We’re bombarded with stories about electronic health records (EHR) evolving to become more flexible and use more services like blockchain, cryptocurrencies, and artificial intelligence, but what do your peers report firsthand? We recently concluded the sixth annual OPEN MINDS National Behavioral Health EHR Survey and found that 53% of provider organizations report their EHR does not have all the functionalities they need. Only 19% report their clinical, scheduling, billing, and reporting and analytics functionalities as meeting their needs. These Core 4 functionalities are crucial to service delivery and organizational sustainability.
In this webinar, OPEN MINDS Senior Associate, Joe Naughton-Travers, shared the results of the 2021 OPEN MINDS National Behavioral Health EHR Survey and discussed what organizations can do to plan for the next advances in health care technology and service delivery. Mr. Travers also discussed the growing concern among providers and what functionalities to be looking at for future service delivery and timely reimbursements.
One of the major developments of the COVID-19 pandemic has been the phenomenal growth of telehealth use, especially in behavioral health care. Telehealth became ubiquitous during the pandemic, and it is predicted that a large percentage of health care will continue via telehealth even after the public health emergency eases. A recent survey by Qualifacts and the National Council for Behavioral Health found that:
At the height of the pandemic, 60% of behavioral health organizations were providing 80% or more of their care virtually – due to policy changes reducing barriers to telehealth.
A majority of behavioral health care executives expect the increased utilization of virtual services to continue, with an estimated 40% to 60% of their overall services being provided via virtual platforms (See The New Role of Virtual Care in Behavioral Health).
Before 2020, health care was poised to start using more technology to allow consumers to make appointments, share records, and connect with their clinical professionals electronically. However, COVID-19 forced the rapid adoption of many of these services, particularly telehealth (See 21st Century Cures Act Paves The Way For Telehealth To Bloom During Pandemic). It turns out, consumers appreciate the ease of telehealth, especially because it allows them to avoid traffic and waiting rooms. Clinical professionals have also benefited from telehealth, finding that it allows them to see how their consumers are living day-to-day. Another advantage of telehealth is the ability to reduce barriers to care, such as time away from work and the stigma associated with seeking care (See What You Should Be Thinking About Now).
Mental health services were among the quickest health care specialty to switch to online treatment. With data collected between November 2020 through February 2021, 33% of all mental health appointments were conducted virtually. Primary care followed behind, holding 17% of its visits virtually. Pediatrics held 9% of its visits virtually, cardiology 7%, and OB/GYN visits were at 4%.
But despite the popularity and advantages of telehealth, clinical professionals must recognize that telehealth does not work for all consumers and all conditions. Regardless of age, many individuals are uncomfortable using technology, especially for sharing private health information. Also, not all consumers have access to high-speed internet, and therefore must resort to telephone appointments when an in-person visit is not an option. Above all, clinical professionals need to deliver the same personal, human interaction over the internet or the phone as they do in person. To ensure your clinical staff are maintaining a high quality of care without losing the personal touch while virtual, be sure to follow these key best practices:
Establish a baseline for in-person versus virtual visits. Take a hard look at your service lines and consumer populations, as well as any payer requirements, when considering how often to require in-person versus virtual visits once the current pandemic ends. Even if your consumers love telehealth, make sure requirements are clear on how frequently they should be seeing consumers in-person — such as once every four telehealth visits — or whatever is determined to be best for your organization, clinical professionals, and payers. Advise your staff to be up front with consumers about the in-person/telehealth requirements from the office. Many people have anxiety as the world re-opens, and it is best to give people advanced notice of plans and expectations for future meetings.
Acknowledge previous statements. Just like in an in-person visit, encourage your clinical professionals to spend a moment to chat with their consumers, perhaps following up and checking in on what you discussed in your last visit to make sure you both understand where you left off. This also works for clinical professionals as they move from topic to topic during consultations – spending a moment to reiterate an earlier conversation confirms you’re both on the same page. This helps the conversation stay on topic and helps your consumers build a connection with their clinical professionals, even if they have only ever met virtually.
Listen to your consumers. As the world starts to re-open, advise your clinical professionals to check in with their consumers to see whether they would like to continue virtually, start meeting in-person again, or some combination of the two. Staff should realize it is also important to acknowledge any frustrations consumers may have regarding the platform or anything else in their lives. Even during a virtual appointment, it is obvious if someone is upset by the tone of their voice. Acknowledging these frustrations will demonstrate to consumers that their clinical professionals are present, even if they are not physically in the same room. This person-centered care approach will help your consumers feel more connected to their clinical professionals and actively involved in their treatment, which can positively impact health outcomes.
Different policies for different diagnoses. As an office policy, it is also important to think about the consumer diagnoses your organization handles to see what works well digitally. Some treatment plans focusing on talk therapy may lend themselves naturally to telehealth, while others requiring injections or blood samples must be conducted in person. Think through the consumer population your organization treats and set some guidelines for your clinical professionals about how they should plan to handle future visits. For example, children being treated for attention deficit hyperactivity disorder (ADHD) are typically weighed to make sure they are not losing weight due to appetite loss from medication. Set a policy for parents to weigh children at home or develop a schedule for in-person visits.
Explain the technology. All these tech tools are great, so long as everyone can use them. As an organization, be prepared to offer some training to your staff on how to effectively use technologies. If consumers are intimidated by a patient portal, they may be too shy to continue with treatments. It is important for your staff to be respectful of consumer’s tech knowledge and offer guidance without being condescending. Depending on your practice, you could even designate someone in the office to handle tech support for all consumers. Whatever you decide–just make sure you have someone available and willing to reach the consumers where they are.
Do not be afraid to ask questions. Even on a virtual visit, your staff must be able to talk with consumers and engage with them as they would in person. Encourage your staff to make simple small talk to start a conversation, such as commenting about the weather or compliment a new hair style. Even in a virtual world, consumers need to feel connected to clinical professionals, so it is important to show attention to the consumer’s person. Teach your staff basic techniques to recenter and engage again with the conversation should their focus wane briefly.
By Monica E. Oss
There is a lot of investment money going into the mental health field—in fact, $14.7 billion in the first half of this year (see Why Are Digital First Mental Health Companies So Popular?). Much of that investment is focused on digital behavioral health systems and tools for both professional and self-care.
For the approximately 5% of the population—those with multiple chronic conditions and complex support needs—that use a majority of the health care resources, a different approach is needed to assure good consumer outcomes and prevent inappropriate use of resources. That population was the focus of our recent discussion with Carole Matyas, Vice President, Operations at Sunshine Health, and the keynote speaker at the upcoming 2021 OPEN MINDS Executive Leadership Retreat.
On September 22, Ms. Matyas will deliver the keynote address, The Future Of Managing Care For Consumers With An SMI—What Works. The cornerstone of progressive interventions for the high-risk/high-needs population with a serious mental illness is based on a “whole person” treatment strategy that encompasses medical, behavioral, pharmacy, social needs, and caregiver collaboration and coordination. Ms. Matyas will review Sunshine Health programs that are showing promising positive outcomes such as reduced use of acute/crisis care, better engagement with primary care that improves medical health outcomes and addresses high comorbidity issues, stabilized community-based living environment by addressing social needs for the enrolled Medicaid and Medicare members served. She will provide an overview of their Long Acting Injectable (LAI) program with data that demonstrates reductions in emergency department and inpatient services, and increase in community-based and medical services for members.
My takeaway from our pre-Institute discussion with Ms. Matyas? The Sunshine Health approach to optimizing the management of consumers with an SMI has four key components—intensive case management to assure care coordination, leveraging long-acting medications, a focus on primary care, and addressing social support needs.
Intensive case management to assure care coordination. One approach that has improved outcomes for SMI consumers is intensive case management. Sunshine Health took its top 400 high-needs, high-risk consumers (who have 30+ hospital admissions a year, go to the emergency room every other week, and reject any type of community-based treatment) and had its staff provide proactive and intensive case management services in collaboration with a host of community provider organizations and stakeholders. For example, case managers work closely with a telehealth provider organization that Sunshine Health contracts with to ensure that consumers discharged from hospital have their seven-day follow up appointment virtually and then connect them with an outpatient provider organization for ongoing care.
Leveraging long medications. Sunshine Health has been encouraging provider organizations to use long-acting injectables (LAIs) for antipsychotic medication administration. Ms. Matyas shared that SMI consumers receiving monthly LAIs have shown significant stabilization in their mental health and also do better at getting care for their comorbid medical conditions, engage with peers socially, and are even able to have part-time employment. She said, “We are promoting use of LAIs and really going a long way in working with hospital systems, primary care physicians, and mental health providers to make it easy to obtain those medications, administer them, monitor, and do outreach so members continue treatment. While the medications can be expensive, the results definitely show reductions in hospitalizations, readmissions, and emergency room visits as well as better outcomes from community-based treatment.”
Sunshine Health has a number of strategies to increase the use of LAIs. They do not require provider organizations to obtain prior authorizations to administer LAIs. In addition, if clinical professionals start an LAI when a consumer is in the hospital, case managers make sure to follow up with the consumer to make sure they get to the outpatient provider organization for their next dose when it’s due. They also have a “concierge program” within their pharmacy network and customer service representatives call members to schedule an appointment for their next LAI dose. Some pharmacies are also authorized to administer the LAIs. Sunshine’s provider relations team is charged with providing information about LAIs to community mental health and primary care provider organizations.
Ms. Matyas said, “We have a goal of increasing long acting injectables 25% year over year. During the pandemic, we had interruptions with folks getting their long acting injectables, but we are working towards getting back to normal state, which is encouraging.” And now there are two barriers to overcome to extend the use of LAIs, she added. The first is adherence which becomes challenging when consumers are say, cycling in and out of homelessness and are not stable in their environment or engaged in their treatment. The other issue is that there’s a history of long acting injectables not getting authorized by managed care. So provider organizations need to be educated and learn that “they don’t have to jump through a lot of hoops” to be able to prescribe LAIs if appropriate for the consumers.
Focus on primary care. Sunshine Health is encouraging provider organizations to go the integrated care route by participating in health home models and value-based reimbursement (VBR) models. They are also leveraging data to encourage collaborations and equipping primary care provider organizations to better address the needs of SMI consumers. Recently, they launched a behavioral health home program and seven community mental health centers have signed up to date. These centers have co-located primary care and behavioral health services and are delivering whole-person care under value-based contracts.
VBR is the cornerstone for integrated care. Sunshine Health offers incentives for provider organizations to address “gaps in medical and behavioral care.” In the behavioral health homes program, the incentive program is contingent on preventive health screenings being conducted for all consumers and on addressing the comorbidities that SMI consumers have. All provider organizations in Sunshine’s network—whether they are primary care practices or community mental health centers—are expected to address comorbidities and to report on the array of HEDIS measures related to both medical and behavioral care. Ultimately, Ms. Matyas explained, “The goal is to move more to value-based care, where we can impact members by having them in a health care environment so that they don’t have to go eight different places to get the care they need. They should be able to be more easily referred and seen, for whatever service it is they need. Value-based care incentivizes providers to work together without dictating a one-size-fits-all model.”
Sunshine Health embeds behavioral health services in primary care and offers psychiatrists who can consult on prescribing patterns and other issues in the care of SMI consumers. Ms. Matyas explained, “Every member covered by us is assigned a primary care provider regardless of whether they have an SMI diagnosis or not. So every one of the 5% of our 2.6 million members with SMI has a primary care physician. We take the data to our primary care practices and say, ‘Here are the demographics of the population assigned to you and here are the care gaps.’ The primary care practices will tell us whether they can handle the whole-health needs of these SMI members or want us to move them to a different provider. Or the practices may say they are equipped to handle some things but not others. So then we bring in behavioral health quality practice advisors to work with them, or we move the SMI members to a primary care practice that is better suited to work with this population.”
Addressing social support needs. Sunshine Health addresses social determinants of health (SDOH) in a variety of ways. Many of their behavioral health provider organizations have robust case management programs and the case managers connect consumers to social supports as needed. The health plan maintains a database of community resources that these case managers can access on request. They also offer micro grants to small community projects that support social needs. Some of their Medicaid programs, like the SMI specialty plan, have expanded benefits such as housing rental deposit or one month’s advance rent to help consumers get into housing. They’ve distributed cell phones and tablets for consumer use. SMI consumers get $35 a month in over-the-counter benefits from CVS to buy non-prescription items.
The fact that health plans are looking at primary care as the hub for SMI treatment should be a wake-up call for specialty provider organization executives who believe that their niche in serving this population assures a steady stream of business. Assuming responsibility for the whole-person care (medical, behavioral, and social) of the SMI populations served and participating in value-based arrangements are becoming the basics for sustainability planning.
For specialty provider organizations, the question is how to address SDOH—and find a funding stream to do just that. Previously, we outlined the two paths to adding social service supports and supports coordination to traditional service lines. One way is to add a social supports coordination element that will get more referrals or improve reimbursement under value-based reimbursement arrangements—and pay for itself as an enhanced service feature with more total revenue for existing services. The other way is to build social supports programs that health plans or government payers will reimburse—and build a new revenue stream. Whatever option an executive team chooses, return-on-investment analysis is key. I wrote recently about our six-step model for assessing the effectiveness (both proactively and in practice) of enhanced social service programming in Building An ROI For Social Service Referrals.
Partners in Care Foundation builds community networks to provide a single point of access for consumers. Partners in Care contracts with health plans—and sometimes with health systems—to provide care management and home and community-based social services. Their goal is to integrate all community health resources and supports into a seamless delivery system for easy access and management. Ms. Simmons said, “If you’re just referring Ms. Smith to go down the street where they provide meals, it’s one thing. But if you’re paying for something, it’s a whole new paradigm. And sometimes you’re going to have to pay for care coordination and concrete services on a targeted basis.”
Partners contracted with Blue Shield of California (BSC) in 2014 to provide SDOH services to BSC consumers through primary care practices. BSC pays Partners for specialized staff—community health advocates (CHAs)—who are trained and supervised by PIC, and embedded in medical practices. To date, Partners has trained and placed 70 CHAs in three years. CHAs assess and analyze consumer needs, work with consumers on care planning, connect them to services, follow up, and track outcomes. The relationship with BSC has grown since over time, with Partners providing a variety of SDOH-related services.
Partners also operates specialized Outreach and Engagement Centers for Anthem in California, Georgia, Colorado, and Virginia. Through these centers, they develop care plans, engage with consumers, and make sure they get the needed social services. “You can take a horse to the water but you can’t make it drink. So engagement is crucial to ensure that consumers actually use the services they are connected to and that’s why the health plans partner with experts like us.”
For health plans, the benefit is in contracting with a single entity that manages the comprehensive network of social care. Access to supports becomes easier for consumers. Data sharing between the health plan and community-based organizations is also streamlined and simplified. Ms. Simmons said, “So if you’re a health plan and want to address a certain population—maybe it’s young moms and kids, maybe it’s frail elders and keeping them out of the nursing home—are you going to go out and identify all the agencies involved, organize them, and contract with them? Or would you like a lead entity that’s going to do that for you—curate the services, qualify the agencies, be the central intake, the oversee the quality, and do the billing?” Working with a trusted local entity is a far more practical and efficient route for health plans in Ms. Simmons’ opinion. She said, “A more mature community entity can bring their neighboring health and human service provider organizations into an organized delivery system, so consumers don’t have to be referred to multiple entities.”
Resources for Human Development addresses food and housing needs. RHD provides outpatient and residential services for consumers with mental illness, substance use disorders, and intellectual and developmental disabilities. RHD partnered with Temple University Hospital and two managed care organizations (MCOs)—Health Partners Plans and Keystone First—to pilot the Housing Smart program. The program was intended to reduce avoidable emergency room utilization and hospital readmissions among homeless individuals through peer outreach, supportive services, and subsidized housing resources.
The MCOs agreed to criteria for eligibility and generated a list of member referrals for RHD. RHD provided the high-users experiencing homelessness with access to housing vouchers that are good for two years. The consumers were housed in apartments across Philadelphia and local food banks provided three meals a day for three months, followed by cooking classes. The pilot resulted in a 74% drop in emergency room use, 48% reduction in hospitalizations, and a 76% increase in outpatient hospital visits. And with stable housing, 12 consumers in the program are actively engaged in behavioral health outpatient services.
At the outset of the program, Temple generated a list of eligible people using target population criteria and shared that with the MCOs. They enrolled 25 high utilizers prioritizing consumers with opioid use disorder, persistent mental illness, and co-occurring physical health conditions. RHD used an MCO-funded team comprising a peer support specialist, care coordinator, and tenant services coordinator to engage consumers in services. While the MCOs reimburse for services, 36% of the program is grant funded and goes toward housing, Ms. Harris said. RHD is exploring expanded health plan funding, now that Pennsylvania allows health systems and MCOs that can save money through a value-based agreement to use the profits to fund housing.
Lessons learned—partnership, evidence-based interventions, data sharing, and more. Ms. Simmons shared the four key elements for successful integration of SDOH—strong partnerships to form a comprehensive community network of care, the capacity to deliver home-based services, the use of good screening tools to assess consumer needs and preferences, and the delivery of evidence-based interventions for SDOH.
At RHD, Ms. Harris attributes the success of their pilot to robust partnerships and collaborations (between provider organizations, a health system, health plans, and other community organizations); cross-sector tools and training; and data sharing to enable a holistic view of consumer needs, goals, and care gaps.
The takeaway for provider organization executives? As my colleague and OPEN MINDS Senior Associate Cathy Gilbert, who moderated the session, said, “Entrepreneurial provider organizations have the opportunity to package many consumer support services that were previously not reimbursable and turn them into new revenue streams in partnership with plans. Providing these services drives better outcomes for consumers and ultimately reduces overall costs.”
The Massachusetts Federally Qualified Health Center (FQHC) Telehealth Consortium’s 35 community health center members have conducted more than one million telemedicine visits since the start of coronavirus disease 2019 (COVID-19) in March of 2020. This achievement comes at the same time the Consortium has passed the halfway mark of its Phase II $12 million fundraising goal – thanks to a major grant from the Gordon and Betty Moore Foundation – to attain sustainable telehealth capacity at health centers and address health disparities in the communities served by them.
Consortium data measuring telehealth use between May 2020 and May 2021 show that telemedicine visits have provided safe and convenient access to primary care for communities of color, which have been disproportionately impacted by COVID-19. Of the 767, 234 Massachusetts health center consumers who accessed primary care via telemedicine visits during that year-long period, more than 52% were white, nearly 21% were Black/African American, more than 6% identified as more than one race, more than 5% were Asian/Pacific Islander, and 1% were Native American. Of those identified by ethnicity, nearly 31% were Latinx/Hispanic.
According to the data, the same held true for behavioral health care services. Of the total number of consumers taking part in behavioral health telehealth visits during the same one-year period, nearly 56% were white, more than 23% were Black/African American, more than 5% were of more than one race, 4.65% were Asian/Pacific islander, and less than 1% were Native American. By ethnicity, 31% again identified as Latinx/Hispanic.
Phase II of the Consortium’s campaign is focused on ensuring that FQHCs have what they need to fully develop, deploy, sustain, and integrate telehealth modalities into primary and behavioral care, while also addressing the digital divide in their communities. This includes providing better access to broadband and remote monitoring equipment, increased digital literacy training, peer learning, outreach in communities that health centers serve, and online dissemination of best practices.
Phase II of the campaign launched in the fall of 2020 with $1,040,000 received from an anonymous donor to create skilled bandwidth at nine pilot sites required to integrate advanced, durable, and mature telehealth capabilities into member FQHCs. Another $3.1 million grant awarded by the U.S. Federal Communications Commission (FCC) in January as part of the FCC Connected Care Pilot Program is providing equipment and hot spots for consumer broadband access. The grant from the Gordon and Betty Moore Foundation ($878,000) is designed to increase the number of consumers with controlled hypertension, particularly for African American/Black consumers, and to test the additional value of telehealth navigators and clinical intervention over federal funding of remote monitoring.
The Consortium is a partnership of Community Care Cooperative (C3), the accountable care organization (ACO) that advances community-based care for MassHealth members, and the Massachusetts League of Community Health Centers, the state-based association of health centers.
Community Care Cooperative (C3) is a not-for-profit ACO that leverages the proven best practices of ACOs throughout the country and is the only ACO in Massachusetts founded and governed by Federally Qualified Health Centers (FQHC) and exclusively focused on advancing integrated and coordinated community-based care for MassHealth members. C3 works with its 18 member FQHCs to strengthen health centers across the state, and continued growth enables C3 to better serve MassHealth members across the Commonwealth. To view a list of C3 health centers, click here.
The Massachusetts League of Community Health Centers (the League) is a not-for-profit membership organization supporting and representing the Commonwealth’s 52 community health centers, which offer primary and preventive care to more than one million residents. The League serves as an information resource on community-based primary care to policymakers, opinion leaders, and the media. It provides a wide range of technical assistance to its health center members, including advocacy on health policy issues, support for workforce development, clinical care and technology initiatives, and guidance to state leaders and community-based organizations seeking to open health centers.
The Gordon and Betty Moore Foundation fosters path-breaking scientific discovery, environmental conservation, consumer care improvements, and preservation of the special character of the Bay Area.
This was reported by The Massachusetts FQHC Telehealth Consortium on August 24, 2021.
On July 29, 2021, Gateway Health, a Pennsylvania Medicaid managed care plan, and WellSpan Health a health system in central Pennsylvania launched a value-based partnership focused on connecting Gateway Health members with primary care professionals. Gateway Health and WellSpan are proactively contacting Gateway Health’s Medicaid members who visit the health system through emergency or urgent care visits, but do not have a relationship with a primary care provider organization. WellSpan case managers will work one-on-one with the Gateway members to address barriers, such as transportation and cost, to establishing an appropriate primary care relationship. Financial details about the partnership have not been disclosed. The goal is to reduce the number of potentially preventable emergency department visits among Gateway members.
Through this value-based partnership, Gateway Health and WellSpan aim to deliver an enhanced level of care, improve health outcomes, and lower health care costs for Gateway Health’s Medicaid members receiving care at WellSpan’s 200-plus health care locations. The partnership will utilize data insights and value-based programs to proactively manage the health care needs for more than 24,000 Gateway Health Medicaid members living in South Central Pennsylvania.
This partnership expands on an existing relationship between Gateway Health and WellSpan. For the past 18 months, they have partnered together for better maternal care and coverage through Foundations Pregnancy Support Services, a program offering coordinated, comprehensive care for mothers and their children with opioid use disorder. WellSpan partners with other Medicaid insurers to provide this support. However, WellSpan said that the commitment and innovative partnership with Gateway Health has resulted in more than double the number of members enrolled than with any other insurer.
Gateway Health was founded in 1992 as a Medicaid managed care plan. It currently provides Medicaid and Medicare Advantage plans. It covers health care services for nearly 340,000 members annually.
Non-profit WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. It has more than 1,600 employed physicians and advance practice professionals; a regional behavioral health organization; a home care organization; eight hospitals, and more than 200 consumer care locations.
But for the executive teams that are taking their organization in that direction, the strategic question goes beyond getting the contracts. It is also how to manage VBR reimbursement arrangements successfully—for the consumer and for their own bottom line. In the executive roundtable at a recent conference, VBR: Where’s The Beef? Managing Payer Expectations For Value Over Volume, two health plans executives—Cindy Ehlers, MS, LPC, Executive Vice President, Clinical Operations at Trillium Health Resources and Rhett Melton, Chief Executive Officer at Partners Behavioral Health Management—described their expectations from provider organizations. And two provider executives—Corbin Petro, Chief Executive Officer at Eleanor Health and Teri Herrmann, MA, Chief Executive Officer at SPARC Services & Programs—described their approaches for success with value-based models.
Our payer and provider executives highlighted four aspects of a value-based relationship that are essential for success—an aligned partnership model, knowing what to measure and why, managing the cost side of the equation, and building in processes that allow flexibility in care planning and delivery.
Well-aligned partnerships are key. Provider organizations have traditionally had “vendor” relationships with health plans—relationships that have bordered on adversarial. Our panelists pointed out that it’s important for providers and payers to lose the “us versus them” mentality and come to the table together to see how they can best serve consumers. Mr. Melton said, “There are three people at the table. There’s the payer, there’s the provider, and there’s the member. We start with the members themselves. It’s not us at the managed care company that should sit in an office somewhere and decide what’s the right outcome, we should be working with our members to say, ‘What do you want out of care? What do you want success to look like? What do you think is important in the care that you get?’ That is how we can demonstrate the so-what.”
To build these partnerships, many health plans are willing to do what it takes to help provider organizations prepare for the shift away from fee-for-service. Both Trillium and Partners Behavioral Health provide support for technology infrastructure upgrades and offer training and education for provider organizations. Mr. Melton said, “We invest in improvements because that stabilizes the system. If a short-term financial cost to the managed care organization can improve accessibility and stability for members, it’s important. We’re looking to walk alongside provider organizations and to bring some of that training to help them grow along with us.” Ms. Ehlers added, “We’re trying to meet providers where they are. So for those that need infrastructure, we try to guide them in that direction. Sometimes we invest in infrastructure to help move them forward. Because it matters to the care of the member. We’ll work with them on training. Lots of providers have done really good work in moving forward as soon as they know that is something they need to do. They’re eager to learn and try.”
Measures are important but must be consumer-centric. The very essence of value-based contracts is performance measurement—it is the means to move away from volume as the foundation of reimbursement. There is a wide range of performance measures in VBR—those affecting cost of care and HEDIS measures being the most common (for more, see our OPEN MINDS-recommended performance dashboard in 12 Steps To Creating Your Data-Driven Organization.)
But the focus on performance for consumers needs to be front and center according to our panelists. Mr. Melton explained, “We require reporting on HEDIS measures—timely follow up from hospitalization, keeping the emergency department utilization down, and decreasing the days of inpatient hospitalization. It is all those things, but we always need to come back to what all those things mean for member satisfaction. It’s great for us to say the days dropped by X number per 1000 for inpatient care. And that’s a good indicator and there are certainly cost ramifications. But did the members think that they had good access to care? And are they happy with the care?”
Ms. Petro said that in its value-based contracts, Eleanor Health (see Eleanor Health’s Value-Based Approach To Medical Homes For Consumers With Addictions & Complex Support Needs) reports on HEDIS measures—emergency room diversion, reduction in hospital readmissions, and net promoter score. But she emphasized that each of these measures is tied to goals that they have defined in tandem with payers and that are consumer-focused. These include improving access to care, engaging the 90% of consumers with substance use disorders who currently don’t seek care, and reducing the total cost of care. She said, “An important part of any value-based payment model is orienting around specific outcomes. This has also been where I saw the most opportunity, having come from the physical side of health care. There aren’t a lot of entities that are tracking to specific outcomes. So payers have been really excited about what we’ve been able to show for the populations that we work with. And outcomes are particularly important for stigmatized populations that historically haven’t been treated well by the health care system. So metrics are an important part of our value models.”
Ms. Herrmann discussed their health plan contracts, which have both upside and downside risk. The incentives can include keeping consumers out of the hospital. Penalties may be incurred if consumers enter residential treatment unnecessarily or exceed a certain length of inpatient stays. However, she said, “They’re really all looking at that same piece—are we able to support that person remaining healthy and in their community, and not using the hospital systems when they don’t need to be? But if residential treatment is needed to keep them safe, are we ensuring that they can get that treatment? Are we doing all of the things that we can do clinically, and giving the clinicians the freedom to intervene in unique ways that fee-for-service doesn’t always allow us to do?”
Cost management is as important as revenue management. There are two parts to the simple equation underlying alternative payment models: Value = Performance/Cost. Performance metrics are critical but cost management is essential for sustainability of provider organizations under these arrangements.
The first step is the understanding how much services costs. There are unit of service costs. But that is only the first step. Cost of care across the continuum and over time are critical measures. Ms. Ehlers said, “Providers don’t know how much services cost, because they have a whole lot of stuff rolled up into their administrative overhead. And so when it comes down to a discrete service, a lot of times they’re unable to tell us what it actually costs them. That’s one of the things that slows us way down.” (For more on this, see our OPEN MINDS Value-Based Contracting Risk Assessment Checklist.)
And there is another cost issue. Delivering services with downside financial risk often requires additional infrastructure with additional costs. This includes capacity to collect data, capacity to analyze data for population health management, ability to run service utilization prediction models, ability to exchange healthcare information, care management functionality, and consumer portal functionality—see The OPEN MINDS Value-Based Reimbursement Readiness Assessment Checklist). Ms. Petro said, “I would argue that the greater piece of information that we can show is the impact that we’re having on the quality and the costs for the that individual we are serving, as opposed to the cost of intervention. We need to know the impact of delivering care that often isn’t supported in a fee-for-service environment—the community health worker and peer support services that break down those non clinical barriers to care. Or are the costs keeping people healthy, keeping people out of the hospital, and really having that total impact?” Her advice is to “move from a billable service metric to a caseload or a risk-adjusted caseload metric” and look at how the needs of a population or set of members is being met. She said, “You really have to look at what do these patients cost? Why do they cost this much? Where are the opportunities for savings? Are they all in the right levels of care and do they have access to care?”
Value fosters flexibility—with a caveat. Provider organization clinical managers have often expressed frustration with the restrictions imposed by “billable services.” The general consensus is that fee-for-service reimbursement hinders a whole-person approach and doing what is best for the consumer. But value-based models bring newfound flexibility, our panelists agreed. At SPARC, value-based models have given clinical professionals a lot of freedom and flexibility to adjust levels and intensity of care based on where consumers are. For example, they have 6-month authorizations so there’s no need to go back to the payer for more units. The administrative burden is significantly reduced.
But there is a caveat. While there are not rules on the volume of care—or necessarily the type of care—clinical professionals are held accountable for outcomes. Ms. Herrmann said that they discuss their commitment to value-based models while hiring clinical professionals. They stress that the clinical team will have flexibility in how they deliver care but also have “skin in the game” for delivering good performance. She said, “We talk about the fact that we have opportunities for incentive payments as an agency if we’re able to keep the children and families we’re working with out of higher levels of care, and if the things that we do stick and work. Then we translate those into incentives for the clinicians.”
This is not about giving carte blanche to clinical professionals to use whatever treatment models they choose. It is providing a framework for consumer-centric, structured flexibility through ongoing assessments and clinical support tools.
These four keys to success may seem like a stretch for many provider organization executive teams. But, as Mr. Melton said, they should be “comfortable being uncomfortable.” The investment required—new best practices in partnerships models and management, in data-driven decisionmaking, in cost management and use of decision support tools—is one part of the equation. Building the management team that can use those tools is the other.
We’ve covered the “triple whammy” of the pandemic on next normal health care—shifting competition based on changing consumer expectations, payer expectations, and price points (see Post-Pandemic, Strategy Needs Technology). I got a better sense of the market factors driving these changes—and the new competencies required for success—in a recent article, How Digital Is Changing The Pharma & Healthcare Industry, by Nikki Gilliland at Econsultancy. My takeaway is that there are four new competencies that executive teams should be thinking about to stay in the game as the effects of the pandemic digital shift become standard market factors.
To start with, the “must have” hybrid service model requires digital first consumer intake processes. For care coordination programs to be successful—and cost-effective—remote monitoring capabilities will likely be a “must have.” Another takeaway—to improve consumer engagement, social communities need to be built on and integrated into existing commercial internet platforms. And finally, without a robust web presence and expertise in search engine optimization, competing for referrals will be increasingly difficult. These are the next frontiers in organizational infrastructure for competitive advantage—and I’m adding them to my specialty provider organization competency map (see From Crisis To Growth: A New Leadership Mindset).
Digital first consumer intake/interface is critical to success with hybrid models. The pandemic has moved much of care delivery to virtual. But as we move to the post-pandemic landscape, the preferred service delivery modality is a combination of virtual and in-person care in clinics and in consumers’ homes. Recent research confirms this preference—in a national survey, more than 40% of consumers said that when it comes to mental health and routine care, they’d rather access services virtually or through a combination of virtual and in-person visits (see Post-Pandemic, Majority Of Patients Say They Prefer In-Person Care, Survey Finds). And a Healthgrades study found that when given a choice between health care providers with similar experience, proximity, availability, and patient satisfaction ratings, the vast majority of consumers—81% for primary care and 77% for specialists—choose the provider who offers online scheduling (see Specialty Care Strategy For A Tech-Enabled Future).
To make hybrid services an operational reality at scale, provider organization executive teams should develop a digital first consumer intake process with a well-designed “digital front door.” This intake process should include real-time appointment scheduling that is linked to both benefits eligibility information and the schedules of clinical team members. Many components of the digital front door, including online scheduling, can likely be built into existing EHR systems but standalone technology platforms are also available and can be integrated with current technology platforms.
Best practice care coordination will require leveraging personalized remote monitoring. Care coordination and case management services are slowly moving to risk-based and value-based reimbursement models—with reimbursement tied to outcomes. To be competitive in this market space, provider organization managers will likely need to deploy a coordinated suite of tech-enabled functionality. What does that look like? Decision support tools for care coordinators, driven by consumer data. Smartphone-based outreach to consumers for active monitoring, self-care supports, and engagement. Passive remote monitoring tools for staying on top of consumer health status over time. Market advantage will go to the organizations that can reduce costs by leveraging their clinical workforce with technology, while managing and optimizing performance and consumer outcomes.
Consumer engagement success will depend on strategies to build specialized social communities on existing platforms. Consumer engagement and participation in managing their health is key to making value-based reimbursement work. The question for clinical management teams is how to connect with those consumers. There are many standalone consumer web portals, discussion boards, blogs, and more. But getting traction with those standalone initiatives is difficult. Rather, consumers are likely to discuss issues and seek health care information, opinions, and suggestions from channels they are already active on. Provider organizations should consider facilitating social networks on existing platforms for their consumers and encouraging staff to weigh in on these online communities to share expertise when appropriate.
Social media platforms like Facebook, Twitter, Instagram, and YouTube (and to a lesser extent, LinkedIn), as well as messaging apps like What’s App and WeChat (in China) host consumer and caregiver groups with interest in specific conditions and treatments. Some of the newer apps for behavior-based chronic disease management also include a social component to let consumers engage with peers. But most consumer and professional engagement communities are web-based—they can be found through simple online searches and accessed with a web browser, while they also maintain a presence on all the major social media platforms. A Pew Research survey indicated that 26% of adult internet users had read or watched someone else’s health experience about health or medical issues in the past 12 months. And 16% of adult internet users in the U.S. go online to find others who share the same health concerns (see The Social Life Of Health Information).
There are a number of existing online communities. For example, MedHelp has communities for mental health, general health, diabetes, heart disease, pregnancy, and coronavirus. PsychU offers information, resources, and collaboration and discussion platforms on challenges and treatment approaches for mental health professionals. Verywell Mind offers consumer-friendly information, generated by clinical professionals, on a range of mental health topics. And, HealthUnlocked offers technology to build health communities and is available free to nonprofits, health advocates, and consumer organizations to start new communities.
Web presence and SEO expertise are needed to compete for customer eyeballs. As care becomes increasingly virtual, referrals will become increasingly virtual. Today, 13% to 17% of visits across all of health care are conducted via telehealth—which is 38 times higher than pre-pandemic use of virtual care (see Telehealth: A Quarter-Trillion-Dollar Post-COVID-19 Reality?). Prior to the pandemic, 67% of consumers searched for health care information online and 60% searched for provider reviews online (see Digital Health Consumer Adoption Report 2020). The pandemic has likely increased this consumer behavior and will also likely change the nature of professional referrals.
As executive teams consider whether their current website and web presence is an impediment to success or an asset, there are some basic questions to ask. Is the website content, user experience, search engine performance, and online reputation strategy meeting current consumer and referral source expectations? (For more, see our on-demand OPEN MINDS Circle Executive Roundtable Session, Designing Best In Class Websites: The OPEN MINDS Website Evaluation & Improvement Process.) The answers will drive strategies for enhancing the online brand presence, upgrading web site design and content, evaluating paid web advertising options to be “found” in web searches, and linking content to social platforms in order to increase reach to consumers and health plan partners.
The bottom line? To meet the preferences of consumers and health plans—and succeed with new reimbursement rates and models—executive teams need to make a few additions to their “core competencies.” This will involve broader planning of infrastructure, both technology and human. The key question is not “What technology should we invest in?” but rather to define how technology can help to drive strategic objectives.
For more on the organizational competencies needed for strategic success, check out these resources:
If your organization is one of many that is thinking about moving to a hybrid service delivery model—virtual, in-clinic and in-home—your team will need to learn more about electronic visit verification (EVV). EVV was mandated for all home-based services by the 21st Century Cures Act, passed in 2016. The act required all state Medicaid programs to start using EVV for personal care services (PCS) by January 1, 2020 and for home health care services (HHCS) by January 1, 2023. EVV is essentially electronic verification that in-home service encounters actually occur and documents the type of service performed, the individuals providing and receiving the service, the date and location of the service, and the time the service begins and ends.
EVV is required for all Medicaid covered in-home visits for personal care and health care services including nursing; home health aide services; and medical supplies, equipment, and appliances that are delivered via an in-home visit under the state’s home health benefit. States also may choose to require EVV for in-home physical therapy, occupational therapy, speech pathology, audiology, and other services (see Frequently Asked Questions: Section 12006 Of The 21st Century Cures Act). CMS does not require EVV in some instances—when the caregiver and consumer live together, for congregate facilities offering 24-hour services, or for Programs of All-inclusive Care for the Elderly (PACE)—although individual states may mandate otherwise.
While EVV does not specifically track consumers and staff, it does require multiple check-ins by staff at specified times with location identification—through a smartphone app with GPS tracking, the use of a landline phone in the consumer’s home, or signing into a device in the consumer’s home. For provider organizations required to comply with EVV mandates, the level of investment depends on the model chosen by their state. States have five options—an open model where provider organizations use their own EVV systems; EVV systems mandated by health plans; a single statewide vendor to be used by all provider organizations; build and manage a state-owned EVV system; or allow provider organizations to opt to use the state system or their own EVV system compatible with the state’s data aggregator (see EVV Systems Section 1: Requirements, Implementation, Considerations, & State Survey Results).
While the intent of EVV is to avoid fraud and ensure that consumers get the services they are supposed to get, there is widespread concern by consumers and advocacy groups on the practical challenges and alleged threats. For example, caregivers in Arkansas have complained about glitches in the state-mandated EVV app that have resulted in missed service entries and delayed paychecks. The Arkansas compliance requirements also have been criticized for placing undue burden on on live-in caregivers and on self-directed consumers who hire their caregivers directly and manage their own services. And some stakeholders do not like the sense of “constant surveillance.” Consumers complained that having an EVV system was comparable to having a wireless dog fence or ankle monitor (see ‘We Don’t Deserve This’: New App Places US Caregivers Under Digital Surveillance).
Other concerns have been expressed about the EVV impact on consumers—the Arc describes it as a “civil rights issue because of the concern around unintended consequences of impeding upon an individual’s privacy rights.” EVV systems that have video and audio recording functionalities and geotracking are not acceptable (see Call For Electronic Visit Verification Delay Grows Strong Nationwide). The National Council on Independent Living decried EVV for being “based on the archaic and offensive idea that disabled people and seniors are unable to leave their homes.” They criticized EVV for requiring multiple check-ins a day from the same location, for geotracking, and for imposing additional burdens on states (see NCIL Position Opposing Electronic Visit Verification).
What are the implications of EVV for specialty health and human service provider organizations offering home-based services? There are a few big issues to contend with—adopting new technology, creating new service delivery workflows, revising policies and procedures, training staff, and educating consumers and obtaining their input. OPEN MINDS Senior Associate Jason Lippman said, “EVV plays into a lot of digital trends we are seeing all around us—requirements for more data and more accountability. And the systems that work as intended can provide more data for planning and management of resources. The key is designing systems to collect that data that are least intrusive for both consumers and staff, creating efficiencies, and mitigating for unintended consequences and privacy issues.”
Like the EHR requirements of the past decades, the requirements for documentation of services delivered in home-based settings are likely not going to go away. And, it is likely that the EVV requirements will prove to be another factor—like value-based care, interoperability requirements, and hybrid service delivery models and ecosystems—that put larger organizations with better technology planning competencies at an advantage. Mr. Lippman pointed out, “As we gear up for 2023 and wait for the HHCS provisions around EVV to kick in, provider organizations should not put off being prepared—now is the time to start looking into what the state is currently doing with PCS, and to initiate the infrastructural and operational changes that will be required to accommodate digital tracking of remote services.”
For more on EVV preparation and management, check out these resources in The OPEN MINDS Circle Library:
Value-based care is here! If you haven’t started thinking about what it is you need to compete in a value-based environment, now is the time to start. With the rise in value-based care contracts and utilization of alternative payment models, provider organizations are challenged with doing the research and homework to get prepared for these new ways of managing care.
Hear an update on where we are with value-based care from OPEN MINDS Senior Associate, Ken Carr, as well as a firsthand case study from Capital Area Human Services (CAHS) on their journey to value-based care. CAHS Director of Business Development, Karla Lee Muzik, and Program Manager, John Nosacka, will showcase how their organization discovered they had been losing money by not having the right technology and how they began to remedy the problem.
During this session, attendees will:
Understand the current state of value-based care
Discover how to tell if they too are losing money with the wrong tools and technology
Hear a real-life case study from one provider organization who was losing money by not having the right tools to succeed with value-based contracting