Data-Driven Care: Using Population Health & High-Utilizer Data

Mental health providers and the organizations they support have more information at their fingertips than ever before. This information, largely known as population health data, allows provider organizations to examine the overall health of the populations they serve, and to observe any trends among their consumers, particularly those who use services frequently. Officially, population health data is defined as information related to the health outcomes of specific groups of people, communities, or ethnic groups (See Technology & Reporting Requirements For Population Health Management: Preparing For Value-Based Reimbursement).

With the advent of electronic health records (EHR), it is now easy for provider organizations of any size to run reports to glean basic information about their practice using common identifiers such as billing codes, medical diagnoses, medications prescribed, time to referral, and next scheduled appointments. Previously, this information was likely only found on paper and rarely stored in one place – much less stored in a way you could run a report to use the information.


“We were so excited just to have the advanced search feature,” said Bob Puckett, Director of Business Operations for Families, Inc. Counseling Services on their switch to a new EHR in 2010. Headquartered in Jonesboro, Arkansas, Families Inc. has 11 locations in northern Arkansas and has been providing mental health services to children, adolescents, and adults since 2000.  “Then we moved to the custom ad hoc feature [in our EHR] where we could actually do a little bit more and thought, ‘Wow. This is awesome.’ And then we moved into business intelligence, and the system keeps taking it up a notch.”

For many providers, the challenge now is not collecting the data, but figuring out what specific data to look at and how to make business sense of all the information collected. In Puckett’s case, they started with an initial focus on compliance and a few key dates (referral date, treatment planning date, and medical evaluation date), narrowing in on about 10 key data points.

“[Our EHR] has all these report functions, but how, as an organization, do I look at that?” Puckett said. Families Inc. staff reached out to analysts with Qualifacts + Credible, their EHR provider, who helped them focus on 10 key indicators, out of more than a 100, to get started. “There’s just so much more [information] than you ever thought you could imagine. How do you narrow it down to what’s important and what’s not?”

Their initial focus on compliance reports gave Families, Inc. a starting point to use with their clinicians and therapists without overwhelming them with stacks of data. Over time, they talked with their providers for feedback on what else could make the report more useful. They found small ways to tweak the formatting, such as replacing a separate column with an icon so that the report was more interesting visually than just a wall of numbers or words. The team also found that using abbreviations for certain data points and pop-up messages helped keep their reports interesting and useful, but not overwhelming.

Families, Inc. was also lucky to have the guidance of an on-staff clinician with a talent in HTML who was able to dig deeper into their health record system and make customizations to benefit the providers and consumers. This staff member was able to help Puckett and his colleagues look at all the information collected and find ways to make it more user friendly. “There are still rows and columns and trying to dig through 60 rows of data trying to find a date that expired [was exhausting]”, said Puckett. To improve the experience, they experimented with highlighting dates in red to show they had expired and yellow to indicate they were going to expire in the next 30 days.       


Using these general data points can help providers learn a lot about the people they serve. For example, Anthem used claims data from the 27 million people they serve to create a report on the state of the nation’s mental health (See State of the Nation’s Mental Health). In their analysis, they discovered that more adult Anthem members were diagnosed and treated for anxiety and post-traumatic stress disorder (PTSD) in 2020 compared to 2019. They also found that use of medications to treat depression among this population rose in 2020 (See Anthem Review Of 2020 Claims Data Finds Decline In Mental Health Treatment Rates).


While Anthem has huge patient numbers to analyze, EHR data makes it possible for smaller organizations with fewer patients to look at their patient population, identify trends, and share their results with others—including publishing in medical journals and organizational newsletters. Researchers at the Mayo Clinic in Rochester, Minnesota used their EHR data to identify current e-cigarette users to targets for smoking cessation programs – ultimately identifying 1,000 current e-cigarette users out of their almost 600,000 consumers (See Improved Documentation of Electronic Cigarette Use in an Electronic Health Record). The researchers also identified the needed to adjust their EHR forms to be more specific about tobacco use and include all types of tobacco, including e-cigarettes. Previously, this information was only recorded as “tobacco use” without specifying between cigarettes, cigars, pipes, or e-cigarettes.

“These documentation efforts are not consistent across clinical practices, nor systematically tracked by the health system,” the researchers said. “Reliable population health data could bolster research efforts to generate evidence addressing gaps in our understanding of trends in e-cigarette use by consumers and their overall impact on health.” The researchers add this additional information is critical as many providers had no idea of their consumers’ e-cigarette use and how it may be impacting other areas of a consumer’s health.


OPEN MINDS Senior Associate, Carol Clayton, Ph.D. recommends acquiring an electronic health record as the first, and most important, step to tracking population health data (See Data-Driven Decision-Making For The Post Pandemic Market). For providers who have an EHR, the first step should be examining what fields are already digitized within the EHR, and can be easily sorted (such as numbers, words, or billing codes) — avoiding information that has to be opened and read, such as .pdf copies of consumer records.  


“As provider organizations plan for sustainability in the ‘next normal,’ having a data-informed strategy is more important than ever before,” said Monica E. Oss, CEO of OPEN MINDS (See Data, Data Everywhere But Little Action). “Data is critical for two reasons—to demonstrate clinical outcomes and adopt population health approaches that payers are looking for under value-based models, and to grow market share and revenue.”

21st Century Cures Act Paves The Way For Telehealth To Bloom During Pandemic

When we look back at health care during the coronavirus disease 2019 (COVID-19) pandemic, many people will remember that time as when medicine finally embraced telehealth. Indeed, during the first four months of the pandemic, telehealth visits accounted for nearly 24% of all medical interactions compared to just .3% in 2019.

However, the groundwork for this swift change to telehealth actually started in 2016 when the 21st Century Cures Act was enacted. This act received bipartisan support when it was passed, gaining a lot of attention for its big-ticket items such as allocating $6.3 billion in federal support for electronic health records (EHRs), precision medicine, mental health supports, substance use disorder treatments, Alzheimer’s disease research, and the cancer “moonshot” initiative. A less well-known part of the legislation was the requirement for the Centers for Medicare and Medicaid Services (CMS) and the Medicare Payment Advisory Commission (MedPAC) to report to Congress on the current and future uses of telehealth for Medicare beneficiaries.

Telehealth is most easily explained as coming in three different formats:

  1. Synchronous. This means that the interaction between the patient and the provider is happening in real-time, whether the patient is contacting the provider over the phone, over a web portal from home, or from an internet station at a provider’s office. Normally, the provider would take the appointment from his or her office. However, during the pandemic, this has been loosened as many providers were working from home to reduce exposure of COVID-19.
  2. Asynchronous. Asynchronous is the opposite of synchronous where providers and patients share information that is not reviewed together. With this method, a patient may ask a question via a web portal and expect an answer back within a certain timeframe. A patient might take a picture of a rash for a provider to review the images and suggest treatments.
  3. Remote Patient Monitoring (RPM). RPM is a mix of the two other formats whereby data from a patient at home is regularly transmitted to a provider for monitoring. For example, patients can collect and record their own blood glucose levels to be sent to a provider who reviews for medication compliance and other issues. Similarly, there are many simple cardiac measures that can be recorded at home and relayed to a provider who can examine the cumulative results to look for patterns or problems. Many smartphones and smartwatches now come equipped with monitoring technology that make it easy to record and share this type of data.

All three methods have been employed creatively during the pandemic to ensure that patients continued to receive care even when access to doctor’s offices and hospitals were restricted. Pre-pandemic, providers were often paid less for telehealth services than in person visits. However, many of those rules were relaxed during the public health emergency to make it easier for individuals to find and pay for much needed mental health care.

So far, CMS has indicated that many of the telehealth expansions allowed during COVID will be made permanent. There were 144 telehealth services temporarily covered by Medicare in 2020 during the height of the emergency, nine of which—such as group psychotherapy, some home visits for an established patient and care planning services—will be covered permanently.

One of the biggest barriers to telehealth adoption in medicine overall has been concerns from policymakers that telehealth will lead to higher utilization and costs in all of medicine. According to the National Committee on Quality Assurance’s Taskforce on Telehealth Policy (TTP), a rare positive impact of the pandemic has been all the telehealth claims data generated over the past year. This will allow analysts with the Congressional Budget Office (CBO), the Office of Management and Budget (OMB), and the CMS Actuary to begin to scientifically explore the pros and cons of telemedicine.

Medicare officials previously had said they believed telehealth would lead to increased costs and utilization for payers. Meanwhile, telehealth proponents argued that the CBO and OMBD estimates lacked real data and failed to account for cost savings obtained through better management of chronic diseases, reduced re-admissions to the hospital after being discharged, and fewer urgent care visits. Very little claims data existed before 2020 to support or refute these claims, but the popularity of telehealth during the pandemic means there will finally be enough data for Medicare officials to make real assessments.

A main factor to the future of telehealth will be determining when telehealth can be used as a substitute for in-person care as opposed to an additional service added on. One 2020 study estimated that telemedicine could effectively take the place of up to $250 billion in current medical care spending. The challenge for providers once the world fully reopens will be deciding what telehealth services to keep and how to manage them. Here are a few of the issues that legislators will have to work through once the pandemic’s public health emergency ends.

Geographic & Originating Site Restrictions

Before 2020, telehealth was only available to rural patients without access to local providers. Even then, patients could not take the appointment from home, they had to be physically present at another approved health care facility to virtually see an approved provider at another location. The rules were relaxed during the pandemic to allow patients and providers to receive and deliver care from home. This home-based care allowed telehealth to really take off and it has been quite popular with patients.

Some behavioral health providers report that patients who might have skipped an in-person appointment, never miss a virtual one. Health practices have consistently reported lower no-show rates with telehealth, especially in mental health where telehealth removes the stigma of visiting a behavioral clinic. For example, the baseline no-show rate for psychiatry services is between 19% and 22% of appointments while a telehealth platform reported no-show rates of 4.4% to 7.26% for its behavioral health telehealth visits during the pandemic (8).

Provider Reimbursement For Telehealth  

Through the public health emergency, Medicare has been reimbursing telemedicine visits at the same rates as in-person office visits. However, outside of the pandemic, Medicare traditionally pays a lower rate for telehealth services compared to office visits. Congress and payers will have to decide on a long-term strategy for telehealth, weighing the popularity of its convenience with patients and the scientific evidence that will come out in the next few years regarding the efficacy and affordability of these services.

Telehealth Platform

Medicare normally requires patients and medical providers to interact in real time over video technology. However, Medicare waived this requirement during the pandemic to allow for some visits to be conducted only exclusively over audio with no video component. During the emergency, CMS has been reimbursing audio-only visits at the same rate they do in-person office visits. Although there is debate among some providers about whether audio-only visits provide the same level of care as video or in-person visits, these telephone visits have definitively allowed many patients to have access to health care who might not have had it otherwise.

State Licensing Laws

State medical laws usually require providers to be physically based in the same state as the patient they are treating. However, many of these laws have been relaxed during the pandemic to make it easier for patients to see any specialist, not just one in their immediate geographic area. These laws have the positive impact of allowing patients to receive care sooner due to shorter wait times to see providers. This also corrects some supply and demand imbalances of some types of specialists in different parts of the country. However, more data is needed still to know if telehealth is as effective long-term as in person care. It may be that a hybrid of in-person and telehealth may be the future for chronic conditions.

The pandemic gave the medical community a reason to test out many variations of telehealth to provide care to patients. The good news is that the claims and outcomes data for Medicare patients have been and continue to be reported. These data points will no doubt play a role in the next report CMS and MedPAC make to congress about the state of telehealth as required by the 21st Century Cures Act.

Babylon, A World Leading, Digital-First, Value-Based Care Company, Announces Plans To Become A Public Company Via $4.2 Billion Merger With Alkuri Global Acquisition Corp.

Babylon Holdings Limited (Babylon), a world leading, digital-first value-based care company, and Alkuri Global Acquisition Corp. (Alkuri Global), a special purpose acquisition company, announced that they have entered into a definitive merger agreement. Upon closing of the transaction, the combined company will operate as Babylon and plans to trade on Nasdaq under the new symbol “BBLN”. The transaction reflects an initial pro forma equity value of approximately $4.2 billion. The transaction is expected to close in the second half of 2021.

Babylon was founded in 2013, with the mission to put accessible and affordable quality healthcare in the hands of every person on Earth. Babylon is poised to re-engineer the $10 trillion global healthcare market to better align systemwide incentives and shift the focus from reactive sick care to preventative healthcare, resulting in better member health, improved member experience and reduced costs. Babylon helps consumers through two primary channels — Babylon 360, its digital-first value-based care service; and Babylon Cloud Services, a suite of digital self-care tools that enables consumers and primary care professionals to gain insights and information either through Babylon directly or through Babylon’s roster of top-tier partners. Combined, those services cover 24 million people across the United States, Canada, Europe, Africa and 13 countries in Asia. In 2020, the company had approximately 6 million consumer interactions. Moreover, Babylon has a 95% user retention rate and a 5-star rating from more than 90% of its users.

Supported by capital raised through the transaction, Babylon will continue to expand its services both with existing and new consumers. Babylon has achieved strong traction in the U.S. market and is focused on building on this momentum by rapidly scaling its operations.

The transaction is expected to deliver up to $575 million of gross proceeds to fund Babylon’s pro forma balance sheet, including the contribution of up to $345 million of cash held in Alkuri Global’s trust account assuming no redemptions. The combination is further supported by a $230 million private placement (the PIPE) – funded over 85% from new, external institutional investors including AMF Pensionsförsäkring, Sectoral Asset Management and Swedbank Robur with strategic investor Palantir – at $10.00 per share. There is additional participation from Ali Parsa, Alkuri Sponsor LLC and existing Babylon investors Kinnevik and VNV Global. In addition, Babylon previously acquired an option to purchase Higi, a consumer health engagement company, and intends to acquire the remaining Higi equity stake it does not already own. The major investors in Higi, including 7wire Ventures, Flare Capital Partners and William Wrigley, Jr., have agreed to accept shares in lieu of a portion of cash consideration if Babylon exercises its option. This agreement is expected to reduce Babylon’s cash needs by approximately $40 million.

Assuming no redemptions, taking existing cash and transaction fees into account, Babylon is expected to have approximately $540 million net cash on its balance sheet following the transaction, which will be used to pursue organic growth strategies as well as attractive and opportunistic acquisitions. The transaction reflects an initial pro forma equity value of approximately $4.2 billion and enterprise value of approximately $3.6 billion. Existing Babylon shareholders will roll 100% of their equity into the combined company and will own approximately 84% of the pro forma company at closing.

The transaction, which has been unanimously approved by the Boards of Directors of both Babylon and Alkuri Global, is expected to close in the second half of 2021, subject to approval by Alkuri Global’s stockholders and other customary closing conditions, including any applicable regulatory approvals. Following the closing of the proposed business combination, Babylon will retain its experienced management team. Dr. Parsa will continue to serve as Chief Executive Officer and Chairman of the Board. An Alkuri Global representative will join the Babylon Board of Directors.

Ardea Partners LP is serving as financial advisor, Citi is serving as financial and capital markets advisor, and Wilson Sonsini Goodrich & Rosati, P.C., Allen & Overy LLP and Walkers (Jersey) LLP are serving as legal counsel to Babylon. Jefferies is serving as exclusive financial advisor and Winston & Strawn LLP is serving as legal counsel to Alkuri Global. Jefferies, Citi, and Pareto Securities AB served as placement agents on the PIPE.

Babylon is a world leading, digital-first, value-based care company whose mission is to make high-quality healthcare accessible and affordable for everyone on Earth. Babylon is re-engineering healthcare, shifting the focus from sick care to preventative healthcare so that consumers experience better health, and reduced costs. This is achieved by leveraging a highly scalable, digital-first platform combined with high quality, virtual clinical operations to provide all-in-one, personalized healthcare. Babylon endeavors to keep consumers at the peak of health and get them back on their feet as quickly as possible, all from their devices, with the aim to promote longer and healthier lives. When sick, Babylon provides assistance to navigate the health system, connecting consumers digitally to the right primary care professional 24/7, at no additional cost. Founded in 2013, Babylon has since delivered millions of clinical consultations and AI interactions, with c.2m clinical consultations and c.3.9m AI interactions in 2020 alone. Babylon works with governments, health provider organizations and insurers across the globe, and support healthcare facilities from small local practices to large hospitals.

Babylon 360 is Babylon’s digital-first value-based care service. Babylon 360 combines cutting-edge AI-powered technology with human medical expertise to help members stay out of the hospital and remain in control of their health. Using a combination of Babylon’s primary care professionals’ expertise and data, Babylon 360 gives members actionable insights and information about their wellbeing, and – by helping members to understand their specific needs – helps them set personalized health goals. If there’s a problem, Babylon 360 gives 24/7 access to a dedicated Personal Care Team, so that consumers can receive the most appropriate care, medication and treatment. A recent survey among Babylon 360 members identified that more than 40% of consultations had resulted in consumers avoiding the emergency room or urgent care visits, generating significant cost savings.

Babylon Cloud Services provides a suite of digital self-care tools that enables consumers and primary care professionals to gain insights and information either through Babylon directly or through Babylon’s roster of top-tier partners. The tools include Babylon’s AI symptom checker, which provides a 24/7 source of health information to consumers when they need it, and Babylon’s Healthcheck, which offers a comprehensive, digital-first health assessment that identifies at-risk conditions and actionable next steps members can take which aim to improve overall health and decrease future risk of disease.

Alkuri Global Acquisition Corp. is a blank check company formed for the purpose of effecting a merger, stock exchange, asset acquisition, stock purchase, reorganization, or similar business combination with one or more businesses or entities. Alkuri Global intends to favor next-generation technology businesses led by visionary founders and teams leveraging data and artificial intelligence in the areas of Consumer Internet and Marketplaces, Healthtech, Fintech and Mobility.

This was reported by Babylon Health on June 3, 2021.

Contact information: Ali Parsa, Ph.D., Chief Executive Officer, Babylon Health, 60 Sloane Avenue, London United Kingdom; SW3 3DD; +44 (0)20 7100 0762; Email: support@babylonhealth.com; Website: https://www.babylonhealth.com/

Contact information: Alkuri Global Acquisition Corp., 4235 Hillsboro Pike, Suite 300 Nashville, TN 37215; 615-632-0303; Website: https://www.alkuri.com/


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Eleanor Health Announces $20 Million Series B Financing To Address The Growing Need For Value-Based Addiction & Mental Health Treatment

Eleanor Health, the first outpatient addiction and mental health provider organization delivering convenient and comprehensive care through a population and value-based payment structure, announced it has closed an oversubscribed $20 million Series B financing round. The company received significant participation from all existing investors including Town Hall Ventures, Echo Health Ventures, and Mosaic Health Solutions, as well as new participation from Warburg Pincus, a global private equity firm which has invested more than $90 billion in over 930 companies.

Eleanor Health will use the capital to meet increased need from communities and demand from payers for population, value-based, whole-person care for individuals with drug addiction and mental health needs. By 2022, Eleanor Health anticipates managing more than 50,000 members under its innovative population-based partnership models.

Within the past two years, the company has shown the following results throughout its physical and virtual footprint:

  • 84% reduction in emergency department and inpatient stays.
  • 70% report improvement in depression and anxiety.
  • 84% improvement in drug addiction.
  • 76% report improvement in social drivers of health.

To date, Eleanor Health operates 18 clinics and a fully virtual model statewide across Louisiana, Massachusetts, New Jersey, North Carolina, Ohio, and Washington, delivering care through population and value-based partnerships with Medicare, Medicaid, and employers. The company plans to scale the business by going deeper in existing markets by executing additional payer contracts to manage new populations and further developing its proprietary analytics and technology platform that will support identification, engagement, and treatment.

Eleanor Health was created in the Oxeon Venture Studio, together with Town Hall Ventures and Mosaic. It remains dedicated to:

  • Providing treatment where most convenient for community members, including in-person care in clinics, community-based care in homes, and a 100% virtual model available from the safety and convenience of home;
  • Delivering comprehensive services including medications for drug addiction, psychiatric evaluation, treatment of co-occurring psychiatric conditions, individual and group therapy, nurse care management, support to address social determinants of health, and peer recovery coaching;
  • Operating on a payment structure that includes accountability to positive health outcomes achieved, including reducing total health care costs, providing unmatched access, and achieving high consumer satisfaction;
  • Employing diverse teams of medical practitioners, nurses, addiction professionals and peer recovery coaches with personal lived experience, to engage and support individuals in achieving their recovery goals;
  • And coordinating care across the health care and social services continuum to improve the consumer journey and increase long-term recovery rates and overall health outcomes for individuals.

This was reported by Eleanor Health on May 17, 2021.

Contact information: Alex Piersiak, Eleanor Health, 155 Federal Street, Suite 700, Boston, MA 02110; 617-909-5022; Email: alexandra.piersiak@eleanorhealth.com; Website: https://www.eleanorhealth.com/

Caron Treatment Centers & Independence Blue Cross Report Value-Based Contract Linked To Lower 90-Day Readmission Rate

Independence Blue Cross (IBC) reported that its value-based arrangement with addiction treatment provider Caron Treatment Centers resulted in a 5.6% 90-day readmission rate during a 2019 pilot. Under the arrangement, IBC paid Caron one single upfront fee for IBC members receiving treatment for addiction disorder, and Caron was at risk for any readmissions that occurred within the first 90 days after discharge.

IBC and Caron reported the pilot outcomes in a presentation at the 2021 Rx Drug Abuse & Heroin Summit. In the presentation, IBC reported that the readmission rates for six other addiction treatment providers in its network ranged from 11.6% to 25.7%. In total, 645 IBC members were treated for addiction during 2019; 71 received treatment at Caron.

Caron entered the value-based arrangement with IBC in 2017. The fee IBC pays Caron was not disclosed. In the presentation, Richard Snyder, M.D., IBC’s chief medical officer said the single payment is more than the rate IBC paid to the other addiction treatment provider organizations. However, he said the total cost of treatment has been about the same because Caron’s readmission rate was lower and IBC was not at-risk for the readmission cost.

Caron Treatment Centers is an internationally recognized non-profit organization that provides addiction and behavioral health care treatment, research, prevention, and addiction medicine education. The organization provides a continuum of care for teens, young adults, women, men, and older adults. Caron’s signature programming provides concierge treatment for executives, health care professionals, older adults and first responders. Caron’s program includes multidisciplinary treatment protocols with a median inpatient stay of 25 days, combined with a long-term disease management plan. Pennsylvania-based Caron provides services in Palm Beach County, Florida; Philadelphia; Washington, D.C.; Atlanta; and New York City. The organization is in-network with Capital BlueCross, Aetna, Highmark, and the Blue Card program, Independence Blue Cross, AmeriHealth Administrators, Independence Administrators, UPMC, Blue Cross Blue Shield, Employer Groups of Penn Medicine, and Tower Health.

IBC is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania. Independence ended 2020 serving 8.1 million members nationwide.

IBC and Caron reported the outcomes at the Rx Drug Abuse & Heroin Summit on April 7, 2021.

Contact information: Karen Pasternack, Senior Director of Media Relations, Caron Treatment Centers, 243 N. Galen Hall Road, P.O. Box 150, Wernersville, Pennsylvania 19565; 610-413-6938; Email: kpasternack@caron.org; Website: https://www.caron.org/

Contact Information: Diana Quattrone, Corporate Communications Manager, Independence Blue Cross, 1901 Market Street, Philadelphia, PA 19103; 215-241-3113; Email: diana.quattrone@ibx.com; Website: www.ibx.com

Value-Based Reimbursement Models Help SPARC Get A Leg Up In Medicaid Managed Care Contracting

By Meena Dayak

SPARC Services & Programs (SPARC) is a behavioral health provider organization in North Carolina that has been providing home and community-based services since 2015. They serve 425 consumers monthly and employ 70 full-time staff. They focus on complex consumers—children and adults with severe and persistent mental illnesses (SPMI) who have not been successful with residential and other traditional treatment services—and work to keep them out of institutional care. Currently, most of their consumers are covered by Medicaid, although they have just started to expand into the commercial insurance space. SPARC’s service array includes outpatient services, home and community-based therapy services, rehabilitation services to help consumers transition from residential treatment to community living, support for daily living activities to help consumers live independently in the community, case management, and enhanced crisis response.

Since its inception, SPARC has operated predominantly through value-based reimbursement (VBR) arrangements with managed care organizations. SPARC’s Co-Founder and Chief Executive Officer, Teri Herrmann, MA, talked to OPEN MINDS about their VBR models and how they have helped to advance the mission of SPARC.

Reimbursement Models

SPARC currently has two VBR contracts with two managed care organizations (MCOs), Cardinal Innovations and Partners Behavioral Health Management. 26% of their consumers receive services under these VBR models, which constitute nearly 48% of SPARC’s total revenue.

Both of SPARC’s VBR contracts are based on per member per month (PMPM) case rates. When a consumer is referred to them, they do an assessment and seek initial authorization for treatment from the health plan. Typically they get a 6-month authorization and bill one unit per month. The case rates range from $2,800 to $3,000 per month.

SPARC’s very first health plan contract with Cardinal Innovations in 2015—for children’s services—was a value-based contract with downside risk. If a child receiving Family Centered Treatment® (FCT) services from SPARC entered into residential care either during the course of treatment or up to a year post-treatment, then SPARC had to give money back to the payer. “It was pretty unheard of in that landscape,” said Ms. Herrmann. After a year, SPARC re-evaluated the contract with the payer and decided that the goal was “too aggressive.” They re-negotiated the contract to make payback contingent on no readmissions within six months of treatment. The health plan was flexible with value-based contracting as it was new territory for them, too, said Ms. Herrmann. So now, if during treatment, or up to six months post-treatment, the consumer enters into residential care or stays in an inpatient setting longer than 10 days, then SPARC is charged back up to 30% of the amount that they have billed. Ms. Herrmann noted that they’ve had to pay monies back to their health plan, especially because the consumers they serve are so complex but SPARC remains committed to value-based contracting because of the longer term potential for revenue growth and the flexibility offered by the model to improve the quality of care.

In a second value-based contract with Partners Behavioral Health, SPARC has an incentive-based payment with upside risk only for children in FCT. If the children—who receive home and community based services from SPARC—are able to remain at home three months and six months after discharge from a residential facility, then SPARC receives incentives.

For one year, SPARC also had a value-based contract with Cardinal Innovations (operating under a North Carolina Department of Justice mandate) to help adults with SPMI—who had been “inappropriately placed” in adult care homes—transition to independent living in the community. This was a value-based contract with upside risk only, where SPARC was rewarded if they could help consumers transition successfully from the adult care homes and keep them in community housing through continuous interventions.

Success Factors For Value-Based Reimbursement

Ms. Herrmann attributes the success of value-based reimbursement to four factors—a strong referral network, the use of evidence-based practices in treatment, robust data integration and reporting capabilities, and a mindset of innovation and risk tolerance.

Value-based reimbursement—and the “willingness to take on consumers that no one else wants”—has strengthened SPARC’s status as a “preferred provider” with health plans and other state entities. They receive referrals from their MCOs, local hospital systems, state social services and juvenile justice departments, residential treatment facilities, and community-based provider organizations. Ms. Herrmann said, “We’ve got a pretty sophisticated referral process that tracks all our referral sources, and then aligns them with the payers. We can see what’s working and see where the holes are so we can put a referral marketing plan in place to address the gaps.” In addition, 85% of referral sources reported that SPARC kept them informed of the status of their referral. This “closed loop” referral approach strengthens SPARC’s appeal in helping to maintain continuity of care.

SPARC was built on the foundation of the family-centered treatment (FCT) model, an evidence-based practice (EBP) with a trauma treatment model of home-based family therapy that Ms. Hermann was involved in developing in the early 2000s. She underscored that using FCT helped to achieve the improved outcomes that value-based models demand. The use of EBPs is accompanied by relevant training and certification for staff using the model, which replaces some of the prior mandated state training that was not always relevant to the services staff delivered.

Ms. Herrmann describes herself as a “data nerd” focused on assimilating and continuously monitoring outcomes data to examine the potential to improve services. She said, “We don’t just want to measure if the person showed up. We want to objectively look at each person and if they are getting better.” They have built their electronic health record system to produce the key data and desired reports and are continuously working with their developers to manipulate and learn from the data. SPARC applies this data-informed approach across their value-based as well as fee-for-service programs so they can improve performance all around. Ms. Herrmann noted that the health plans are primarily looking for data on avoidance of emergency department utilization and avoidance of inpatient services or residential care for the consumers that SPARC serves. She said, “We’ve had a pretty long placement culture here in North Carolina that we’re slowly changing the tide on. If someone really needs those more acute levels of care, there is a place in the continuum for them. But we don’t want those services to be overutilized for the wrong reasons. And so that’s where we’re really focused for outcomes measurement right now.”

SPARC was proactive from the outset and proposed value-based contracting to their health plans. Ms. Herrmann elaborated, “As we were brainstorming and envisioning the concept for this company, we wanted to serve those niche individuals whose needs weren’t being met. And we were hearing from stakeholders and payers that they were really struggling to figure out what services to get to them. So we saw that we had to be innovative. We knew that starting a company and immediately jumping into value-based contracts was a little risky. But we also knew it would say a lot about us. As a new provider organization, we said to the health plans, ‘Let’s take this walk in value-based work together and learn.’ And this pitch for risk-based contracting opened doors that may not otherwise have been opened.”

Services & Outcomes

For 2019, SPARC reported the following outcomes from its range of services covered by value-based contracts (see SPARC Services & Programs: 2019 NC Outcome Data).

Family-Centered Treatment: Family-centered treatment (FCT) is an evidence-based practice with four phases of treatment—joining and assessment, restructuring, valuing changes, and generalization. FCT is targeted toward consumers at risk for higher levels of residential service—those with extensive histories of using acute services without successful outcomes; those who’ve been hospitalized with little prior treatment and are being recommended for residential services; and those currently in residential treatment where discharge is delayed because of lack of family systems.

Services are intensive with a minimum of 10 hours per month provided to the family. FCT incorporates trauma treatment and coordination with other systems, such as the school, justice, primary care, and social service systems as well as 24/7/365 crisis intervention services. FCT seeks to confirm and capitalize on internal changes within the family so that the family is not dependent on the therapist once services terminate. Families also have the opportunity to give back to their communities and share what they have learned with other families.

While starting FCT at SPARC, 57% of referrals were in some form of an out-of-home placement and 43% were at home with their family. After treatment, 81% of consumers receiving FCT were able to remain with or be reunified in the community with their family or another caregiver. 100% of families were engaged in treatment, participating in five or more sessions in 30 days. And 96% of families reported that treatment improved their family life.

In-Home Therapy Services: In-home therapy services (IHTS) is a combination of motivational interviewing and care coordination provided in the home and community to children and their families where there are complex clinical needs that traditional outpatient therapy cannot adequately address. IHTS is a time limited service, approximately 6 months, in which a therapist and the case manager work with the child and their family to meet the therapeutic needs as well as provide linkage to professional and natural supports. The case manager works with the various systems involved with the child and family, such as the school, primary care, social services, and justice systems. Upon discharge from IHTS, children and their families can continue to receive outpatient therapy to ensure continuity of care.

85% of families successfully completed treatment and 97% of consumers were either at home with family, or in other family placements, at the time of discharge from treatment.

Transition management services: Transition management services (TMS) is a rehabilitative service intended to increase and restore a consumer’s ability to live successfully in the community by maintaining tenancy in community housing. TMS increases the consumer’s ability to live as independently as possible, managing their illness, and reestablishing their community roles related to emotional, social safety, housing, medical and health, educational, vocational, and legal services. TMS provides structured rehabilitative interventions and works in partnership with the individual’s behavioral health service provider.

90% of members participating in services were able to both obtain and maintain their housing in 2019. Only 5% were discharged from the program because they needed a higher level of care. And the program is working with 98% of consumers are on four or more social determinants of health in addition to their housing needs.

Enhanced crisis response: The enhanced crisis response (ECR) service is intended to put supports in place as quickly as possible for youth with behavioral health needs that are at risk for abandonment, crisis episodes, or being placed in restrictive levels of care. With timely assessments and supports, ECR is intended to keep youth in their environment—such as non-therapeutic foster homes, kinship placements—or minimize needs for long stays in residential treatment. Services last 60 to 90 days on average. SPARC staff work with consumers and families to diffuse the imminent crisis and get the family linked to appropriate community-based services that allow the consumer to thrive and meet their goals.

71% of youth who were discharged from the program in 2019 were able to be discharged into the community with community-based services.

Overall, SPARC’s services received an average customer satisfaction rating of 4.6 stars on a 5-point scale. The net promoter score (based on consumers and families sharing the likelihood that they would refer others to SPARC services) was 4.3 stars.

Benefits Of Value-Based Reimbursement

Ms. Hermann explained that value-based treatment has incentivized service quality and built more staff buy-in for outcomes-driven treatment, afforded flexibility, and proved to be good for business development. She said, “We knew that the landscape of health care is shifting to value-based care, we want to jump in with both feet and have skin in the game. It forced us to say doing ‘A-level’ work isn’t good enough, we need to do ‘A-plus’ work. We committed to a pretty aggressive value-based contract because without that, we knew this would not be a sustainable model.”

The value-based model drives performance-based compensation incentives for staff, which increases their buy-in for achieving better outcomes. Ms. Hermann elaborated, “If a client is in crisis, the therapist response at eight o’clock at night is not just ‘Well go to the emergency room.’ Sometimes that’s a needed intervention but often it’s not. They know that once somebody goes to the emergency room, the whole treatment plan can get derailed. And so our clinicians want to go the extra mile, not only because it’s the right thing to do but also because we have some skin in the game. It creates just a little shift for them at the frontline level, so that they’re committed to providing unique services and really engage in creative problem solving.”

The services SPARC delivers under value-based contracts are labeled “in lieu of services” and have been designated by MCOs to meet an unmet need in their communities. Therefore service definitions afford more freedom and flexibility and avoid the need to fit the treatment model into a state plan amendment service definition which sometimes can be like “fitting a square peg in a round hole.” The VBR model is also designed to reduce administrative burden on provider organizations and payers. For example, given that FCT as an EBP is known to typically discharge families with successful outcomes after six months of treatment, six months of services are authorized at the outset. So instead of wrangling submissions for authorization, clinical professionals can focus on delivering needed services. And the intensity of treatment can be increased or decreased depending on current needs. “If a crisis happens and we need to increase the intensity and frequency of services, we don’t have to go back to that payer and request more time and risk potential denial. That is a huge difference between some of our fee-for-service vs. value based contracts,” said Ms. Herrmann.

Value-based contracting has created opportunity for SPARC to expand its mission to keep consumers out of institutional care. And it has allowed stakeholders to see their innovation and that creativity and to come to them when there are new needs. “It has allowed us to have opportunities that I’m not sure we would’ve had if we’d come in as a provider saying we want to do regular fee-for-service contracting,” Ms. Hermann said.

What’s next? As SPARC moves into providing more services for mild and moderate mental illnesses and pursues contracts with commercial insurance, value-based contracting will continue to define their business development efforts. They plan to work with their MCOs to move from an individual consumer focus to applying a population health lens in their VBR models. They are also looking to focus more on whole-person value-based care and to and certify and train staff to become a “care management agency” as part of North Carolina’s Medicaid transformation (see North Carolina Extends Deadline For Tailored Plan Care Management Applications To June 1, 2021). In addition to Cardinal Innovations Healthcare and Partners Behavioral Health Management, SPARC has entered into contracts with five more managed care organizations appointed by North Carolina Medicaid—WellCare of NC, AmeriHealth Caritas of NC, Blue Cross and Blue Shield of NC, United Healthcare of NC, and Carolina Complete Health, Inc. As these new MCOs get ready for value-based care—once they understand their new consumers and the needs—SPARC is well-poised to leverage their experience and hit the ground running. “We’re really committed to continuing to learn more and doing more in the value based space,” summarized Ms. Herrmann.

Eight Tips To Ensure Your Organization Keeps Innovating Post-Pandemic

The COVID-19 pandemic has led to many technology innovations in health care. The most noticeable transformation is the rise of telehealth with claims skyrocketing from less than 0.01% of total visits to 80% of behavioral health visits during the first quarter of the pandemic (see How’s That Strategic Plan Going?). We predict consumers and payers alike will continue to expect virtual service delivery as part of everyday service long after the pandemic has ended. How can organizations can continue innovating after the pandemic has passed?

There are two big trends  to focus on—the first is virtualization and the second is digital transformation. At Qualifacts + Credible, the focus continues to be on helping behavioral health and human services agencies improve clinical outcomes, enhance operations, and activate their full potential through the use of an EHR.

Not only will consumers continue to engage virtually with their providers post-pandemic, but consumers will continue to expect some level of integrated telehealth functionality. Not all provider visits lend themselves well to telehealth and not all consumers will want to meet virtually, but everyone will expect to see some telehealth options for routine care. And provider organizations will find a way to use artificial intelligence and machine learning to streamline routine tasks like notetaking.

Organizations have to be strong operationally at their core business in order to be effective and successful. At the same time, they have to have a somewhat less structured environment for managing innovation. To set your provider organization up for success and continue to innovate you should:

  1. Empower employees to innovate. Managers sometimes fear that encouraging innovation among their staff will distract them from their everyday jobs. If you want your teams to innovate, make sure you include those expectations on job descriptions. There are too many organizational constraints available that deter innovation—and the best way to overcome them is for the C-suite has to sponsor the innovation.
  2. Incentivize innovative thinking/ideas. Empowering employees usually isn’t enough—think about ways to incentivize them through bonuses, contests, and/or unstructured time off. The reward doesn’t have to be an all-expenses-paid trip to the Caribbean, just something to show employees you value their ideas, such as gift cards to restaurants or retailers.
  3. Designate an innovation leader. Not every staff member is a born innovator so rather than ask everyone to dedicate 5% of their time to it, consider making it a job responsibility for the staff member in charge of innovation for the organization. An empowered, dedicated leader can make a big difference.
  4. Be open to failure. Make sure you cultivate a culture that is willing to accept that not all ideas can be homeruns and failures will happen. Innovation requires being brave enough to be willing to experiment and tolerate failures.
  5. Foster collaboration. Many employers have had to scramble this past year figuring out telework solutions on the fly to keep businesses running. This has disrupted how we previously brainstormed. With the expectation that clinicians and staff will continue to work remotely, businesses must find ways to foster collaboration and relationships when there is no shared water cooler for gathering and sharing ideas.
  6. Hire with an eye toward innovation. One question to ask is if the organization has the competencies necessary to innovate or needs supplemental competencies. When hiring for a position, think about which candidate would bring new ideas and challenge current thinking. Consider adding innovation case studies or scenarios to the hiring process to see what ideas candidates come up with. Even if the candidate does not ultimately take the job, you may still find some good ideas.
  7. Talk to your customers. No one knows more about your business than your current customers. Make it a regular part of the job to check in with your clients to see what’s happening for them and ways your organization can help. Due to the pandemic, we haven’t had the luxury of attending business networking events so use these customer check-ins to find out what’s happening in the market.
  8. Innovate, innovate, innovate. Just because you have well-liked product offerings now, doesn’t mean it will always be that way. There will always be someone else coming along that is better, faster, and/or cheaper. To stay at the top of the game, you need to constantly be looking to innovate.

To hear more about the innovations happening in health and human services technology, listen to Joe Naughton-Travers, Senior Associate at OPEN MINDS and Eric Arnson, Chief Product Officer at Qualifacts + Credible discuss how performance and outcomes play a critical role in your future success in a recording of the session, “Why Measuring Performance & Tracking Outcomes Are Your Roadmap to Success: A Discussion With Eric Arnson, Chief Product Officer, Qualifacts + Credible.”

CMS Value-Based Care Opportunities In Medicaid

On September 15, 2020, the Centers for Medicare and Medicaid Services issued guidance to support state Medicaid Directors in moving towards value-based arrangements and alternative payment models. The guidance outlines lessons learned from early state and federal experiences in implementing value-based care reforms, and includes a number of examples of innovative payment models to help states achieve value-based payment.

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The Data-Driven Leader

In an unfamiliar environment, the leader with the best data has a distinct advantage. That is a frequently heard adage, but I was really struck by the concept at one of our OPEN MINDS Executive Leadership Retreats. The historian talked about how Robert E. Lee’s strategy at Gettysburg was compromised when his cavalry (the advanced surveillance unit of its time) was waylaid.

While leaders know that the right information allows better decisionmaking, in a recent survey, 67% of U.S. corporate executives say they are not comfortable accessing or using data from their tools and resources. And shockingly, the number of companies that say they are data-driven actually declined from 37% in 2017 to 31% in 2019 (see How CEOs Can Lead a Data-Driven Culture).

So where is your organization on the journey to a data-driven culture? One way to assess that is to look at the OPEN MINDS process for becoming a data-driven organization. Where is your team on this path?

  1. Identify a market-driven strategy

The first step on the path to becoming data-driven requires the executive team to get on the same page as to what metrics are considered important for monitoring strategy in terms of growth, quality, and finance. Specifically, what are the key actionable drivers that will give a clear indication that the strategy is working? (see A Data Driven Strategy – A Blueprint For Organizational Success).

  1. Begin the participatory process through c-suite technical assistance

The second step in the process is to engage in a participatory discussion to start identifying the metrics desired by each member of the executive team to manage strategy. In this step of the process, you may walk away with a 10-person wish list totaling 600 measures but it will get you on the road to narrowing the list down to those metrics that matter most (see From Big Data To Small Data—From The Ideal To The Possible).

  1. Create the “wish list”

After each executive team members’ desired metrics are identified, the next step in the process is to create an inventory of potential metrics, prioritizing each by what data is available, what is actually feasible to measure, and what is the anticipated cost of measuring each (see When It Comes To Performance Metrics, Not Any Measure Will Do).

  1. Select the c-suite base metrics set

Once the C-suite metrics are identified and prioritized, the key is to start small. Creating a very limited data set with key metrics is critical to the implementation process and to avoiding ‘data overload’ (see What Gets Measured Is What Gets Done: Keys To Selecting Measures For Performance Management).

  1. Operationalize and automate

Going from vision to production is not necessarily complicated, but it can be time consuming. In this step of the process, ensuring that the metrics are clearly defined and operationalized is critical, along with how the data will be displayed. Once defined, the reporting must be automated to ensure timeliness and limit work on the backend (if it’s not automated, put it back on the wish list to revisit in the future) (see Driving Without A Dashboard? You’ll Be Running On Empty Soon and Building A Data Dashboard For VBR: Case Studies In Combining Clinical, Financial & Outcomes Data).

  1. Practice at the C-suite level

The next step in the process is to actually practice using the data at the C-suite level. But, it’s important to remember, initial disbelief is common particularly when turnover is reporting as especially high or productivity is especially low. Make sure the data is valid and reliable—and then turn to problem solving. Pick out the major pain points and hone in on those to guide executive team meetings rather than taking a deep dive into every data point (see Performance Management Needs Performance-Driven Leaders).

  1. Add high-value metrics that require investment

As executive teams begin to master the basics, additional metrics can be added in terms of their return on investment (ROI). Whether the team desires to merge two electronic health records, pull data in from the financial system, or highlight claims data, this all comes at an increased cost and should show a clear ROI. The point to remember here is, no performance dashboard is ever static. The metrics that are important now may be overshadowed by other metrics over time as your business model or payer contracts change (see Data Makes The Difference: Using Data To Manage Care Coordination & Value-Based Arrangements and Reducing The Cost Of Reporting 558 Unique Performance Measures).

  1. Extend within the organization

The next step to becoming a data driven organization—once the executive team and board are “on board”—is to extend and distribute the data across the organization (billing department, web team, clinical staff and programs, contract managers). Consider the data that each team needs to successfully manage their own performance. While transparency in this regard is important, focus is key, because what gets measured is what gets done (see Making Your Clinical Team Data Driven).

  1. Educate

While every organization may educate team members differently, it’s critical for supervisors and clinical staff to not only understand the data, but also understand why it matters—whether it’s to the consumer or payer or for financial sustainability. The more meaningful the data is, the more likely the team will learn to embrace it (see Don’t Underestimate The Culture Change In Becoming Data Driven).

  1. Implement performance-based team compensation

Once the executive team has laid out clear, data-driven performance expectations to staff members, they can be integrated into both performance evaluations and compensation planning (see Implementation Of An Effective Performance-Based Compensation System).

  1. Share with external stakeholders

As you begin to “know” your data (and the equivalent benchmarking data of competitors), there is a new opportunity to use performance data as a marketing advantage. As provider organizations conduct outreach to consumers or engage in discussions with health plans, knowing your performance is superior (and having the data to quantify and prove it) is essential to become an advanced data-driven organization (see Using Data To Follow The Money & Stay True To The Mission).

  1. Share (real-time) with partners

The final (and hardest) step is data transparency. Sharing data in real-time with key stakeholders, affiliation partners, or health plans is a characteristic of a mature, strong partnership and one that will likely be more successful with shared performance metrics (see No Common Language = No Data Sharing and Population Health Management For The Complex Consumer Market: How To Utilize Data To Coordinate Services Across The Care Continuum).

The executive teams that have the best data—and the best insights based on that data—are those that have been able to pivot quickly in our current crisis. But they will likely need to pivot again. As we enter the post-crisis normal, demonstrating your value, and having the data to back it up, will be key not only for future strategy development but also for long-term sustainability.

From Fee-For-Service To Episode-Based Payments: The Shift Continues

As the prolonged pandemic continues, every executive in every industry is asking the question, “what’s next?” The health care sector has been completely upended by the pandemic crisis. From our analysis, it appears that the “next normal” holds more focus on “whole person” health management models, “hybrid” service programs with a mix of telehealth and face-to-face services, more leverage of technology, and more focus on value (see my recent presentation, Navigating From Challenge To Opportunity: The Best Of The 2020 OPEN MINDS Management Best Practices Institute).

That last piece—the focus on value—will be a move away from fee-for-service (FFS) reimbursement to some type of non-FFS alternative payment methodology (APM): bundled rates, case rates, episodic payments, and capitation reimbursement. I’m not certain what exactly that will look like and there will likely be significant variance by payer, consumer typology, and service models. Skeptics will say that we’ve been inching toward widespread acceptance of value-based reimbursement (VBR) for a decade or more with limited adoption. In 2018, 39% of payments were FFS, and another 25% were FFS with some link to quality and/or value, such as pay-for-reporting and pay-for-performance (see Entering The Next Phase Of Value-Based Payment Reform).

But that was before the pandemic. Moving to non-FFS APMs addresses multiple issues for payers and health plans. APMs support integrated care models. They allow health plans to address the growing prevalence of behavioral health conditions. They provide steady income for provider organizations. They address the likely budget compression that lies ahead by getting more alignment with provider organizations by increasing their downside financial risk—and shifting some administrative costs to them as well.

Immediately prior to the pandemic, the Centers for Medicare and Medicaid Services (CMS) implemented Patient Driven Groupings Model (PDGM) for home health agencies (HHAs) on January 1, 2020. PDGM was the most significant change to HHA reimbursement in 20 years, tying payment to an individual’s overall health condition rather than to therapy visits. Prior to implementation, there was widespread “the sky is falling” fear of the financial impact. The sky didn’t fall. There was the expected interruption in cash flow, but overall documentation, coding accuracy, and timeliness of claims submission have all improved, and reimbursement rates are better than projected. In some ways, PDGM helped HHAs prepare for the very sudden drop in utilization with the onset of COVID-19. That too, is turning around. Skilled nursing facilities (SNFs) had similar experiences with its new payment model, the Patient Driven Payment Model (PDPM). SNF utilization is declining, as expected, as the industry shifts to right person, right treatment, right setting with home being the preferred care delivery location.

And in anticipation of the “next normal,” on Tuesday, September 15, 2020, CMS released new guidance to help state Medicaid plans continue their shift towards VBR (see Value-Based Care State Medicaid Directors Letter). And, the CMS’ innovation center is about to roll out new risk-based model for those dually eligible for Medicare and Medicaid (see CMS Innovation Agency To Launch Risk-Based Model For Dual Eligibles). The model will allow Medicaid health plans to take on financial risk for a consumer’s FFS Medicare services.

In addition to CMS, health plans are also increasing their use of APMs. On September 14, 2020, Humana announced it was adding two more episode-based payment models—the Coronary Artery Bypass Grafting (CABG) model and the Total Shoulder Specialist Reward Program. These two episode-based models are in addition to Humana’s Maternity Episode-Based Model and Oncology Model of Care. Humana now offers a total of six specialty care payment models, with more than 2.6 million individual Medicare Advantage (MA) and commercial members receiving care through 1,000 value-based relationships across 43 states and Puerto Rico (see Humana Launches Two More Value-Based Programs for Specialty Care).

The implications are clear. More health and human service reimbursement is moving to non-fee-for-service payment models. And the provider organizations that are best prepared to accept value-based contracts with managed care plans are the organizations with a competitive edge. To get your team up to speed, these are some of the best OPEN MINDS resources on VBR models.

Assessments & Educational Programs

Managed Care Competencies Assessment

OPEN MINDS has developed a Managed Care Competencies Assessment, focused on the organizational and technical competencies needed to make the transition successful. This online self-assessment helps to evaluate and identify improvements in 12 domains.

Value-Based Readiness Assessment

To help provider organizations navigate the management challenges of transition to VBR, OPEN MINDS has developed a web-based readiness self-assessment for value-based reimbursement readiness, focused on scoring organizational and technical competencies needed for the transition. This tool was designed to evaluate and identify improvements in six domains.

Succeeding With Value-Based Reimbursement: An OPEN MINDS Executive Seminar On Organizational Competencies & Management Best Practices For Value-Based Contracting

The evolution of health and human services away from a focus on cost-based/volume-based reimbursement—and the growing expectations of consumers, caregivers, and health plans—are changing both the successful business model and the market role of many service provider organizations. This evolution is one that will (like in retail, banking, and publishing) create new winners.

How To Build Value-Based Payer Partnerships: Best Practices Marketing, Negotiating & Contracting With Health Plans

In this presentation at the 2020 OPEN MINDS Management Best Practices Institute, OPEN MINDS Senior Associate Paul Duck discussed how to develop relationships with the payers in your market, initiate strategic conversations, demonstrate value, and secure and optimize service agreements. He also discussed how to help payers meet their performance requirements, align programs and services with their goals, and provide data to show that how service lines can deliver quality outcomes with lower costs.

Strategic Implications Of VBR

VBR: Are You Walking In Your Customers Shoes?

Despite the significant upset to the health and human service system caused by the pandemic crisis, the move to value-based reimbursement (VBR) seems to be moving along. On June 3, The Centers for Medicare and Medicaid Services (CMS) announced adjustments to 16 value-based care (VBC) models, with goals of accounting for COVID-19-related changes in health care delivery (and the uptick in costs), as well as allowing more time for participating provider organizations to transition to VBC (see CMS Makes COVID-19-Related Changes To Value-Based Care Models). And, on June 19, CMS issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based payment (VBP) arrangements with drug manufacturers (see CMS Proposes Regulatory Changes To Promote Medicaid Value-Based Drug Purchasing).

Why Value-Based Purchasing For Medications Matters

On June 17, CMS issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based payment (VBP) arrangements with drug manufacturers. The rule’s definition of VBP is an arrangement intended to align payments to therapeutic or clinical value in a population, such as evidence-based measures. The cost should be linked to existing evidence of the effectiveness and/or outcomes-based measures. Or payment should be linked to the drug’s actual performance in a consumer or a population—such as reduction in medical expenses.

Collect The Data, Connect The Dots Value

One key tool for executive teams planning for recovery after this crisis period is having the metrics to make the right decisions. I tend to think of this data in three domains. There is financial data for short-term cash management strategy. There is strategic market information for planning long-term post-recovery strategy (this includes both external and internal data). And there is service performance data to optimize value.

Show Me The Value, Show Me The Money

This year, what has been top of mind for many executives attending the Institute is how to adapt your strategy in the current crisis—and how to use innovation to succeed in an altered health and human service landscape. But one question keeps coming up—where do “value” and “value-based” reimbursement fit in all of this?

The Blues Move To Value—Will Others Follow?

In the past two weeks, we’ve covered two initiatives sponsored by Blues plans to move behavioral health to some value-based arrangement. Blue Cross and Blue Shield of North Carolina launched a new value-based purchasing model, Blue Premier Behavioral Health, which allows behavioral health professionals who either meet or exceed quality benchmarks to earn higher reimbursement rates. In New York, BlueCross BlueShield of Western New York announced that it entered into a value-based reimbursement arrangement with Value Network.

Bundled Rates – Opioid Treatment & More

We’re seeing more use of episodic payments, case rates, and bundled rates. Our recent health plan survey found the number of health plans using bundled payments or case rates rose from 39% to 59% from 2017 to 2019 (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System and What Are The Health Plans Doing About VBR?). And, our recent survey of specialty provider organizations found that 24% of those organizations have some bundled rate contracts (see 2020 OPEN MINDS Performance Management Executive Survey: Where Are We On The Road To Value).

VBR – Where’s The Beef?

Greetings from Florida and the opening day of The 2020 OPEN MINDS Performance Management Institute. It’s a power-packed agenda full of sessions focused on optimizing performance and sustainability in the complex consumer market. I opened the institute with results from our 4th annual survey on the state of value-based reimbursement (VBR) in the market (see Where Are We On The Road To Value? The 2020 OPEN MINDS Performance Management Survey). The findings reminded me of the 1980s advertisement for Wendy’s with the woman, the insistent Clara Peller, asking, “Where’s The Beef?” (see Where’s The Beef) – and saying “I don’t think there is anybody back there…”

Access Matters: Payer Provider Partnerships & Shared Vision

This presentation was delivered on August 26, 2020 at The 2020 OPEN MINDS Management Best Practices Institute. Speakers discuss how the problem of access in behavioral health requires new partnerships, integrated care, collaboration, and a shared vision between payers and provider organizations; and how each payer is working to solve the access problem.

Getting Paid More For What You Do – Tactics To Increase Fees & Rates From Payers & Moving To New Reimbursement Models

OPEN MINDS hosted an executive web forum for executives of health and human service organizations. Led by OPEN MINDS Senior Associate Paul M. Duck, the forum took a deeper dive into different tactics and strategies provider organizations can leverage with payers to negotiate optimal fees and reimbursement rates.

VBR Updates

Alternative Payment Methods For Behavioral Health Associated With Lower Utilization & Spending

Alternative payment methods (APMs) for mental health and addiction disorder treatment are associated with lower behavioral health service utilization and lower spending, as well as improvements in process of care outcomes, according to a review of evaluations of 17 APM implementations. Of the 17 APM implementation evaluations, 11 assessed utilization changes and five found lower utilization. Eight evaluations assessed spending, and half found an association with lower spending. Fifteen evaluations assessed process of care, and 12 reported statistically significant improvements due to the APM.

CMS Unveils APM Strategy For Rural Health Care

On August 11, 2020, the Centers for Medicare & Medicaid Services (CMS) announced an alternative payment methodology (APM) for rural health care services. The APM is called the Community Health Access and Rural Transformation (CHART) Model. CHART has two value-based payment models: the Community Transformation model and the Accountable Care Organization (ACO) Transformation model.

Blue Cross Blue Shield of Massachusetts Launches New Value-Based Payment Model For Small Practices

On July 15, 2020, Blue Cross Blue Shield of Massachusetts (BCBSMA) announced plans to pilot a new value-based payment model for small practices that provides financial support through a global payment, upside risk incentives, and an immediate support payment.