Qualifacts + Credible Named 2022 Best In Klas: Software & Services

GETTYSBURG, Pa. (February 20, 2022) — Qualifacts + Credible, a leading provider of electronic health record (EHR) platforms for behavioral health and human services organizations, today announced the Credible platform has ranked No. 1 in the 2022 Best in KLAS: Software and Services report.

Additionally, Qualifacts + Credible’s CareLogic EHR platform is ranked No. 2 in the 2022 Best in KLAS: Software and Services report.

The Best in KLAS report recognizes software and services companies who excel in helping healthcare professionals improve patient care. All rankings are a direct result of the feedback of thousands of providers over the last year. A Best in KLAS award signifies to the healthcare IT industry the commitment and partnership that the top vendors should provide.

“We are honored by the trust our partners place in us every day, and their success is our highest priority. This recognition from KLAS is a great validation of the remarkable work our teams have done in support of our mission to be an innovative and trusted technology and solutions partner, said Paul Ricci, chief executive officer at Qualifacts + Credible.

“Each year, thousands of healthcare professionals across the globe take the time to share their voice with KLAS. They know that sharing their perspective helps vendors to improve and helps their peers make better decisions. These conversations are a constant reminder to me of how necessary accurate, honest, and impartial reporting is in the healthcare industry. The Best in KLAS report and the awards it contains set the standard of excellence for software and services firms. Vendors who win the title of Best in KLAS should celebrate and remember that providers now accept only the best from their products and services. The Best in KLAS award serves as a signal to provider and payer organizations that they should expect excellence from the winning vendors,” said KLAS CEO Adam Gale.

About Qualifacts + Credible   
Qualifacts + Credible is one of the largest behavioral health and human services EHR vendors in the country. Its mission is to partner with customers to support and extend their ability to deliver quality care and improve the lives of the clients they serve. With more than 20 years of experience its products and services help customers achieve interoperability goals, optimize efficiency, improve productivity, and maximize reimbursement. The company offers several EHRs – CareLogic, Credible and InSync – while collaborating to build an even brighter future for partner agencies and their clients.

About KLAS
KLAS has been providing accurate, honest, and impartial insights for the healthcare IT (HIT) industry since 1996. The KLAS mission is to improve the world’s healthcare by amplifying the voice of providers and payers. The scope of our research is constantly expanding to best-fit market needs as technology becomes increasingly sophisticated. KLAS finds the hard-to-get HIT data by building strong relationships with our payer and provider friends in the industry. Learn more at klasresearch.com.

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: Kathleen.Dougherty@state.de.us; Website: https://www.dhss.delaware.gov/dhss/dmma/

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: jill.fredel@state.de.us; Website: https://dhss.delaware.gov/

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).

Qualifacts + Credible Acquires InSync Healthcare Solutions

GETTYSBURG, Pa. (January 9, 2022) – Qualifacts + Credible, a leading provider of electronic health record platforms for behavioral health and human services organizations, today announced it has acquired InSync Healthcare Solutions.

InSync Healthcare Solutions is a leading provider of EHR and practice management software plus revenue cycle management services for behavioral, medical and rehabilitative professionals.

Qualifacts + Credible is adding InSync’s highly configurable, clean and intuitive platform to their portfolio of EHR solutions.

“The acquisition allows the combined organization to deliver innovation, technology, customer support, and complementary solutions to a broader behavioral health and human services market,” said Paul Ricci, chief executive officer of Qualifacts + Credible. ”It also better positions us for long-term growth by expanding our ability to serve small to medium-sized practices and agencies.”

Demand for behavioral health is on the rise, according to data from the Kaiser Family Foundation. As of January 2021, approximately four in 10 U.S. adults reported symptoms of anxiety or depression compared to one in 10 from January–June of 2019.

About 40% of behavioral providers work in smaller behavioral health organizations with fewer than 50 full time employees.

The company will continue to support all three platforms, with CareLogic and the Credible platforms remaining primarily focused on enterprise accounts.

InSync’s flexible and easy to use solutions for small to medium-sized practices and agencies will be enhanced by Qualifacts + Credible’s innovation and advanced technology capabilities.

“We’re excited to be part of an organization that is also focused on providing technology that empowers behavioral health providers to deliver the best care,” said Roland Therriault, executive vice president and general manager of InSync Healthcare Solutions.

Qualifacts + Credible currently has over 900 customers across 43 states making it one of the largest behavioral health EHR vendors in the country. The addition of InSync doubles the size of the organization’s customer count and it will serve over 10 million patients in all 50 states.

ABOUT QUALIFACTS + CREDIBLE    

Qualifacts + Credible is one of the largest behavioral health and human services EHR vendors in the country. Its mission is to partner with customers to support and extend their ability to deliver quality care and improve the lives of the clients they serve. With more than 20 years of experience and two of the highest rated platforms, its products and services help customers achieve interoperability goals, optimize efficiency, improve productivity, and maximize reimbursement.

ABOUT WARBURG PINCUS 
Qualifacts + Credible is a portfolio company of private equity firm Warburg Pincus LLC.

This leading global growth investor has more than $67 billion in private equity assets under management. The firm’s active portfolio of more than 215 companies is highly diversified by stage, sector, and geography. Warburg Pincus is an experienced partner to management teams seeking to build durable companies with sustainable value.

ABOUT INSYNC HEALTHCARE SOLUTIONS    
InSync Healthcare Solutions is a leading provider of EHR and practice management software plus revenue cycle management services for behavioral, medical and rehabilitative professionals. InSync leverages advanced technology, best-in-class partnerships and proven business processes to provide services and solutions that translate into better efficiency for healthcare organizations.

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 https://www.pwc.com/us/en/industries/health-industries/library/health-services-deals-insights.html (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: ryan.a.cangialosi@pwc.com; Website: https://www.pwc.com/

Think Of Your EHR & Vendor As A Technical Consultant Rather Than Software

It’s common knowledge that it’s less expensive for organizations to retain employees than to hire new ones. According to recent data, it costs as much as 33% of a worker’s annual salary to replace them. When applied to a median employee salary of $45,000, the average cost of turnover comes out to about $15,000 (see Avoidable Turnover Costing Employers Big). The same principle holds true for other areas of your business, but no where is this more evident to behavioral health providers than in their relationship with an electronic health record (EHR) and the companies that make them.

We’re bombarded with stories about EHRs evolving to become more flexible and use more services, such as artificial intelligence, but what do your peers report firsthand? We recently concluded the sixth annual OPEN MINDS National Behavioral Health EHR Survey and found that 53% of provider organizations report their EHR does not have all the functionalities they need. Only 19% report their clinical, scheduling, billing, and reporting and analytics functionalities as meeting their needs. These Core 4 functionalities are crucial to service delivery and organizational sustainability (see Providers Growingly Concerned About EHR Functionalities & The Technologies Needs For Future Service Delivery & Reimbursement: Top EHR Trends From The 2021 OPEN MINDS National Behavioral Health EHR Survey.

Research shows the cause of this dissatisfaction stems from the EHR’s initial implementation within an organization (see Selecting The Right EHR Partner: An EHR Return-On-Investment Analysis). According to a recent white paper, there are two main reasons that an EHR fails to live up to expectations. The first issue is an incomplete EHR implementation. This is when, for one reason or another, the organization has been unable to successfully implement all the components of a system that would move to a completely paperless health record. The second issue is an ineffective EHR implementation. With this problem, all of the components have been activated, but the staff is struggling to use these tools as they were intended.

Both scenarios are exceptionally frustrating for staff who have often been working on the implementation for months, or even years. The immediate response might be to start over fresh with a new vendor, but, like replacing employees, it can be much more expensive to start over with a new EHR rather than working with your EHR vendor to get the one you have to meet your needs. Here are some tips to consider if you’re debating whether to fix or replace your EHR.

  1. Create a technology workgroup. Technology workgroups come in all shapes and sizes and provide numerous benefits to any organization that uses an EHR (see The Benefits Of Technology Workgroups On Program Quality: An EHR Best Practices Community Interview With Bob Puckett). Implementations go awry for a variety of reasons, including lack of organization or staff accountability, and inability to prioritize implementation tasks to move the implementation forward. An effective technology workgroup can help ensure a streamlined EHR implementation and on-going functioning. Some organizations find it best to choose workgroup members based on skillsets and not solely by job title, as is the case with many other organizations. It is imperative for executive teams to keep this work group operational even after the EHR implantation. They may not need to meet as often, but these individuals will be the eyes and ears of the project on the front lines of your organization.
  2. Make a list of your issues. Task your technology workgroup with conducting brief focus groups with your top users to find out what features of your EHR are working as planned and which are not. If staff have created workarounds outside your EHR instead of using what is offered, find out how and why. Is it because the solution built in doesn’t work? Is it too clunky? Hard to use? Buy in from your power users on which necessary improvements are most important will help the project succeed.
  3. Understand future needs from your payers and funders. The reporting requirements for receiving timely payments and grant funding are constantly shifting. As you look at enhancing your system, talk to some of your payer and funding partners to find out what they will need from you in the not-to-distant future. This helps ensure that the changes you make today will remain relevant in the future (see Data-Driven Care: Using Population Health & High-Utilizer Data).
  4. Connect with other clients of your EHR vendor. Most vendors hold user’s group meetings where providers using a specific technology can talk to other users and staff to solve common problems. Before the pandemic these groups often met in person, but many have shifted to an online-only format due to COVID-19. If you’re not already participating, ask your vendor how to get involved. Often, you’ll find that other real-world users of a technology can provide additional insight from the front lines that you can’t get specifically from your sales representative(s). It also helps to sign up for any mailing lists or websites where users can ask and answer common questions.
  5. Talk to your current vendor. Before putting out any requests for proposals or shopping for a new EHR, contact your current vendor and discuss your problems. It’s highly likely that your vendor has seen this situation with another client and may have solutions that would be easier and less expensive than starting over from scratch. If you don’t currently have a productive relationship with your vendor representative, request someone new and/or rethink your main liaison within your organization. Some of the problems may boil down to personality differences between the staff implementing the project and the vendors assigned to your project.

Lay it on the line – explain that you are unhappy and that certain conditions must be met for you to continue with this vendor. Even if your contract doesn’t renew for another few years, you may have a clause in your contract for non-performance. The key is to document everything so that you’ll have the receipts should a break-up become inevitable.

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 https://www.careinnovationinstitute.com/episodes-summaries/ (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:

Providers Growingly Concerned About EHR Functionalities & The Technologies Needs For Future Service Delivery & Reimbursement: Top EHR Trends From The 2021 OPEN MINDS National Behavioral Health EHR Survey

Originally presented on October 19, 2021.

We’re bombarded with stories about electronic health records (EHR) evolving to become more flexible and use more services like blockchain, cryptocurrencies, and artificial intelligence, but what do your peers report firsthand? We recently concluded the sixth annual OPEN MINDS National Behavioral Health EHR Survey and found that 53% of provider organizations report their EHR does not have all the functionalities they need. Only 19% report their clinical, scheduling, billing, and reporting and analytics functionalities as meeting their needs. These Core 4 functionalities are crucial to service delivery and organizational sustainability.

In this webinar, OPEN MINDS Senior Associate, Joe Naughton-Travers, shared the results of the 2021 OPEN MINDS National Behavioral Health EHR Survey and discussed what organizations can do to plan for the next advances in health care technology and service delivery. Mr. Travers also discussed the growing concern among providers and what functionalities to be looking at for future service delivery and timely reimbursements.

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Top EHR Trends In 2021: Results Of The Annual Behavioral Health EHR Survey

We’re bombarded with stories about electronic health records (EHR) evolving to become more flexible and use more services like blockchain, cryptocurrencies, and artificial intelligence, but what do your peers report firsthand? We recently concluded the sixth annual National Behavioral Health EHR Survey and found that only 19% of provider organizations report their clinical, scheduling, billing, and reporting and analytics functionalities as meeting their needs. These Core 4 functionalities are crucial to service delivery and organizational sustainability.

Join OPEN MINDS Senior Associate, Joe Naughton-Travers, for a free webinar on October 19 at 1:00pm ET to hear the results of the 2021 National Behavioral Health EHR Survey and what your organization can do to plan for the next advances in health care technology and service delivery. Mr. Travers will also discuss the differing needs of small and large provider organizations when it comes to EHRs for service delivery and timely reimbursements. Join us to learn:

  • Results of the 2021 National Behavioral Health EHR Survey
  • How small and large provider organizations differ in their EHR needs
  • Best practices for finding an EHR that is the right fit for your organization