40% & Counting

By Monica E Oss, Chief Executive Officer

The proportion of U.S. health care reimbursement dollars paid in advanced value-based reimbursement (VBR) models—contracts with shared savings, downside financial risk, and/or population-based payments—just passed 40%. The slow adoption of VBR with financial gain sharing and downside risk sharing—along with the unique challenges to specialty provider organizations in participating in these arrangements—may cause executive teams to think there isn’t much movement. But this development is glacial—slow but changing the landscape along the way.

In addition to the national snapshot of reimbursement patterns, the recent survey by the Health Care Payment Learning & Action Network (see APM Measurement Methodology And Results Report  and The 2020 LAN APM Measurement Effort), also reported that the reimbursement model that health plan executive think will grow the most in the next year were arrangements with both shared savings and downside financial risk. This includes reimbursement with fee-for-service-based shared-risk and procedure-based bundled/episode payments

This trend is reflected in some current market developments. In a recent earnings report, Wyatt Decker, M.D., CEO of Optum Health, said that the company had exceeded their projections for value-based reimbursement. Optum Health has raised its projects of consumers in VBR arrangements from 500,000 new consumers to 600,000 (see Optum Health Has Raised Its Expectations For Value-Based Care Participation. Here’s Why). The increase was attributed to changes in provider reimbursement for dual special needs consumers with high acuity who need care across the continuum and wrap-around services in the home.

In other news, the federal Department of Health and Human Services (HHS) proposed testing models that use value-based payments in Medicare Part B to link payment with a medication’s clinical value (see HHS Proposes Testing Value-Based Payments For Medicare Part B Drugs). This plan also includes testing total-cost-of-care models to assess whether the models result in changes to drug utilization, reductions in total spending, and improvements in beneficiary health outcomes. And in January the Colorado Department of Health Care Policy & Financing (HCPF) launched its first two value-based contracts for the Colorado Medicaid pharmacy program—two Medicaid value-based contracts with drug manufacturer Novartis (see Colorado Medicaid Implements Two Pharmacy Value-Based Contracts With Novartis). Both contracts hold Novartis financially accountable for meeting the clinical outcomes demonstrated in clinical trials.

And in February, the U.S. Centers for Medicare and Medicaid Services (CMS) announced it will increase performance measurements and the use of value-based reimbursement for nursing homes (see CMS Planning New Staffing Requirements & Value-Based Reimbursement Plans For Nursing Homes). This will include an effort to reduce unnecessary medications, staffing, and the inappropriate use of antipsychotic medications, and strengthen the skilled nursing facility (SNF) value-based purchasing (VBP) program with incentive funding to facilities based on quality performance.

Among specialty provider organizations, 45% are participating in some form of VBR. But only 9% have more than 20% of revenue coming from VBR contracts (see The OPEN MINDS 2022 Survey On Value-Based Reimbursement In Specialty And Primary Care).

From our recent discussions with health plan executives, the challenge for specialty provider organizations in participating in robust VBR arrangements is attribution of consumer care coordination and financial management responsibilities. (For more on this, see my articles on the presentations by Dr. Indira Paharia, Chief Operating Officer, Behavioral Health, Centene Corporation, Eric Bailly, LPC, LADC Business Solutions Director, Behavioral Health Clinical Strategy, Anthem, Inc. at The 2022 OPEN MINDS Performance Management Institute—Collaborative Care At Scale – More Important Than Ever and The Choppy Road To Better Value.) My takeaway is that specialty provider organizations have two possible approaches for moving ‘upstream’ in risk arrangements with health plans—specialty service programs or health home/medical homes with primary care.

The question for executive teams of specialty and primary care provider organizations is how to navigate this change in the market and maintain (and grow) revenue. For an answer to that question, I recently spoke with my colleague and OPEN MINDS Senior Associate, Paul Duck. His observation—executive teams need to think less about volume and more about value. “They need to understand the ‘value’ of their services to consumers and payers—and develop models to get paid for that value.”

“Most provider organization executive teams have not adequately prepared their infrastructure for arrangements with downside financial risk—their data systems, their clinical delivery systems, and their culture,” explained Mr. Duck. “While many professionals service consumers with behavioral and cognitive disorders have traditionally had a mindset that therapies are more of an art form than science, the science has grown over the past decade and payers want to reimburse on this emerging new science and the performance it will bring.”

“Executive teams need to retool for the four major market shifts that are top-of-mind for payers—“integrated” care coordination models, ‘hybrid’ service delivery models, and a push for lower costs and value with financial alignment with risk sharing reimbursement.”

To test how prepared your organization is for reimbursement arrangements with risk sharing, check out the got an error message when trying to link to this on PRC OPEN MINDS Value-Based Reimbursement Readiness Assessment. And for more on the changing health and human service reimbursement landscape, check out these resources in The OPEN MINDS Circle Library:

And for even more, join us on June 16 at The 2022 OPEN MINDS Strategy & Innovation Institute for the session, Metrics Matter – Utilizing Quality Measures & Key Outcomes As Performance Drivers, featuring Isamu Pant, Director of Business Intelligence, Aurora Mental Health Center; Dominick DiSalvo, Corporate Director of Clinical Services, KidsPeace; and Tammy Pearson, Senior Associate Director, Marshall Center of Excellence for Recovery, Marshall University.

VBR Marches On – A Trend Driving 2022 Strategy

By Monica E. Oss, Chief Executive Officer

We started the year with the release of new reports on the continued movement away from fee-for-service reimbursement to alternate, value-based reimbursement (VBR) models. Over half of health systems are planning to move to “payvider” market positioning in 2022 (see Nearly 60% Of Health Systems Aim To Become ‘Payviders’ In 2022). These ‘payvider plans’ include many arrangements – provider-sponsored health plans; direct contracting with health plans; joint ventures with health plans; and risk-based contracting. In addition, a new survey found 56% of health plans and pharmacy benefit managers (PBMs) report using outcome-based, non-fee-for-service provider reimbursement. However, when it comes to mental health reimbursement, only 22% reported having outcomes-based contract (OBC) (see 56% Of Payers Had Outcomes-Based Provider Reimbursement In Place As Of September 2021).

This disparity between the use of VBR for reimbursement for behavioral health services and other areas of health care is not new. Our survey, The 2021 OPEN MINDS Performance Management Executive Survey: Where Are We On The Road To Value, reported 53% of specialty provider organizations serving consumers with chronic and complex conditions are participating in VBR, compared to 74% of primary care organizations. And, 12% of specialty provider organizations reported 20% or more of their revenue was tied to VBR, compared to 32% of primary care organizations.

There are several reasons for this disparity. Many specialty provider organization executives report difficulties securing VBR contracts. Health plan executives express concerns about balancing choice and access with value-based contracts for behavioral health. In addition, when it comes to behavioral health reimbursement, health plans have issues with linking behavioral health provider compensation to total cost of care in systems with capitation of primary care services; with data sharing and systems interoperability; and with making necessary system changes.

Executive teams of specialty provider organizations need to get ahead of this curve and develop a strategy to “fit” in established value-based relationships. That will involve understanding the dominant health plans in their market areas – and how they prefer to contract for delivering services to consumers living with behavioral health and cognitive conditions. With that market information, executive teams can decide if new partnerships, a merger, or an investment in a different service delivery and management capacity is the best strategy.

Many executive teams are skeptical of participating in the new alternative payment methodologies because the options are limited. Fee-for-service rates for undifferentiated services have been flat for a number of years (on the decline, on an inflation-adjusted basis). To maintain margins, executive teams need to build a plan for creating “value-added services” that get above-market reimbursement. Or, the other options for margins is VBR.

In 2021, there were some great perspectives on future health plan strategy from our keynote speakers at our institutes and summits. To watch any of those presentations, check out:

For the VBR year in review, check out these 2021 resources in the OPEN MINDS Industry Library:

And for even more, join OPEN MINDS on February 10 for The 2022 OPEN MINDS Performance Management Institute, where OPEN MINDS Chief Marketing Officer, Timothy Snyder and OPEN MINDS Senior Associate, Casey Zanetti, will present the executive seminar Maximizing Revenue, Aligning Internal Growth Strategy & Succeeding In Value-Based Care.

Who Should Do What? Scope of Practice; Treatment Tech Shift Clinical Best Practices

By Monica E. Oss, Chief Executive Officer

There has been a long debate about the scope of health care practices. What type of licensed clinical professionals can perform particular functions? Should psychologists and/or pharmacists prescribe psychotropic medications? What supervision do nurse practitioners and physician assistants need? (Should ‘physician assistants’ be renamed ‘physician associates’?)

Psychologists can prescribe in five states: Louisiana, New Mexico, Illinois, Iowa, and Idaho (see Can Psychologists Prescribe Medications?). The scope of pharmacists’ practices is state-dependent and varies widely from state-to-state (see Mapping U.S. Statewide Protocols For Pharmacist Prescriptive Authority). Pharmacists may or may not give injections and immunizations and prescribe everything from naloxone, tobacco cession aids, travel medications, and more. Physician Assistants are licensed to practice in all 50 states, the District of Columbia, all US territories, and the uniformed services. Physician Assistants are authorized to prescribe medications in all jurisdictions where they are licensed, except Puerto Rico (see PA Prescribing and Assessing Scope of Practice in Health Care Delivery: Critical Questions in Assuring Public Access and Safety).

Executives of health and human service organizations need to plan to leverage the ‘value’ of their clinical team members by developing systems where they can work at the ‘top of their practice’—with most of their time going to the services that require their specific level of training. But that is easy to say and much harder to accomplish in practice. This type of service specialization is an essential part of the specialization needed to achieve maximum operational efficiency—and the highest value.

But there are two factors that complicate plans for specialization to increase value. The first is that in systems that are increasingly rewarded for a ‘whole person’ approach to care—which runs contrary to specialization. The second is that health care treatment technologies are reaching a level of sophistication that they can be a replacement for some of the work of licensed clinical professionals. The key for executive teams is using technology to address both of these issues. The first is ‘virtual integration’—creating a singular consumer data set that is available to all health care professionals. The second is to use data—both small data and big data—to develop algorithms that curate the recommendation of treatment services for specific consumers—both treatment technology and the most appropriate clinical professional. These are essentials to sustainability—building organizational efficiencies that result in competitive advantage.

For more on our coverage of efficiency and effectiveness in staffing models—and in emerging treatment technology, check out these resources in the OPEN MINDS Industry Library.

Scope of Practice Issues

Digital Treatment Trends & Strategy

Digital Treatment Developments

For more on managing and practicing at the top of your team’s skillsets, join me for The 2022 OPEN MIND Management Best Practices Institute in Newport Beach, California from August 30 to September 1, 2022.

The Opportunities & Challenges Of VBR – Making It Work On The Ground

By Monica E. Oss, Chief Executive Officer

Despite significant movement, behavioral health is trailing the rest of health care domains in value-based reimbursement contracting. Forty-five percent of specialty provider organizations have some value-based reimbursement (VBR)—compared to 72% of primary care organizations (for more, see, The OPEN MINDS 2022 Survey On Value-Based Reimbursement In Specialty And Primary Care). And at the health plan level, 22% of plans report having some form of VBR for mental health services in 2021, compared to 79% in the cardiovascular services and 54% in respiratory services (see 56% Of Payers Had Outcomes-Based Provider Reimbursement In Place As Of September 2021).

This gap is due to a combination of factors. Some are due to the structure of financing and reimbursement in health plans. (For more on key opportunities for specialty provider organization value-based contracting, see Treatment Transformation Ahead and The Sustainability Challenge – Capitalizing On Emerging Market Opportunities In Behavioral Health.) Others are due to issues as diverse as consumer choice and provider organization readiness.

How can executives of provider organizations and health plans work together to make this happen in the behavioral health space? Getting to the answer for that question was central to the recent 2022 OPEN MINDS Health Plan Partnership Summit session, “Looking For Quality Outcomes? It Starts With Innovative Value-Based Contracting,” delivered by Monica Collins, senior director, system transformation, Magellan Behavioral Health of Pennsylvania, and Charlotte Chew, vice president, outpatient operations, Pyramid Healthcare.

In January of 2018, the Pennsylvania Medicaid program implemented new requirements for the value-based purchasing (VBP) initiative for the behavioral health HealthChoices program. The state’s goal was to have an increasing percentage of total medical expenses paid through VBP over a three year period (for more, see Pennsylvania Medicaid Moving To Value-Based Reimbursement For Behavioral Health and Pennsylvania Medicaid Managed Care Contracts). Pennsylvania’s value-based strategies requirements fall along a continuum. There are fee-for-service payments linked to performance (low risk), supplemental payments attached to shared savings and risk (medium risk), bundled payment arrangements (medium risk), and global payments based on quality measures (high risk). Eventually, 30% of total medical cost must be in VBR arrangements by year five (originally set for 2022). Pennsylvania originally set staggered targets, beginning with 5% in year one, and increasing to 10% each year.

While the pandemic has slowed the implementation timeframe, Ms. Chew and Ms. Collins discussed the planned value-based relationship between Magellan and Pyramid Healthcare—and the steps required to make it work. In the model, there are limited shared savings models based on spending targets that encourage coordination of behavioral health care. The model also requires addressing social determinants of health (SDOH) issues.

But challenges to getting this up and running are substantial. There are multiple provider organizations among consumers and across episodes of care, which makes it harder to coordinate care. There also exists a lack of medication assisted treatment (MAT) services available and resources for follow up care. The speakers offered two pieces of advice—develop a collaborative model to solve problems and engage at a ‘grassroots’ level to assure success.

Work together to solve hurdles. Operationalizing value-based models has a number of hurdles to overcome—including attribution, managing care transitions, and having the right staff in place. Much of the time well spent involves connecting consumers through various points of care transitions from inpatient to outpatient community models. It’s also difficult to define what ‘value’ is and what drives outcomes—from reduced emergency room visits, medication adherence, better nutrition, less comorbidities, etc. To maximize effectiveness, the whole care delivery system needs to work together to attribute consumer outcomes back to the providers that serve them (see Specialty Primary Care As A Growth Strategy). Magellan and Pyramid Healthcare recommend having weekly touchpoints to examine data, discuss successes and opportunities, and share information among teams to clinically shape what happens next.

Get to the grassroots level. For both payer and provider organization management teams, this requires a cultural shift, centered around the consumer experience, utilizing peers, and making sure all the right information gets to provider organizations (see Nimble Applies To Information Too). Ms. Chew explained how “much of the work has to happen at a local level in different pockets or pilots, balancing expectations and taking the best parts of certain programs and models and adapting and integrating them into others.” One strategy that Pyramid Healthcare introduced is an alumni program, where consumer peers can continue to be involved and integrated into the community, with certified training, job placement assistance, and linkages to wellness programs.

Specialty provider organization executive teams need to renew their focus on getting in ‘first-position’ with health plans by creating opportunities for financial alignment—and for increasing revenues through achieving superior outcomes. In a health care landscape where fee-for-service reimbursement is not keeping pace with inflation (even before this year of hyper-inflation), this shift is a key to sustainability.

For an assessment of organizational preparedness for value-based reimbursement, take the OPEN MINDS Value-Based Reimbursement Readiness Assessment. For more information on value-based reimbursement strategies and partnerships, checkout these resources in the OPEN MINDS Industry Library:

And for more discussion on value-based payment and strategies, join me for the following executive seminars at The 2022 OPEN MINDS Management and Best Practices Institute in Newport Beach, California on August 30: How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating & Contracting With Health Plans.

Technology Strategy For Sustainability—EHRs Are Just The Start

This closing keynote presentation took place October 27, 2021 during The 2021 OPEN MINDS Technology & Analytics Institute. OPEN MINDS Chief Executive Officer Monica E. Oss gave an up-to-the-minute look at the critical changes in the landscape for serving complex consumers – and what they mean for organizational sustainability post-pandemic.

This session covered:

  • The context for selecting technology in an ever changing and shifting field
  • Critical organizational competencies your organization must have for efficiency and sustainability
  • A framework for data-driven strategy and technology assessment
  • This closing keynote presentation took place October 27, 2021 during The 2021 OPEN MINDS Technology & Analytics Institute. OPEN MINDS Chief Executive Officer Monica E. Oss gave an up-to-the-minute look at the critical changes in the landscape for serving complex consumers – and what they mean for organizational sustainability post-pandemic.

    This session covered:

    • The context for selecting technology in an ever changing and shifting field
    • Critical organizational competencies your organization must have for efficiency and sustainability
    • A framework for data-driven strategy and technology assessment

Making Tech Work

By Monica E. Oss, Chief Executive Officer

Tech investment in health care is big. Eighty percent of health care provider organization executive teams are looking to make additional investments in technology in the next five years (see Future Of Healthcare Report: Exploring Healthcare Stakeholders’ Expectations For The Next Chapter). As a result, the health care tech market is expected to grow from $326.1 billion in 2021 to $821.1 billion by 2026 (see Healthcare IT Market by Products & Services, Components, End-User, and Region).

Currently, tech investments by specialty provider organizations have focused on EHRs (88%) and telehealth platforms (85%). About half of specialty provider organizations have invested in referral tracking systems, health information exchange technology, fundraising tools, ePrescribing tools, and clinical decision support systems (see The Computer Is A Moron and The 2021 OPEN MINDS Health & Human Services Technology Survey). But the changing landscape is changing the tech functionality that specialty and primary care provider organizations need to maintain competitive advantage and sustainability. According to The OPEN MINDS 2021 National Behavioral Health Electronic Health Record Survey, 56% of these provider organization executive teams report having tech functionality gaps—and 21% stated an intention to procure a new EHR (see The Times Have Changed. So Have Our EHR Concerns.). Our team at OPEN MINDS thinks this focus will be on integrated analytics, technologies supporting hybrid care delivery (scheduling, mobile, visit verification, etc.), consumer engagement, and managing alternate reimbursement contracts.

But with more technology come problems of implementation and optimization. First, there are privacy and security issues. About a third of behavioral health provider organizations were cited by Accreditation Commission for Health Care (ACHC) for having incomplete, substandard policies related to protection of patient data (see One-Third Of Behavioral Health Organizations Have Incomplete Policies For Health Information Protection). The ACHC also cited 26% of these organizations for missing documentation, 20% for missing information on staff background checks, and 20% for missing information on staff Hepatitis B vaccination. And the on-line apps in the behavioral health field are not doing much better (see Does Mental Health Privacy Really Matter To Consumers?).

Another issue—adoption of data-driven decision making. A recent survey found that 74% of health care provider organizations use clinical decision support technology—but in limited ways. The key uses of clinical decision support are medication orders (30%), lab orders (24%), and medical imaging orders (20%) (see The Process Matters). And, only 16% of community mental health center executives have adopted measurement-based care (MBC) technology (see 16% Of Community Mental Health Centers Use Measurement-Based Care, Despite Knowledge Of Value).

For more, I reached out to my colleague and OPEN MINDS Senior Associate Joe Naughton-Travers to get an understanding of why, when technology is so critical to the future competitive advantage of provider organizations, are there so many challenges in both adoption and implementation. “I think the biggest issue for health and human services is that organizations usually don’t have a technology strategy and roadmap,” Mr. Naughton-Travers said. “Some organizations are still struggling to get the basic data systems in place (EHR, human resources information systems, and general ledger systems) and others are still a long way off from achieving analytic and performance optimization. In terms of poor management practices, the problem is usually the lack of formal project planning and project management in both selecting and implementing technologies.”

How to plot a path to tech success? He had three recommendations—systematically identify technology gaps, adopt a deliberate adoption roadmap, and make sure you have the right staff to get the job done.

Systematically identify technology gaps—Provider organization executive teams should conduct a regular needs assessment to ascertain what functions they are lacking, and what tech can fulfill that need. This needs assessment should be concurrent with implementation planning for a strategic plan. Answering three critical questions should drive the process: what competency do you need, who on your team will be using the tool, and how will that technology adoption create and drive value for the consumer, the payer, and the care continuum?

Develop a deliberate tech adoption roadmap—Once an executive team has determined the technologies needed to achieve both strategic and business objectives, a timeline for selecting and implementing new tech tools is the next step. Managers need to look beyond “the basics” and identify the technology requirements needed to support strategic plan objectives.

Invest in the right staff—New technology brings new competency requirements among executives and managers. Success requires upgrading the skills of existing team members and/or finding new team members with the competencies to implement, manage, and optimize the new tools. Technology is no longer an afterthought—the entire executive team needs to be involved with ongoing technology planning and optimization.

Mr. Naughton-Travers concluded, “When technology implementations fail to achieve their goals, it’s a “double whammy”—you have spent a bunch of money and the problem you needed to solve still exists. Far too many organizations make this exact, costly mistake.”

For more on technology adoption and implementation, check out these resources in The OPEN MINDS Circle Library:

And for more on getting your “tech game” where it needs to be, mark your calendar for June 14-16 and The 2022 OPEN MINDS Strategy & Innovation Institute in New Orleans, Louisiana. Be sure to check out the session, Technology For Innovation: How Do You Know What You Need?, featuring Julie Sjordal, Chief Executive Officer at St. David’s Center for Child & Family Development, along with OPEN MINDS Senior Associates, Carol Clayton, Ph.D. and Sharon Hicks.

Tech For Success: How To Assess Current Tech Functionality Readiness For Future Growth

By Joe Naughton-Travers, Ed.M.

With my work at OPEN MINDS, I’m often asked by my specialty health care provider organization clients which type of technology is the most important. My answer is always the same: it’s not about the individual technology itself, it’s about how all of the technology platforms come together and “play nice” to manage and optimize overall clinical and financial performance. Without the integration across all platforms, each are merely working in silos without the ability to use each platform’s data as decision-making guides for the organization.

In response, I’ve worked with our team of senior advisors to develop a technology platform framework for specialty provider organizations to aid in planning technology needed for the future. This framework has six domains:

#1 Electronic Health Record & Billing System — The functionality of a comprehensive electronic health record (EHR) software application.

#2 Human Resource Information System & Financial/General Ledger System — These are the two other key software applications for administrative operations. The Human Resource Information System (HRIS) is the software that maintains, manages, and processes detailed employee information and human resources-related policies and procedures. The Financial/General Ledger System is the software that tracks all financial transactions and is used to generate a company’s financial statements.

#3 Hybrid & Community Based Service Delivery Platform — Technology tools that support virtual and community-based service delivery.

#4 Consumer Experience & Engagement Platform — Technologies for enhancing consumer engagement in the health care experience and optimizing consumers’ experience with the system of care.

#5 Value-Based / Risk-Based Reimbursement Platform — Technology capabilities that support measuring value in terms of customer experience and engagement and of the cost and quality of services.

#6 Integrated Analytics & Service Performance Optimization — Software applications for aggregating and analyzing the data from all the other software systems and databases to manage and optimize clinical and financial performance.

Domain #1: A Whole Person Care Record: Comprehensive EHR Software

The first requirement is a comprehensive EHR software application for all the consumers your organization serves, and all the service lines delivered. The EHR must record the demographic and clinical data for consumers, the services they receive, and the corresponding clinical documentation. Additionally, the EHR must:

  • Document all referrals and referral dispositions
  • Support tracking performance and clinical quality metrics
  • Include standard functionality for medical services (e.g., e-prescribing, laboratory orders, and electronic medication administration records)
  • Provide support for the delivery of routine primary care services

Mobile access to the EHR (both on- and off-line) is a must, and clinical decision support for medical necessity, clinical appropriateness for care, evidence-based practices, and payer-mandated clinical pathways is highly desirable. The EHR should be interoperable with the EHRs of other provider organizations to facilitate care coordination. Lastly, the software must handle all of your organization’s billing and accounts receivable operations (including fee-for-service, bundled, case rate, and VBR payment models) and have tools for maximizing revenue collection.

That covers the technical details—the functionality of a good electronic health record. The essential questions to ask about any EHR system are:

  • Does the EHR help you manage whole person care for the consumers you serve?
  • Does it have functionality to monitor physical and behavioral health as well as social determinants of health (SDoH)?
  • Does it aid in care coordination with other provider organizations to achieve the best health outcomes?

If your EHR software application is not addressing these key service management functions, it is time to consider a change.

Domain #2: Managing Administrative Functions: Human Resource & Financial Management Software

The second domain helps provider organizations ensure that key administrative operations—human resources and finance—have the right software applications to meet your organization’s needs. The HRIS (human resource information system) must do more than track employees, salaries, and benefits. The HRIS also should include functionality for job applicant tracking and position control, time and attendance tracking, employee self-service capabilities, and a learning management system. A final requirement is comprehensive support for employee appraisals and development plans.

The financial management software (sometimes called the general ledger or accounting system) should have all the basic capabilities: budgeting, financial reporting, payroll, accounts payable, and fixed asset management. To support VBR contracts, the financial management software also needs to have the capability to aid in the management of the cost-of-service delivery—overall—and for individual health plan contracts. (It will need access to the service delivery data in the EHR to do this.) Lastly, this software application should have functionality for monitoring and managing health plan contracts and other payer contracts.

Domain #3: Delivering Care Conveniently: Hybrid & Community-Based Service Delivery Capabilities

This domain is more than just the telehealth services that your organization has become proficient at delivering during the COVID-19 pandemic. It includes other technologies that support and enhance your community- and home-based care delivery. Telehealth capabilities must be integrated into the EHR itself and should also be available on mobile devices so that community-based staff can bring in additional staff virtually when needed. Electronic visit verification (EVV) is needed to report that staff were physically present at consumer service delivery sites during community-based care. Smart home and remote health monitoring technologies can be used to ensure the health and safety of consumers. Secure communication between staff and consumers should be available in multiple formats (text, email, telephone, and video). Ideally, you would also have technologies that aid in route optimization for staff travel in the community as well as tools for managing these field and remote-based staff.

Domain #4: A Focus On Customer Service: Consumer Experience & Engagement Tools

Technology in this fourth domain is new to many specialty provider organizations. Consumer experience is the subjective response consumers have with any contact with your organization. Questions you might consider when evaluating for consumer experience include:

  • Are your services convenient and easy to access?
  • Are communication and other interactions smooth and painless?
  • Is there a personal touch to service delivery and an impression of quality?

Consumer engagement is when individuals take action to become more informed and more proactively involved in his or her health and the health care services received. There are numerous technology tools to help with both consumer experience and engagement, including:

  • 24/7 centralized access to care
  • An easy to navigate website with the ability to access care and schedule appointments
  • A consumer portal for communication, bill payment, and health record access
  • Web- and app-based self-directed consumer health and well-being technologies
  • Enhanced social media presence
  • Net promoter scoring integrated into all aspects of care delivery
  • Appointment and health check-in reminders via telephone, text, and email

As provider organizations expand their focus on consumer experience and engagement, a key focus is to determine which technology tools they may already have to support these efforts and which they will need to acquire and implement.

Domain #5: Managing Care & Costs:  A Value-Based Reimbursement Platform

The fifth domain of the technology platform framework is technology tools for managing service performance and cost. Provider organizations should assume that most, if not all, of their health plan contracts in the future will be value-based, with both upsides and downsides in terms of payment models. You’ll need technologies that monitor clinical quality metrics in comparison to contract requirements. Will these be in your EHR? In other software applications? In analytic dashboards?

You’ll also need to monitor other contract performance metrics. Examples include metrics to monitor access to care, treatment engagement, telephone and referral response time, and other industry standard metrics such as Healthcare Effectiveness Data and Information Set (HEDIS) and Certified Community Behavioral Health Clinic (CCHBC) requirements. You may also be required to track and monitor SDOH and adherence to evidence-based practices.

Other key questions you’ll want to consider about managing care and cost include:

  • What other technologies can better facilitate your ability to manage care and cost?
  • Can you accomplish this with your EHR and financial management software alone?
  • Do you need to invest in a better telephone system and website?
  • Should you implement separate technology tools for quality and performance tracking that your EHR cannot handle?

This leads to Domain #6—does your organization need business intelligence and data analytic technologies to aggregate, analyze, and present the data in a meaningful way to your staff?

Putting It All Together With Domain #6:  Analytics & Optimization

The last domain uses technology for aggregating your data in a meaningful way to proactively manage your organization. This is accomplished by utilizing business intelligence (BI) or other data analytic software applications that aggregate data for analysis and performance optimization. This is the ‘holy grail’ of performance measurement and optimization, having meaningful data to report your organization’s financial strength and operational performance and to monitor progress towards strategic objectives.

Most commonly, provider organizations begin with using these technology tools to manage and optimize clinical quality and performance metrics through reporting. The next step is to implement the use of dashboards for the board of directors, the executive team, department managers and individual staff. The most sophisticated use of BI software applications for specialty provider health care organizations is for population-health management. Here, BI software applications are used to provide the analytics to improve the health of the overall population of consumers served, to enhance consumer experience, and to reduce costs through consumer segmentation and analytics.

Where To Start In Building A “Next Generation” Technology Platform

The question is how to proceed with planning for and implementing the technology functionality needed to support future growth plans. There is a two-step process—addressing both immediate functionality needs for success in the current market and assessing the technology needed to support your strategic plan.

For the first, addressing immediate functionality needs, we have created a short assessment of ‘must have’ current tech functionality—The OPEN MINDS’ Technology Requirements Checklist – Eighteen Must-Have Capabilities For Specialty Provider Organization Success. To see how your organization stacks up in this preliminary list, go through the checklist.

OPEN MINDS’ Technology Requirements Checklist – Eighteen Must-Have Capabilities For Specialty Provider Organization Success   Yes   No   Working
    On It
#1 Electronic Health Record & Billing System
Does your EHR handle all your health record documentation and billing requirements?
Does your EHR have the capability to share data with other provider organizations (interoperability)?
Does your EHR have mobile access (both on-line and off-line)?
#2 Human Resource Information System & Financial/General Ledger System
Does your HRIS include functionality for job applicant tracking, position control, and employee self-service?
Is your Financial/General Ledger System chart of accounts set-up so that you can report the unit cost and case costs of all the services you deliver?
Does your Financial/General Ledger System include contract management functionality?
#3 Hybrid & Community Based Service Delivery Platform
Do you have secure telehealth technologies in operation?
Do you have electronic visit verification (EVV) in operation?
Do you have technologies in place to monitor or report consumers’ health status (e.g. blood pressure, body mass index, lab levels, etc.)?
#4 Consumer Experience & Engagement Platform
Do you have centralized scheduling or other tools that make it easy for consumers, their families, and referral sources to access care at your organization?
Can consumers communicate securely with their care providers through a web portal, text, or other technologies?
Have you implemented net promoter scores, or a similar measure, to routinely measure consumer experience?
#5 Value-Based / Risk-Based Reimbursement Platform
Does your team have a system for reporting payer-centric and consumer-centric performance metrics?
Do you have technologies in place to report timely access to care and hospitalization readmission performance metrics?
Do you have a system to report other value-based and risk-based reimbursement contract performance measures such as follow-up after hospitalization, emergency room utilization, and use of evidence-based care protocols?
#6 Integrated Analytics & Service Performance Optimization
Do you have software technologies in place that can aggregate data from your EHR, HRIS, and Financial/General Ledger System to report on key strategy metrics?
Do executives and managers have access to real-time dashboards for key performance and operational metrics?
Does your staff know how to interpret and use the data that is available to them for performance management (data literacy)?

This checklist provides an assessment of basic technology-enabled management capabilities. Where there are gaps in these management capabilities, management teams should develop a plan to meet these functionality basics. If there are functionality deficiencies in Domain #1 and #2 (the EHR, HRIS, and GL systems) these should be an area of immediate focus.

Beyond these basic areas of tech-enabled management capabilities, executive teams need to also crosswalk their strategic plans with the tech requirements to support those strategic initiatives. For more on that process, see From Strategic Plan To Tech Strategy: Building Your Crosswalk.

Looking ahead, every executive team member—and not just the CIO or CTO—need to focus on the coming digital transformation of the health and human service field—and the strategy and technology needed to succeed.

Metrics-Based Management: Using Analytics For Strategy Implementation & Business Optimization

By Joe Naughton-Travers, Ed.M.

If you have great staff and great infrastructure, your organization still needs a strong management team—and management practices—to make sure that organizational plans to deliver great performance becomes reality. To do this, management teams need well-designed, real-time performance metrics. In successful organizations, metrics-based management happens in two contexts: managing strategy implementation and optimizing business operations. The key is to ensure you have the right data and the right analytical tools to report these performance metrics.

Managing Strategy Implementation

The use of metrics in implementing a strategic plan is considered a core element of strategic management built around key performance indicators (KPIs). Simply put, KPI’s are the ‘metrics’ that measures progress towards your strategic objectives, as well as whether your organization has achieved them. Some metrics are a direct measures of success. For example, if a strategic objective is to operate at a 10% positive financial margin, then the KPI for this objective is the margin, which is reported at least monthly. In other instances, you may choose process or proxy metrics that measure progress made in various initiatives to accomplish a particular strategic objective.

There are four important steps to selecting these KPIs and managing strategy implementation:

Step #1: Start with your strategic plan.  It should have a short list of quantifiable strategic objectives, initiatives for accomplishing them, timelines, assignments, and budgets.

Step #2: Select metrics for success. These are your key performance indicators (KPIs) calculated from obtainable data that indicate organizational performance in progressing toward and accomplishing strategic objectives. An effective KPI is specific, measurable, and actionable. Use a ‘balanced scorecard’ framework that includes metrics that report financial performance, customer performance, organizational innovation, and effective internal operations.

Step #3: Create a KPI reporting system. Ideally, this is from a business intelligence (BI) or data analytics software application that includes management dashboards to report the metrics, showing a comparison to the performance trend from past to present. Minimally, the KPIs are reported monthly with the trend data as well as against performance targets. This reporting system and its use communicates the importance of the organization’s strategic objectives and the executive team’s focus on them. As Peter Drucker said, “You can’t improve what you don’t measure.”

Step #4:  Coach your staff to use the KPIs. Engage in ongoing monitoring and proactive management using the KPIs with your executive team and staff. Modify the KPI metrics if needed to ensure progress in implementing your organizational strategy.

Much has been written about the development of KPIs and models for selecting both leading and lagging financial and non-financial indicators of performance. The challenge, beyond selecting the measures, is two-fold: developing the ability to routinely report the measures using data from existing software systems or databases (or expanding current information systems to collect the data) and analyzing the KPIs monthly to develop or update organizational strategies to improve performance.

Optimizing Business Operations

Metrics-based management also plays a key role in optimizing business operations for specialty provider organizations. What exactly is business process optimization? It is the management discipline that promotes efficiency and effectiveness of organizational process—employing methods, policies, management practices, software tools, and metrics to optimize an organization’s activities across the business process life cycle.

Optimizing business operations is critical for provider organizations. All aspects of service delivery (referral, admission, routine services, and discharge or transfer) and administrative operations need to run smoothly. Processes should be standardized to be effective and consumer and staff friendly. Data and analytics are critical tools for doing this.

Organizations that have superior process management performance share a few key competencies—corporate strategy that is connected to performance indicators as described above, process and project management expertise, deliberately designed process models that promote service quality, access to information, support of management for process improvement initiatives, and incentive-focused employee compensation.

It sounds simple. But if business process management is so simple, why do so many organizations have bad performance from bad processes? Author Janne Ohtonen, in an article titled, “Enabling strategic growth and improved performance through Business Process Management,” offered some interesting insights. His list of the ten key capabilities needed to be successful with business process management and optimization include:

  1. Co-workers have confidence and trust in each other
  2. There is open communication between employees and managers
  3. Managers share vision and information with employees
  4. The organization is able to respond to changes in markets quickly
  5. Senior management has confidence and trust in managers
  6. There are efficient communication channels for transferring information
  7. The organization has appointed people responsible for processes
  8. The organization extensively uses information systems
  9. No one has to worry about losing his or her job because of process changes
  10. Managers support changes in processes

How does your organization stack up in terms of using data and analytics to drive strategy and to optimize operations? Your team can’t perform or manage without the metrics to support both of these. In fact, I would argue that, beyond strategy, metrics and metrics-based management competency are the most fundamental ingredients for organizational success for providers in today’s market. Why?

I’ve seen executive teams of organizations with all sorts of other competencies—but with no access to timely performance metrics or the ability to use them—fail to optimize performance. Without real-time performance metrics for your management team:

  • Identification of performance issues is often delayed
  • Organizational performance relative to competitors is more a matter of opinion than a measured achievement
  • The identification of performance problems requires constant observation—and is often anecdotal
  • The “causes” of poor performance are harder to identify (and often the subject of disputes between team members)
  • It is difficult to sort out persistent performance problems and separate “trends” from short-term issues
  • It is challenging to prioritize operational improvement initiatives and investments

I could go on…

If current performance data is not the focus of your management team meetings, it will be more difficult for your team to respond to evolving consumer and payer demands, a rapidly changing health care market, or emerging competitive threats. I liken it to flying blind; the airline pilot without the dashboard.

Key elements of an organization with metric-based, performance-driven culture:

  1. Visible metrics—both customer-centric and organizational—and the data and analytical tools for reporting them routinely
  2. Actionable insights based on rich data and identification of the actions needed to improve performance
  3. Clear team member accountability for specific performance metrics
  4. Real-time performance feedback at all levels of the organization
  5. Targeted coaching based on performance data with individualized goals to improve team member performance
  6. Recognition of great performance
  7. An interactive strategy and budgeting process
  8. Nimble and data-driven service line reengineering and development

So, collect the data and teach staff how to use metrics and analytics to improve your business operations and achieve your strategic objectives. Metrics-based management is one of those “must develop” competencies for health and human service organizations. Organizational performance—including financial, service, quality, compliance, etc.—matters more to the sustainability and success of organizations every passing year.

The Four Pillars of Strategic Technology Success

By Monica Oss

Many organizations are focused on technology—specifically, which technologies they need, how to best select and implement them, and ultimately, how to ensure that technology investments “pay off” for the organization. My take is that most executive teams know they need to incorporate some of the many emerging technologies into their organization’s operations. The rationale is simple—keeping the competitive advantage and assuring organizational success and sustainability in a rapidly evolving health care market.

But the question is, which technology platforms are needed and how to integrate those technologies into organizational operations? OPEN MINDS has identified what we refer to as the “four pillars of strategic technology success” that management teams need to consider in getting the leverage they need from technology investments.

#1 Technology In Sync With Strategy And Future Needs. It doesn’t matter which technology platforms your organization adopts if the technology doesn’t align with your strategic goals. The question is, how do you decide which technology tools are the best fit for your organization’s future strategies for sustainability and success? The process starts with strategic planning and a clear understanding of your organization’s future market positioning and service lines. A common mistake in strategy is to think about technology as an “addition” to current service delivery models rather than conceptualizing the next generation of technology-enabled services and operations that are possible. How can technology be leveraged to aid in achieving each of your organization’s strategic objectives? What technology is needed to ensure that your organization has its ‘next big thing’ in terms of services and operations for the future? It is in this phase of the strategic planning process that questions about your business model and technology investments need to be addressed.

#2 The Right Technology And The Right Vendor. Once you’ve made the decision about the technology you need, selecting that specific technology from a specific vendor should be a very straightforward process. Unfortunately, it is easy to make the wrong choices. When selecting the technology product itself, it’s essential that you ensure that it actually does what you are looking for! Identify critical functional needs and make sure you’ve seen them demonstrated and confirm with other customers that it really works.

Another key issue is to remember that you’re not only selecting a technology product—you’re selecting a new business partner, the vendor organization. Make certain you know that the company is stable and provides good implementation and support services.

#3 Best Practice Implementation

In our experience, when technology implementations fail, the blame with both the management team and the vendor. Oftentimes, provider organizations are good at delivering services but bad at technology implementation. Budget your technology investments to ensure success—with the right project management tools and staff, and the development and use of effective training materials.

The other variables in successful technology implementation are about ownership. Management teams must assume responsibility for the technology planning and implementation—owning their functional requirements, their workflow processes and staff buy-in, and the successful integration of the technologies into operations.

#4 On-Going “Operational” Management Of Technology

Developing the strategy, selecting the technology and vendor, and implementing the technology successfully are all complex tasks, and the on-going management of all of your technology solutions is also challenging. This is where the “rubber hits the road,” so to speak, in getting the strategic leverage from technology investments. Does your organization have the right structure, operations, and staff competencies to manage and optimize the technologies you’ve implemented? Do you have technology leadership in place to oversee current technology operations and to think strategically about technology decisions?

When technology implementations fail to achieve their goals, there is plenty of blame to go around—the wrong product, an ineffective vendor partner, mangled implementation, and poor operations. I have seen far too many organizations do just this. For CEOs, when any of these factors are “out of sync”—bad vendor selection, bad technology, bad contracts, and implementation delays (or failures)—the results are costly.

Quite simply, executive teams need to assume responsibility for getting technology right—or they will end up assuming responsibility for its failure.

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/