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Finding the Value in Value-Based Contracting
RCPA Conference
September 30, 2016
Perspective
What We’re Going to Cover
– Key elements of value-based contracting
– Importance outcomes measurement
– The use of data to understand your business
– First steps
The History of BH Financing in PA Or, everything old is new again
• 70/80’s
• 90’s
• HealthChoices – FFS
• P4P
Current System Challenges
• Payment Models
• Underfunding
• Impacting Change
Regulatory Challenges
• Travel/Billing restrictions
• Billing
• Confidentiality
• BH/PH Integration
• PROMISe
• FLSA
Health OutcomesBehavioral
Patterns, 40%
Social Circumstances, 15%
Genetic Predisposition,
30%
Environment, 5%
Health Care, 10%
• What does this mean?
• What impacts outcomes?
• Can you PROVE impact?
SOURCE: Schroeder, SA. (2007). We Can Do Better — Improving the Health of the American People. NEJM. 357:1221-8
Social Determinants
Economic
Stability
Neighborhood
and Physical
Environment
Education Food Community and
Social Context
Health Care
System
Health Outcomes
Employment Housing Literacy Hunger Social integration Health coverage Mortality
Income Transportation Language Access to healthy
options
Support systems Provider
availability
Morbidity
Expenses Safety Early childhood
education
Community
engagement
Provider linguistic
and cultural
competency
Life expectancy
Debt Parks Vocational
training
Discrimination Quality of care Health care
expenditures
Medical bills Playgrounds Higher education Health status
Support Walkability Functional
limitations
SOURCE: Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity, Kaiser Family Foundation November 2015
So, What is Value?
CMS thinks Value will:
• Improve clinical quality• Address misuse of services• Deliver patient-centered care• Improve patient safety• Avoid unnecessary costs• Reduce existing care disparities• Re-engineer processes and system-wide
workflows• Make performance results transparent
CMS Quality Strategy, 2014
How Do We Accomplish Value?
• What drives changes in behavior?
• How do you incorporate knowledge of social determinants?
• What role will care management have?
• What does patient-centered care look like?
• Can we provide culturally competent/informed care (and do it well?)
• What about disparities in engagement?
What is VBC Supposed to Do?
• Shift from volume-based service delivery
• Focus on the individual, not the diagnosis
• Wellness vs. illness
• Accommodate the “non-medical” stuff
• Allow for creativity
What Does VBC Look Like?
• Quality vs. Quantity
– Shift towards meaningful interventions, not
just number of units delivered
• Payments for meeting performance targets
– Outcomes
– Customer satisfaction
– Costs
How to Think About VBC
• Where are you now & what do you know?– Benchmarking
• What does your population look like? – Demographics
– Risk Assessments
• Clinical Responsibility– Do you have primary clinical responsibility for this
individual?
• Financial Risk– Know your costs and what your data says
Forecasting the Future
• Predictive Modeling
– Understanding the population
– Learning service patterns
– Monitoring intervention points
Defining True BH Outcomes is Hard
Outcomes – Allegheny County
• Outpatient Workgroup w/Community Care – 12 providers
– 4 years
– Measuring progress with appointments w/in 7 days of IPMH, second appointments, and engagement, > 3 appointments
– Provider performance incentives
• Outcomes Measurement Grant w/Jewish Healthcare Foundation & Staunton Farms Foundation (TCOBI)– 11 Providers
– Free capacity building and training initiative where group agreed to measure the same set of tools
– Measuring changes in PHQ-9, GAD-7 and/or RAS over time (began measurement period July 2016)
HealthChoices & Carve Out
• How does VBC work in a BH carve out?
• How can BH providers support PH initiatives and vice versa?
• Data sharing
* It’s happening, but everyone needs to be
committed to the process: County/MCO/Provider
How Do You Get Started?
BH Providers
Physical Health
Aging
Criminal Justice
Housing
Vocational Services
Child Welfare
Education
Community Health Choices
ID
Partnerships and/or Agreements should be in place with many different systems & groups
Service Agreements
• Understand and seek information on who else participates in care to your clients
• Develop agreements and communication channels between those entities
• Establish data sharing arrangements and consent documents
Data Drives Success
• Beyond data sharing, what else is needed?
• Real-time PH information:
– ED visits (preferably when they’re there)
– Hospital admissions/discharges
– Prescriptions/pharmacy changes
– Early warning signs
Using Data for Quality Assurance
Let’s assume you get even some of that data.
Now what?
• Data mining
• Analysis on populations
• How to act on the information
Using Data for Quality Assurance
• Find a translator - someone who speaks IT AND clinician (note: start looking, they’re hard to find)
• Develop a culture where clinicians see/understand/use this data
• Work to use information to inform clinical practice
Quick Survey - EHR
• Who uses an Electronic Health Record?
– Is it really just your billing system?
– Does it integrate all client information into one
place?
– Can it accept external data?
– What type of reporting do you get?
– Do you actually use those reports?
Using Your EHR for VBP
• Development of decision support tools
• Using EHR for more than “today’s visit”
• Integration of PH data and other information
• Dashboards for administrative review
Using Data for Financial Purposes
• Determining your true & total cost of care
– This is not your budget!
– How much does each visit in each level of
service cost?
– What’s your total cost per person?
• Segregate by diagnosis
• Are there other segments worth reviewing?
– Fixed vs. variable costs
Value
• Combining the quality and financial data to determine Value
– Does the math work?
– Do your clients agree?
– What are the trends?
Organizational Assessment
Assess your:
– Financial position (cash flow/reserves)
– Risk tolerance
– Clinical work flows
– Clinical staff
– Administrative/operational systems
– Client population
Leadership’s Role
• Engage your Board of Directors & ensure their support
• Engage your senior clinicians and leadership team & work towards their support
• Consider how risk-tolerant you and the organization are willing to be
• Identify needs within your IT systems
• Begin preliminary discussions with your payors and partners
For Consideration
Are you comfortable:
– Stepping outside of your comfort zone
– Forging new relationships with different types of
providers/payors
– Navigating within a foreign payment arrangement
– Re-vamping your clinical and administrative
processes
– Serving all of the needs of the individuals with
whom you work
On Declaring a New Strategy
• Get clear on your role within the system
• Understand the financial implications
• Be able to quantify “value”
– Through data
– Through satisfaction
But all of this is irrelevant if you’re not meeting the needs of those you serve
Considerations for Serving Your Clients
Does this new strategy address:
• Time
• Money
• Control/Individual Identity
• Legal Issues
• Capital
• Governance
• Economies of Scale
How Do You Create Your Infrastructure?
A level of capacity is needed to succeed in VBP
• Build it vs. Buy It– Make the case to large organizations that you’re a better
option than they can build, and support that with your data
• Outsourcing– What will you give up and to whom?
– How will you monitor performance?
• Collaborations
• Mergers
Considering Mergers, for a Minute
• Values
• Culture
• Cost/Economies
• Integration
• Risk
• Control
• Regulations
• Governance
• Integration
• Performance
First Steps
• Educate yourself and senior management
• Engage your Board
• Assess your level of readiness
– Variety of tools available
• Ensure that these types of endeavors are in line with your strategic plan
Choluteca Bridge
• In 1930, a Japanese engineering firm worked with the Honduran government to build the Choluteca Bridge.
• It was a state-of-the-art, much-needed access point for the people of the Honduras, built to withstand the high winds and hurricanes that plagued the region.
• Then in 1998, the unthinkable happened. A tropical storm in the Caribbean Sea turned into a brutal category 5 hurricane hit and Honduras was decimated—but, just as intended, the Choluteca Bridge stood strong.
• However, something very strange and unexpected happened that changed everything: The river moved and the bridge suddenly lead from nothing to nowhere.
#change
#adaptability
