WellSpan Health & Gateway Health Launch Value-Based Partnership For Medicaid Members

On July 29, 2021, Gateway Health, a Pennsylvania Medicaid managed care plan, and WellSpan Health a health system in central Pennsylvania launched a value-based partnership focused on connecting Gateway Health members with primary care professionals. Gateway Health and WellSpan are proactively contacting Gateway Health’s Medicaid members who visit the health system through emergency or urgent care visits, but do not have a relationship with a primary care provider organization. WellSpan case managers will work one-on-one with the Gateway members to address barriers, such as transportation and cost, to establishing an appropriate primary care relationship. Financial details about the partnership have not been disclosed. The goal is to reduce the number of potentially preventable emergency department visits among Gateway members.

Through this value-based partnership, Gateway Health and WellSpan aim to deliver an enhanced level of care, improve health outcomes, and lower health care costs for Gateway Health’s Medicaid members receiving care at WellSpan’s 200-plus health care locations. The partnership will utilize data insights and value-based programs to proactively manage the health care needs for more than 24,000 Gateway Health Medicaid members living in South Central Pennsylvania.

This partnership expands on an existing relationship between Gateway Health and WellSpan. For the past 18 months, they have partnered together for better maternal care and coverage through Foundations Pregnancy Support Services, a program offering coordinated, comprehensive care for mothers and their children with opioid use disorder. WellSpan partners with other Medicaid insurers to provide this support. However, WellSpan said that the commitment and innovative partnership with Gateway Health has resulted in more than double the number of members enrolled than with any other insurer.

Gateway Health was founded in 1992 as a Medicaid managed care plan. It currently provides Medicaid and Medicare Advantage plans. It covers health care services for nearly 340,000 members annually.

Non-profit WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. It has more than 1,600 employed physicians and advance practice professionals; a regional behavioral health organization; a home care organization; eight hospitals, and more than 200 consumer care locations.

For more information, contact:

Four Keys To Success With Value-Based Reimbursement

By Monica M. Oss

The move away from fee-for-service reimbursement—toward value-based arrangements with financial alignment between health plans and provider organizations—continues. A look at some of the reporting over the past quarter illustrates the continuing activity—Humana To Acquire One Homecare Solutions To Accelerate Development Of Value-Based Home Health OfferingGateway Health & Wellspan Health Announce Value-Based PartnershipCaron Treatment Centers & Independence Blue Cross Report Value-Based Contract Linked To Lower 90-Day Readmission Rate, and 60 Provider Organizations Chosen By CMS For The New ‘Value In Opioid Use Disorder Treatment’ Demonstration.

And as revenue slowly moves away from fee-for-service, most provider organization executive teams are going to have to make the decision about whether or not they want and can manage contracts with downside financial risk. Currently, nearly 36% of all health care payments in the United States are value-based (see 2019 HCP-LAN Alternative Payment Model Measurement Effort: Report & Infographic). A recent survey showed that 53% of specialty provider organizations caring for complex consumers are participating in some form of value-based reimbursement. And 12% of specialty provider organizations report 20% or more of their revenue tied to VBR agreements (see The 2021 OPEN MINDS Performance Management Executive Survey: Where Are We On The Road To Value). As these numbers rise, the available market share outside of these arrangements shrinks.

But for the executive teams that are taking their organization in that direction, the strategic question goes beyond getting the contracts. It is also how to manage VBR reimbursement arrangements successfully—for the consumer and for their own bottom line. In the executive roundtable at a recent conference, VBR: Where’s The Beef? Managing Payer Expectations For Value Over Volume, two health plans executives—Cindy Ehlers, MS, LPC, Executive Vice President, Clinical Operations at Trillium Health Resources and Rhett Melton, Chief Executive Officer at Partners Behavioral Health Management—described their expectations from provider organizations. And two provider executives—Corbin Petro, Chief Executive Officer at Eleanor Health and Teri Herrmann, MA, Chief Executive Officer at SPARC Services & Programs—described their approaches for success with value-based models.

Our payer and provider executives highlighted four aspects of a value-based relationship that are essential for success—an aligned partnership model, knowing what to measure and why, managing the cost side of the equation, and building in processes that allow flexibility in care planning and delivery.

Well-aligned partnerships are key. Provider organizations have traditionally had “vendor” relationships with health plans—relationships that have bordered on adversarial. Our panelists pointed out that it’s important for providers and payers to lose the “us versus them” mentality and come to the table together to see how they can best serve consumers. Mr. Melton said, “There are three people at the table. There’s the payer, there’s the provider, and there’s the member. We start with the members themselves. It’s not us at the managed care company that should sit in an office somewhere and decide what’s the right outcome, we should be working with our members to say, ‘What do you want out of care? What do you want success to look like? What do you think is important in the care that you get?’ That is how we can demonstrate the so-what.”

Ms. Herrmann noted that SPARC Services & Programs has multiple value-based contracts with multiple payers (see Value-Based Reimbursement Models Help SPARC Get A Leg Up In Medicaid Managed Care Contracting). The key to success has been coming together with each payer to figure out the pain points for both the health plan and their diverse consumer members.

To build these partnerships, many health plans are willing to do what it takes to help provider organizations prepare for the shift away from fee-for-service. Both Trillium and Partners Behavioral Health provide support for technology infrastructure upgrades and offer training and education for provider organizations. Mr. Melton said, “We invest in improvements because that stabilizes the system. If a short-term financial cost to the managed care organization can improve accessibility and stability for members, it’s important. We’re looking to walk alongside provider organizations and to bring some of that training to help them grow along with us.” Ms. Ehlers added, “We’re trying to meet providers where they are. So for those that need infrastructure, we try to guide them in that direction. Sometimes we invest in infrastructure to help move them forward. Because it matters to the care of the member. We’ll work with them on training. Lots of providers have done really good work in moving forward as soon as they know that is something they need to do. They’re eager to learn and try.”

Measures are important but must be consumer-centric. The very essence of value-based contracts is performance measurement—it is the means to move away from volume as the foundation of reimbursement. There is a wide range of performance measures in VBR—those affecting cost of care and HEDIS measures being the most common (for more, see our OPEN MINDS-recommended performance dashboard in 12 Steps To Creating Your Data-Driven Organization.)

But the focus on performance for consumers needs to be front and center according to our panelists. Mr. Melton explained, “We require reporting on HEDIS measures—timely follow up from hospitalization, keeping the emergency department utilization down, and decreasing the days of inpatient hospitalization. It is all those things, but we always need to come back to what all those things mean for member satisfaction. It’s great for us to say the days dropped by X number per 1000 for inpatient care. And that’s a good indicator and there are certainly cost ramifications. But did the members think that they had good access to care? And are they happy with the care?”

Ms. Petro said that in its value-based contracts, Eleanor Health (see Eleanor Health’s Value-Based Approach To Medical Homes For Consumers With Addictions & Complex Support Needs) reports on HEDIS measures—emergency room diversion, reduction in hospital readmissions, and net promoter score. But she emphasized that each of these measures is tied to goals that they have defined in tandem with payers and that are consumer-focused. These include improving access to care, engaging the 90% of consumers with substance use disorders who currently don’t seek care, and reducing the total cost of care. She said, “An important part of any value-based payment model is orienting around specific outcomes. This has also been where I saw the most opportunity, having come from the physical side of health care. There aren’t a lot of entities that are tracking to specific outcomes. So payers have been really excited about what we’ve been able to show for the populations that we work with. And outcomes are particularly important for stigmatized populations that historically haven’t been treated well by the health care system. So metrics are an important part of our value models.”

Ms. Herrmann discussed their health plan contracts, which have both upside and downside risk. The incentives can include keeping consumers out of the hospital. Penalties may be incurred if consumers enter residential treatment unnecessarily or exceed a certain length of inpatient stays. However, she said, “They’re really all looking at that same piece—are we able to support that person remaining healthy and in their community, and not using the hospital systems when they don’t need to be? But if residential treatment is needed to keep them safe, are we ensuring that they can get that treatment? Are we doing all of the things that we can do clinically, and giving the clinicians the freedom to intervene in unique ways that fee-for-service doesn’t always allow us to do?”

Cost management is as important as revenue management. There are two parts to the simple equation underlying alternative payment models: Value = Performance/Cost. Performance metrics are critical but cost management is essential for sustainability of provider organizations under these arrangements.

The first step is the understanding how much services costs. There are unit of service costs. But that is only the first step. Cost of care across the continuum and over time are critical measures. Ms. Ehlers  said, “Providers don’t know how much services cost, because they have a whole lot of stuff rolled up into their administrative overhead. And so when it comes down to a discrete service, a lot of times they’re unable to tell us what it actually costs them. That’s one of the things that slows us way down.” (For more on this, see our OPEN MINDS Value-Based Contracting Risk Assessment Checklist.)

And there is another cost issue. Delivering services with downside financial risk often requires additional infrastructure with additional costs. This includes capacity to collect data, capacity to analyze data for population health management, ability to run service utilization prediction models, ability to exchange healthcare information, care management functionality, and consumer portal functionality—see  The OPEN MINDS Value-Based Reimbursement Readiness Assessment Checklist). Ms. Petro said, “I would argue that the greater piece of information that we can show is the impact that we’re having on the quality and the costs for the that individual we are serving, as opposed to the cost of intervention. We need to know the impact of delivering care that often isn’t supported in a fee-for-service environment—the community health worker and peer support services that break down those non clinical barriers to care. Or are the costs keeping people healthy, keeping people out of the hospital, and really having that total impact?” Her advice is to “move from a billable service metric to a caseload or a risk-adjusted caseload metric” and look at how the needs of a population or set of members is being met. She said, “You really have to look at what do these patients cost? Why do they cost this much? Where are the opportunities for savings? Are they all in the right levels of care and do they have access to care?”

Value fosters flexibility—with a caveat. Provider organization clinical managers have often expressed frustration with the restrictions imposed by “billable services.” The general consensus is that fee-for-service reimbursement hinders a whole-person approach and doing what is best for the consumer. But value-based models bring newfound flexibility, our panelists agreed. At SPARC, value-based models have given clinical professionals a lot of freedom and flexibility to adjust levels and intensity of care based on where consumers are. For example, they have 6-month authorizations so there’s no need to go back to the payer for more units. The administrative burden is significantly reduced.

But there is a caveat. While there are not rules on the volume of care—or necessarily the type of care—clinical professionals are held accountable for outcomes. Ms. Herrmann said that they discuss their commitment to value-based models while hiring clinical professionals. They stress that the clinical team will have flexibility in how they deliver care but also have “skin in the game” for delivering good performance. She said, “We talk about the fact that we have opportunities for incentive payments as an agency if we’re able to keep the children and families we’re working with out of higher levels of care, and if the things that we do stick and work. Then we translate those into incentives for the clinicians.”

This is not about giving carte blanche to clinical professionals to use whatever treatment models they choose. It is providing a framework for consumer-centric, structured flexibility through ongoing assessments and clinical support tools.

These four keys to success may seem like a stretch for many provider organization executive teams. But, as Mr. Melton said, they should be “comfortable being uncomfortable.” The investment required—new best practices in partnerships models and management, in data-driven decisionmaking, in cost management and use of decision support tools—is one part of the equation. Building the management team that can use those tools is the other.

If You Don’t Measure It, You Won’t Implement It: Setting Strategic Plan Metrics

By Carol Duncan Clayton, Ph.D., Senior Associate, OPEN MINDS

As management guru Peter Drucker said, “What gets measures is what gets done.” The surest way to ensure implementation of the strategic plan is to translate the plan objectives into quantifiable metrics and to hold executive team members and managers and staff at all levels accountable to achieving those metrics. The question our team at OPEN MINDS often gets is “But what metrics should we set for the strategic plan?” While there is no formula or template, following a defined process will result in establishing meaningful measures of success. We’ve defined the 12-step process to becoming a data-driven organization (see 12 Steps To Creating Your Data-Driven Organization). And here, we narrow down the steps pertinent to setting strategic plan metrics.

Once the strategic plan is finalized and approved, with clear overarching objectives and strategic initiatives, executive teams should follow a five-step process to establish metrics—break down objectives into key performance indicators (KPIs) for each business unit or domain, work with business unit leaders to establish KPIs, determine how data will be measured and shared, cascade the metrics down to the individual level, and establish a review and action framework for when targets are not being achieved.

Translate Strategic Objectives Into Key Performance Indicators

Ideally, your strategic plan should have no more than three to five overarching objectives for the organization as a whole. And a well-constructed strategic plan should identify a handful of key strategic initiatives designed to achieve those objectives. Strategies are the plan for “how” your organization is going to accomplish the objectives—not the action items. Strategic initiatives can include developing new services lines, expanding into new markets, pursuing acquisitions, improving margins on selected services, changing business development strategies, etc.—all dependent on the specific organization and its specific objectives.

The overarching objectives should be broken down into key performance indicators for each business unit or domain for every one of the strategic initiatives. A key performance indicator (KPI) is a metric used to measure and track progress toward achieving a specific objective. KPIs are quantifiable, measurable, and intended to indicate if an organization is hitting its targets. Ideally, KPIs should specify a frame of comparison—the current level of something and what it will increase or decrease to and by when.

For example, a strategic objective to “Become the market leader in providing xx type of services in xx region” could break down to outcome measures for the clinical, marketing, and customer service units. For the clinical unit, KPIs could be “Reduce hospital readmissions by xx% from current levels” or “Proactive outreach to xx consumers with PHQ-9 scores above xx” or “Establish workflows and protocols to adopt xx new evidence-based practices” For the marketing unit, KPIs might look like “xxx website visitors in 2021, resulting in xx inquiries about services.” A business development unit’s performance may be measured in terms of new payer contracts procured, rate increases negotiated, or number of visits resulting from community partner referrals. For customer service, the KPIs may relate to how quickly calls are answered, reduced wait times for appointments, a certain number of positive online review by consumers, or improvement in net promoter score. For the technology department, the objective might translate to a performance metric such as “Set up online appointment scheduling capability and train xx staff.” For the finance department, the KPI may be to “Reduce the billing cycle by xx days.”

My colleague and OPEN MINDS Senior Associate Ken Carr recommends sample KPIs in six performance domains—high performance on payer contracts, the speed and cost factors, the consumer experience, clinically cutting-edge, and financial sustainability (see Experience Alone Is Not Enough For Decisionmaking: Using Metrics To Develop & Evaluate Your Strategic Plan).

Depending on your strategic objectives, there are six core areas in which KPIs should be established to determine organizational strengths and growth, according to OPEN MINDS Chief Executive Officer Monica E. Oss (see For The Next Normal, Ready = Resilient). Portfolio strength is determined by analyzing revenue and profitability by service line and payer and determining the degree to which an organization is vulnerable to specific market shifts. Customer strength is determined by consumer and payer ratings and measures—net promoter score, consumer experience, HEDIS measures, STARS ratings from the Centers for Medicare and Medicaid, and other consumer and payer metrics. Marketing strength is your organization’s ability to reach prospective customers. Financial strength is the financial “reserves” available to your organization to withstand unexpected market shifts. Value-based reimbursement strength is the ability of an organization to successfully move beyond cost-based and volume-based reimbursement models. And innovation strength is measured in an organization’s demonstrated ability to respond to customer requests and take new services to scale.

Allow Business Unit Leaders To Drive KPIs But Provide Guidance

One key question is who should establish metrics and KPIs. Ideally, the managers of each business unit in a provider organization are best suited to do this. However, the executive team should work closely with these managers to make sure they understand the organizational strategic objectives and how those apply to their business unit. Managers should be able to provide clear rationale for how every KPI they recommend links to one or more strategic objectives. A framework and examples will guide the managers in the right direction. They also need to understand how their unit’s KPIs will tie into those of other units and where collaboration will be needed to set and achieve goals jointly. The executive team should also clarify expectations—should KPIs be aspirational or stretch goals or should they be limited by current level of performance, will the appropriate resources and support be available if stretch goals are set, what are the consequences of non-performance etc. How to encourage managers to “think big” without causing negative stress through unattainable goals is a challenge to be addressed through an iterative process.

Ultimately the executive team, and the Chief Executive Officer specifically, is responsible for final approval of the KPIs. But engaging business unit and frontline managers up front will help to secure buy-in. Moving to a metrics-based system of performance will likely involve a major cultural shift for most specialty provider organizations—and the executive team should drive this shift with firmness and tact.

Define The Pathways To Collect, Measure, & Share Data

Managers who recommend KPIs should provide clarity on where the data for measurement will be sourced from, how often it is collected, and who will process the data. The executive team should develop an organization-wide system of dashboards and reporting, defining frequency of reporting and levels of access.

It’s important to get everyone on the same page about how each metric is defined, how it’s displayed, and whether the planned representation yields the desired takeaways for each manager. Keep the data visual and finding a quick way to draw attention to trends and anomalies is of utmost importance.

Everything on the dashboard has to be automated. If data needs to be complied manually, put it on a waiting list until it can be automated. Nobody wants one more thing to do—and any data that needs to be hand tabulated ends up not being collected, or being so delayed that it loses value. While there are sophisticated dashboards and programs and platforms to manage those dashboards, starting simple is always best—there is a lot you can do with Microsoft Excel and PowerPoint. Microsoft PowerBI is also a good data visualization and connection tool, with affordable prices for initial out of the box solutions. And your electronic health record system can likely be leveraged for many of the reports you need—so talk to your vendor about what is possible. But remember, “form follows function” and keep the data easy to understand and easy to act on.

Tie Business Unit Metrics To Individual Performance

Business unit KPIs should be cascaded down to individual employees and be reflected in their individual goals. Transparency and follow-through are the keys to success here (see Aligning Staff Compensation To Value). Transparency is key to getting staff buy-in—so make sure each employee knows how metrics are established, how individual goals are derived from organizational goals, and exactly how their performance will be measured. While alignment of individual goals to KPIs is imperative if the organization has performance-based compensation plans in place, it is a best practice to motivate and engage employees even if such plans are not yet in play.

Leaders must continuously work with their teams to assess performance and provide direction and support in improving that performance. “Connecting the dots” between each team member’s role and organizational strategic objectives is a leadership imperative.

Clarify The Process For Review & Remedial Action

So you’ve got the data, the dashboards are set up and the numbers and reports are flowing in. But what if performance targets are not being met? It would be helpful to define a process up front for what actions need to be taken—and by whom and over what period of time—to understand the reasons for under-performance or non-performance and put remedial measures in place.

There could be any number of reasons why KPIs are not being achieved—and any number of solutions. It may be that individual employees need help to improve productivity and quality, or that workflows and processes need to be streamlined, or that costs need to be managed more tightly, or that marketing needs to be more targeted…And if the identified solutions are applied and the results still don’t improve, the executive team and managers should have a candid, data-informed discussion about whether KPIs need to be adjusted and scaled up in a phased manner. While stretch goals are important, goal-setting and achievement can be an iterative process.

Ultimately, organizations that have the best data—and the best insights based on that data—are those that are able to achieve strategic objectives while leveraging the needed degree of flexibility in getting from here to there. As we enter the next normal, demonstrating success with strategy implementation, and having the data to back it up, will be key for long-term sustainability and for future updates to the strategic plan.

CMS Proposes Expansion Of Home Health Value-Based Purchasing Program

On June 28, 2021, the Centers for Medicare & Medicaid Services (CMS) proposed to expand the nine-state Home Health Value-Based Purchasing (HHVBP) Model to all Medicare-certified home health agencies (HHAs) in the 50 States, territories, and District of Columbia beginning January 1, 2022. The proposal would shift home health Medicare reimbursement from fee-for-service (FFS) (a set payment amount decided by CMS) to a value-based system relying on quality metrics and savings generated.

The CMS Innovation Center (CMMI) implemented the HHVBP Model on January 1, 2016, based on the authority of Section 1115A of the Social Security Act. Like other value-based payment systems, the HHVBP model tested whether payment incentives can significantly change health care providers’ behavior to improve quality of care, through payment adjustments based on quality performance during a given model performance year. The HHVBP Model’s current participants are in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington.

This proposed rule would expand the HHVBP to all 50 U.S. States, U.S. territories, and the District of Columbia. CMS would use 2022 as the first performance year and 2024 as the first payment year, which means the home health groups would be paid based on their performance in 2022. CMS is also proposing that the maximum payment adjustment, upward or downward, would be 5% in the nationwide expansion of HHVBP. The proposal is lower than the current 7% maximum adjustment currently used in the nine-state program, but it is higher than the 3% maximum when the program was first started in 2018.

Since put into action, HHVBP has resulted in an average 4.6% improvement in home health agencies’ quality scores as well as average annual savings of $141 million to Medicare according to CMS. The overall financial impact of the HHVBP Model for 2022 through 2026 is an estimated $3.154 billion in total savings to home health in the Medicare fee-for-service (FFS) payment system. The savings are mainly from a reduction in unnecessary hospitalizations and use of skilled nursing facilities (SNF), which allowed quality of care improvements for the home health industry.

CMS is currently taking comments from all interested stakeholders on the proposed expansion of HHVBP. The final rule is expected in November this year and will go into effect on January 1, 2022.

A link to the full text of “CMS Final Rule Relating To Medicare & Medicaid Home Health Payment & HHVBP” may be found at https://openminds.com/market-intelligence/resources/070721cmsrulemedicaremedicaid/.

This topic was last reported in “Medicare Home Health Value-Based Purchasing Reduces Costs Without Adverse Effects On Access To Care,” which published on January 27, 2021. The article is available at https://openminds.com/market-intelligence/news/during-first-three-years-medicare-home-health-value-based-purchasing-model-reduced-unplanned-hospitalization-snf-stays-without-adverse-effects-on-access-to-care/.

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

Massachusetts Releases 1115 Waiver Extension Proposal With Changes To Ambulatory Behavioral Health System

On July 15, 2021, the Massachusetts Medicaid program, MassHealth, released details on its proposed MassHealth 1115 Demonstration waiver extension request with changes to the state’s ambulatory behavioral health system, based on outcomes from its delivery system restructuring for 2019. The state intends to release the proposal for a 30-day public comment period in September 2021, submit the waiver to the Centers for Medicare & Medicaid Services (CMS) in November 2021, and anticipates that the waiver extension would go into effect on July 1, 2022. New accountable care organization (ACO) contracts under the extended 1115 demonstration waiver will likely begin in January 2023, if the proposed extension is approved.

Ambulatory behavioral health treatment is defined as behavioral health treatment in an outpatient setting which may include counseling, specialized individual/group or family psychotherapy, and/or evaluation/assessment for medication and medication monitoring. Ambulatory care sensitive conditions are health conditions where appropriate ambulatory care prevents or reduces the need for hospital admission. Outpatient treatment occurs at community behavioral health centers (CBHCs) with access to real-time urgent care and evidence-based, integrated mental health and addiction treatment for all ages. Additional inpatient psychiatric beds are also being planned for acute and 24-hour treatment, to address co-occurring needs and better meet consumer needs. There are five goals for the 1115 demonstration waiver extension:

  1. Continue the path of restructuring and re-affirm accountable, value-based care – increasing expectations for how ACOs improve care and trend management, and refining the model.
  2. Reform and invest in primary care, behavioral health and pediatric care that expands access and moves the delivery system away from siloed, fee-for-service health care.
  3. Advance health equity, with a focus on initiatives addressing health-related social needs and specific disparities, including maternal health and health care for justice-involved individuals.
  4. Streamline the MassHealth delivery system for members and providers by standardizing behavioral health networks and pharmacy formularies, and by simplifying and streamlining care coordination.
  5. Sustainably support the Commonwealth’s safety net and maintain near-universal coverage – including level, predictable funding for safety net providers, with a continued linkage to accountable care, and updates to eligibility policies to support coverage and equity.

The 1115 demonstration waiver extension was developed with the help of more than 100 stakeholders that met throughout 2020 and 2021. These stakeholders include consumer advocates, health care providers (such as community health centers, hospitals, and behavioral health providers, LTSS providers, and community organizations). MassHealth will continue engaging stakeholders throughout the summer and fall of 2021 before submitting the waiver extension request to CMS, including a formal public comment period on the draft proposal.

A link to the full text of “MassHealth 1115 Demonstration: Strategy For 2022 Extension” may be found at https://openminds.com/market-intelligence/resources/071521masshealthstrat1115extension/.

A link to the full text of “MassHealth Delivery System Restructuring: 2019 Update Report” may be found at https://openminds.com/market-intelligence/resources/071421masshealthrestructuringrpt/.

OPEN MINDS last reported on this topic in “Massachusetts Medicaid Planning New Reimbursement Models For Community Behavioral Health,” which published on July 13, 2021. The article is available at https://openminds.com/market-intelligence/news/massachusetts-medicaid-seeks-comment-on-community-behavioral-health-center-payment-models/.

For more information, contact: Health Innovations, Massachusetts Department of Health and Human Services, One Ashburton Place, 11th Floor, Boston, Massachusetts 02108; Email: MassHealth.Innovations@Mass.gov; Website: http://www.mass.gov/eohhs/

Four ‘Must Have’ Competencies For Post-Pandemic Competitive Advantage

By Monica E. Oss

We’ve covered the “triple whammy” of the pandemic on next normal health care—shifting competition based on changing consumer expectations, payer expectations, and price points (see Post-Pandemic, Strategy Needs Technology). I got a better sense of the market factors driving these changes—and the new competencies required for success—in a recent article, How Digital Is Changing The Pharma & Healthcare Industry, by Nikki Gilliland at Econsultancy. My takeaway is that there are four new competencies that executive teams should be thinking about to stay in the game as the effects of the pandemic digital shift become standard market factors.

To start with, the “must have” hybrid service model requires digital first consumer intake processes. For care coordination programs to be successful—and cost-effective—remote monitoring capabilities will likely be a “must have.” Another takeaway—to improve consumer engagement, social communities need to be built on and integrated into existing commercial internet platforms. And finally, without a robust web presence and expertise in search engine optimization, competing for referrals will be increasingly difficult. These are the next frontiers in organizational infrastructure for competitive advantage—and I’m adding them to my specialty provider organization competency map (see From Crisis To Growth: A New Leadership Mindset).

Digital first consumer intake/interface is critical to success with hybrid models. The pandemic has moved much of care delivery to virtual. But as we move to the post-pandemic landscape, the preferred service delivery modality is a combination of virtual and in-person care in clinics and in consumers’ homes. Recent research confirms this preference—in a national survey, more than 40% of consumers said that when it comes to mental health and routine care, they’d rather access services virtually or through a combination of virtual and in-person visits (see Post-Pandemic, Majority Of Patients Say They Prefer In-Person Care, Survey Finds). And a Healthgrades study found that when given a choice between health care providers with similar experience, proximity, availability, and patient satisfaction ratings, the vast majority of consumers—81% for primary care and 77% for specialists—choose the provider who offers online scheduling (see Specialty Care Strategy For A Tech-Enabled Future).

To make hybrid services an operational reality at scale, provider organization executive teams should develop a digital first consumer intake process with a well-designed “digital front door.” This intake process should include real-time appointment scheduling that is linked to both benefits eligibility information and the schedules of clinical team members. Many components of the digital front door, including online scheduling, can likely be built into existing EHR systems but standalone technology platforms are also available and can be integrated with current technology platforms.

Best practice care coordination will require leveraging personalized remote monitoring. Care coordination and case management services are slowly moving to risk-based and value-based reimbursement models—with reimbursement tied to outcomes. To be competitive in this market space, provider organization managers will likely need to deploy a coordinated suite of tech-enabled functionality. What does that look like? Decision support tools for care coordinators, driven by consumer data. Smartphone-based outreach to consumers for active monitoring, self-care supports, and engagement. Passive remote monitoring tools for staying on top of consumer health status over time. Market advantage will go to the organizations that can reduce costs by leveraging their clinical workforce with technology, while managing and optimizing performance and consumer outcomes.

Consumer engagement success will depend on strategies to build specialized social communities on existing platforms. Consumer engagement and participation in managing their health is key to making value-based reimbursement work. The question for clinical management teams is how to connect with those consumers. There are many standalone consumer web portals, discussion boards, blogs, and more. But getting traction with those standalone initiatives is difficult. Rather, consumers are likely to discuss issues and seek health care information, opinions, and suggestions from channels they are already active on. Provider organizations should consider facilitating social networks on existing platforms for their consumers and encouraging staff to weigh in on these online communities to share expertise when appropriate.

Social media platforms like Facebook, Twitter, Instagram, and YouTube (and to a lesser extent, LinkedIn), as well as messaging apps like What’s App and WeChat (in China) host consumer and caregiver groups with interest in specific conditions and treatments. Some of the newer apps for behavior-based chronic disease management also include a social component to let consumers engage with peers. But most consumer and professional engagement communities are web-based—they can be found through simple online searches and accessed with a web browser, while they also maintain a presence on all the major social media platforms. A Pew Research survey indicated that 26% of adult internet users had read or watched someone else’s health experience about health or medical issues in the past 12 months. And 16% of adult internet users in the U.S. go online to find others who share the same health concerns (see The Social Life Of Health Information).

There are a number of existing online communities. For example, MedHelp has communities for mental health, general health, diabetes, heart disease, pregnancy, and coronavirus. PsychU offers information, resources, and collaboration and discussion platforms on challenges and treatment approaches for mental health professionals. Verywell Mind offers consumer-friendly information, generated by clinical professionals, on a range of mental health topics. And, HealthUnlocked offers technology to build health communities and is available free to nonprofits, health advocates, and consumer organizations to start new communities.

Web presence and SEO expertise are needed to compete for customer eyeballs. As care becomes increasingly virtual, referrals will become increasingly virtual. Today, 13% to 17% of visits across all of health care are conducted via telehealth—which is 38 times higher than pre-pandemic use of virtual care (see Telehealth: A Quarter-Trillion-Dollar Post-COVID-19 Reality?). Prior to the pandemic, 67% of consumers searched for health care information online and 60% searched for provider reviews online (see Digital Health Consumer Adoption Report 2020). The pandemic has likely increased this consumer behavior and will also likely change the nature of professional referrals.

As executive teams consider whether their current website and web presence is an impediment to success or an asset, there are some basic questions to ask. Is the website content, user experience, search engine performance, and online reputation strategy meeting current consumer and referral source expectations? (For more, see our on-demand OPEN MINDS Circle Executive Roundtable Session, Designing Best In Class Websites: The OPEN MINDS Website Evaluation & Improvement Process.) The answers will drive strategies for enhancing the online brand presence, upgrading web site design and content, evaluating paid web advertising options to be “found” in web searches, and linking content to social platforms in order to increase reach to consumers and health plan partners.

The bottom line? To meet the preferences of consumers  and health plans—and succeed with new reimbursement rates and models—executive teams need to make a few additions to their “core competencies.” This will involve broader planning of infrastructure, both technology and human. The key question is not “What technology should we invest in?” but rather to define how technology can help to drive strategic objectives.

For more on the organizational competencies needed for strategic success, check out these resources:

Going Hybrid? Charge Your EVV

By Monica E. Oss

If your organization is one of many that is thinking about moving to a hybrid service delivery model—virtual, in-clinic and in-home—your team will need to learn more about electronic visit verification (EVV). EVV was mandated for all home-based services by the 21st Century Cures Act, passed in 2016. The act required all state Medicaid programs to start using EVV for personal care services (PCS) by January 1, 2020 and for home health care services (HHCS) by January 1, 2023. EVV is essentially electronic verification that in-home service encounters actually occur and documents the type of service performed, the individuals providing and receiving the service, the date and location of the service, and the time the service begins and ends.

For PCS, many states applied to the Centers for Medicare and Medicaid (CMS) for “good faith exemptions” and received an extension until January 1, 2021. States are in different stages of implementation and some already require EVV for HHCS as well (see What Are The EVV Compliance Rules In Your State?) States that don’t implement EVV will have to take a cut in their annual federal medical assistance percentage (FMAP) starting at 0.25 percentage points and gradually increasing to one percentage point (see States Must Use Electronic Visit Verification By January 1, 2020 For Medicaid Personal Care Services).

EVV is required for all Medicaid covered in-home visits for personal care and health care services including nursing; home health aide services; and medical supplies, equipment, and appliances that are delivered via an in-home visit under the state’s home health benefit. States also may choose to require EVV for in-home physical therapy, occupational therapy, speech pathology, audiology, and other services (see Frequently Asked Questions: Section 12006 Of The 21st Century Cures Act). CMS does not require EVV in some instances—when the caregiver and consumer live together, for congregate facilities offering 24-hour services, or for Programs of All-inclusive Care for the Elderly (PACE)—although individual states may mandate otherwise.

While EVV does not specifically track consumers and staff, it does require multiple check-ins by staff at specified times with location identification—through a smartphone app with GPS tracking, the use of a landline phone in the consumer’s home, or signing into a device in the consumer’s home. For provider organizations required to comply with EVV mandates, the level of investment depends on the model chosen by their state. States have five options—an open model where provider organizations use their own EVV systems; EVV systems mandated by health plans; a single statewide vendor to be used by all provider organizations; build and manage a state-owned EVV system; or allow provider organizations to opt to use the state system or their own EVV system compatible with the state’s data aggregator (see EVV Systems Section 1: Requirements, Implementation, Considerations, & State Survey Results).

While the intent of EVV is to avoid fraud and ensure that consumers get the services they are supposed to get, there is widespread concern by consumers and advocacy groups on the practical challenges and alleged threats. For example, caregivers in Arkansas have complained about glitches in the state-mandated EVV app that have resulted in missed service entries and delayed paychecks. The Arkansas compliance requirements also have been criticized for placing undue burden on on live-in caregivers and on self-directed consumers who hire their caregivers directly and manage their own services. And some stakeholders do not like the sense of “constant surveillance.” Consumers complained that having an EVV system was comparable to having a wireless dog fence or ankle monitor (see ‘We Don’t Deserve This’: New App Places US Caregivers Under Digital Surveillance).

Other concerns have been expressed about the EVV impact on consumers—the Arc describes it as a “civil rights issue because of the concern around unintended consequences of impeding upon an individual’s privacy rights.” EVV systems that have video and audio recording functionalities and geotracking are not acceptable (see Call For Electronic Visit Verification Delay Grows Strong Nationwide). The National Council on Independent Living decried EVV for being “based on the archaic and offensive idea that disabled people and seniors are unable to leave their homes.” They criticized EVV for requiring multiple check-ins a day from the same location, for geotracking, and for imposing additional burdens on states (see NCIL Position Opposing Electronic Visit Verification).

What are the implications of EVV for specialty health and human service provider organizations offering home-based services? There are a few big issues to contend with—adopting new technology, creating new service delivery workflows, revising policies and procedures, training staff, and educating consumers and obtaining their input. OPEN MINDS Senior Associate Jason Lippman said, “EVV plays into a lot of digital trends we are seeing all around us—requirements for more data and more accountability. And the systems that work as intended can provide more data for planning and management of resources. The key is designing systems to collect that data that are least intrusive for both consumers and staff, creating efficiencies, and mitigating for unintended consequences and privacy issues.”

Like the EHR requirements of the past decades, the requirements for documentation of services delivered in home-based settings are likely not going to go away. And, it is likely that the EVV requirements will prove to be another factor—like value-based care, interoperability requirements, and hybrid service delivery models and ecosystems—that put larger organizations with better technology planning competencies at an advantage. Mr. Lippman pointed out, “As we gear up for 2023 and wait for the HHCS provisions around EVV to kick in, provider organizations should not put off being prepared—now is the time to start looking into what the state is currently doing with PCS, and to initiate the infrastructural and operational changes that will be required to accommodate digital tracking of remote services.”

For more on EVV preparation and management, check out these resources in The OPEN MINDS Circle Library: