Succeeding With Value-Based Reimbursement: An OPEN MINDS ...€¦ · I. The Fee For Service Business Model II. The Value-Based Reimbursement Business Model III. Becoming A Data-Driven

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Succeeding With Value-Based Reimbursement: An OPEN MINDS

Executive Seminar On Organizational Competencies & Management Best

Practices For Value-Based Contracting

S t r a t e g y & I n n o v a t i o n I n s t i t u t eM o n d a y , J u n e 3 , 2 0 1 | 1 : 0 0 p m – 4 : 0 0 p m

K e n C a r r , S e n i o r A s s o c i a t e , O P E N M I N D S

© 2019 OPEN MINDS

AgendaI. The Fee For Service Business Model

II. The Value-Based Reimbursement Business Model

III. Becoming A Data-Driven Organization

IV. The Role Of Population Health Management In A Data-Driven

Organization

V. The Role of Technology In Value-Based Reimbursement

VI. The OPEN MINDS Value-Based Reimbursement Management

Readiness Assessment

2

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I. The Fee For Service Business Model

3

© 2019 OPEN MINDS

Financial Model – Fee For ServiceVariable Costs

Create Less Risk

Under FFS

© 2019 OPEN MINDS

The Fee-For-Service Payer Network Contract

Most fundamental of all business relationships

for provider organizations in health

and human services

Often need to begin with privileging professionals

individually, rather than being privileged at the

organization level

Difficult market position but often

necessary

No assurance of volume and no

likelihood of referrals

Often ‘commodity’ positioning

© 2019 OPEN MINDS

Key Challenges In A FFS Environment

Revenue Cycle

• Aligning internal operations to manage payer requirements

Market Positioning

• Position the organization in the market to maximize payer opportunities

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Revenue Cycle

Referral & Intake

Service Delivery

Billing & Collections

Monitoring & Process

Improvement

• Verifications

• Authorizations

• Credentials

• Documentation

• Claims Submission

• Denials Management

• Payment Receipt &

Posting

• Claims Analytics

• Process

Improvement

© 2019 OPEN MINDS

The Goal: Preferred & Exclusive

Being ‘Preferred’ Within A Payer Network

Having preferential referrals due to some

market differentiation

Need a demonstrable value proposition –

almost always involving P4P or value-based

payment

Gaining ‘Exclusivity’ Within A Payer System

Having a financial relationship (most often with

significant financial risk) that gives you

exclusivity by geography and/or consumer type

Your organization is the ‘narrow network’


II. The Value-Based Reimbursement Business Model

9

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The Shifting Reimburse Market

A Change In Focus:

Reducing costs while delivering and

demonstrating value

A Change In Methods:

Managed Care & Value-Based Purchasing

© 2019 OPEN MINDS

Business Model Transition For Provider Organizations

Payer Policy

Pay-For-Cost/Volume

Payer Policy Pay-For-Value

Business Model

What is paid for is

good for the

consumer and

doing more is the

business model

Business Model

Giving the

consumer (and

their payer) good

outcomes at a low

cost, conveniently

A revolution in

performance

management

required

Focus on achieving

outcomes and

managing risk

Focus on maximizing

price and managing

volume

© 2019 OPEN MINDS

Why More Value-Based Purchasing (Risk-Based Contracting & P4P Contracting)?

• Increase “pressure” for improvement

• Facilitate consumer-directed careIncrease Transparency

Of Performance

• Improved access to care

• Increase care integration and coordination

• Person-centered planning and recovery focus

Link Professional, Service Provider

Organization, & Care Manager

Reimbursement To Desired Performance

• Financial incentives to help consumers become and remain healthy for longer periods of time

• Increase lower-cost interventions for “not yet seriously ill” population

• Reduce unnecessary use of high-cost services

Control Costs Of Care

© 2019 OPEN MINDS

Health Plan Reimbursement Moving From Volume To Value:Supporting “Integrated Care Coordination”

Compensation Continuum By Level Of Financial Risk

Capitation + Performance-

Based Contracting

CapitationShared RiskShared Savings

Bundled & Episodic

Payments

Performance-Based

Contracting

Fee-for-service

No Financial Accountability Moderate Financial Accountability Full Financial Accountability

Passive Involvement Provider Engaged Provider Active In Management Providers Assumes Accountability

Management Via 100% Case By

Case External Review

Internal Ownership Of Performance

Using Internal Data Management

Small % Of Financial Risk Moderate % Of Financial Risk Large % Of Financial Risk

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Changing Reimbursement Models

Provider Organizations With VBR Revenue

• 41% of primary care organizations

• 33% of behavioral health organizations

• 34% of child & family services organizations

• 14% of I/DD & LTSS organizations

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What Are The Pay-For-Value Reimbursement Options?

Case Rates

& Bundled Rates

Medical Homes & Specialty Medical

Homes

Capitation &/Or Population Health

Gainsharing Arrangements

With P

ay-F

or-

Perf

orm

ance C

om

ponents

Specialist

positioning

Comprehensivist

positioning

© 2019 OPEN MINDS

Managed Fee-For-Service

Provider Paid An Established Fee For A

Defined Service

• Clearly defined package of services to be provided

• Quality standards can be established for defined services

Varying Degrees Of ‘Management’

• Preauthorization

• Concurrent review

• Retrospective review

© 2019 OPEN MINDS

Pay-For-Performance

A term that describes health care payment systems that offer financial rewards to providers who achieve, improve, or exceed their performance on specified quality, cost, and other benchmarks

Pay-for-Performance

(P4P)

© 2019 OPEN MINDS

Capitation In Population Health Arrangements

Arranged with the physician, hospital, or other health care provider or plan

A contracted rate for each member assigned, known as the "per-member-per-month"

(PMPM) rate

Regardless of the number or nature of services

provided

Contractual rates are usually adjusted for age,

gender, illness, and regional differences

Capitation/Sub capitation

• PMPM for behavioral health treatment benefits (or other cognitive disability support services)

Behavioral Health Carve-

Out Capitation

• PMPM to cover the cost of care coordination and preventative services

Medical Home/Health

Home Capitation

• PMPM for primary care services (assess, prescribe, refer)

Primary Care Capitation

• PMPM for cost of delivering all (or some) of the care for a group of consumers

Global Capitation

Population Health Capitation

© 2019 OPEN MINDS

Example: Value-Based Payment Methodology

Goal for a pediatric practice is to immunize

80% of its patients by age 2, in accordance with the

nationally accepted immunization guidelines.

A provider that exceeds that goal and immunizes 90% of its patients would

receive bonuses in addition to the standard FFS reimbursement rate

from the payer.

© 2019 OPEN MINDS

All Types Of Services Moving To Pay-For-Value

Specialty medical homes for consumers with serious mental

illness (SMI), addictions, traumatic brain injury (TBI),

Alzheimer’s, and chronic health conditions – with all care

coordination services paid in per member per month (PMPM)

payment

Capitated contracts for Intellectual and Developmental

Disabilities (I/DD) services – Kansas Medicaid and 18 other

states to follow

Capitated contracts for senior services (including nursing

home care) planned for 19 state Medicaid plans

Case rates for children’s services in child welfare system

Case rates for TBI support services

Voluntary self-directed I/DD services with individuals

consumer budgets launching in California

Pay-for-value changes the rules for service reimbursement – and opens up opportunities for leveraging new science and technology to reduce costs and improve consumer convenience.

© 2019 OPEN MINDS

Strategic Financial Implications Of Shifting Reimbursement Market

Develop competencies and internal culture to

compete in a performance-based

market

Develop infrastructure and information

technology and re-align processes

Improve understanding of cost drivers – manage and

reduce costs

© 2019 OPEN MINDS

Value-Based Reimbursement Here To Stay Because...

• Political and competitive pressure on payers – federal

government and employers

• Downward price pressure on health plans

• The success of ‘some’ ACOs

• The early findings of the Medicare bundled rate

initiative

• Pressure on health plan medical loss ratios

Consumerism

Technology

adoption

Value-based

reimbursement

“Integration” for

improved cost and

quality


III. Becoming A Data-Driven Organization

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Tactical Data Focus

Data, No Outcomes

Focus

Data Driven

No Data Or

Outcomes

Outcomes Focus, No

Data

Data Management Discipline

Ou

tco

me

Focused In

tent

Tactical Orientation Grid

• Assesses organizations on tactical infrastructure to capture data, and cultural focus to use data to drive better outcomes

• Data-driven organizations must have data and an outcomes focused intent to use that data

© 2019 OPEN MINDS

Strategic Data Focus

Performance Tracking, But No

Adaptation Of Approach

Tracks Performance And Adapts Approach

No Performance Tracking Or Adaptation

Of Approach

Adapts Approach,

But No Performance

Tracking

Relate Efforts To OutcomesA

dju

stA

ppro

ach

Strategic Data Orientation Performance Domain

• Assesses organizations on their ability to adapt performance to improve outcomes

• Data-driven organizations must track and analyze services, and adapt performance to create social value

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Program Impact Data Focus

Program Results, Not

Those Intended

Data Demonstrates

Intended Impact

No Intended Results Or Supporting

Data

Intended Results, But

No Supporting

Data

Program Impact DataC

ap

acity

To D

eliv

er S

erv

ices

/ Pro

gra

ms W

ith F

idelity

Program Value Performance Domain

• Assesses organizations on their ability to deliver intended outcomes

• Focus is on program data, not capacities and practices of the organization

© 2019 OPEN MINDS

Achieving Data-Driven Decision Making

Tactical Orientation

Grid

Program Value Grid

Strategic Orientation

Grid

Data Driven

© 2019 OPEN MINDS

Key Effects Of Moving From FFS To Managed VBR

Focus On Outcomes

Create A Data-Driven Culture

Data, Analytics, Change

Management

Implement Effective

Technology

Manage Unit Costs &

Financial Risk

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Focus On Four Types Of Outcomes

The New Value

Assessment

Contract-Specific Performance

Measures

Routine Services & Transactions

Great Customer Service

Cutting Edge Expertise

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1. Contract-Specific Performance Measures

The floor for success

Requires a payer perspective

and a consumer perspective of

‘value’

Reflect outcomes that are the

costliest to the payer

Reflect outcomes that the payer

is accountable to achieve to

receive maximum reimbursement

Mandated Health Home

Performance Measures

Adult body mass index assessment

Controlling high blood pressure

Screening for clinical depression

and follow-up plan

Follow-up after hospitalization for

mental illness (7 and 30 day)

Initiation and engagement of

alcohol and other drug (AOD)

dependence treatment

Plan all-cause readmissions

Prevention quality indicator (PQI)

92: chronic conditions composite

Ambulatory care: emergency

department visits

Inpatient utilization

Nursing facility utilization

10 national health home measures

NCQA HEDIS measures

CMS STARS measures

Most common health plan

contract measures

Your specific health plan

contract measures

© 2019 OPEN MINDS

Follow-Up After Hospitalization & Readmission Rates Are The Most Popular Measures For Determining Performance

Top Five Performance Measures In Value-Based Contracts, %, 2019

22%

22%

23%

32%

36%

Access to caremeasures

Patient/consumersatisfaction

Emergency roomutilization

Readmission rates

Follow-up afterhospitalization

31

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Common HEDIS Measures Focused On Complex Populations

32

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CMS STAR Ratings

The use of CMS Star Ratings allows the Medicare program to determine the quality of all

Medicare-sponsored plans including Medicare Advantage and prescription drug MA plans.

Star Ratings for Medicare sponsored plans are determined using five major factors:

If Medicare beneficiaries remain healthy while on their plan

Management and improvement of beneficiary chronic conditions

Member experience with health plans

Customer service performance

Member complaints with health plans

Changes in overall health plan performance

Medicare collects quality data to determine a plan’s rating through regular monitoring of

health plan operations and beneficiary surveys that record consumer experiences.

Payers can achieve higher star ratings by investing in member engagement platforms and

developing strategic communications that build relationships with Medicare beneficiaries.

33

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CMS STARS Measures Focused on Complex Consumers

34

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2. Routine Services And Transactions

Consumer sovereignty - a business philosophy assuming the best profit

will come from providing customers with the best products and best

customer service at the lowest possible price

The Amazon

Doctrine -

above all else,

align with

customers.

Search engine ranking and optimization

scores

InquiriesInquiry

response time

Inquiry conversion

rates

Time to appointment

Service rates

© 2019 OPEN MINDS

3. Customer Service

Providing service that creates ‘passionate advocates’ of your brand

Designing workflow from a consumer experience perspective –

preventing consumers from “feeling like they are simply another

transaction”

Developing a written

service strategy to

ensure consistency of

consumer experience

- and cultivate

consumer loyalty

Net promoter scoreCustomer

satisfaction

Customer experience monitoring

(“mystery shopper”) results

Online reputation

© 2019 OPEN MINDS

4. Clinically Cutting Edge – A Consumer Advisor On Emerging Science

Can you be replaced by an online clinical decision support tool?

Understanding the new science in your area of specialization

Mastering the

new

technologies –

and integrating

them into your

service array

(whether you

provide them or

not)

Consistency in ‘treatment model’ -lack of unexplained

variability

Time to evaluation/adoption of

new treatment technology

© 2019 OPEN MINDS

Steps To Building An Effective KPI System

Identify performance measures – key measures for every domain

Set and communicate targets based on strategic and operational

success factors

Build a system to turn data into strategic insight

Communicate results through a dashboard

Drive results to targets through a system and culture of data analysis

and process improvement


IV. The Role Of Population Health Management

In A Value-Driven Market

39

© 2019 OPEN MINDS

“The health outcomes of a group

of individuals, including the

distribution of such outcomes within the

group”

Population health management seeks to

improve the health outcomes of a group by

monitoring and identifying individual

patients within that group...

A best-in-class PHM program brings

clinical, financial and operational data

together from across the enterprise and

provides actionable analytics for providers

to improve efficiency and patient care…

Population Health Management

© 2019 OPEN MINDS

Behavioral Health System Optimization Is Central To Successful Population Health Management

Consumers with behavioral disorders are often

‘superutilizers’ of health care resources

Undiagnosed and/or untreated behavioral health conditions

hinder the treatment of a wide range of medical conditions

Consumers with behavioral disorders and comorbid chronic medical conditions have higher

average costs than those consumers without comorbid

conditions

Lack of integrated care coordination – addressing the

medical, behavioral, and social needs of consumers - results in

poorer outcomes and higher cost per consumer

© 2019 OPEN MINDS

Key Components Of Population Health Management

Aggregation Of Health Data On A

Population Of Consumers

Analysis & Risk Stratification Of The

Health Data

Identification Of High-Risk

Consumers

Identification Of Optimal

Interventions For High-Risk

Consumers

Care Management & Follow-up


V. The Role of Technology In Value-Based Reimbursement

43

© 2019 OPEN MINDS

Shifting Role Of Technology In Health & Human Services

Administrative Tool

Compliance Requirement

Platform For Competitive Advantage

© 2019 OPEN MINDS

The Shift From The Functional To The Strategic

The result of compliance focus of the past ten years – less focus on

usability and clinical effectiveness

From ‘cost’ to ‘investment’

From ‘administrative management’ to ‘imbedded in service lines’

Essential for competitive advantage – and market positioning - over the

next five years

© 2019 OPEN MINDS

The Four-Stage Evolution Of Service Lines In Health & Human Services

Stage I: The Transition to (Semi) Competitive Market

Stage 2: The Integration Phase

Stage 3: The Value-Based Reimbursement Phase

Stage 4: The Tech Leverage Phase

© 2019 OPEN MINDS

New Genetics, Pharma, & Neurotech:

The “What” of Service

Telehealth & Remote Services: The “Where” of Service

Web-Enabled Admin Tools:

The “How” of Service

Analytics & Decision Support:

The “Right” Service

New Service Delivery

Paradigm

A New Market Model Is Emerging

© 2019 OPEN MINDS

Technology Has Changed The Expectations Of Payers & Consumers

1. Personalization of consumer treatment through analytics-informed decision support

2. More efficient and effective coordination of consumer services across the service system

3. The measurement of “value” of services

Telehealth and virtual

consultation changing

geographic market

boundaries for services

Smartphone and other technologies

for inexpensive consumer-

directed disease management

Health information exchange provides data exchange and creates ‘big data’ for

consumer service planning

New treatment technologies have

changed the options for consumers

Leveraging Technology For Long-Term Sustainability

© 2019 OPEN MINDS

The Value Of Investing In Technology

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Strategic Quality Concept

Invest in ‘quality improvement’ that differentiates you from

competitors – and customer is willing to pay for the

differential cost

Requires an understanding of:

Customer perceptions

Customer segmentation

Competitive offerings

Customer perceptions of competitive offerings

Price elasticity

Eight Dimensions Of “Quality”

Performance

Features

Reliability of service system

Conformance to standards

Durability and length of effect

Serviceability and customer experience

Aesthetics

Perceived quality

© 2019 OPEN MINDS

Reducing Service Cost

Engaging Consumers

Technology Infrastructure To Optimize Value Of Consumer Care

Patient portals,

websites, and web-

based consumer

tools

Automated

consumer outreach

Telehealth and

telemedicineRemote monitoring

Tech improving

admin efficiencies

Tech-enabled

treatment

© 2019 OPEN MINDS

Optimizing Organizational

Performance, Care

Coordination & Population

Health Management

Getting The

Necessary Data

Technology Infrastructure To Support Performance Management

Electronic health

records

Health information

exchange and data

aggregation

Care

coordination

platforms

Advanced population

analytics and clinical

decision support

Performance

monitoring and

management tools

Consumer

segmentation and

health risk

stratification

Consumer referral

trackingPatient registries


IV. The OPEN MINDS Value-Based Reimbursement

Management Readiness Assessment

53

© 2019 OPEN MINDS

I. Provider Network Management

II. Clinical Management & Clinical Performance Optimization

III. Consumer Access, Service, and Engagement

IV. Financial Management

V. Technology & Reporting Infrastructure

VI. Leadership & Governance

Six Domains In OPEN MINDS Model For Assessing Value-Based Reimbursement Management Readiness

© 2019 OPEN MINDS

I. Four Competencies Of Provider Network Management

1. Network Management & Credentialing

2. Care Coordination & Care

Management

3. Consumer Screening, Care,

Provider Referrals & Case Authorizations

4. Integration of Physical Health,

Behavioral Health & Social Services

© 2019 OPEN MINDS

1. Network Management & Credentialing

Focus:

Ability to negotiate contracts, manage

credentials of clinicians, and meet the requirements of payer

organizations

Key Competencies for Success

Accreditation in serving consumers

with complex needs

Payer relationship management

Identification of payer needs

Effective workflows for managing

clinician credentials

© 2019 OPEN MINDS

2. Care Coordination & Care Management

Focus:

Ability to identify care management needs,

obtain payer authorizations and refer to appropriate services


Processes in place to receive care

management referrals, assess needs

and refer consumers for services

Authorizations expertise

Focus on integration, follow-up and

communications

© 2019 OPEN MINDS

3. Consumer Screening, Care Provider Referrals & Case Authorizations

Focus:

Ability to identify high-risk and high-needs

individuals and ensure the more effective care management plan and

services


Ability to identify high-utilization

consumers

Process to screen, assess and

refer consumers to the appropriate

level of service

Systems to track usage of other

community providers

© 2019 OPEN MINDS

4. Integration Of Physical Health, Behavioral Health & Social Services

Focus:

Ability to ensure that chronic physical health issues are integrated

into the care plan


Established referral and data

sharing relationships with primary

care

Established protocols for referrals

and care transitions

Focus on identifying consumer

preferences when making primary

care referrals

© 2019 OPEN MINDS

II. Two Key Competencies Of Clinical Management & Performance Optimization

1. Decision Support & Care Standardization

2. Clinical Performance Tracking, Assessment &

Optimization

© 2019 OPEN MINDS

1. Decision Support & Care Standardization

Focus:

Ability to use data to determine the most effective evidenced-

based practices


Standardized guide to care

management and treatment

Implementation of data-informed

planning, treatment and referral

Continuity of care planning and

transition between care settings

© 2019 OPEN MINDS

2. Clinical Performance Tracking, Assessment and Optimization

Focus:

Ability to track outcomes, assess how

to optimize services, and implement performance

improvements


Established KPIs

Ability to measure clinical outcomes

Process to assess outcomes against

KPIs and improve quality

© 2019 OPEN MINDS

III. Seven Key Competencies Of Consumer Access, Service & Engagement

1. Consumer-Informed Access

to Services

2. Automated Consumer

Service Functionality

3. Mobile Health Applications

4. Consumer Wellness Support

5. Appeals & Grievance

Procedures

6. Consumer Satisfaction Feedback

7. Consumer Performance

Metrics

© 2019 OPEN MINDS

1. Consumer-Informed Access To Care

Focus:

Technology to improve consumer access to self-service tools for

both clinical and administrative services


Access to online forms and assessment

tools

Centralized call center with 24/7

accessibility

Web-enabled provider network access

and self-referral process

Web-enabled follow-up care processes

© 2019 OPEN MINDS

2. Automated Consumer Service Functionality

Focus:

Ability for consumers to seek information and

self-refer to services in a timely fashion


Focus on identifying and responding to

consumer access preferences

Identification and removal of consumer

barriers to health information

Care and treatment approach that

involved consumers and family

members

Prompt availability of services

© 2019 OPEN MINDS

3. Mobile Health Applications

Focus:

Ability to maximize consumer engagement

through the use of mobile health applications


Availability of mobile technology that assists

with assessment, clinical decision support,

treatment, and cognitive function restoration

Availability of mobile technology supporting

early detection of relapse and relapse

prevention

Availability of mobile technology that makes

treatment more accessible

Link of mobile technology to care

coordination functionality

© 2019 OPEN MINDS

4. Consumer Wellness Support

Focus:

Ability to educate, provide resources, and document effectiveness

related to wellness support


Processes and program to engage

consumers in ongoing wellness support

and self-management

© 2019 OPEN MINDS

5. Appeals & Grievance Procedures

Focus:

Ability to receive, investigate, and resolve consumer concerns in a fast, effective manner


Function to notify consumers of rights

processes related to grievances and

appeals

Established processes for receiving,

tracking, investigating and resolving

consumers’ grievances

Process to inform systems of provider

organizations in system of care of appeal

and grievance issues, with the focus on

preventing avoidable grievances

© 2019 OPEN MINDS

6. Customer Satisfaction Feedback

Focus:

Assess ability to obtain frequent consumer

feedback through easy, non-obtrusive methods


Survey tools and processes for obtaining

consumer feedback on the consumer

experience including:

Access to care

Facilities

Interactions with staff

Effectiveness of treatment

Net promoter score (consumer

willingness to refer other for treatment)

© 2019 OPEN MINDS

6. Clinical Performance Metrics

Focus:

Ability to track and analyze outcomes, identify options to

improve services, and quickly change

processes


Systems in place to measure clinical

quality of care, patient experience and

service cost measures

Transparent process to publicly report

outcomes

Collaborative efforts to identify

performance improvement initiatives

© 2019 OPEN MINDS

IV. Four Key Competencies Of Financial Management

1. Revenue Cycle Effectiveness

2. Encounter Reporting

3. Value-Based

Payment Capabilities

4. Financial Performance Monitoring

© 2019 OPEN MINDS

1. Revenue Cycle Effectiveness

Focus:

Ability to align operational and financial

processes to assure adequate cash flow


Effective processes for reconciliation

of authorizations and payment

verification to credentialed provider

organizations

Ability to submit invoices to payers for

services delivered under value-based

reimbursement agreements

© 2019 OPEN MINDS

2. Encounter Reporting

Focus:

Ability to capture, analyze, and report

granular utilization data to payers and to internal

teams for management


Ability to electronically capture and

report reliable encounter data in the

format and in the timeframe required

by payers

Ability to analyze encounter data to

manage service outcomes and

utilization

Aggregation of encounter data to

manage value-based reimbursement

agreements

© 2019 OPEN MINDS

3. Value-Based Payment Capabilities

Focus: Ability to track manage contractual

outcomes and payments


Ability to report on actual performance

data – outcomes and financial

performance – against budget and

against contractual targets

Ability to bill for multiple types of

value-based reimbursement models

© 2019 OPEN MINDS

4. Financial Performance Monitoring

Focus: Ability to monitor actual

financial results against contracts,

budgets, and forecasts


Ability to report incurred but not

reported (IBNR) liabilities

Ability to monitor service utilization

and costs and reconcile to service and

revenue projections

System to link population health

management and value-based

contracting strategies to resources

planning and reporting

Comprehensive set of key

performance indicators for short-term

and long-term financial health

© 2019 OPEN MINDS

V. Seven Key Competencies Of Technology & Reporting Infrastructure

1. Capacity to Collect Data

2. Capacity to Analyze Data for Population Health

Management

3. Ability to Manage Value-

Based Contracts

4. Ability to Exchange Healthcare Information

5. Care Management Functionality

6. Consumer Portal

Functionality

7. IT Performance Monitoring

© 2019 OPEN MINDS

1. Capacity To Collect Data

Focus:

Technology infrastructure to collect

data strategic in identifying health

needs of the population of

consumers served


EHR core functionalities fully

implemented

Structured data collection around

assessments, diagnoses, and services

Workflows and processes to ensure

data integrity

Ability to collect data at the time and

source of service provision

© 2019 OPEN MINDS

2. Capacity To Analyze Data For Population Health Management

Focus:

Ability to perform strategic analysis of

data for risk stratification and care management


Development of or access to

consumer data registries

Deployment of data analysis tools

Implementation of risk stratification

strategies

Ability to integrate multiple sources of

data

© 2019 OPEN MINDS

3. Ability To Manage Value-Based Contracts

Focus:

Ability to track performance metrics, submit invoices, and

maximize performance of value-based

contracts


EHR functionality that meets billing

requirements for value-based

purchasing models

Integration of clinical, operational and

financial data

Unit costing and cost accounting

capabilities

Predictive modeling and forecasting

capabilities

© 2019 OPEN MINDS

4. Ability To Exchange Health Care Information

Focus:

Ability to exchange clinical and financial

information with other health care provider

organizations


Health information exchange

agreements with key providers

Secure infrastructure, policies and

workflows that comply with HIPAA and

HITECH

Service notification agreements,

automation and processes with other

providers

© 2019 OPEN MINDS

5. Care Management Functionality

Focus:

Ability to manage eligibility, coordination

of benefits, inquiries/referrals,

decision support, care authorization, care coordination and

utilization management

Key Competencies For Success

Automated risk assessment tools

Redesigned workflows to maximize

care management technology

Provider referral database to aid in care

matching and management

© 2019 OPEN MINDS

6. Consumer Portal Functionality

Focus: Ability to provide service data,

resources and interaction options with consumers through the

EHR


Convenient, secure access to personal

health information through the internet

Ability to access staff and services through

technology

Access to forms and account payment

functionality

© 2019 OPEN MINDS

7. IT Performance Monitoring

Focus: Ability to monitor actual IT outcomes against established goals


Established key performance indicators

Ability to generate real-time reporting on

performance under value-based

reimbursement arrangements

© 2019 OPEN MINDS

VI. Three Key Competencies Of Leadership & Governance

1. Strategic Alignment Around Population Health

Management

2. Culture of Innovation

3. Workforce Adequacy

© 2019 OPEN MINDS

1. Strategic Alignment Around Population Health Management

Focus:

Alignment of leadership around population health

management and the ability to manage

financial risk


Resources and infrastructure to manage

clinical and financial risks of population

health management

© 2019 OPEN MINDS

2. Workforce Adequacy

Focus:

Ability to attract and retain the right staff to succeed at population health management


Workforce culture, experience, and

capacity to innovate and adapt to new

service and business models

Ability to attract, develop, and retain staff

with expertise in clinical innovation,

technology. and financial management

Compensation alignment with performance

outcomes and strategic priorities

© 2019 OPEN MINDS

3. Culture of Innovation

Focus:

Ability to adapt and realign current services

to meet the needs of population health

management – staff openness to change and ability to develop

new services


Established and effective quality

improvement processes in place – Lean,

Root Cause Analysis, Six Sigma

Experience and expertise creating new

services lines

Blue Ocean Strategy

Three Box Solution


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OPEN MINDS Organizational Assessment Tools

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Documents

Succeeding With Value-Based Reimbursement: An OPEN MINDS ...€¦ · I. The Fee For Service Business Model II. The Value-Based Reimbursement Business Model III. Becoming A Data-Driven