% increase over the number of deals in this sector in 2020. The $3.4 billion deal value in 2021 was 408% above the value in 2020.
  2. Physician medical groups: The 407 deals in 2021 represented a 119% increase over the number of deals in this sector in 2020. The $5.5 billion deal value in 2021 was 55% above the value in 2020.
  3. Managed care: The 47 deals in 2021 represented a 114% increase over the number of deals in this sector in 2020. The $7.2 deal value in 2021 was 2% above the value in 2020.

For the behavioral health sector, the 114 deals in 2021 were 56% above the 2020 volume. The 2021 $5.7 billion deal value was 103% above the 2020 deal value.

These statistics were reported in “Health Services: Deals 2022 Outlook” by researchers at PricewaterhouseCoopers, LLP. The analysis is based on merger and acquisition data tracked by LevinPro HC and LevinPro LTC, and through S&P Capital IQ.

The full text of “Health Services: Deals 2022 Outlook” was published in December 2021 by PricewaterhouseCoopers, LLP. A free copy is available online at (accessed January 4, 2022).

For more information, contact: Ryan Cangialosi, Senior Director, PricewaterhouseCoopers, LLP, 2121 North Pearl Street, Suite 2000, Dallas, Texas 75201; 347-443-2157; Email:; Website:

CMS Designates Connecticut Health Plan’s Episodes-Of-Care Payment Model As One Of TheFirst Commercial Plan Other Payer Advanced Alternative Payment Model

On October 7, 2021, the Centers for Medicare & Medicaid Services (CMS) approved a new payment model—the Episodes of Care program—between the State of Connecticut Health Plan for state employees and several provider organizations as an Other Payer Advanced Alternative Payment Model (A-APM). This Other Payer A-APM designation is one of the first earned by a commercial health plan, which starting in 2022 allows the Connecticut Health Plan network professionals to earn credit for participating in value-based care for the Medicare Quality Payment Program (QPP). The Connecticut Health Plan Episodes of Care program is for covered state employees and retirees, as well as members of the Connecticut Partnership Plan, which offers health care coverage to municipal employees.

The State of Connecticut’s commercial employee and retiree health plans, as well as the Connecticut Partnership Plan, launched the Episodes of Care program in October 2020. The Connecticut Health Plan covers state and certain municipal workers, retirees, and their dependents, totaling about 260,000 covered lives, and 210,000 are covered by the episode program. The remaining 50,000 are in a group Medicare Advantage plan in which the episode program does not apply.

The Episodes of Care program sets fixed episode prices covering evaluation through recovery for over 40 common health episodes that may be delivered by multiple provider organizations or professionals across multiple sites. The services included in the episodes account for up to 60% of the average health plan spending. The episodes include knee replacement, colonoscopy, cataract surgery, care related to pregnancy, and a comprehensive spine episode. The full list can be viewed online at (accessed October 27, 2021).

The Connecticut State Health Plan episode-of care-model establishes a target episode price with each participating provider organization based upon the provider organization’s past performance. The episodes are retrospective, meaning that episode performance against the benchmark is calculated after the completion of the episode by aggregating the cost of all the claims associated with the baseline episode. Episodes are reconciled on a quarterly basis. The risk level of the participating provider organization groups varies based upon the financial ability of each to take on risk and their risk tolerance.

The Connecticut Office of the State Comptroller partnered with Signify Health during 2020 to create a new “Network of Distinction” program. The network includes hospitals, health systems, and physician groups. Each has low rates of complications and below-average episode prices. Since its inception last year,1,400 physicians have committed to the state’s quality and cost standards through their participation in the Network of Distinction. Additional provider organization groups are still eligible to join.

The hospitals, health systems, and physician groups selected into the Network of Distinction all have low rates of complications and below-average episode prices. Signify Health is supporting the Connecticut Episodes of Care program by identifying, contracting with, and supporting participating provider organizations with services, technology, and analytics, as well as securing fixed, episodes-of-care pricing with high-value network provider organizations participating in the Network of Distinction.

The QPP was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which restructured how Medicare pays clinical professionals. MACRA repealed the Medicare sustainable growth rate; established permanent statutory payment updates; and created incentive payments for participants in A-APMs. An A-APM must meet three criteria: require clinical professionals to use certified electronic health records (EHRs); tie payments to quality measures; and require eligible clinical professionals to bear nominal financial risk. Eligible Medicare professionals must participate in an A-APM or the merit-based incentive payment system (MIPS). Non-exempt eligible clinical professionals who fail to participate in an A-APM or MIPS are subject to lower Medicare reimbursements for the following year. Those who do participate are eligible for QPP bonus payments.

Signify Health is a health care platform that leverages advanced analytics, technology, and nationwide health care provider networks to create and power value-based payment programs. Its mission is to transform how care is paid for and delivered. Its solutions support value-based payment programs by aligning financial incentives around outcomes, providing tools to health plans and health care provider organizations designed to assess and manage risk and identify actionable opportunities for improved consumer outcomes, coordination, and cost-savings.

For more information, contact:

MAT Inside Service Walls by the Maine Department of Corrections — An OPEN MINDS Program Profile

Program History

In early 2019, Maine Governor Janet Mills signed an executive order directing state resources to be directed at the Maine Department of Corrections (MDOC) to help justice-involved residents suffering from opioid addiction. After getting the okay from the governor, Deputy Commissioner Ryan Thornell, who oversees the program, brought together staff from all levels in the MDOC to participate in a steering committee to map out the timeline and procedures for implementing MAT treatment for residents. This committee consisted of security staff, nurses, case managers, administrators, clinicians, and community treatment professionals. One of the important pieces was listening to concerns from security officers who worried medication assisted treatment (MAT) was similar to contraband items forbidden by the MDOC.

Population Served

Maine’s pilot MAT services started at four of the state’s six adult correctional facilities focusing on caring for residents who fit medical criteria and were 90 days from their release date. This pilot was population focused on ensuring continuity of care so that as the client was released, he or she had a solid plan in place to continue treatment and engage with community programs like peer support, harm reduction, and community-based recovery groups. By November 2019, the department expanded MAT access to a fifth facility, and three months later, in February 2020 expanded MAT access to the remaining sixth facility, the Maine State Prison.

Less than a year after the pilot, MDOC expanded the MAT program again to provide different types of buprenorphine and naltrexone to residents six months from their release date and provide maintenance to those entering the system already on an MAT, including methadone. By May 2021, the eligibility criteria were further expanded to include residents who still had two years until being released. Today, MAT services are universally accessible to any resident in Maine’s state correctional system, regardless of sentence length. MDOC started with about 100 residents and now reaches about 700 adult residents a year.

Program Fees & Funders

Costs associated with the first-year pilot during fiscal year 2020 totaled $1.2 million and included $450,000 in braided funds through a partnership with the Maine Office of Behavioral Health (OBH) and the Director of Maine’s Opioid Response, Gordon Smith. With the expansion in 2021, costs increased as projected, but they were below expectations, totaling close to $930,000. Ongoing costs for the service will run close to $1.5 million, which is about $500,000 less than originally anticipated, the added costs related to universal expansion.

Program Performance & Metrics

As Maine evaluates the costs associated with this established service, the department will be able to continue using the braided funds from state and federal agencies, will tap into overall savings acquired through reduced costs from having more healthier residents, and consider the option of establishing an Opioid Treatment Program within a facility, which some addiction professionals say is the most cost-effective manner to way administer methadone to residents. In addition to treatment, MDOC staff has been focused on reducing the stigma of addiction recovery among residents. For example, staff worked to change their language in speech and in documentation to non-stigmatizing, person-first, person-centered language, using terms like “resident,” “client,” and “person with substance use disorder. MDOC has done away with stigmatizing words like “prisoners,” “probationers,” and “drug addicts.


For the future, the MDOC plans to continue universal access to MAT and look to meet other cross-over needs for residents, such as treatment for Hepatitis C.

General info

Maine Department of Corrections Central Office
25 Tyson Drive, Third Floor
State House Station 111
Augusta, ME 04333
(207) 287-2711

Key Staff

Randall Liberty, Commissioner
Ryan Thornell, Ph.D., Deputy Commissioner
Gary LaPlante, Director of Operations
Susan Gagnon, Director of Adult Community Corrections
Anna Black, Director of Government Affairs


Thinking Sustainable New Services? Think Integration

By Monica E. Oss

How to navigate through these uncertain times? When planning for future sustainability, health and human service executive teams have to track three factors related to future competitive advantage—the drivers of change and how they affect their specific market; the emerging new opportunities and the strength of the competition in their market in these areas; and the efficiency and resilience of their organization to navigate through and succeed given these changes. In my keynote at last month’s 2021 OPEN MINDS Management Best Practices Institute, I discussed this roadmap to sustainability in my closing remarks, Best Practices For Success In The ‘Next Normal’ – Building A Foundation For An Efficient & Resilient Organization.One key area for building new service lines that capitalize on emerging opportunities is services that “fit” in the emerging integrated care/whole person care model. The Patient Protection and Affordable Care Act ushered in the era of integrated care with no preexisting condition clauses, no annual/lifetime limits, and behavioral health parity. These new requirements changed the clinical and financial playing field. And, finally, many payers (employers, health plans, units of government) are concluding that “whole person” approaches to care are not only a better consumer experience and lead to better consumer outcomes, but they decrease costs as well.

At last month’s institute, we heard presentations of three different models to achieve that same end. Many health plans are building their own internal integrated care coordination teams. Raphael Gonzalez-Amezcua, M.D., Chief Medical Officer at Aetna Better Health of California, in his opening keynote, A Payer’s Perspective On Crucial Integrated Health Components In The “Next Normal”, pointed out that health plans are focused on “high needs, high cost” consumers—those with three or more chronic conditions and challenges with activities of daily living. They have moved to a consumer-prioritized multi-health determinant integration model that assesses health, behavioral, and social support needs to assist these consumers in their planning their care. This intensive approach is driven by the fact that more than 60% of these complex consumers receive conflicting recommendations from their care team.

Caroline Carney, M.D. Chief Medical Officer at Magellan Health, shared with us the roadmap to a new “next generation” model of behavioral health carve-outs—an analytics-intensive model where behavioral health takes the lead in overall consumer wellbeing and early intervention. She described Magellan’s whole health management model, MPath, based on an integrated digital ecosystem with multiple functionalities, in which aggregated consumer data from various sources is used to drive targeted interventions with consumers. This new approach also features a wellbeing solution, resiliency training, a curated suite of health care-adjacent apps, eCBT, and high-risk care coordination. (For more, see a recording of Dr. Carney’s keynote, A Time For Transformation: Reimagining The Partnership Approach For Behavioral Health, at The OPEN MINDS Health Plan Partnership Summit: An Assessment Of Payer Partnership Priorities In The “Next Normal.”)

And, Michelle Berthon, Behavioral Health Clinical Operations and Government Sector Product Development at Optum and Kimberly Macakiage, Medicaid Waiver Director at Integral Health, presented their provider partnership model for integrated care coordination in “P” Is For Payers, Priorities, Partnership … & Platforms. The model integrates the data-driven centralized management at the plan with a delegated, value-based arrangement with local provider organizations to provide the in-the-field care coordination with consumers.

The key for provider organization executive teams is tracking the direction of preferred integrated care coordination models by dominant payers in their market—and determining the best strategies for partnership with those payers and health plans based on their model.

How To Manage The 5% With Multiple Chronic Conditions & Complex Support Needs

By Monica E. Oss
There is a lot of investment money going into the mental health field—in fact, $14.7 billion in the first half of this year (see Why Are Digital First Mental Health Companies So Popular?). Much of that investment is focused on digital behavioral health systems and tools for both professional and self-care.

However, these new platforms and tools are not the perfect fit for every consumer with a mental illness. In fact, 25% of consumers with any mental illness have a serious mental illness (SMI). In all, 13.1 million consumers, or 5% of the total United States population, have an SMI (see Key Substance Use & Mental Health Indicators In The United States: Results From The 2019 National Survey On Drug Use & Health). Of consumers with SMI, 27% have co-occurring substance use disorders. We also know that SMI consumers on average tend to die 10 to 25 years earlier than the general population—and have a mortality rate that is twice as high as that of the general population because of chronic physical medical conditions such as cardiovascular, respiratory, and infectious diseases; diabetes; and hypertension (see Premature Death Among People With Severe Mental Disorders). 20% of the SMI population lives in poverty Approximately 20% of jail inmates and 15% of state prison inmates have an SMI (see Mental Health & Criminal Justice). 33% of the homeless population has an SMI (see 250,000 Mentally Ill Are Homeless. 140,000 Seriously Mentally Ill Are Homeless).

For the approximately 5% of the population—those with multiple chronic conditions and complex support needs—that use a majority of the health care resources, a different approach is needed to assure good consumer outcomes and prevent inappropriate use of resources. That population was the focus of our recent discussion with Carole Matyas, Vice President, Operations at Sunshine Health, and the keynote speaker at the upcoming 2021 OPEN MINDS Executive Leadership Retreat.

On September 22, Ms. Matyas will deliver the keynote address, The Future Of Managing Care For Consumers With An SMI—What Works. The cornerstone of progressive interventions for the high-risk/high-needs population with a serious mental illness is based on a “whole person” treatment strategy that encompasses medical, behavioral, pharmacy, social needs, and caregiver collaboration and coordination. Ms. Matyas will review Sunshine Health programs that are showing promising positive outcomes such as reduced use of acute/crisis care, better engagement with primary care that improves medical health outcomes and addresses high comorbidity issues, stabilized community-based living environment by addressing social needs for the enrolled Medicaid and Medicare members served. She will provide an overview of their Long Acting Injectable (LAI) program with data that demonstrates reductions in emergency department and inpatient services, and increase in community-based and medical services for members.

My takeaway from our pre-Institute discussion with Ms. Matyas? The Sunshine Health approach to optimizing the management of consumers with an SMI has four key components—intensive case management to assure care coordination, leveraging long-acting medications, a focus on primary care, and addressing social support needs.

Intensive case management to assure care coordination. One approach that has improved outcomes for SMI consumers is intensive case management. Sunshine Health took its top 400 high-needs, high-risk consumers (who have 30+ hospital admissions a year, go to the emergency room every other week, and reject any type of community-based treatment) and had its staff provide proactive and intensive case management services in collaboration with a host of community provider organizations and stakeholders. For example, case managers work closely with a telehealth provider organization that Sunshine Health contracts with to ensure that consumers discharged from hospital have their seven-day follow up appointment virtually and then connect them with an outpatient provider organization for ongoing care.

Leveraging long medications. Sunshine Health has been encouraging provider organizations to use long-acting injectables (LAIs) for antipsychotic medication administration. Ms. Matyas shared that SMI consumers receiving monthly LAIs have shown significant stabilization in their mental health and also do better at getting care for their comorbid medical conditions, engage with peers socially, and are even able to have part-time employment. She said, “We are promoting use of LAIs and really going a long way in working with hospital systems, primary care physicians, and mental health providers to make it easy to obtain those medications, administer them, monitor, and do outreach so members continue treatment. While the medications can be expensive, the results definitely show reductions in hospitalizations, readmissions, and emergency room visits as well as better outcomes from community-based treatment.”

Sunshine Health has a number of strategies to increase the use of LAIs. They do not require provider organizations to obtain prior authorizations to administer LAIs. In addition, if clinical professionals start an LAI when a consumer is in the hospital, case managers make sure to follow up with the consumer to make sure they get to the outpatient provider organization for their next dose when it’s due. They also have a “concierge program” within their pharmacy network and customer service representatives call members to schedule an appointment for their next LAI dose. Some pharmacies are also authorized to administer the LAIs. Sunshine’s provider relations team is charged with providing information about LAIs to community mental health and primary care provider organizations.

Ms. Matyas said, “We have a goal of increasing long acting injectables 25% year over year. During the pandemic, we had interruptions with folks getting their long acting injectables, but we are working towards getting back to normal state, which is encouraging.” And now there are two barriers to overcome to extend the use of LAIs, she added. The first is adherence which becomes challenging when consumers are say, cycling in and out of homelessness and are not stable in their environment or engaged in their treatment. The other issue is that there’s a history of long acting injectables not getting authorized by managed care. So provider organizations need to be educated and learn that “they don’t have to jump through a lot of hoops” to be able to prescribe LAIs if appropriate for the consumers.

Focus on primary care. Sunshine Health is encouraging provider organizations to go the integrated care route by participating in health home models and value-based reimbursement (VBR) models. They are also leveraging data to encourage collaborations and equipping primary care provider organizations to better address the needs of SMI consumers. Recently, they launched a behavioral health home program and seven community mental health centers have signed up to date. These centers have co-located primary care and behavioral health services and are delivering whole-person care under value-based contracts.

VBR is the cornerstone for integrated care. Sunshine Health offers incentives for provider organizations to address “gaps in medical and behavioral care.” In the behavioral health homes program, the incentive program is contingent on preventive health screenings being conducted for all consumers and on addressing the comorbidities that SMI consumers have. All provider organizations in Sunshine’s network—whether they are primary care practices or community mental health centers—are expected to address comorbidities and to report on the array of HEDIS measures related to both medical and behavioral care. Ultimately, Ms. Matyas explained, “The goal is to move more to value-based care, where we can impact members by having them in a health care environment so that they don’t have to go eight different places to get the care they need. They should be able to be more easily referred and seen, for whatever service it is they need. Value-based care incentivizes providers to work together without dictating a one-size-fits-all model.”

Sunshine Health embeds behavioral health services in primary care and offers psychiatrists who can consult on prescribing patterns and other issues in the care of SMI consumers. Ms. Matyas explained, “Every member covered by us is assigned a primary care provider regardless of whether they have an SMI diagnosis or not. So every one of the 5% of our 2.6 million members with SMI has a primary care physician. We take the data to our primary care practices and say, ‘Here are the demographics of the population assigned to you and here are the care gaps.’ The primary care practices will tell us whether they can handle the whole-health needs of these SMI members or want us to move them to a different provider. Or the practices may say they are equipped to handle some things but not others. So then we bring in behavioral health quality practice advisors to work with them, or we move the SMI members to a primary care practice that is better suited to work with this population.”

Addressing social support needs. Sunshine Health addresses social determinants of health (SDOH) in a variety of ways. Many of their behavioral health provider organizations have robust case management programs and the case managers connect consumers to social supports as needed. The health plan maintains a database of community resources that these case managers can access on request. They also offer micro grants to small community projects that support social needs. Some of their Medicaid programs, like the SMI specialty plan, have expanded benefits such as housing rental deposit or one month’s advance rent to help consumers get into housing. They’ve distributed cell phones and tablets for consumer use. SMI consumers get $35 a month in over-the-counter benefits from CVS to buy non-prescription items.

The fact that health plans are looking at primary care as the hub for SMI treatment should be a wake-up call for specialty provider organization executives who believe that their niche in serving this population assures a steady stream of business. Assuming responsibility for the whole-person care (medical, behavioral, and social) of the SMI populations served and participating in value-based arrangements are becoming the basics for sustainability planning.

Addressing Social Determinants As A Path To Revenue Growth

By Monica E. Oss

Over the last 15 years, there have been many pilot projects by payers, health plans, and public and private entities to address social determinants of health (SDOH). In the past couple years, we’ve heard from several health plan executives about their SDOH initiatives (see Mind, Body, Community: Kaiser Permanente’s Unique ApproachInnovation: Tag, You’re It‘Leaning In’ To Medicare: Social Needs OpportunitiesWill Investing In Social Determinants Pay OffHousing = Health: The Five Levers, and Medicaid Wants More Than Health: Be Prepared For Contract Changes). We’ve seen many new SDOH program launches by health plans—UnitedHealthcare’s recent Empowering Health grants, Humana’s Bold Goals program, Horizon Blue Cross Blue Shields of New Jersey’s Neighbors in Health program, and North Carolina Medicaid’s Healthy Opportunities Pilots, to name just a few. And there are the requirements to address SDOH under new Medicaid managed care contracts in a number of states (see Medicaid Authorities & Options To Address Social Determinants Of Health).

For specialty provider organizations, the question is how to address SDOH—and find a funding stream to do just that. Previously, we outlined the two paths to adding social service supports and supports coordination to traditional service lines. One way is to add a social supports coordination element that will get more referrals or improve reimbursement under value-based reimbursement arrangements—and pay for itself as an enhanced service feature with more total revenue for existing services. The other way is to build social supports programs that health plans or government payers will reimburse—and build a new revenue stream. Whatever option an executive team chooses, return-on-investment analysis is key. I wrote recently about our six-step model for assessing the effectiveness (both proactively and in practice) of enhanced social service programming in Building An ROI For Social Service Referrals.

We heard two great case studies of provider organizations that are taking the second path— building service lines for social services with payer/health plan revenue—during the session, Incorporating Social Determinants Of Health Into Your Practice To Improve Patient Outcomes & Increase Reimbursement at last week’s 2021 OPEN MINDS Management Best Practices Institute (session recordings and decks are available at until September 27). June Simmons, President and Chief Executive Officer of Partners in Care Foundation and Karin Annerhed-Harris, Vice President, Business Development at Resources for Human Development (RHD), shared how they are working with health plans on unique initiatives to address SDOH for complex consumers.

June Simmons, President & CEO, Partners In Care Foundation

Partners in Care Foundation builds community networks to provide a single point of access for consumers. Partners in Care contracts with health plans—and sometimes with health systems—to provide care management and home and community-based social services. Their goal is to integrate all community health resources and supports into a seamless delivery system for easy access and management. Ms. Simmons said, “If you’re just referring Ms. Smith to go down the street where they provide meals, it’s one thing. But if you’re paying for something, it’s a whole new paradigm. And sometimes you’re going to have to pay for care coordination and concrete services on a targeted basis.”

Partners contracted with Blue Shield of California (BSC) in 2014 to provide SDOH services to BSC consumers through primary care practices. BSC pays Partners for specialized staff—community health advocates (CHAs)—who are trained and supervised by PIC, and embedded in medical practices. To date, Partners has trained and placed 70 CHAs in three years. CHAs assess and analyze consumer needs, work with consumers on care planning, connect them to services, follow up, and track outcomes. The relationship with BSC has grown since over time, with Partners providing a variety of SDOH-related services.

Partners also operates specialized Outreach and Engagement Centers for Anthem in California, Georgia, Colorado, and Virginia. Through these centers, they develop care plans, engage with consumers, and make sure they get the needed social services. “You can take a horse to the water but you can’t make it drink. So engagement is crucial to ensure that consumers actually use the services they are connected to and that’s why the health plans partner with experts like us.”

For health plans, the benefit is in contracting with a single entity that manages the comprehensive network of social care. Access to supports becomes easier for consumers. Data sharing between the health plan and community-based organizations is also streamlined and simplified. Ms. Simmons said, “So if you’re a health plan and want to address a certain population—maybe it’s young moms and kids, maybe it’s frail elders and keeping them out of the nursing home—are you going to go out and identify all the agencies involved, organize them, and contract with them? Or would you like a lead entity that’s going to do that for you—curate the services, qualify the agencies, be the central intake, the oversee the quality, and do the billing?” Working with a trusted local entity is a far more practical and efficient route for health plans in Ms. Simmons’ opinion. She said, “A more mature community entity can bring their neighboring health and human service provider organizations into an organized delivery system, so consumers don’t have to be referred to multiple entities.”

Karin Annerhed-Harris, VP, Business Development, Resources for Human Development

Resources for Human Development addresses food and housing needs. RHD provides outpatient and residential services for consumers with mental illness, substance use disorders, and intellectual and developmental disabilities. RHD partnered with Temple University Hospital and two managed care organizations (MCOs)—Health Partners Plans and Keystone First—to pilot the Housing Smart program. The program was intended to reduce avoidable emergency room utilization and hospital readmissions among homeless individuals through peer outreach, supportive services, and subsidized housing resources.

The MCOs agreed to criteria for eligibility and generated a list of member referrals for RHD. RHD provided the high-users experiencing homelessness with access to housing vouchers that are good for two years. The consumers were housed in apartments across Philadelphia and local food banks provided three meals a day for three months, followed by cooking classes. The pilot resulted in a 74% drop in emergency room use, 48% reduction in hospitalizations, and a 76% increase in outpatient hospital visits. And with stable housing, 12 consumers in the program are actively engaged in behavioral health outpatient services.

At the outset of the program, Temple generated a list of eligible people using target population criteria and shared that with the MCOs. They enrolled 25 high utilizers prioritizing consumers with opioid use disorder, persistent mental illness, and co-occurring physical health conditions. RHD used an MCO-funded team comprising a peer support specialist, care coordinator, and tenant services coordinator to engage consumers in services. While the MCOs reimburse for services, 36% of the program is grant funded and goes toward housing, Ms. Harris said. RHD is exploring expanded health plan funding, now that Pennsylvania allows health systems and MCOs that can save money through a value-based agreement to use the profits to fund housing.

Lessons learned—partnership, evidence-based interventions, data sharing, and more. Ms. Simmons shared the four key elements for successful integration of SDOH—strong partnerships to form a comprehensive community network of care, the capacity to deliver home-based services, the use of good screening tools to assess consumer needs and preferences, and the delivery of evidence-based interventions for SDOH.

At RHD, Ms. Harris attributes the success of their pilot to robust partnerships and collaborations (between provider organizations, a health system, health plans, and other community organizations); cross-sector tools and training; and data sharing to enable a holistic view of consumer needs, goals, and care gaps.

The takeaway for provider organization executives? As my colleague and OPEN MINDS Senior Associate Cathy Gilbert, who moderated the session, said, “Entrepreneurial provider organizations have the opportunity to package many consumer support services that were previously not reimbursable and turn them into new revenue streams in partnership with plans. Providing these services drives better outcomes for consumers and ultimately reduces overall costs.”

Massachusetts FQHC Centers Surpass One Million Telehealth Visits

The Massachusetts Federally Qualified Health Center (FQHC) Telehealth Consortium’s 35 community health center members have conducted more than one million telemedicine visits since the start of coronavirus disease 2019 (COVID-19) in March of 2020. This achievement comes at the same time the Consortium has passed the halfway mark of its Phase II $12 million fundraising goal – thanks to a major grant from the Gordon and Betty Moore Foundation – to attain sustainable telehealth capacity at health centers and address health disparities in the communities served by them.

Consortium data measuring telehealth use between May 2020 and May 2021 show that telemedicine visits have provided safe and convenient access to primary care for communities of color, which have been disproportionately impacted by COVID-19. Of the 767, 234 Massachusetts health center consumers who accessed primary care via telemedicine visits during that year-long period, more than 52% were white, nearly 21% were Black/African American, more than 6% identified as more than one race, more than 5% were Asian/Pacific Islander, and 1% were Native American. Of those identified by ethnicity, nearly 31% were Latinx/Hispanic.

According to the data, the same held true for behavioral health care services. Of the total number of consumers taking part in behavioral health telehealth visits during the same one-year period, nearly 56% were white, more than 23% were Black/African American, more than 5% were of more than one race, 4.65% were Asian/Pacific islander, and less than 1% were Native American. By ethnicity, 31% again identified as Latinx/Hispanic.

Phase II of the Consortium’s campaign is focused on ensuring that FQHCs have what they need to fully develop, deploy, sustain, and integrate telehealth modalities into primary and behavioral care, while also addressing the digital divide in their communities. This includes providing better access to broadband and remote monitoring equipment, increased digital literacy training, peer learning, outreach in communities that health centers serve, and online dissemination of best practices.

Phase II of the campaign launched in the fall of 2020 with $1,040,000 received from an anonymous donor to create skilled bandwidth at nine pilot sites required to integrate advanced, durable, and mature telehealth capabilities into member FQHCs. Another $3.1 million grant awarded by the U.S. Federal Communications Commission (FCC) in January as part of the FCC Connected Care Pilot Program is providing equipment and hot spots for consumer broadband access. The grant from the Gordon and Betty Moore Foundation ($878,000) is designed to increase the number of consumers with controlled hypertension, particularly for African American/Black consumers, and to test the additional value of telehealth navigators and clinical intervention over federal funding of remote monitoring.

The Consortium is a partnership of Community Care Cooperative (C3), the accountable care organization (ACO) that advances community-based care for MassHealth members, and the Massachusetts League of Community Health Centers, the state-based association of health centers.

Community Care Cooperative (C3) is a not-for-profit ACO that leverages the proven best practices of ACOs throughout the country and is the only ACO in Massachusetts founded and governed by Federally Qualified Health Centers (FQHC) and exclusively focused on advancing integrated and coordinated community-based care for MassHealth members. C3 works with its 18 member FQHCs to strengthen health centers across the state, and continued growth enables C3 to better serve MassHealth members across the Commonwealth. To view a list of C3 health centers, click here.

The Massachusetts League of Community Health Centers (the League) is a not-for-profit membership organization supporting and representing the Commonwealth’s 52 community health centers, which offer primary and preventive care to more than one million residents. The League serves as an information resource on community-based primary care to policymakers, opinion leaders, and the media. It provides a wide range of technical assistance to its health center members, including advocacy on health policy issues, support for workforce development, clinical care and technology initiatives, and guidance to state leaders and community-based organizations seeking to open health centers.

The Gordon and Betty Moore Foundation fosters path-breaking scientific discovery, environmental conservation, consumer care improvements, and preservation of the special character of the Bay Area.

This was reported by The Massachusetts FQHC Telehealth Consortium on August 24, 2021.

Contact information: Abby Akoury, Chief of Staff, Community Care Cooperative, 75 Federal Street, 7th Floor, Boston, Massachusetts 02110; 857-302-4261; Email:; Website:

Contact information: The Massachusetts League of Community Health Centers, 40 Court Street, 10th Floor, Boston, Massachusetts 02108; 617-426-2225; Email:; Website:

Contact information: The Gordon and Betty Moore Foundation, 1661 Page Mill Rd, Palo Alto, CA 94304; 650-213-3000; Email:; Website: