Mobile App Click here to download our Mobile App for iOS or Android
Not a member? Sign up for free!

Prior To COVID-19, Primary Care Physician Salaries Increased 2.5% From 2019; Specialist Salaries Increased 1.5%

Prior to the coronavirus disease 2019 (COVID-19) pandemic, the average primary care physician compensation rose by 2.5%, from $237,000 in 2019 to $243,000 in 2020. Between October 4, 2019 and February 10, 2020, average specialist salaries rose by 1.5%, from $341,000 in 2019 to $346,000 in 2020. The highest average annual compensation was for orthopedics at $511,000; the lowest was for pediatrics at $232,000. Average annual compensation for psychiatrists was $268,000.

For the time period reviewed, about 58% of primary care physician practices, and 55% of specialist practices offered an incentive bonus. Examples of incentive bonuses are collections bonuses (monies collected from consumers, resulting in a net profit) and work relative value unit (productivity measure) bonuses. The average incentive bonus for all health care workers is about $26,000; however, the average incentive bonuses for specialty physicians ranges from $31,000 to $96,000. PCP physicians usually earn 64% of an incentive bonus, while specialists usually earn 69% of an incentive bonus.

These statistics were released on May 14, 2020, in the Medscape “Physician Compensation Report 2020” by Leslie Kane, MA. The findings are based on analysis of survey responses collected between October 4, 2019 and February 10, 2020, from more than 17,000 physicians working in 30 specialties. The survey examined salary, incentive bonus, and denied claims, and their attitudes about the field of medicine.

The full text of the Medscape “Physician Compensation Report 2020,” was released on May 14, 2020. A copy is available online at https://www.medscape.com/slideshow/2020-compensation-overview-6012684.

For more information, contact: 

  • Leslie Kane, MA, Business of Medicine, Medscape, 825 8thAvenue, New York, New York 10019; 212-301-6700; Email: LKane@webmd.net; Website: https://www.medscape.com/author/leslie-kane

The Medicare Advantage 2021 final rules include changes to telehealth that will allow plans to count telehealth clinical professionals in 12 specialty areas towards meeting network adequacy standards. The specialty areas are dermatology, psychiatry, cardiology, otolaryngology, neurology, ophthalmology, allergy and immunology, nephrology, primary care, gynecology/OB/GYN, endocrinology, and infectious diseases. The changes are intended to make telehealth more widely available in Medicare Advantage, give members access to the latest telehealth technologies, and increase plan choices for beneficiaries residing in rural areas.

The Centers for Medicare & Medicaid Services (CMS) is strengthening network adequacy rules for Medicare Advantage plans by finalizing its existing network adequacy methodology and policies that address maximum time and distance standards in rural areas, telehealth, and Certificate of Need (CON) laws. The Bipartisan Budget Act of 2018 incentivized Medicare Advantage plans to offer additional telehealth benefits to cover beneficiary access to health care beginning in 2020. As a result, CMS has been examining its network adequacy standards overall to determine how contracted telehealth professionals should be considered when evaluating the adequacy of a Medicare Advantage plan network.

CMS reduced the percentage of beneficiaries that must reside within the maximum time and distance standards in non-urban counties from 99% to 85% in order for the plan to comply with network adequacy standards. Medicare Advantage plans will be eligible to receive the 10-percentage point credit towards the percentage of beneficiaries residing within published time and distance standards when they contract with telehealth professionals.

CMS released the finalized requirements in “Medicare Program: Contract Year 2021 Policy & Technical Changes To The Medicare Advantage Program, Medicare Prescription Drug Benefit Program & Medicare Cost Plan Program.” CMS finalized a subset of the proposed policies in advance of the June 1, 2020, Medicare Advantage and Part D bid deadline for the 2021 plan year. The remaining proposals will be finalized later in 2020; they will apply to the 2022 plan year.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/.

On May 26, 2020, the Indiana Family and Social Services Administration (FSSA) awarded three contracts for Hoosier Care Connect, the state’s Medicaid managed care program for aged, blind, and disabled (ABD) beneficiaries, to incumbents Anthem and Centene/Managed Health Services (MHS), and to UnitedHealthcare. The full-risk contracts are worth a total of $6.4 billion. Implementation is expected April 1, 2021; the contracts will run for four years with two optional one-year renewals. Hoosier Care Connect serves approximately 90,000 individuals.

Hoosier Care Connect is a risk-based coordinated care program that launched on April 1, 2015. Currently, two MCOs—Anthem and Managed Health Services—serve approximately 90,000 beneficiaries with disabilities who are not eligible for Medicare, not living in an institution, and not enrolled in a waiver to receive home- and community-based services (HCBS). FSSA released the request for proposals (RFP 20-041) on October 21, 2019, with proposals due by January 6, 2020. Bids were also submitted by CareSource and MDwise.

Enrollment is mandatory for non-institutionalized aged, blind, or disabled individuals not eligible for Medicare; those receiving Supplemental Security Income; and individuals participating in the FSSA Medicaid for Employees with Disabilities (MED) Works buy-in program. MED Works offers the same coverage levels as regular Medicaid. It allows the participants to work without fear of losing Medicaid eligibility. Individuals in the following categories may voluntarily enroll in Hoosier Care Connect: children receiving adoption assistance, foster children, and former foster youth ages 18 to 26.

Hoosier Care Connect provides comprehensive coverage, including for Opioid Treatment Program (OTP) services. The plan covers short-term institutional care of up to 30 days. Members admitted to a state hospital for psychiatric treatment will be disenrolled; however, enrollment will only be suspended for members admitted to a psychiatric residential treatment facility. Hoosier Care Connect members who are admitted to an intermediate care facility for individuals with intellectual/developmental disabilities (ICF/IDD) are disenrolled and enrolled in Medicaid fee-for-service. Individuals approved for long-term services and supports are disenrolled, as are those who become eligible for Medicare. Hospice coverage is an exception and there is no limitation on days. Hoosier Care Connect has carve-outs for the following:

  • Certain high cost, low utilization drugs, such as hepatitis C and hemophilia drugs.
  • Diabetes supplies, such as test strips and meters.
  • Medicaid Rehabilitation Option (MRO) services, which are intensive community-based behavioral health services delivered exclusively by community mental health centers.
  • First Steps services.
  • School corporation services for student Medicaid beneficiaries with an individualized education plan for services provided by a school. However, the contractor must communicate and coordinate with the school to ensure continuity of care and avoid duplication of services.

The proposals were evaluated by assigning points to scoring categories; the maximum score was 103. Adherence to mandatory requirements was evaluated as pass/fail. For the scored components, 80 points were allocated to the management assessment/quality proposal. The remaining points were allocated at five points for each of the following preference categories: Buy Indiana, minority business enterprise subcontractor, women business enterprise subcontractor, and Indiana veteran business enterprise subcontractor. One bonus point for each of the last three preference categories (minority, women, and veteran) could also be earned.

For more information, contact: 

  • Jill Carnell, Chief Administrative Officer, Indiana Department of Administration, 402 West Washington Street, Room W-478, Indianapolis, Indiana 46204; 317-232-3150; Fax: 317-232-3153; Email: https://www.in.gov/idoa/; Website: www.in.gov/fssa/4828.htm
  • Will Shanley, Director of Public Relations, United Healthcare, 5901 Lincoln Drive, Minneapolis, Minnesota 55436; 612-486-4361; Email: will.shanley@uhc.com; Website: https://www.uhc.com/
  • Marcela Manjarrez-Hawn, Senior Vice President And Chief Communications Officer, Centene Corporation, 7700 Forsyth Boulevard, St. Louis, Missouri 63105; 314-445-0790; Email: mediainquiries@centene.com; Website: https://www.centene.com/
  • James Freeman, Media Contact, Anthem BlueCross BlueShield Indiana, 220 Virginia Avenue, Indianapolis, Indiana 46204; 215-756-2495; Email: james.freeman2@anthem.com; Website: https://www.anthembcbs-medicareadvantage.com/

On May 29, 2020, the Kentucky Cabinet for Health and Family Services (CHFS) awarded five Medicaid managed care contracts with an aggregate value of about $8 billion. The five companies are Aetna, Humana, Molina Healthcare, UnitedHealthcare, and WellCare. Aetna will also serve children in Kentucky SKY, the Medicaid risk-based managed care delivery program for the state foster care program and the Department for Juvenile Justice. The plans are at-risk for all Medicaid physical health, behavioral health, and pharmacy services. The contracts are slated to go live on January 1, 2021 and will run through December 31, 2024. The contracts may be extended by six additional two-year periods.

The state’s current managed care contracts are with Aetna (via Coventry Cares), Anthem, Humana (via CareSource), Passport Health Plan, and WellCare. These contracts have been extended through December 31, 2020. About 1.3 million beneficiaries are enrolled in one of the five current Medicaid managed care plans.

The state issued the request for proposals (RFP 2000000202) on January 10, 2020. This was a rebid after the state cancelled contracts awarded on November 26, 2019, due to concerns about how the award process was handled. Proposals were due by February 7, 2020. Responses were also submitted by Anthem Kentucky Managed Care Plan, Inc.; and Passport Health Plan, Inc.

The proposals received the following scores:

  • Aetna received 1,653 points.
  • WellCare received 1,662 points.
  • Humana received 1,605 points.
  • UnitedHealthcare received 1,520.5 points.
  • Molina received 1,507 points.
  • Anthem received 1,491 points.
  • Passport received 1,409.5 points.

The proposals for Kentucky SKY received the following scores:

  • Aetna received 1,126.3 points.
  • WellCare received 1,120.6 points.
  • Humana received 1,066.6 points.
  • UnitedHealthcare received 1,044.2 points.
  • Molina received 1,017.4 points.

PsychU last reported on this topic in “Kentucky Announces Cancellation Of Medicaid Managed Care Contracts; To Be Rebid In January,” which published on January 5, 2020. The article is available at https://www.psychu.org/kentucky-announces-cancellation-of-medicaid-managed-care-contracts-to-be-rebid-in-january/.

For more information, contact: 

  • Susan Dunlap, Executive Director of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-564-7042; Email: Susan.Dunlap@ky.gov; Website: https://chfs.ky.gov/
  • Kate Marx, Corporate Communications, Humana, 500 West Main Street, Louisville, Kentucky 40202; 502-271-9288; Email: kmarx1@humana.com; Website: https://www.humana.com/
  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802; 562-951-1588; Email: Caroline.Zubieta@molinahealthcare.com; Website: https://www.molinahealthcare.com/members/common/en-US/abtmolina/compinfo/newsmed/Pages/newsmed.aspx
  • Charles N. Talbert, Manager, External Communications, WellCare Health Plans, Inc., 211 Perimeter Center, Suite 800, Atlanta, Georgia 30346; 770-913-2181; Email: charles.talbert@wellcare.com; Website: https://www.wellcare.com/
  • Will Shanley, Director of Public Relations, United Healthcare, 5901 Lincoln Drive, Minneapolis, Minnesota 55436; 612-486-4361; Email: will.shanley@uhc.com; Website: https://www.uhc.com/
  • Leigh M. Woodward, Senior Communications Partner, Aetna Medicaid, 4630 Woodland Corporate Boulevard, Tampa, Florida 33614; 860-900-6058; Email: WoodwardL1@aetna.com; Website: https://www.aetna.com/

The Centers for Medicare & Medicaid Services (CMS) will require hospitals to adopt the Medicare Hybrid Hospital-Wide 30-Day Readmission (HWR) measure by 2023, and will begin a mandatory measurement period running from July 1, 2023 to June 30, 2024. In July 2025, the results will be posted to Medicare Hospital Compare. The HWR is based on electronic health record data and claims data for Medicare beneficiaries. CMS believes that the proliferation of EHR systems and standardization of extraction and reporting of clinical data for quality measurement provide an opportunity to integrate these data into measures of hospital performance. The HWR will replace the current Claims-Based Hospital-Wide All-Cause Readmission measure.

The new HWR measure was included in the Medicare 2020 Hospital Inpatient Prospective Payment System Final Rule, released on August 16, 2019. During 2019, 150 hospitals participated in a voluntary HWR pilot program. In preparation for the mandatory HWR reporting period that starts July 1, 2023, CMS will implement two voluntary year-long measurement periods, with the first starting on July 1, 2021 and running through June 30, 2022. The second period will start July 1, 2022, and run through June 30, 2023.

The HWR measure will be required as a part of each hospital’s inpatient quality reporting (IQR) program requirements. The Medicare Hospital IQR Program is a pay-for-reporting quality program which reduces payment to hospitals that fail to meet program requirements.

For the HWR measure, the numerator is unplanned all cause 30-day readmission. Readmission is defined as an inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an earlier, eligible index admission. The denominator is admissions for Medicare fee-for-service (FFS) beneficiaries age 65 and older enrolled in Part A for the 12 months prior to admission who are matched in EHR and claims data and who are discharged alive, and not transferred to an acute care facility. The measure excludes the following populations:

  • Admitted to Prospective Payment System-exempt cancer hospitals
  • Without at least 30 days post-discharge enrollment in FFS Medicare
  • Discharged against medical advice
  • Admitted for primary psychiatric diagnoses
  • Admitted for rehabilitation
  • Admitted for medical treatment of cancer

The HWR measure uses clinical data elements from the EHR for risk adjustment in addition to claims data. The goal is to use clinical data, such as laboratory test values and vital signs, to risk adjust for consumer-level factors that influence readmission to adjust for severity of illness in hospital outcome measures.

Under the current Claims-Based Hospital-Wide All-Cause Readmission measure, CMS reports risk-standardized readmission rates for several conditions, including acute myocardial infarction, heart failure, pneumonia, and hip and knee arthroplasty. CMS has also developed hospital readmission measures for stroke and chronic obstructive pulmonary disease. In 2013, CMS began publicly reporting a hospital-wide, all-condition readmission measure that captures 92% of readmissions following eligible admissions.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

On May 19, 2020, Microsoft announced that it has launched a “health care cloud service” called Micorsoft Cloud for Healthcare. The goal of the service is to assist payers and provider organizations more easily function during the coronavirus disease of 2019 (COVID-19) pandemic by providing assistance with telehealth, care management, and consumer engagement through apps that monitor data collected by medical devices linked to the cloud. Microsoft Cloud for Healthcare is available through a free trial through mid-November 2020.

The new cloud service is a conglomeration of products that are already available by the company, which sits on top of a common data model that makes it easier to share data between applications and analyze gathered data. Microsoft is working to add additional tools in the near future. The tools currently offered through the platform include:

  • Microsoft 365: a way for businesses to subscribe to both Windows and Office software
  • Microsoft Dynamics: a set of intelligent business applications that offer predictive insights through proprietary artificial intelligence
  • Microsoft Power Platform: a platform that allows users to create and deploy tailored applications that can be used on desktop and mobile devices
  • Microsoft Azure: cloud services for building, deploying, and managing intelligent applications through a global network of data centers

In addition to the above tools, Microsoft is also working with specialized partners to provide health care provider organizations with specialized services. Current partners in the effort include Epic (health-related software development), Allscripts (electronic health record (EHR) system), GE Healthcare (provider of health care technologies, digital infrastructure, data analytics, and decision support tools), Adaptive Biotechnologies (commercial-stage biotech company focused on adaptive immune system biology), and Nuance (computer software technology).

Microsoft will be rolling out additional, industry-specific cloud offerings related to doing business during COVID-19 in the near future. However, details about these offerings, including a timeline, is not yet available.

For more information, contact:

  • Microsoft Cloud for Healthcare, c/o Microsoft Media Relations, WE Communications, 225 108th Avenue Northeast, Suite 600, Bellevue, Washington 98004-5737; 425-638-7777; Fax: 425-638-7001; Email: rrt@we-worldwide.com; Website: https://www.microsoft.com/en-us/industry/health/microsoft-cloud-for-healthcare

Iowa Medicaid expansion enrollees who participated in the Iowa Medicaid Healthy Behaviors Program (HBP) had substantial reductions in their utilization of hospital-based care. Compared to the non-participants, HBP participants from 2014 through 2017 were less likely to visit an emergency department; the likelihood was 9.6 percentage points lower. The HBP participants were also less likely to be hospitalized, at 2.8 percentage points lower. However, the HBP participants had total spending $1,594 higher than non-participants’ spending.

HBP is a mandatory program for Iowa Medicaid expansion enrollees. They must complete an annual wellness exam and health risk assessment. Those who fail to complete the exam and assessment must pay monthly premiums to avoid disenrollment.

These findings were reported in “Iowa’s Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012–17” by Brad Wright, Youn Soo Jung, Natoshia M. Askelson, Elizabeth T. Momany, and Peter Damiano. They analyzed Medicaid data from 2012 through 2017, and HBP from 2014 through 2017 for a sample of beneficiaries who were continuously enrolled in IowaCare for at least one year before and after Medicaid expansion. The goal was to evaluate how HBP changed utilization and spending.

The full text of “Iowa’s Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012–17” was published in the May 2020 issue of Health Affairs. An abstract is posted online at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.01145.

For more information, contact:

  • Brad Wright, Director of Health Services and Outcomes Research, Department of Family Medicine and Associate Professor, Health Care Economics and Finance, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 590 Manning Drive, CB #7595, Chapel Hill, North Carolina 27599; 984-974-4536; Email: brad_wright@med.unc.edu; Website: https://www.med.unc.edu/fammed/directory/brad-wright-phd/
  • Sue Ducat, Senior Director of Communications, Health Affairs, 7500 Old Georgetown Road, Suite 600, Bethesda, Maryland 20814; 301-841-9962; Email: sducat@projecthope.org; Website: https://www.projecthope.org/

On April 21, 2020, the Centers for Medicare & Medicaid Services (CMS) urged Medicare Advantage organizations and Part D sponsors to halt their usual prior authorization requirements during the coronavirus disease 2019 (COVID-19) public health emergency. Absent a disaster or emergency, Medicare Advantage organizations and Part D sponsors have had flexibilities to waive prior authorization requirements at any time to facilitate access to services with less burden on beneficiaries, plans, and provider organizations. The relaxation or waiver must be uniformly provided to similarly situated enrollees who are affected by the disaster or emergency.

Additionally, the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act directed Medicare Advantage organizations to make changes specific to COVID-19 for clinical laboratory tests to detect or diagnose the virus and administration of vaccines. Medicare Advantage organizations are not permitted to impose any prior authorization or other utilization management requirements with respect to the coverage of these services when those items or services are furnished on or after March 18, 2020 and during the applicable emergency period. The plans are also not permitted to charge cost sharing (including deductibles, copayments, and coinsurance).

Medicare Advantage organizations must follow already outlined requirements for disasters and emergencies to ensure access to benefits. They must cover Medicare Parts A and B services and supplemental Part C plan benefits furnished at non-contracted facilities that have participation agreements with Medicare. They must waive, in full, requirements for gatekeeper referrals where applicable. They must provide the same cost-sharing for the enrollee as if the service or benefit had been furnished at a plan-contracted facility.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/.

On May 22, 2020, the federal Centers for Medicare & Medicaid Services (CMS) finalized its proposals for Medicare Advantage related to increasing access to telehealth. CMS also finalized requirements to expand access to Medicare Advantage for beneficiaries diagnosed with end-stage renal disease (ESRD). CMS finalized its proposal to phase out Medicare Advantage dual eligible special needs pan (D-SNP) look alikes.

Plans will be able count telehealth clinical professionals in certain specialty areas (such as Dermatology, Psychiatry, Cardiology, Ophthalmology, Nephrology, Primary Care, Gynecology, Endocrinology, and Infectious Diseases) towards meeting CMS network adequacy standards. The goal is to encourage plans to enhance their benefits to give beneficiaries access to the latest telehealth technologies and increase plan choices for beneficiaries residing in rural areas.

Previously, beneficiaries with ESRD were only allowed to enroll in Medicare Advantage plans in limited circumstances. Starting in 2021, due to changes made by the 21st Century Cures Act, all beneficiaries with ESRD will have the option to enroll in a Medicare Advantage plan, which CMS anticipates will give them access to supplemental benefits such as health and wellness programs, transportation, or home-delivered meals that are not available in Medicare fee-for-service. The cost of kidney acquisition for Medicare Advantage members with ESRD will be covered fee-for-service, and the costs will be excluded from Medicare Advantage benchmarks. CMS will offer a more flexible approach to meeting network adequacy standards for outpatient dialysis than the current pre-determined time and distance requirements.

D-SNP look alikes have similar levels of dual eligible enrollment as D-SNPs but avoid the related regulations and contracting requirements of a D-SNP. The Bipartisan Budget Act (BBA) of 2018 required CMS to establish additional requirements related to Medicaid integration for D-SNPs. CMS intends to phase out D-SNP look-alikes. A plan considered a D-SNP look-alike has 80% or more of members who are entitled to Medicaid. The phase-out timeline is as follows:

  • Beginning for the 2021 plan year, D-SNP look-alikes will be able to transition their membership into a D-SNP or another qualifying zero-premium plan offered by the Medicare Advantage organization.
  • Starting for the 2022 plan year, CMS will not contract with any new Medicare Advantage plan, other than a SNP, that projects in its bid that 80% or more of total plan members will be entitled to Medicaid.
  • Starting for the 2022 plan year, CMS will not contract with any new Medicare Advantage plan, other than a SNP, that project it will be a D-SNP look-alike. Starting in 2023, CMS will not contract with a renewing plan, other than a SNP, with enrollment meeting the definition of a D-SNP look alike, unless the plan has been active for less than one year and has enrollment of 200 or less at the time of determination.

CMS released the finalized requirements in “Medicare Program: Contract Year 2021 Policy & Technical Changes To The Medicare Advantage Program, Medicare Prescription Drug Benefit Program & Medicare Cost Plan Program.” CMS finalized a subset of the proposed policies in advance of the June 1, 2020, Medicare Advantage and Part D bid deadline for the 2021 plan year. The remaining proposals will be finalized later in 2020; they will apply to the 2022 plan year.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/.

On May 8, 2020, the Pennsylvania (PA) Clinical Network announced that it entered a value-based contract for Aetna’s Medicare Advantage members in Pennsylvania. The organizations is a physician-led clinically integrated network. The contract calls for PA Clinical Network to enhance care coordination and increase quality for Aetna members.

According to Jaan Sidorov, M.D., chief executive officer for Pennsylvania Clinical Network, the arrangement provides incentive payments for meeting “a basket of quality metrics and utilization targets” during calendar year 2020. The incentive payments are designed to drive team-based improvement across the continuum of care. The benchmarks align with industry-wide standards and are configured to link increasing performance in patient care with increasing rewards. Aetna and the Pennsylvania Clinical Network are meeting regularly to monitor progress toward goals.

PA Clinical Network currently works with over 50 private practices with 150 advanced practice clinical professionals. Each practice is independent, but all have joined the clinically integrated network to pool their resources to serve their assigned Aetna members. The organization is supported by the Pennsylvania Medical Society and its Care Centered Collaborative.

Under the contract, PA Clinical Network will provide team-based and physician-led care management in addition to the HealthEC population-health data analytics platform. PA Clinical Network and Aetna will work through a Joint Operating Committee to monitor progress in a cycle of continuous improvement.

For more information, contact:

  • Jaan Sidorov, M.D., Chief Executive Officer, Pennsylvania Clinical Network, 777 East Park Drive, Harrisburg, Pennsylvania 17111; 866-441-2392; Email: jsidorov@patientccc.com; Website: https://www.pennsylvaniacin.com/
  • Ethan Slavin, Communications, Aetna, 2777 North Stemmons Freeway, 13th Floor, Dallas, Texas 75207; 214-200-8056; Email: SlavinE@Aetna.com; Website: https://www.aetna.com/
  • Laura Porto, Director of Marketing, HealthEC, 343 Thornall Street, Suite #630, Edison, New Jersey 08837; 732-271-0600; Email: laura.porto@HEALTHEC.COM; Website: https://www.healthec.com/

During the first quarter of 2020, $576 million in equity funding worldwide went to mental health startups, rising 400% from $115 million during the last quarter of 2019. There were 44 recorded deals involving mental health startups during the first quarter of 2020, up 18.9% from 37 in the last quarter of 2019. During the first quarter of 2019, there were 42 recorded deals in this sector with a value of $210 million.

Some of the companies involved in the first quarter 2020 investments were as follows:

  • Lyra Health received an investment of $75 million in March. The company offers a mental health platform based on evidence-based treatments.
  • Modern Health received an investment of $31 million in January. The company offers a suite of mental health solutions comprised of digital programs, virtual coaching, and clinical therapy.
  • Spring Health received an investment of $22 million in January. The company provides a platform that emphasizes a data-driven approach to delivering individualized behavioral health care through exercise, digital cognitive behavioral therapy, individual therapy sessions, and medication
  • Oxford VR received an investment of $13 million in February. The company offers a clinically validated virtual reality platform to treat mental health disorders.
  • Psychological Treatment by VR received a seed investment of $1.1 million in January. The company offers a virtual reality platform for health care professionals, including those practicing in mental health. The current applications include treating anxiety, addiction, and eating disorders.

Globally across the health care industry, equity funding grew by 4% between the last quarter of 2019 to the first quarter of 2020. The investments rose from $14.1 billion to $14.6 billion. The number of deals dropped by 6% between quarters, from 1,228 to 1,156.

In the United States, the total number of health care equity investments increased by 4.4%, from 636 in the last quarter of 2019 to 664 in the first quarter of 2020. In the first quarter of 2019, there were 645 investments. The number of “mega-rounds” (investments of $100 million or more) rose by 257%, from 7 in the last quarter of 2019 to 25 in the first quarter of 2020. During the first quarter of 2019, there were 14 mega rounds.

These findings were reported in “State Of Healthcare Q1’20 Report” by researchers with CB Insights. The researchers analyzed equity investment into emerging health care companies. They verified the investments via various federal and state regulatory filings, direct confirmation with firms or investors, or press releases. These financing vehicles include convertible notes, seed, Series A, Series B, Series C, Series D, Series E+, private equity, growth equity, other venture capital, and other investment rounds. The analysis also includes funding for only private companies. However, the analysis excludes funding rounds raised by public companies, even if they received investment from a venture firm. For tranched investments, the analysis only includes the investment made in a particular quarter. Further, the analysis included only the amount of investment that had closed. The researchers defined “digital health companies” as those in the health care sector that use technology/software as a key differentiator versus their competition. The digital health sector includes technologies focused on disease diagnostics, technology-enabled health, and artificial intelligence-driven drug discovery.

The full text of “State Of Healthcare Q1’20 Report” was published April 28, 2020, by CB Insights. A copy can be requested at https://www.cbinsights.com/research/report/healthcare-trends-q1-2020/.

For more information, contact:

  • CB Insights, 498 7thAvenue, New York, New York 10018; 212-292-3148; Email: info@cbinsights.com; Website: https://www.cbinsights.com/.

About 87% of Medicare inpatient psychiatric facility (IPF) claims with outlier payments during 2014 and 2015 failed to meet the medical necessity or documentation requirements set by Medicare. During fiscal years (FYs) 2014 and 2015, the number of IPF claims with outlier payments increased by 28%. Total Medicare payments for the IPF claims with outlier payments rose by 19%, from $450 million to $534 million. The Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS) estimates that Medicare overpaid IPFs by $93 million for stays that resulted in outlier payments, but were non-covered or partially non-covered because inpatient treatment was not medically necessary for all or part of the stay.

An audit of a random sample of 160 claims found that 142 had missing or inadequate medical record elements. Most were missing physician certifications. Of the 142 medical records, 12 did not clearly support that the IPF had protected the individual’s right to make informed decisions regarding care. Oversight by the Centers for Medicare & Medicaid Services was not adequate to prevent or detect the IPFs’ errors.

These findings were reported in “An Estimated 87 Percent of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements” by the OIG. The audit covered 36,120 inpatient claims with nearly $1 billion in total Medicare payments. The goal was to determine whether IPFs complied with Medicare coverage, payment, and participation requirements for services provided in FYs 2014 and 2015 that resulted in outlier payments.

A link to the full text of “An Estimated 87 Percent of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements” may be found at www.openminds.com/market-intelligence/resources/040820oigiptpsychoutliers.htm.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7thStreet, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: Donald.white@oig.hhs.gov; Website: https://oig.hhs.gov/

As of mid-April 2020, about 43% of community-based addiction treatment provider organizations in North Carolina lacked sufficient cash on hand to remain in business for the next 30 days due to financial constraints created by the coronavirus disease 2019 (COVID-19) outbreak and public health emergency. According to survey responses provided by 70 community-based addiction treatment provider organizations, in addition to the 43% that reported having no more than 30 days cash on hand to fund operations without receiving reimbursements, 10% reported having 31 to 45 days cash on hand, 13% reported having 46 to 60 days cash on hand, and 16% reported having 61 to 90 days cash on hand. The remaining 18% reported having more than 90 days cash on hand.

Across the state, addiction treatment provider organizations lost revenue as demand for treatment dropped during the public health emergency, while new expenses to acquire personal protective equipment (PPE) and to implement telehealth treatment increased. To respond to the financial stress, about 27% of the organizations have laid off staff or cut positions, and another 40% were considering staff cuts. About 33% were staffing as normal. More than half, 57%, have closed at least one program. About 10% of programs cannot admit new consumers. About 19% of the organizations said they were operating as normal without service disruptions.

These statistics are the result of a survey conducted by Addiction Professionals of North Carolina (APNC). From April 13 to 20, APNC surveyed 70 of its member addiction treatment provider organizations. APNC is a network of more than 650 provider organizations and professionals. The survey was sent to executives at its member organizations statewide. The respondents are representative of provider organizations across all regions of North Carolina in terms of revenue mix and consumer volume.

For more information, contact:

  • Sarah Potter, Executive Director, Addiction Professionals of North Carolina, 3373 National Drive, Suite 225, Raleigh, North Carolina 27612; 919-630-8134; Email: spotter@apnc.org; Website: http://www.apnc.org/.

On March 27, 2020, Kansas awarded its next correctional health care contract to Centurion of Kansas, LLC, a Centene subsidiary, replacing the incumbent Corizon, LLC. Centurion was awarded a two-year full-risk contract to provide comprehensive health care services in the Department of Corrections’ (KDOC) facilities. The contract is expected to commence on July 1, 2020 and run through June 30, 2022, followed by two additional two-year renewal periods. Centurion will provide medical, dental, behavioral health, and related support services for offenders in nine facilities across the state. The contract is valued at a maximum of $554 million if all options are exercised.

The Kansas Department of Administration released the request for proposals (RFP EVT0006973) on October 10, 2019. Proposals were due by January 10, 2020. The state’s procurement negotiating committee (PNC) considered five proposals. The responding bidders were Centurion of Kansas, LLC; Corizon, LLC; VitalCore Health Strategies, LLC; Kansas Health and Recovery Solutions PC/WellPath LLC; and Wexford Health Sources, Inc. After evaluating the technical and cost proposals, the PNC met with four bidders: Centurion of Kansas, LLC; Corizon, LLC; VitalCore Health Strategies, LLC; and Wexford Health Sources, Inc.

KDOC serves a current population of approximately 10,000 adult inmates and 165 juvenile offenders. It operates nine facilities and three satellite facilities. Specialized services may be provided through agreements with area provider organizations such as hospitals, clinics, medical specialists, laboratories, and other specialized services.

The RFP asked for the bidders to provide two cost proposals for scenarios in which the selected contractor would or would not be responsible for paying for hepatitis C (Hep C) medications. The KDOC offered opt-out testing for Hep C for the existing inmate population. That testing was implemented in October 2018 and concluded in March 2019. Opt-out Hep C testing continues to be offered at admission. KDOC estimates that about 500 offenders will require treatment annually thereafter.

The state’s PNC noted that Centurion had the second lowest pricing bid, but the proposal had other persuasive factors that led to its selection. A key factor was “a unique opportunity that no other vendor shares to partner with Sunflower Medicaid Provider in addressing discharge needs” which exists because Centene owns both Centurion and Sunflower, one of the state’s Medicaid managed care organizations. Additionally, Centurion demonstrated good understanding of physician recruiting, and offered to partner with the state to find the cheapest Hep C drug pricing including 340B and return any funds of the $7.5 million cap to KDOC.

For more information, contact:

  • Randall Bowman, Executive Director, Public Affairs, Kansas Department of Corrections, 714 Southwest Jackson Street, Topeka, Kansas 66603; 785-296-5656; Email: Randall.Bowman@ks.gov; Website: https://www.doc.ks.gov/

On April 30, 2020, the Centers for Medicare & Medicaid Services (CMS) issued regulatory changes to further expand beneficiary access to telehealth services in their homes for the duration of the coronavirus disease 2019 (COVID-19) public health emergency. CMS is waiving limitations on the types of clinical practitioners and provider organizations that can furnish Medicare telehealth services, and is raising reimbursement rates for audio-only telephone services. CMS will reimburse for Medicare telehealth services provided by rural health clinics and federally qualified health clinics.

Prior to this change, only physicians, nurse practitioners, physician assistants, and certain others could deliver telehealth services. CMS will now allow physical therapists, occupational therapists, and speech language pathologists to provide telehealth services.

CMS will also allow hospitals to bill as the originating site for providing telehealth services to beneficiaries registered as hospital outpatients but who are staying at home. The beneficiary’s home can serve as a temporary “department of the hospital” where the beneficiary can receive counseling and educational service as well as therapy services via telehealth technology.

Reimbursement for audio-only telehealth services is increased to match the outpatient office rate, from a range of about $14 to $41 to about $46 to $110. The payments are retroactive to March 1, 2020.

In addition to raising reimbursement rates for audio-only telephone services, CMS also expanded the list of eligible audio-only telephone services to include many behavioral health and consumer education services. CMS is waiving the video requirement for certain telephone evaluation and management services, and adding them to the list of Medicare telehealth services because some Medicare beneficiaries may lack access to interactive audio-visual technology required for telehealth services. CMS also recognizes that some beneficiaries would choose not to use audio-visual telehealth services offered by their health care professionals.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

On April 21, 2020, the Centers for Medicare & Medicaid Services (CMS) approved a Washington State Medicaid 1115 waiver that will allow the state to pay higher rates to home- and community-based services (HCBS) provider organizations to maintain capacity during the coronavirus disease 2019 (COVID-19) public health emergency. Most of the approved provisions affect long-term services and supports (LTSS). In particular, they extend HCBS flexibilities available under 1915 (c) to beneficiaries receiving LTSS through a state plan amendment.

Additional provisions will allow the Washington State Health Care Authority (HCA) to establish a COVID-19 Disaster Relief Fund. Under these provisions, HCA will be able to use Medicaid funds to stabilize provider organizations as they implement new and expanded care delivery sites while managing economic disruptions. The fund will help provider organizations access needed equipment, broaden access to COVID-19 testing and care, and respond to higher demand.

CMS approved the following additional provisions:

  • HCA can receive federal reimbursement for providing LTSS to beneficiaries, even if they are not timely, updated in the plan of care, or delivered in otherwise-allowable settings.
  • To reduce administrative burden on HCA and beneficiaries, individuals will be permitted to self-attest, or HCA could use an alternative verification of individuals’ income and assets, disability, and level-of-care to qualify for LTSS.
  • Delay initial assessments or annual reassessments for up to one year.
  • HCA can make retainer payments for many habilitation and personal care services provider organizations to maintain capacity during the emergency.
  • HCA can make retainer payments to those organizations that include personal care as a component.

The state had previously been approved for a 1135 Medicaid waiver on March 19, 2020. HCA submitted the 1115 waiver on March 24, 2020, two days after CMS announced the availability of such waivers.

The HCA waiver affects the independent “individual providers” who deliver personal care services but are not employed through a home care provider organization. It also affects an array of residential provider organizations, such as adult family homes, assisted living facilities, home care agencies, adult day health and adult day care programs. HCA also uses the term “provider” to refer to the clinic or hospital billing for the services delivered by an “individual provider.”

Retainer payments were available to be claimed as of May 4, 2020 for residential and adult day providers, along with the rate enhancements. They can claim retainer payments for up to 30 days at 70% of the individual consumer’s rate.

In Washington, payment and rates for residential facilities and individual providers are collectively bargained and ratified by the legislature. Any changes must be approved by SEIU 775 and the residential facility councils. As of May 11, 2020, an agreement had been reached regarding retainer payments for all residential facilities, but rate changes for “individual providers” and home care provider organizations were still pending due to Washington’s parity requirements

CMS was still evaluating HCA’s request for Medicaid expenditure authority to use the Disaster Relief Fund to cover costs associated with treatment for uninsured individuals with COVID-19, housing, nutrition supports, and other COVID related expenditures for states and individuals as well as retainer payments for more than 30 days for provider organizations. Several other requests are also under review. CMS denied HCA’s request to establish a temporary eligibility group for those with incomes 138% to 200% of the federal poverty level.

PsychU last reported on emergency waivers in “34 States Approved For Medicaid 1135 Waivers During COVID-19 Public Health Emergency,” which published on May 11, 2020. The article is available at https://www.psychu.org/34-states-approved-for-medicaid-1135-waivers-during-covid-19-public-health-emergency/ .

For more information, contact:

  • Amy Blondin, Chief Communications Officer, Washington State Health Care Authority, Post Office Box 45502, Olympia, Washington 98504-5502; 360-725-1915; Email: amy.blondin@hca.wa.gov; Website: http://www.hca.wa.gov/.

Editor’s note: this article was updated on May 12 to include clarifications from HCA about the retainer payments and rate enhancements. 

During the coronavirus disease 2019 (COVID-19) national public health emergency, behavioral health provider organizations can accept donations of mobile devices and data plans to facilitate telehealth treatment, according to the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS). Such an arrangement during the public health emergency would not violate federal anti-kickback regulations on providing inducements to beneficiaries. The OIG posted its opinion on April 23, 2020.

The OIG maintains an online document with its feedback on a variety of questions submitted by provider organizations seeking guidance on arrangements to facilitate provision of services during the COVID-19 public health emergency. The feedback explains the application of OIG’s administrative enforcement authorities as applied to arrangements in existence solely during the time period subject to the public health emergency. This feedback is different than an OIG advisory opinion, which is a legally binding decision between the OIG and the requesting organizations.

One or more behavioral health provider organizations asked if they could accept donations of mobile devices, data plans, or both to facilitate telehealth treatment during the COVID-19 disruption for consumers who are financially needy and who do not own their own cell phone. The OIG’s response made the following points:

  • Normally the provision of valuable technology and services to federal health care program beneficiaries for free or at a reduced cost likely implicates the federal anti-kickback statute and beneficiary inducements civil money penalty (CMP).
  • In the context of the COVID-19 outbreak and in light of flexibilities in coverage for various telehealth and other virtual services payable by federal health care programs, the provision of a mobile device, service or data plan, or both by a behavioral health provider organization to a consumer likely presents a sufficiently low risk of fraud and abuse if safeguards are implemented.
  • The safeguards include a good-faith determination that an established consumer is in financial need before the telecommunications technologies are provided and that the consumer needs the technologies to access medically necessary services related to behavioral health treatment. The services must be medically necessary to reduce the risk of overutilization or inappropriate utilization. The third-party funding must be used only for telecommunication technologies.
  • The provider organization must not market the telecommunication technologies or offer/provide free phones to generate business.
  • The devices must be returned and the data plans canceled at the end of the COVID-19 Declaration.

The OIG noted that under certain circumstances, such as the Federal Communications Commission (FCC) distributing grants to certain provider organizations to fund telecommunications technologies, the remuneration from the donor to the provider organization would not trigger federal fraud and abuse laws. However, under other circumstances, arrangements between the donor and the provider organization, or indirect financial relationships between the donor and the consumer, could present risk under the federal fraud and abuse laws. The OIG advised provider organizations to separately assess any fraud and abuse risks that may arise with respect to any direct or indirect financial relationships between the donor and the provider organization, or consumer.

The clarifications were posted at https://oig.hhs.gov/coronavirus/authorities-faq.asp.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7thStreet, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: Donald.white@oig.hhs.gov; Website: https://oig.hhs.gov/

On April 30, 2020, Molina Healthcare announced a definitive agreement to acquire the Magellan Complete Care (MCC) business line from Magellan Health, Inc. for $820 million. Molina intends to fund the purchase with cash on hand. The acquisition will enable Molina to enter three new states—Arizona, Massachusetts, and Virginia—and expand into New York City. The transaction is expected to close in the first quarter of 2021, subject to federal and state regulatory approvals.

MCC, with revenue of over $2.7 billion in 2019, manages full-service Medicaid and Medicare health plans. As of December 31, 2019, MCC served approximately 180,000 members through the following plans:

  • Magellan Complete Care in Arizona, Florida, and Virginia
  • Senior Whole Health in Massachusetts and New York
  • TMG by Magellan in Wisconsin

With the addition of MCC, Molina will serve more than 3.6 million members in government-sponsored health care programs in 18 states. Pro-forma 2020 revenue after the acquisition closes is projected at over $20 billion. The transaction is expected to add approximately $3 billion in revenue by 2021 and presents an opportunity to significantly leverage Molina’s fixed cost base.

Molina believes that the acquisition of the MCC assets represents a strong strategic fit with its portfolio of core Medicaid, high-acuity, and duals businesses. The acquisition also creates new markets for growth opportunities in Medicare and Marketplace in an expanded Medicaid footprint.

Molina’s President and Chief Executive Officer, Joe Zubretsky said, “Acquiring MCC expands our geographic footprint in our core businesses of managed Medicaid, dual eligibles, and long-term services and supports. We believe it will allow us to scale our enterprise-wide platforms and benefit from both operating and fixed cost leverage.” He said, “We will also intensely focus on maintaining the continuity of care for MCC’s members and stability for its state partners.”

PsychU last reported on Molina in “Navajo Corporation Plans To Contract With Molina Healthcare For A New Mexico Medicaid Indian Managed-Health Care Entity,” which published on February 24, 2020. The article is available at https://www.psychu.org/navajo-corporation-plans-to-contract-with-molina-healthcare-for-a-new-mexico-medicaid-indian-managed-health-care-entity/.

For more information, contact:

  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802; 562-951-1588; Email: Caroline.Zubieta@molinahealthcare.com; Website: https://www.molinahealthcare.com/members/common/en-US/abtmolina/compinfo/newsmed/Pages/newsmed.aspx
  • Lilly Ackley, Vice President, Corporate Communications, Magellan Health, 5 Nod Road, Avon, Connecticut 06001; 860-5071923; Email: ackleyl@magellanhealth.com; Website: https://www.magellancompletecare.com/

Between January 2013 and December 2016, the Iowa Medicaid program may have failed to adequately document about half of claims paid to health home provider organizations. Iowa’s health home provider organizations did not document core services, integrated health home outreach services, diagnoses, and enrollment with provider organizations. In addition, the health home provider organizations did not maintain documentation to support higher payments for intense integrated health home services and did not ensure that beneficiaries had full Medicaid benefits.

A review conducted by the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS) considered documentation of 130 health home payments selected at random. For each payment, the OIG reviewed the documentation submitted by the health home provider organization and the beneficiaries’ medical records. For 62 of the 130 payments, documentation was inadequate to support the claim. The OIG concluded that Iowa improperly claimed federal Medicaid reimbursement.

During this period, the state paid 795,000 health home claims totaling $107 million, with $92 million as the federal share and the remainder covered by state funds. Based on the improper payment rate in the sample, the OIG recommended that Iowa return $37.1 million. The state disagreed with most of the findings, but did say it was improving its monitoring of the health home program and that it was revising the state Medicaid plan.

These findings were reported in “Iowa Inadequately Monitored Its Medicaid Health Home Providers, Resulting In Tens Of Millions In Improperly Claimed Reimbursement” by the OIG for HHS. The goal was to determine whether Iowa’s claims for Medicaid reimbursement for payments made to health home providers complied with federal and state requirements.

During 2016, Iowa’s health home reimbursements accounted for 3% of the entire federal total nationwide, although Iowa’s population represents only 1% of the national population. For federal fiscal year 2016, nationwide, states claimed federal reimbursement of Medicaid health home services totaling $750 million, with the federal share at $431 million.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7th Street, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: white@oig.hhs.gov; Website: https://oig.hhs.gov/
  • Matt Highland, Public Information Officer, Iowa Department of Human Services, 1305 E Walnut Street, Hoover Building, 1st Floor, Des Moines, Iowa 50319-0114; 515-281-4848; Email: mhighla@dhs.state.ia.us; Website: https://dhs.iowa.gov/ime/providers/integrated-health-home.

The following is a summary of Panchal N., et al. The Implications of COVID-19 for Mental Health and Substance Use. Health Reform Issue Brief – 9440, Kaiser Family Foundation (April 21, 2020), which was developed independently of the article authors.

Key Messages

·The COVID-19 pandemic, associated restrictions and ensuing economic downturn will have mental illness and substance use consequences, as predicted by the self-report of its negative impact on mental health in this Kaiser Family Foundation (KFF) Survey

·The report reveals certain vulnerable demographics (e.g. older adults, families with adolescents, low income, poor physical health) as well as associated factors (e.g. social isolation and income-loss) disproportionately exacerbate the mental health risk

·Scientific research prior to COVID-19 indicates that negative mental health effects in vulnerable social/economic/health features may likely result in increased anxiety, depression, distress, substance use and suicide. Given the pervasiveness of COVID-19, existing and new shortcomings in access to support services essential for the mental health crisis are likely to be exposed

Background

  • Prevalence of any mental illness as well as serious mental illness (associated with functional impairments and poor quality of life) were high in 2017-18. Reports of drug overdose and suicide were also on the rise.
  • Fear, uncertainty and epidemics are stressors that impact overall mental health, and increases risk of developing mental health issues, substance use and suicide

Purpose

  • This brief explored the effects of the COVID-19 pandemic, social distancing policies, and economic crisis on mental health using data from a survey and discussing access to mental health and substance use services.

Methodology

  • Data was collected from a Kaiser Family Foundation survey (KFF Health Tracking Poll) of US adults from March 25-30, 2020. The survey assessed whether worry or stress related to coronavirus had a negative impact (minor and/or major) on the mental health of the responders. Percentage of adults expressing an overall negative impact on their mental health were categorized based on various factors, such as sheltering-in-place, age, gender, presence of children under 18, household income, job status, health status, etc. Sub-analysis differentiated between percentages expressing major versus minor negative impact.

Results

  • Social isolation due to COVID-19 as a mental health risk
    • Social isolation, a factor associated with poor mental and physical health as well as increased risk for suicidal ideation, can be caused by the policies essential for mitigating the spread of COVID-19; e.g. social distancing, self-quarantine, closure of non-essential businesses and schools, and prohibition of large gatherings
    • KFF polling data shows the negative mental health impact was higher in people sheltering-in-place compared to those who were not (overall impact 47% vs 37%; major impact 21% vs 13%). Also, negative mental health impact increased as the perceived level of disruption increased between “a little/not at all”, “some” and “a lot” (overall impact 28%, 44% and 57%, respectively; major impact 10%, 15%, and 28%, respectively)
    • The impact of social isolation differed by demographic group
      • Older adults were less likely to report mental health impact compared to adults between 18-64 years (31% vs 49%); however previous research shows older adults are at a higher baseline risk of poor mental health due to loneliness, and bereavement, contributing to depression and suicide
      • School closures affected all households with children and adolescents. Among parents, negative mental health impact was higher in women (57% vs 32% in men). Among students, those depending on schools for key mental health services were suggested to be greatly impacted, especially given the high rates of mental health issues, substance use and suicide risk among adolescents
    • Income insecurity and job-loss due to COVID-19 as a mental health risk
      • As a historically high number of people file for unemployment benefits during the COVID-19 crisis, previous research discussed herein suggests job-loss is associated with depression, anxiety, higher substance use disorder and increase in suicide rates
      • The KFF poll revealed greater negative mental health impact in those who have “lost job or income” compared to those who have not (overall impact 54% vs 40%; major impact 26% vs 15%). Furthermore, major negative health impact was more in households with lower income (26% for income <$40K; 17% for $40K-89K; 14% for >$90K)
    • Burnout among frontline healthcare workers
      • A combination of an overwhelming number of patients and a shortage of supplies during this pandemic have rapidly increased the demands on healthcare workers
      • A recent publication reported that healthcare workers in China feel an increased psychological burden. But the KFF poll did not find a difference in negative mental health impact between households with and without healthcare workers
    • Poor Physical health during COVID 19 as a mental health risk
      • Centers for Disease Control (CDC) reports that people with chronic physical health conditions (diabetes, serious heart conditions, asthma and chronic lung disease) are at a greater risk for higher severity of COVID-19
      • The KFF poll revealed greater negative mental health impact in people with “only fair or poor health” compared to those with “good, very good or excellent health” (overall impact 53% vs 44%, major impact 29% vs 17%)

Conclusions

The potential negative mental health consequences of the COVID-19 pandemic has been recognized by the World Health Organization as well as national institutions like the CDC and the National Institute of Drug Abuse. The current KFF poll results suggest job-loss, low income and poor physical health, as well as social isolation in older adults and households with adolescents, are of concern with respect to the negative mental health effects during COVID-19. The long- and short-term mental health implications of COVID19 pandemic may reveal existing and new challenges to accessing mental health and substance use services. Some access barriers discussed include loss of insurance coverage, lack of in-network options for those with some coverage, and an overall shortage of mental health professionals.

Clinical Implications

·The article reveals social isolation, higher disruption to life, older age, women in households with children and adolescents, loss of job or income, low household income and poor physical health were factors that disproportionately exert a negative mental health impact during the COVID-19 pandemic.

·COVID-19 associated restrictions and economic downturn are likely to further exacerbate the gaps in mental health access

This summary has been developed independently of the authors. The following disclosures were reported in the original article: “This work was supported in part by Well Being Trust. We value our funders. KFF maintains full editorial control over all of its policy analyses, polling and journalism activities.”

 

This summary was written by Sucharita S. Somkuwar, PhD, BPharm, Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.

A recent survey of medical practices found that practices report a 55% decrease in revenue and 60% decrease in health care consumer volume since the beginning of the Coronavirus Disease 2019 (COVID-19) crisis. Overall, 97% of practices have experienced a negative financial impact directly or indirectly related to COVID-19.

At the same time, 48% of medical practices have furloughed staff since March 13, 2020, when the national public health emergency due to the Coronavirus Disease 2019 (COVID-19) pandemic was declared. Many practices that had not yet implemented staff layoffs or furloughs at the time of the study would consider doing so if conditions persist over the next 30 days. The survey respondents estimate that by May 8, 2020, 60% of medical practices will be forced to furlough staff, and 36% will be forced to lay off staff if, and 36% will be forced to lay off staff if conditions continue as they were during the survey.

These findings were reported in “COVID-19 Financial Impact on Medical Practices” by Medical Group Management Association (MGMA). On April 7 and April 8 of 2020, MGMA conducted a survey of medical practices across the United States. The survey included responses from 724 medical practices, of which approximately 75% of respondents were part of independent medical practices and employ less than 50 full-time equivalent (FTE) physicians. The goal was to gauge the economic impact of COVID-19 on the health care sector.

The full text of “COVID-19 Financial Impact on Medical Practices” was published on April 10, 2020, by Medical Group Management Association. A copy is available online at https://mgma.com/getattachment/9b8be0c2-0744-41bf-864f-04007d6adbd2/2004-G09621D-COVID-Financial-Impact-One-Pager-8-5×11-MW-2.pdf.aspx?lang=en-US&ext=.pdf.

For more information, contact:

  • Terri Pollock, Associate Director of Public Affairs, Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado 80112; Email: tpollock@mgma.org; Website: https://www.mgma.com/

The last decade has brought myriad innovations to digital technologies within the health and human services market. Health care payers and providers often turn to tech to boost access, improve adherence, and to provide cost-effective care. This trend holds true for both physical and mental health markets. However, as seen with previous tech waves, behavioral health providers’ adoption continues to trail behind physical health providers’ tech adoption.

For many, tech innovation offers a way to reach remote, often resource- and provider-limited settings to improve patient access and outcomes. Given the widespread, sustained workforce and access issues inherent in the current behavioral health field, why is mental health tech adoption still lagging? What is the hesitation to implement tech as a strategy to improve outcomes? Is the evidence base lacking? Are the research outcomes insignificant? Or is it a case of the unknown—a lack of storytelling about the effectiveness of the currently existing tech? Maybe the field just hasn’t taken stock of the ways that providers are, in fact, successfully utilizing tech across the globe to address disparities in mental health.

In an attempt to fill this knowledge gap, authors Nadi Nina Kaonga and Jonathan Morgan released their recent article, “Common Themes and Emerging Trends for the Use of Technology to Support Mental Health and Psychosocial Well-Being in Limited Resource Settings: A Review of the Literature,” which was published in Psychiatry Research.  In the study, the authors take the pulse of behavioral digital health by examining 67 articles, all focused on positive progress in resource-strapped locales. Their findings are specific to eMental health, a sub-category within the digital health market focused on providing web-, internet-, or telephonic-based mental health services and education to patients, caregivers, and providers.

The Positive Market “Pulse”

The authors spent two months in 2019 scouring three databases of peer-reviewed journal articles with topical search terms. Eligibility of identified research rested upon seven factors. Research had to:

  1. Be original.
  2. Focus on mental health and illness, substance abuse, or mental well-being. For the researchers this included measures of psychosocial well-being such as emotional distress or social issues.
  3. Utilize digital technology as a support mechanism for treatment or education.
  4. Report outcomes.
  5. Focus on settings with resource scarcity. The researchers defined “resource-limited settings” in two ways: (1) using the World Bank’s classifications for lower income countries; and (2) in cases where original studies identified locales as “’rural’, ‘low-income’ or ‘marginalized’”
  6. Be recent. For the authors this meant published no earlier than 2005.
  7. Report full-text English or French.

To cross-compare study results, the authors used qualitative mixed-methods text analysis and synthesized results to report on prevalent themes. The 67 studies included in the review spanned 19 countries, though approximately 35% were focused within the United States. The majority of implementation settings were community-based. Sample size of original research varied from 3 to 17,000 participants. The authors discussed their findings in terms of mental illness supported, type of tech intervention, service/education delivered, and common lessons learned from implementation.

Mental Illness Use Case. Search results indicated eMental Health tech was focused on two main use cases: depression (37%) and general mental health (31%). Other behavioral health issues were supported much more infrequently. They included (ordered by frequency): substance use, posttraumatic stress disorder, anxiety, attention deficit/hyperactivity disorder, autism, psychosis, adjustment disorder, bipolar disorder, personality disorder, and somatoform disorder. The authors indicated that approximately 9% of the previous research studied multiple mental health uses.

eMental Health Tech. Research analysis found an even division among tech types included in previous studies. Approximately one-third of the studies used short messaging service (SMS), another third used the web- or internet-based approaches, and the final third used other methods like telephone calls, smartphone apps, or audio recordings. Interestingly, the majority of the web- and internet-based interventions focused on video teleconferencing (74%).

Services/Education Delivered. Almost half the studies focused on delivering mental health services (47%), including interventions focused on behavioral change. Though much more infrequently mentioned, data collection, training, and diagnostic uses were also mentioned in the literature. Application use coalesced around six main themes:

  1. Treatment Adherence – Studies focused on adherence were more likely to utilize telephone or SMS interventions to provide appointment and treatment reminders. The one exception was a pilot SMS intervention used as supplemental intervention alongside cognitive behavioral therapy provided face-to-face. The main outcome assessed across studies was improved engagement.
  2. Real-Time Assessment – Previous research analyzed included five studies using SMS or telephonic interventions to collect self-reported momentary assessment data. This data allowed health workers to track and assess patient behavior and symptoms in real time. The main outcome assessed across studies was improved patient adherence.
  3. Daily Mood Improvement – Five studies focused on SMS and telephonic interventions that promoted well-being by sending encouraging, supportive messages to participants at set time intervals. The main outcome assessed across studies was patient perceptions of support and feelings of hope.
  4. Health Care Education – A total of nine analyzed studies included health education for either patients/caregivers or health care providers. The main outcome assessed across studies was evidence-based knowledge among participants.
  5. Telemedicine – Unsurprisingly, due to its increasing rates of adoption, telemedicine by phone, videoconferencing software, or SMS was included in more than 40% of studies analyzed (n=28). Many of the studies focused on cognitive behavioral therapy, and outcomes assessed varied from drops in no-show rates to perceptions of safety to cost-effectiveness.
  6. Machine Learning – Recent innovations in machine learning was evidenced in search results, which included five topical studies within the last three years. In the majority of studies, machine learning was coupled with neuroimaging to predict risk/outcome, analyze brain regions, or attempt to diagnose mental illness.

Lessons Learned – Finally, 18% of studies recommended considerations for eMental Health tech adoption and implementation, including ethics (e.g., informed consent), privacy (e.g., data protection), and quality control (e.g., maintaining the therapeutic relationship).

Field Diagnosis

This literature review provides an overview of the demonstrated positive outcomes associated with eMental Health tech for individuals in low-resource areas across the globe. However, limitations of this qualitative study (e.g., variable methodology, lack of long-term outcome measures, and lack of analysis on return-on-investment) reveal the need for additional, long-term trials and analysis to improve the reliability and generalizability of its findings.

The authors’ research was supported by REPSSI. The authors have no competing interests to declare.

This summary was developed independently of the authors.

The Centers for Medicare & Medicaid Services (CMS) project that aggregate payments to skilled nursing facilities (SNFs) will rise by 2.3% during federal fiscal year (FY) 2021, according to statements in the proposed rule updating the SNF prospective payment system (PPS). The proposed rule was issued on April 15, 2020. It makes changes to the case-mix classification code mappings used under the SNF PPS. The proposed rule also includes minor administrative proposals related to the Skilled Nursing Facility Value-Based Purchasing (VBP) Program that affects Medicare payment to SNFs. Comments are due by June 9, 2020.

Aggregate payments to SNFs during FY 2021 are projected to be $784 million higher than payments in FY 2020. The estimated increase is attributable to two PPS components: a 2.7% market basket increase factor with a 0.4 percentage point reduction for multifactor productivity adjustment.

The proposed changes to case mix classification code mappings are in response to stakeholder feedback about the Patient Driven Payment Model (PDPM), which went into effect on October 1, 2019 (the start of FY 2020). Under PDPM, SNF payment is linked to beneficiary characteristics, rather than volume. The PDPM uses International Classification of Diseases, Version 10 (ICD-10) codes to classify Medicare SNF beneficiaries into case mix payment groups. The unadjusted federal per diem rates are divided into six components, five of which are case-mix adjusted components: physical therapy, occupational therapy, speech-language pathology, nursing, and non-therapy ancillaries. The last is a non-case-mix component.

The SNF VBP program began distributing incentive payments on October 1, 2018. It scores SNFs on a single all-cause claims-based measure of hospital readmissions, and then adjusts Medicare fee-for-service payments under the SNF PPS. The goal is to reduce unplanned hospital readmissions. Under this program, payments to all SNFs are reduced by 2% to create a distribution pool. CMS redistributes between 50% to 70% of the pool to SNFs as incentive payments. CMS estimates that the SNF VBP program will reduce aggregate SNF payments by $199.54 million for FY 2021.

For FY 2021, CMS is not proposing to make any changes to the measures, SNF VBP scoring policies, or payment policies. The proposed administrative changes would apply the 30-day Phase One Review and Correction deadline to the baseline period quality measure quarterly report and establish performance periods and performance standards for upcoming program years.

Send comments to:

  • Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1737-P, Post Office Box 8016, Baltimore, Maryland 21244-8016.

National Quality Forum recently endorsed four behavioral health quality measures. The measures address maximum hours of physical restraint use or seclusion, and separately address timeliness of follow-up after an emergency department visit for an alcohol or other drug abuse or dependence, and timeliness of follow-up after an emergency department visit for mental illness or intentional self-harm. The latter two measures had previously been a single measure.

The endorsed measures are:

  • 0640 HBIPS-2 Hours of Physical Restraint Use:This process measure for facilities was recommended for continued endorsement. It refers to the total number of hours that all individuals admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraints. The data comes from electronic and paper medical records. The measure is reported as the number of times that physical restraints are used for more than two hours divided by the number of psychiatric inpatient days.
  • 0641 HBIPS-3 Hours of Seclusion Use: This process measure for facilities was recommended for continued endorsement. It refers to the total number of hours that all individuals admitted to a hospital-based inpatient psychiatric setting who are held in seclusion. The data comes from electronic and paper medical records. The measure is reported as the number of events divided by the number of psychiatric inpatient days.
  • 3488 Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence:This process measure for health plans was recommended for continued endorsement. It is a maintenance measure because it was previously part of an endorsed measure that combined mental health and addiction disorder emergency department follow-up visits. Data for this measure comes from claims for members ages 13 and older who have an emergency department visit with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence and who have a follow-up outpatient visit for AOD. Two rates are reported: the percentage of emergency department visits for which the member receives a follow-up visit within seven days and the percentage of follow-up visits within 30 days of the emergency department visit.
  • 3489 Follow-Up After Emergency Department Visit for Mental Illness:This process measure for health plans was recommended for continued endorsement. It is a maintenance measure because it was previously part of an endorsed measure that combined mental health and addiction disorder emergency department follow-up visits. Data for this measure comes from claims for members ages 13 and older who have an emergency department visit with a principal diagnosis of mental illness or intentional self-harm who have a follow-up visit for mental illness. Two rates are reported: the percentage of emergency department visits for which the member receives a follow-up visit within seven days and the percentage of follow-up visits within 30 days of the emergency department visit.

The recommendations were issued in “Behavioral Health and Substance Use, Spring 2019 Review Cycle: CDP Report” by National Quality Forum (NQF). During the spring 2019 project cycle, the Behavioral Health and Substance Use Standing Committee evaluated six measures. The following two measures were not endorsed during this cycle: NQF  0560 HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification; and NQF 1922 HBIPS-1 Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths Complete. Each Behavioral Health and Substance Use project cycle aims to endorse measures of accountability for improving the delivery of behavioral health care in the United States.

NQF is a consensus-based healthcare organization created in 1999 that works with all members of the healthcare community to drive measurable health improvements. Its mission includes promoting and ensuring consumer protections and healthcare quality through evidence-based measurement and public reporting. NQF-endorsed measures are used by the federal government (Medicare and Medicaid), states, and private-sector organizations to evaluate performance and to share information with consumers. To endorse measures, NQF committees evaluate the evidence-base for measures submitted by measure developers. NQF reconsiders endorsed measures and considers new measures during project cycles. Previously endorsed measures relevant to the project are reconsidered to assess their ongoing importance, validity, reliability, feasibility, and utility.

The full text of “Behavioral Health and Substance Use, Spring 2019 Review Cycle: CDP Report” was published in February 2020 by National Quality Forum. A copy is available online at http://www.qualityforum.org/Publications/2020/02/Behavioral_Health_and_Substance_Use_Final_Technical_Report_-_Spring_2019_Cycle.aspx.

For more information, contact:

  • Information Office, National Quality Forum, 1099 14thStreet Northwest, Suite 500, Washington, District of Columbia 20005; 202-783-1300; Fax: 202-783-3434; Email: info@qualityforum.org; Website: http://www.qualityforum.org/.

On March 30, 2020, the Centers for Medicare & Medicaid Services (CMS) announced temporarily expanded access to telehealth services for Medicare beneficiaries nationwide to permit them receive services where they live, including residents of nursing homes or assisted living facilities, and those receiving home health or hospice benefits. If a physician determines that a Medicare beneficiary should not leave home because of a medical contraindication or due to suspected or confirmed COVID-19, and the beneficiary needs skilled services, the beneficiary will be considered homebound and will qualify for the Medicare home health benefit to receive telehealth services at home. During the COVID-19 public health emergency, Medicare is allowing telehealth to fulfill many face-to-face visit requirements for clinical professionals to see beneficiaries in inpatient rehabilitation facilities, receiving hospice services, or receiving home health.

With the goal of preventing the spread of COVID-19, Medicare will cover more than 80 additional services provided via telehealth technologies, and in some cases the services can be provided via telephone. Eligible services include:

  • Emergency department visits;
  • Initial nursing facility admission and discharge visits; and
  • Home visits.

Medicare still requires that the services be delivered by a clinical professional permitted to provide telehealth services. During the public health emergency, beneficiaries can use commonly available interactive apps with audio and video capabilities to visit with their health care professional. Previously, Medicare covered telehealth services only for beneficiaries in rural areas; they had to travel to an approved site to receive the services because homes were not an approved site.

The expansion will permit home health provider organizations to offer more services to beneficiaries via teleheath, as long as the services were part of the beneficiary’s plan of care and the telehealth services do not replace needed in-person visits ordered in the plan of care. Hospice provider organizations can offer Medicare beneficiaries routine home care through telehealth, a long as it is feasible and appropriate to deliver services in that way.

Physicians will be permitted to conduct Medicare Virtual Check-In services (brief check-ins) by audio or video devices for new and established consumers. Previously, the Virtual Check-In service was reserved only for consumers with an established relationship with the physician. Further, clinical professionals can provide remote monitoring services and collect vital sign data via devices to manage symptoms of a chronic condition or COVID-19.

PsychU last reported on this topic in “New Federal Coronavirus Bill Waives Medicare Telehealth Restrictions,” which published on March 16, 2020. The article is available at https://www.psychu.org/new-federal-coronavirus-bill-waives-medicare-telehealth-restrictions/.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

Health care navigators, or “patient navigators,” cut emergency visits and hospitalization for high-risk health care consumers, according to an analysis of a navigator program implemented by Texas Tech University Health Sciences Center (TTUHSC). Among consumers who were assigned a navigator, emergency room visits dropped from 3.1 visits per person per year to 1.1 visits per person annually. Hospital admissions dropped from 1.5 per person annually to zero. Nearly three-quarters (74.9%) of those assigned navigators decreased both hospital and emergency room utilization. The effects of the navigator program persisted across various insurance types, and whether or not the person had a primary care physician.

The estimated value of the net reduction in hospital admissions and emergency department among those who were assigned a navigator was $1.2 million. Net estimated hospital admission savings attributable to the navigator program were $963,900, plus another $707,427 for emergency department visits resulted in total savings of $1.6 million. The cost of the TTUHSC navigator program averaged $404,754 with net savings of $1.2 million. Over three years, the navigator program cost an estimated $1.2 million to implement and produced estimated avoided costs of nearly $3.8 million.

These findings were reported in “An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System” by Charles F. Seifert, Pharm.D., FCCP, BCPS; Taylor J. Horyna, Pharm.D., BCPS; Dolores Buscemi, M.D., FACP; and Rosalinda Jimenez, Ed.D., APRN, FNP-BC, PMHNP-BC, and Linda McMurry, DNP, RN, NEA-BC. The researchers analyzed results generated by 11 Medicare Coordinated Care Demonstration programs, which showed that coordinated care resulted in an 8% to 33% decrease in hospitalization among high-risk Medicare beneficiaries.

For the TTUHSC navigator program, the researchers recruited 364 low-income individuals age 50 and older with health conditions that put them at high risk of frequent hospitalization or emergency department visits. Their median age was 59 years. About 75% were enrolled in Medicaid or Medicare. About 70% had mental health issues. Most reported relying on a hospital emergency room for their primary care because they believed the best physicians worked at a hospital or they were skeptical of care provided outside a hospital. The goal of the TTUHSC program was to determine whether a navigator intervention had a positive effect on hospital and emergency room visits.

The program employed four navigators once fully implemented. Each navigator worked with an average of 150 individuals. The participants were required to host one home visit where they made face-to-face contact with the navigator. During home visits, navigators checked blood pressure, conducted medication adherence checks, and performed a home environment scan. The navigators were able to collaborate with nurse practitioners to arrange for education during a home visit if the participant did not understand the purpose of prescribed medications.

The full text of “An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System” was published in the January- February 2020 issue of Journal of Healthcare Management. An abstract is available online at https://journals.lww.com/jhmonline/Abstract/2020/02000/An_Evaluation_of_Interprofessional_Patient.11.aspx.

For more information, contact: 

  • Charles F. Seifert, Pharm.D., FCCP, BCPS, Professor of Pharmacy Practice, Health Sciences Center, School of Pharmacy, Texas Tech University, 3601 4thStreet, Lubbock, Texas 79430-8162; 806-743-7639; Email: charles.seifert@ttuhsc.edu; Website: https://www.ttuhsc.edu/pharmacy/default.aspx

On March 25, 2020, Metrocare Services announced it had reached a contract agreement with the North Texas Behavioral Health Authority (NTBHA), following a contract dispute about payment rates. The two entities had been in a dispute because NTBHA proposed reducing Metrocare’s contract rate by about $600,000 annually because NTBHA seeks to equalize its support to all of its contractors (about 24 organizations) that provide similar services, which would reduce how much state funding is directed to Metrocare. However, the new agreement allows for continuation of services without a reduction in funding through August 31, 2020, the end of the state fiscal year. The announcement did not disclose the contract amount or terms of the agreement. NTBHA opted to continue the contract under its previous terms to avoid disruption during the current COVID-19 public health emergency.

About 16% of the Metrocare budget had been from NTBHA. Metrocare said its funding should remain at the same level because it serves the most at-risk population in Dallas County. The situation was discussed at the NTBHA Board of Directors meetings on January 8, 2020, and February 12, 2020. According to the meeting minutes, the issues included the following:

  • Metrocare believes that the proposed contract with NTBHA “is so bad that if they were a private entity, they would walk away and that it actually costs them to do NTBHA business.”
  • NTBHA pays Metrocare $112 per person for each opened authorization, and pays an additional $1,000 per person for assertive community treatment.
  • NTBHA stated Metrocare’s rate pay per hour is more expensive for NTBHA compared to its other contractors. Overall, the Metrocare services are provided by individuals with lower types of credentials.

NTBHA is the Local Behavioral Health Authority (LBHA) contracted by the Texas Human Services Commission (HHSC) to provide mental health and addiction treatment services to qualified uninsured or indigent consumers in its six-county-region of Dallas, Ellis, Hunt, Kaufman, Navarro, and Rockwall counties. Metrocare is NTBHA’s largest contracted provider organization; it serves an average of 10,000 Dallas County residents per month, and more than 60,000 adults and children annually. In addition to behavioral health care, Metrocare provides primary care centers, services for veterans and their families, accessible pharmacies, housing and supportive social services.

For more information, contact:

  • North Texas Behavioral Health Authority, 9441 Lyndon B Johnson Freeway, #350, Dallas, Texas 75243; 214-366-9407; Email: info@ntbha.org; Website: https://ntbha.org/
  • Calley McGee Herth, Marketing & Communications Manager, Metrocare Services, 1380 River Bend Drive, Dallas, Texas 75247; 214-743-6138; Email: herth@metrocareservices.org; Website: https://www.metrocareservices.org/

On March 12, 2020, the Joint Commission released eight new addiction treatment standards for accredited behavioral health organizations. The new standards go into effect as of July 1, 2020. The standards affect levels of care, transitions of care and follow-up, and proper use of urine drug testing.

The eight new standards have 14 new and revised elements of performance (EPs). One standard is related to the Leadership (LD) chapter of the accreditation manual, and seven are related to the Care, Treatment, and Services (CTS) chapter.

LD.04.02.03: Ethics guiding the organization’s business practices. A new EP has been added to require that the organizations provide the individual with information about the charges and financial responsibility for care, treatment, and services, which includes making the individual aware of responsibility for any travel or other expenses related to care, treatment, or services that the organization provides.

CTS 02.02.09: Process to provide medical histories, physical examinations, and diagnostic and laboratory tests. One EP has been updated, and a new EP was added. Previously the EPs in this standard referred to opioid treatment programs only, but the updated EPs (5 and 15) now refer to all addiction treatment programs.

  • Collecting toxicological specimens should take place in a way that demonstrates trust and respect, while taking reasonable steps to prevent falsification of samples. Direct observation may be necessary for some individuals in treatment, but observation is not necessary or appropriate for all individuals. Previously, the EP referred to “patients” rather than individuals.
  • Organizations that provide opioid treatment programs and medication assisted treatment (MAT) programs should initiate MAT by conducting medical assessments and testing according to current national guidelines established for the treatment being used. This is a new EP.

CTS.02.03.07: Assessments of the individual’s history of addictive behaviors. Three EPs have been updated, as follows:

  • In addition to age of onset, and duration, the history should include the method of acquiring the substance. The patterns of abuse examples have been expanded to include frequency, amounts, and route that the substance is taken, in addition to the previous examples: continuous, episodic, or binge.
  • The update deleted a question from the history about the consequences of dependence or addiction experienced by the individual, and added some of those consequences as examples to a question about the social consequences of dependence or addiction to include legal problems, divorce, loss of family members or friends, job-related incidents, financial difficulties, blackouts, and memory impairment.
  • The update added items about the individual’s belief system and the role of spirituality or religion on recovery; the individual’s readiness to change; and the individual’s current living arrangements and environment, and options for an alternative and supportive living environment. The individual’s treatment history should also include information about the individuals’ acute intoxication and/or withdrawal potential.

CTS.02.03.13: Appropriate levels of care. A new EP has been added. The organization providing care, treatment, or services to individuals with addiction must use an evidence-based, multidimensional admission assessment that includes, at a minimum, mental health, medical, and substance-use history for placement of the individual at the appropriate level of care.

CTS.02.03.15: Drug testing. Three new EPs have been added. Organizations must follow their written policies on performing drug testing, and the testing must consider when testing is appropriate based on the individual’s diagnosis, progress in treatment, history of use, and the professional’s clinical judgement. The organization must document in the individual’s clinical/case record the reasons for the drug testing, the results, and actions based on the results. Further, the organization must provide education and training for staff who are involved in drug testing to include at least test administration and storage of the specimen.

CTS.03.01.03: Treatment plans that reflect the individual’s assessed needs, strengths, preferences, and goals. A new EP has been added. The organization must develop a plan for care, treatment, or services at the time of admission or entry into care that reflects the assessed needs, strengths, preferences, and goals of the individual served.

CTS.04.03.35: Response to medical emergencies. One EP was updated and one was added. The updated EP adds MAT programs as responsible for having staff on duty who are trained and proficient in cardiopulmonary resuscitation, management of opiate overdose, and management of medical emergencies, and other relevant techniques. The new EP requires the organization to provide information on how to obtain life-saving medication, such as naloxone, in the case of opioid overdose from the organization or another source.

CTS.06.02.01: Continuity of care, treatment, or services when an individual is transferred or discharged. An EP was updated to clarify that the discharge planning process must address referrals for continuing outpatient care after the last dose of medication and the plan for re-entry to maintenance treatment if relapse occurs.

The Joint Commission presented these standards in “R3 Report Issue 25: Enhanced Substance Use Disorders Standards for Behavioral Health Organizations.” For the report, the Joint Commission evaluated literature and national guidelines, and stakeholder comments. The report explains the rationale and research behind the new and revised requirements. The goal was to determine how enhancing the standards would help improve the quality and safety of care.

The Joint Commission is an independent, non-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States. These accreditations include 3,310 addiction treatment organizations; and 7,026 addiction treatment sites. Joint Commission accreditation is recognized nationally as a symbol of quality that indicates a provider organization’s commitment to meeting certain performance standards.

The “Revised Requirements for Substance Use Disorder Treatment” was released on March 12, 2020. A copy is posted online at https://www.jointcommission.org/-/media/tjc/documents/standards/prepublications/1015_prepublication_report_sud_3_11_2020.pdf

The full text of “R3 Report Issue 25: Enhanced Substance Use Disorders Standards for Behavioral Health Organizations” was published in March 2020, by The Joint Commission. A copy is available online at https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3-25-sud-for-bhc-12-20-19.pdf

For more information, submit a question to The Joint Commission Standards Interpretation Group at: https://web.jointcommission.org/sigsubmission/sigquestionform.aspx.

On February 27, 2020, the Federal Trade Commission (FTC) issued an administrative complaint and authorized a federal court action to block the proposed merger of Jefferson Health and Albert Einstein Healthcare Network, which is projected to affect 70% of the inpatient acute rehabilitation (IRF) services market in the Philadelphia, Pennsylvania area. Collectively, Jefferson and Einstein operate six of the eight IRFs in the Philadelphia area in and around Einstein’s flagship Moss at Elkins Park facility.

The two organizations are academic medical centers that both provide inpatient general acute care hospital services and inpatient acute rehabilitation services in Philadelphia County and Montgomery County, Pennsylvania. They began pursuing the merger in March 2018 when they signed a letter of intent. In September 2018, they signed a binding agreement to the ideas and commitments described in the letter of intent. According to an announcement by Albert Einstein Healthcare Network on February 27, 2020, the key goals of the merger are to broaden the delivery of accessible and value-based care to consumers and provide an exceptional education and training experience for medical students.

Jefferson Health operates 11 general acute care hospitals in Pennsylvania (with four in Philadelphia and two in Montgomery County) and New Jersey, and three IRFs in Pennsylvania. Jefferson operates the largest number of hospital beds in the greater Philadelphia region. Systemwide, it discharges approximately 130,000 people annually. Additionally, it operates over 50 outpatient and urgent care locations in Pennsylvania and New Jersey. During fiscal year 2019, Jefferson Health generated revenue of $5.2 billion.

Albert Einstein Health System operates seven general acute care hospitals with three in Philadelphia and two in Montgomery County, as well as five IRFs. It also operates 15 outpatient centers. It discharges more than 30,000 people annually. During fiscal year 2019, it generated $1.2 billion in revenue.

If the merger proceeds, the FTC believes that in addition to controlling 70% of the IRF market, the merged system would provide 60% of general acute care services in North Philadelphia area and 45% of services in Montgomery county. The FTC believes the merger would “eliminate the robust competition between Jefferson and Einstein for inclusion in health insurance companies’ hospital networks” to the detriment of consumers.

The FTC issues administrative complaints when it has “reason to believe” that the law has been or is being violated, and it appears to the Commission that a proceeding is in the public interest. After an administrative complaint is issued, the allegations are tried in a formal hearing before an administrative law judge. The administrative trial is scheduled to begin on September 1, 2020.

A link to the full text of “FTC Complaint For Temporary Restraining Order & Preliminary Injunction Against Merger Of Jefferson Health & Albert Einstein Healthcare Network” may be found at www.openminds.com/market-intelligence/resources/022720ftjfrsnhltheinsteinmerge.htm.

For more information, contact:

  • Betsy Lordan, Office of Public Affairs, Federal Trade Commission, 600 Pennsylvania Avenue Northwest, Washington, District of Columbia 20580; 202-326-3707; Email: elordan@ftc.gov; Website: https://www.ftc.gov/
  • Jefferson University Hospitals, 833 Chestnut Street, Suite 1140, Philadelphia, Pennsylvania 19107; 215-955-6300; Email: MediaRelations@jefferson.edu; Website: https://hospitals.jefferson.edu/
  • Damien Woods, Senior Director, Corporate Communications, Albert Einstein Healthcare Network, 5501 Old York Road, Philadelphia, Pennsylvania 19141; 215-456-7890; Email: woodsdam@einstein.edu; Website: https://www.einstein.edu/

On April 22, 2020, the federal Department of Health and Human Services (HHS) announced it started releasing $100 billion in funding through the “Provider Relief Fund” created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which was signed into law on March 27, 2020. The CARES Act provides emergency assistance and health care response for individuals, families, and businesses affected by the 2020 coronavirus pandemic. The Provider Relief Fund is intended to address both the economic harm across the entire health care system due to the stoppage of elective procedures, and the economic impact on provider organizations incurring additional expenses to care for people with COVID-19. A key provision will reimburse provider organizations for treatment provided to uninsured consumers.

The relief funds are available for two types of provider organizations. Half of relief funds are for provider organizations that receive Medicare fee-for-service (FFS) payments. The second half of funds will be shared among multiple types of provider organizations. The CARES Act provides targeted relief funds for provider organizations in high impact areas, and selected organizations that solely accept Medicaid. It also provides for reimbursement to any provider organizations that offer COVID-19 diagnosis and treatment for the uninsured.

$50 Billion General Distribution Immediate Relief Funds For Facilities & Provider Organizations That Receive Medicare FFS Payments

To receive the general distribution relief funds, provider organizations and eligible professionals must agree to the terms and conditions, one of which requires them to agree not to collect out-of-pocket payments from consumers with presumptive or confirmed COVID-19 for sums greater than what the consumer would have been required to pay if the care had been provided in-network. The terms and conditions also specify that reimbursement for treating uninsured people with COVID-19 will be at the Medicare FFS rate. A condition of receiving the payments requires the provider organizations to submit claims data to verify, and they must agree that if they submit for reimbursement for treating the uninsured, they will accept the Medicare FFS rate as payment in full. Provider organizations that do not agree to the terms will not receive the funding, and they will not be prevented from billing uninsured consumers for the full cost of treatment.

From April 10 through 17, HHS began releasing $30 billion in the first wave of relief funds to Medicare provider organizations and health care professionals. The funds are payments, not loans. The first wave of payments is based on the provider organization/professional share of the total $484 billion Medicare FFS reimbursements in 2019. On April 24, HHS will begin distributing the remaining $20 billion of the general distribution to these provider organizations and professionals to augment their allocation so that the whole $50 billion general distribution is allocated proportional to their share of 2018 net consumer revenue.

The relief payments are being made according to provider organization or health care professional tax identification numbers (TIN). Additional details are as follows:

  • Large organizations and health systems will receive relief payments for each of their billing TINs that bill Medicare. Each organization should look to the part of their organization that bills Medicare to identify details on Medicare payments for 2019 or to identify the accounts where they should expect relief payments.
  • Employed physicians should not expect to receive an individual payment directly. The employer organization will receive the relief payment as the billing organization.
  • Individual physicians and eligible health care professionals in a group practice are unlikely to receive individual payments directly, because the group practice will receive the relief fund payment as the billing organization. The eligible professionals should look to the part of their organization that bills Medicare to identify details on Medicare payments for 2019 or to identify the accounts where they should expect relief payments.
  • Solo clinical professionals who bill Medicare will receive a payment under the TIN used to bill Medicare.

A portion of provider organizations will automatically be sent an advance payment based off the revenue data submitted in CMS cost reports. Provider organizations without adequate cost report data on file will need to submit their revenue information to this portal, https://www.hhs.gov/provider-relief/index.html. Provider organizations that receive an automatic advance payment will still need to submit their revenue information for verification. Payments will go out weekly as information is validated, with the first wave being delivered on April 24, 2020.

HHS partnered with UnitedHealth Group (UHG) to provide rapid payment to provider organizations and professionals eligible for the distribution of the initial $30 billion in funds. Payments to practices that are part of larger medical groups will be sent to the group’s central billing office. The relief payments are made to the billing organization according to its TIN. The payment will be via Automated Clearing House account information on file with UHG or CMS. The automatic payments will be delivered via Optum Bank with “HHSPAYMENT” as the payment description. Those who normally receive a paper check for reimbursement from CMS will receive a paper check in the mail for this payment as well, within the next few weeks. Within 30 days of receiving the payment, provider organizations (and solo professionals) must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment. Not returning the payment within 30 days of receipt will be viewed as acceptance of the Terms and Conditions.

At Least $20.4 Billion For Targeted Allocations To High Impact Areas, Rural Areas, Indian Health Service & Medicaid-Only Provider Organizations

Specific funding amounts have been allocated to provide additional relief to hospitals in areas with a high prevalence of COVID-19 cases and hospitalizations, and to provide relief to rural health clinics and hospitals, including those operated by the Indian Health Service. Separate funding will be available to skilled nursing facilities, dentists, and provider organizations that solely accept Medicaid; however, as of April 23, 2020, HHS had not released additional details about the additional Medicaid allocations.

A total of $10 billion will be allocated for targeted distribution to hospitals in areas that have been significantly impacted by the COVID-19 outbreak. HHS anticipates that hospitals in New York, which has more cases than any other state, will receive a large share of the funds. Eligible hospitals have already been contacted. To apply for these funds, hospitals had to provide four pieces of information by 3:00 PM (EDT) April 25, 2020. The information includes the hospital TIN, National Provider Identifier, the total number of intensive care unit beds as of April 10, 2020, and the total number of admissions with a positive diagnosis for COVID-19 from January 1, 2020 to April 10, 2020. HHS will use the information to determine which hospitals will qualify for a targeted distribution based on those that show the greatest impact from COVID-19. Supplying the information does not guarantee receipt of funds. The distribution will take into consideration the challenges faced by facilities serving a significantly disproportionate number of low-income individuals, as reflected by their Medicare Disproportionate Share Hospital (DSH) Adjustment.

For rural areas, $10 billion will be allocated for rural health clinics and hospitals. The funds will be distributed on the basis of operating expenses, using a methodology that distributes payments proportionately to each facility and clinic. HHS anticipates distributing the funds starting the last week of April 2020.

An allocation of $400 million is reserved for Indian Health Service facilities. It will be distributed on the basis of operating expenses. HHS anticipates distributing the funds starting the last week of April 2020. This funding complements other funding provided to Indian Health Service facilities.

Reimbursement Of Treatment For The Uninsured, Subject To Available Funding

Starting April 27, 2020, every health care provider organization or professional who provided treatment for uninsured COVID-19 consumers on or after February 4, 2020, can request claims reimbursement through the program and will be reimbursed at Medicare rates, subject to available funding. The size of this allocation has not been disclosed.

Registered provider organizations can begin submitting claims in early May 2020. Reimbursement will be made for qualifying testing for COVID-19 and treatment services with a primary COVID-19 diagnosis, including the following:

  • Specimen collection, diagnostic, and antibody testing.
  • Testing-related visits including in the following settings: office, urgent care, or emergency room or via telehealth.
  • Treatment-related office visits (including via telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC), acute inpatient rehab, home health, durable medical equipment (e.g., oxygen, ventilator), emergency ground ambulance transportation, non-emergent consumer transfers via ground ambulance, and FDA approved drugs as they become available for COVID-19 treatment and are administered as part of an inpatient stay.
  • When an FDA-approved vaccine becomes available, it will also be covered.
  • For inpatient claims, date of admittance must be on or after February 4, 2020.

Services not covered by traditional Medicare will also not be covered under this program. In addition, the following services are excluded:

  • Air and water ambulance
  • Any treatment without a COVID-19 primary diagnosis, except for pregnancy when the COVID-19 code may be listed as secondary
  • Hospice services
  • Outpatient prescription drugs covered under Medicare Part D

To request reimbursement, the provider organization must first register for the program and enroll at https://www.hrsa.gov/coviduninsuredclaim. The provider organization must check the individual’s eligibility and benefits, submit information about the individual, submit claims, and receive payment via direct deposit. All claims submitted must be complete and final.

For more information, contact:

  • U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, District of Columbia 20201; 202-690-6343; Email: media@hhs.gov; Website: https://www.hhs.gov/provider-relief/index.html.

Between 1996 and 2016, inflation adjusted spending on treatment of behavioral health disorders in the United States rose by 2.7% per year, or 54% for the period, for a group of six behavioral health conditions with 2016 spending of $10 billion or higher. The six conditions include anxiety, attention deficit/hyperactivity disorder, bipolar disorder, depressive disorder, drug addiction, and schizophrenia. Over the same 20-year time period, health care spending rose by 121.4% and the consumer price index rose 52.97%. The size of the U.S. population increased by 20%.

For this group of conditions, after adjusting for changes in inflation, population size, and age group, spending by public payers (Medicare, Medicaid, other federal, other public/state/local government, and Veterans Affairs) rose by 2.4% annually. Spending by private payers (other private, TRICARE, and worker’s compensation) rose by 2.6% annually. Out-of-pocket spending rose by 1.1%

For the six specific behavioral health conditions, the annualized cost growth trend varied, as did the trend rates for public, private, and out-of-pocket payers. For example, between 1996 and 2016, costs for schizophrenia treatment dropped by 1.1% annually for all payer types. For public payers, costs dropped 1.0% annually. For private payers, spending dropped 0.4% annually. Out-of-pocket costs dropped by 3.2% annually.

These findings were reported in “US Health Care Spending by Payer and Health Condition, 1996-2016” by Joseph L. Dieleman, Ph.D.; Jackie Cao, MS; Abby Chapin, BA; et al. The researchers analyzed government budgets, insurance claims, facility records, household surveys, and official U.S. records from 1996 through 2016. The goal was to estimate spending on health care, for both private insurance, public insurance, and out-of-pocket spending in the U.S. The process used to generate spending estimates by payer were based on methods previously developed by the Institute for Health Metrics and Evaluations for the Disease Expenditure Project.

The full text of “US Health Care Spending by Payer and Health Condition, 1996-2016” was published March 3, 2020 by JAMA Network. An abstract is available online at https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.0734.

For more information, contact: 

  • Joseph L. Dieleman, Associate Professor, Global Health & Health Metrics Sciences at the University of Washington, Institute for Health Metrics and Evaluation, 2301 Fifth Avenue, Suite 500, Seattle, Washington 98121; 206-897-2800; Fax: 206-897-2899; Email: dieleman@uw.edu; Website: http://www.healthdata.org/

The average adjusted cost per day of an inpatient hospital stay in state and local government community hospitals in the United States was $2,260 in 2018. For inpatient stays in non-profit hospitals, the average adjusted cost per day was $2,653. For inpatient stays in for-profit hospitals, the average cost per day was $2,093. “Community hospitals” are defined as all non-federal, short-term general, and specialty hospitals whose facilities and services are available to the public.

Highs and lows for these hospital categories by state include:

These findings were reported in “Hospital Adjusted Expenses per Inpatient Day by Ownership” by researchers with the Kaiser Family Foundation (KFF). Researchers with KFF analyzed information from the 2018 American Hospital Association Annual Survey. The goal was to determine the adjusted expenses per inpatient day in 2018 for the three hospital types in each state.

The full text of “Hospital Adjusted Expenses per Inpatient Day by Ownership” was published February 21, 2020 by Kaiser Family Foundation. An abstract is available online at https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership/.

For more information, contact: 

  • Chris Lee, Senior Communications Officer, Kaiser Family Foundation, 1330 G Street NW, Washington, District of Columbia 20005; Email: clee@kff.org; Website: http://www.kff.org/

On February 27, 2020, the Massachusetts attorney general announced agreements with five health insurance companies and two companies that manage behavioral health coverage for insurers to improve access to behavioral health services and resolve violations of the federal Mental Health Parity and Addiction Equity Act (MHPAEA). The organizations are AllWays Health Partners; Blue Cross Blue Shield of Massachusetts (BCBS); Fallon Community Health Plan and Beacon Health Strategies; Harvard Pilgrim Health Care and United Behavioral Health, dba, Optum; and Tufts Health Plan. The state investigated the organizations’ compliance with behavioral health parity laws, as well as the accuracy of health insurers’ provider organization network directories.

Settlements with three of the insurance companies—AllWays, Fallon, and Harvard Pilgrim—resolved the state’s claims that they violated the MHPAEA. The three companies agreed to limit prior authorization for certain behavioral health care. The companies agreed to change, or have already changed, how they determine minimum reimbursement rates for outpatient behavioral health services at all clinical professional levels, including psychiatrists, psychologists, and social workers. All the companies agreed to make extensive changes to their directories to allow members to more easily reach behavioral health care professionals and provider organizations.

For Harvard Pilgrim, Fallon, and AllWays, the state alleged that the insurers used methods to establish base rates for outpatient behavioral health services that were not comparable to and were applied more stringently than the methods used to establish base rates for outpatient medical/surgical services; this methodology led to different base rates for behavioral health visits and medical/surgical office visits billed with the same evaluation and management codes. The companies allegedly used utilization management processes for inpatient and outpatient behavioral health services that were not comparable to and were applied more stringently than the processes used for medical/surgical care. The state alleged that all three published and maintained provider organization directories that were materially inaccurate and deceptive. The state alleged that the directories did not accurately reflect whether the listed professionals were accepting new consumers, whether the professional was in or out of network, and whether the contact information and practice location was correct.

  • A link to the full text of “Massachusetts AllWays Assurance Of Discontinuance” may be found in the at www.openminds.com/market-intelligence/resources/022720maallways.htm.
  • A link to the full text of “Massachusetts Fallon/Beacon Assurance Of Discontinuance” may be found at www.openminds.com/market-intelligence/resources/022720mafallonbeacon.htm.
  • A link to the full text of “Massachusetts Harvard Pilgrim/Optum Assurance Of Discontinuance” may be found at www.openminds.com/market-intelligence/resources/022720harvardpilgrimoptum.htm.

BCBS and Tufts allegedly published and maintained provider organization directories that were materially inaccurate and deceptive. The state alleged that the directories did not accurately reflect whether the listed professionals were accepting new consumers, whether the professional was in or out of network, and whether the contact information and practice location was correct.

  • A link to the full text of “Massachusetts Blue Cross Blue Shield Assurance Of Discontinuance” may be found at www.openminds.com/market-intelligence/resources/022720mabcbs.htm.
  • A link to the full text of “Massachusetts Tufts Health Plan Assurance Of Discontinuance” may be found at www.openminds.com/market-intelligence/resources/022720matufts.htm.

For more information, contact:

  • Meggie Quackenbush, Deputy Press Secretary, Massachusetts Attorney General’s Office, 1 Ashburton Place, 20thFloor, Boston, Massachusetts 02108; 617-727-2543; Email: Margaret.Quackenbush@mass.gov; Website: https://www.mass.gov/orgs/office-of-attorney-general-maura-healey.

On March 4, 2020, Humana announced it had launched a Medicare Advantage value-based program (VBP) focused on addressing member social determinants of health (SDOH) such as food insecurity, social isolation, loneliness, and housing instability. The first participating provider organization is Ochsner Health, a large non-profit, academic health care system in Louisiana. A Humana spokesperson said the insurer intends to expand the program to include participation elsewhere in the country; however, the company does not currently have a set timeline for expansion.

The program provides compensation for providers for enhanced care coordination centered on three program components—SDOH screenings; documentation of assessment findings; and connecting the member to appropriate resources. Compensation is based on completion of the three pillars of the program. Humana has not released its baseline expectations, or the program performance targets, but the SDOH program takes place in the context of other VBP arrangements. The SDOH model offers provider organizations tools and resources to identify at-risk members and address their non-medical barriers to better health outcomes. Humana has not released additional details about the tools it will provide.

As of January 2020, Humana had approximately 4.4 million Medicare Advantage members. As of December 31, 2019, Humana had more than 2.4 million individual Medicare Advantage members and approximately 115,000 commercial members cared for by a primary care physician in value-based relationships with Humana, across 43 states and Puerto Rico.

In 2018, Ochsner Health served about 811,000 consumers from across the United States and from 70 countries. The organization was formed in 1941. It has nearly 1,500 group practice physicians and more than 3,200 affiliated physicians across the Louisiana. Humana approached Ochsner Health about participating in the SDOH VBP because Humana believed it fit with Ochsner‘s interest in value-based care, and its interest in tackling SDOH.

For more information, contact:

  • Alissa Krinsky, Humana Corporate Communications, Humana, Inc., 500 Adams Street, Chicago, Illinois 60661; 312-441-5576; Email: akrinsky@humana.com; Website: https://www.humana.com/
  • Giselle Hecker, Director, Public Relations, Ochsner Healthcare System, 1450 Poydras Street, Suite 550, New Orleans, Louisiana 70112; 504-842-9219; Email: ghecker@ochsner.org; Website: ochsner.org
  • Jennifer Bollinger, Vice President, Communications and Public Relations, Ochsner Accountable Care Network, 1450 Poydras Street, Suite 550, New Orleans, Louisiana 70121; 504-842-9268; Email: jbollinger@ochsner.org; Website: https://ochsneracn.org/

The Drug Enforcement Administration (DEA) recently proposed revising its regulations for federally certified opioid treatment programs (OTPs) to allow the programs to operate a mobile component without obtaining a separate registration. Such programs could dispense narcotic drugs in schedules II-V at a remote location for the purpose of maintenance or detoxification treatment. The proposed rule would consider the mobile program to be a “coincident” activity.

Specifically, for OTPs with mobile components, the DEA said it would waive the requirement of a separate registration at each principal place of business or professional practice where controlled substances are dispensed, as long as the dispensing location is within the same state as the registration, and complies with the requirements of the proposed rule. The revisions are intended to make maintenance or detoxification treatments more widely available, while ensuring that safeguards are in place to reduce the likelihood of diversion.

The proposed rule, “Registration Requirements for Narcotic Treatment Programs With Mobile Components,” was issued on February 26, 2020. Comments will be accepted through April 27, 2020. Currently there are more than 1,700 narcotic treatment programs registered with DEA, including OTPs, detoxification treatment services that utilize methadone, and compounders. Before 2007, DEA authorized mobile NTPs on an ad hoc basis, but then imposed a moratorium on further authorizations. Since 2015, only 19 NTPs have operated a mobile component. Currently, only eight NTPs operate mobile units under those agreements.

The goal of the proposed rule is to expand access to evidence-based medication assisted treatment for addiction disorders, including opioid use disorder. The demand for treatment has expanded and in some areas, has resulted in long waiting lists and high service fees. In rural and other underserved communities, the distance to the nearest OTP or the lack of consistent access to transportation may pose a substantial barrier to accessing treatment. The proposed rule formalizes the requirements for operating a mobile NTP while maintaining controls to reduce the likelihood of diversion.

For more information, contact:

  • Scott A. Brinks, Drug Enforcement Administration, Attn: DEA Federal Register Representative/DPW, Diversion Control Division; Mailing Address: 8701 Morrissette Drive, Springfield, Virginia 22152; 571-362-3261; Website: https://www.dea.gov/
  • Public Affairs, Drug Enforcement Administration, U.S. Department of Justice, 700 Army-Navy Drive, Room W-12228, Arlington, Virginia 22202; 202-307-7977; Email: DEA.Public.Affairs@usdoj.gov; Website: https://www.dea.gov/

The South Carolina Department of Mental Health (SCDMH) is updating its qualified provider organization list of community residential care facilities (CRCFs) available for people with mental illness who are at high risk for hospitalization. The list was created in 2011, and resubmitted following expiration in 2018. The SCDMH intends to use the new list to recommend placements for specific individuals currently served by three of its community mental health centers. SCDMH released the solicitation (5400019224) on March 23, 2020, with responses due by April 6, 2020. The initial 12-month contract term is followed by four one-year renewal options. The start date is April 20, 2020.

The state seeks to establish a fixed price contract with a source or sources to provide the services. The established maximum fixed price rate is $30.00 per resident per day.

CRCFs, unlike boarding homes, include not only room and board, but provide a degree of personal care for a period of time in excess of 24 consecutive hours for two or more persons, 18 years old or older. CRCFs are often referred to as “assisted living facilities.” They are licensed and monitored by the South Carolina Department of Health and Environmental Control’s Division of Health Licensing. A CRCF can be a transitional or a permanent placement depending on the preferences of the resident and their support networks/families for independent living settings.

Eligible CRCF residents are those who have had a serious mental illness or other behavioral health disorder and who have had a history of multiple hospitalizations and inpatient psychiatric treatment for 90 or more days, and/or who otherwise may be at significant risk of re-hospitalization. The three centers need the following number of CRCF beds:

  • Columbia Area Mental Health Center (CAMHC) needs 75 CRCF beds in Richland and Fairfield counties
  • Santee Wateree Mental Health Center needs 45 beds in Sumter and Kershaw counties
  • Coastal Empire Mental Health Center needs 45 beds across Beaufort, Hampton, Colleton, Allendale, and Jasper counties.

For more information, contact:

  • Tracy LaPointe, Public Information Director, South Carolina Department of Mental Health, Post Office Box 485, Columbia, South Carolina 29202; 803-898-8581; Email: tracy.lapointe@scdmh.org; Website:https://scdmh.net/dmh-components/community-residential-care-facilities/.

The Department of Veterans Affairs (VA) recently proposed standardizing eligibility criteria for its Program of Comprehensive Assistance for Family Caregivers (PCAFC). Specifically, the VA seeks to expand the definition of serious injury to include any service-connected disability, whether it resulted from an injury, an illness, or a disease. Further, the VA seeks refine the eligibility criteria for personal care services to capture the service needs of veterans and service members with cognitive or neurological impairment or mental health conditions. The VA also proposed changes to the PCAFC stipend payment methodology, definitions for financial planning and legal services, and procedures for revocation and discharge, to include advance notice requirements aimed at improving communication between VA and PFAFC participants. These changes are intended to ensure that the PCAFC regulations reflect changes required by the VA MISSION Act of 2018.

The proposed rule, “Program Of Comprehensive Assistance For Family Caregivers Improvements And Amendments Under The VA MISSION Act Of 2018,” was released on March 6, 2020. Comments will be accepted through May 5, 2020.

The PCAFC, established in 2011, is a component of the VA Caregiver Support Program, which provides services to family caregivers to help veterans with disabilities remain in their homes. It provides caregivers with training, peer mentoring, respite care, a telephone support line and self-care courses. The PCAFC provides additional benefits including a monthly stipend for qualifying family caregivers of eligible veterans who were seriously injured in the line of duty on or after September 11, 2001.

Under the MISSION Act, the VA will expand eligibility for PCAFC to veterans from all eras, starting with those who incurred or aggravated a serious injury in the line of duty on or before May 7, 1975. After that first expansion phase, PCAFC will be extended to eligible veterans who were seriously injured in the line of duty between May 7, 1975 and September 11, 2001. Prior to expanding, VA must fully implement an information technology system required by the MISSION Act.

PsychU last reported on this topic in “VA Expands Private Provider Options For Veterans Under MISSION Act,” which published on July 15, 2019. The article is available at https://www.psychu.org/va-expands-private-provider-options-for-veterans-under-mission-act/.

For more information, contact:

  • Elyse Kaplan, National Deputy Director, Caregiver Support Program, Care Management and Social Work, 10P4C, Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Ave. NW, Washington, District of Columbia 20420; 202-461-7337; Website: https://www.caregiver.va.gov/ and https://www.caregiver.va.gov/support/support_benefits.asp

The current COVID-19 epidemic is projected to raise Medicare costs from $38.5 billion to $115.4 billion over the next 12 months, according to an analysis by the National Association of Accountable Care Organizations (NAACOS). The projected costs due to COVID-19 represent between 6% to 18% of the $582 billion in Medicare spending during 2018.

According to the Kaiser Family Foundation, the cost range is based on the projected penetration rate of COVID-19 among the nearly 59 million Medicare beneficiaries aged 65 and older. If 20% of these beneficiaries’ contract COVID-19, 7,500 people will be affected and 1,689 will be hospitalized; costs are estimated at $38.5 billion. If 40% contract COVID-19, 15,000 will be affected and 3,378 will be hospitalized; costs are estimated at $77 billion. If 60% contract COVID-19, 22,500 will be affected and 5,067 will be hospitalized; costs are estimated at $115.4 billion.

About 20% of Medicare beneficiaries are served by a Medicare ACO through the Medicare Shared Savings Program (MSSP) or the Next Generation Model ACO program. Potential COVID-19-related costs for this subset of beneficiaries served by a Medicare ACO could range from $7.7 billion to $23.1 billion. In 2018, combined spending for beneficiaries attributed to a MSSP or NextGen ACO totaled $125 billion. The additional 6% to 18% in Medicare spending would completely overshadow the 1.6% cost savings generated by the MSSP ACOs and the 1.4% generated by the NextGen ACOs.

These estimates were presented in “Potential Impact Of COVID-19 On Medicare Spending: Implications For ACOs,” by the NAACOS. The estimate is based on the number of Medicare beneficiaries, with scenarios presented for infection rates of 20%, 40%, and 60%, and related inpatient admission rates over the next 12 to 18 months. The estimates are based on prevalence and hospitalization data from China. The average cost of a 90-day pneumonia hospitalization was used as a proxy for new Medicare spending. This includes clinically relevant services provided post-discharge. The estimate does not include COVID-19-related costs for beneficiaries who are not hospitalized. It also does not include hospital and health system costs for infection-control protocols and equipment.

In mid-March 2020, NAACOS and nine other leading health care organizations asked the Centers for Medicare & Medicaid Services (CMS) for relief so that provider organizations participating in alternative payment models are not inappropriately penalized for the extreme costs of handling the COVID-19 pandemic. Requests included holding clinicians harmless from performance-related penalties for 2020, making appropriate adjustments to spending targets, performance scores, consumer attribution and risk adjustment, and providing financial support and reinsurance. In the context of a global, public health pandemic, NAACOS believes that COVID-19 threatens to derail adoption of alternative payment models and the movement to value-based care. Without relief from CMS, ACOs may drop out of the program to avoid losses.

The full text of “Potential Impact Of COVID-19 On Medicare Spending: Implications For ACOs” was published on March 24, 2020, available online at https://www.naacos.com/potential-impact-of-covid-19-on-medicare-spending–implications-for-acos.

For more information, contact:

  • David Pittman, Health Policy and Communications Advisor, National Association of Accountable Care Organizations, 601 13thStreet Northwest, Suite 900 South, Washington, District of Columbia 20005; 202-640-2689; Email: dpittman@naacos.com; Website: https://www.naacos.com/.

The Medicaid and CHIP Payment and Access Commission (MACPAC) found that most state Medicaid programs use one or more legal authorities to use Medicaid funds to pay for residential or inpatient services provided by an institution of mental diseases (IMD). However, since 1965, the federal Medicaid program has excluded payment for IMD services to ensure that states alone fund inpatient psychiatric services. The goal of this exclusion was to encourage states to build community-based behavioral health capacity.

The federal Medicaid program defines an IMD as “a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.” The term IMD is only relevant to Medicaid; they are not singled out by other payers, state licensure agencies, or accrediting bodies. For licensing purposes, IMDs can provide inpatient or residential mental health and addiction treatment as needed.

Medicaid authorities that states use to pay for services in IMDs include:

  • Demonstration waivers under Section 1115 of the Social Security Act gives the Secretary of Health and Human Services (HHS) authority to waive provisions of major health and welfare programs authorized under the Act, including certain Medicaid requirements, and to allow a state to use federal Medicaid funds in ways that are not otherwise allowed under federal rules. This authority is provided for “experimental, pilot, or demonstration” projects which, in the view of the Secretary, are “likely to assist in promoting the objectives of” the program.
  • In-lieu-of services in managed care are alternative services in a setting that are not included in the state plan or otherwise covered by the contract but are medically appropriate, cost-effective substitutes for state plan services included within a contract.
  • Statutory exceptions to the exclusion for services provided to adults age 65 and older and children and youth under age 21.
  • A new state plan option is in effect from October 1, 2019 to September 30, 2023. This option covers IMD services for up to 30 days in a year for individuals with addiction.

MACPAC also found that state licensure agencies, accrediting bodies, and other payers do not have standards specific to IMDs, given that the designation is unique to Medicaid. Instead, states regulate inpatient and residential treatment facilities separately, and standards vary according to whether a facility provides addiction treatment or mental health care. Federal standards for IMDs are largely determined by whether or not the facilities are Medicare provider organizations; however, there is no federal certification process for these organizations because Medicare does not pay for addiction treatment services in most free-standing facilities.

These findings were presented in “MACPAC Report To Congress: Oversight of Institutions for Mental Diseases.” The report fulfills a statutory requirement in the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act). The requirement is to identify and describe facilities designated as IMDs in selected states and summarize state licensure, certification, or accreditation requirements and Medicaid clinical and quality standards for these facilities. MACPAC estimated the number of IMDs accepting Medicaid in seven selected states (California, Colorado, Florida, Massachusetts, New Jersey, Ohio, and Texas) and determined the types of services these facilities offer. They also determined the roles of federal and state government agencies in the regulation and oversight of IMDs, and selected outpatient behavioral health facilities, including licensure requirements and licensure standard enforcement. Finally, they analyzed standards that select state Medicaid programs and managed care plans place on behavioral health facilities, including facilities that may be considered IMDs, how Medicaid agencies enforce these standards, and state laws governing consumer protection in IMDs.

For more information, contact: 

  • Kathryn Ceja, Director of Communications, Medicaid and Children’s Health Insurance Program Payment and Access Commission, 1800 M Street Northwest, Suite 650 South, Washington, District of Columbia 20036; 202-350-2000; Fax: 202-273-2452; Email: Kathryn.Ceja@macpac.gov; Website: https://www.macpac.gov/

On March 31, 2020, federal approval expired for the New York Medicaid Delivery System Reform Incentive Payment Program (DSRIP). The New York Department of Health (DOH) had asked the Centers for Medicare & Medicaid Services (CMS) to extend the DSRIP in two phases. The first phase would have extended the waiver through March 2021 and allowed the state to use $625 million in unspent funds from its original $7.4 billion program. The second phase, stretching into March 2024, sought $8 billion more in federal funding to continue the DSRIP. However, on February 21, 2020, CMS notified the New York Department of Health (DOH) that it would consider the first phase proposals but would not consider extending DSRIP.

CMS had approved the state’s waiver for the DSRIP on April 14, 2014. Under the current DSRIP waiver, Performing Provider Systems (PPS), regional networks of provider organizations, work in partnerships to collaborate in a regional project plan focused on improving health outcomes while reducing avoidable hospital readmissions. The projects included expanding medication assisted treatment into primary care and emergency room settings, targeting seriously mentally ill populations for enhanced supports, and addressing housing and other social determinants of health. Without the extension, the PPSs must decide whether they will continue to operate without federal support.

In its denial letter dated February 21, 2020, CMS noted that the initial DSRIP award in 2014 was intended to be a time-limited one-time investment in system transformation that could be sustained through ongoing reimbursement mechanisms and/or state and local initiatives. CMS said it intended to maintain that agreement and preserve the original expiration of the DSRIP expenditure authority. Further, the letter noted that if CMS were to approve an extension, it would be rebased consistent with new CMS policy. The rebasing would mean that the state basis would be limited to just five years of its current budget neutrality savings. As a result, CMS believes its staff would not be able to adequately assess New York’s proposal for the second phase. CMS said it was continuing to review the phase one proposal in light of the federal goal of increasing value-based care (VBC) in the Medicaid program. The state’s VBC efforts will continue beyond the planned expiration of the DSRIP program. Those plans were released in January 2020 as “New York State Roadmap For Medicaid Payment Reform, A Path Toward Value Based Payment: Annual Update June 2019: Year 5.”

The state’s Medicaid program serves more than 6 million beneficiaries. It contracts with more than 50 fully and partially capitated managed care plans. Eligible services include inpatient hospital care, outpatient hospital services, clinics, nursing homes, managed care, prescription drugs, home care and services provided in a variety of community-based settings (including mental health, addiction treatment, developmental disabilities services, school-based services, and foster care services). The proposed 2021 budget included $76.7 billion for the Medicaid program.

On March 19, 2020, the New York Medicaid Redesign Team II (MRT II) approved reforms to reduce the state’s Medicaid spending by $2.5 billion annually. The recommendations were sent to the governor and legislature for consideration in the state budget. Governor Andrew Cuomo had formed the MRT II on February 4, 2020 to develop proposals to restore financial sustainability to the Medicaid program while connecting other program initiatives that would advance core health care strategies.

On April 3, 2020, Governor Cuomo signed the state’s $177 billion fiscal year 2021 budget. It includes Medicaid changes recommended by MRT II to help close a $6 billion budget gap, but includes language to delay any provisions that might make the state ineligible for $6.7 billion in short-term federal aid to enhance Medicaid payments as part of the federal response to the COVID-19 public health emergency. On March 29, Governor Cuomo said he intended to refuse the short-term federal aid because the maintenance of effort requirements would prevent implementing the MRT II Medicaid redesign proposals, one of which would shift Medicaid costs from the state to localities.

For more information, contact:

  • Jonah Bruno, Director of Communications, New York State Department of Health, Empire State Plaza, Corning Tower, Albany, New York 12237; Email: dohweb@health.ny.gov; Website: https://www.health.ny.gov/health_care/medicaid/redesign/mrt2/.

On April 8, 2020, the Centers for Disease Control and Prevention (CDC) issued interim workplace safety practices for critical infrastructure workers with potential exposure to a person with suspected or confirmed COVID-19. Critical infrastructure workers include those working in the following sectors:

  • Federal, state, and local law enforcement
  • 911 call center employees
  • Fusion Center employees (Fusion centers are state-owned and operated centers that organize localized domestic intelligence gathering of threat-related information. The centers receive, analyze, gather, and share data between the Department of Homeland Security; federal intelligence, law enforcement at the federal, state, local, tribal and territorial levels; and private sector partners.)
  • Hazardous material responders from government and the private sector
  • Janitorial staff and other custodial staff
  • Workers, including contracted vendors, in food and agriculture, critical manufacturing, informational technology, transportation, energy, and government facilities

This guidance does not pertain to health care, first responder, or correctional facility workers for which the CDC had already issued guidelines. The federal Occupational Safety and Health Administration (OSHA) requires employers of workers in the health care industry, emergency response organizations (e.g., emergency medical, firefighting, and law enforcement services), and correctional institutions to make work-relatedness determinations for cases of COVID-19. Employers outside these industries in areas where there is ongoing community transmission of COVID-19 will not be required to make work-relatedness determinations.

The CDC defined a potential exposure as being a household contact or having been in close contact (within six feet) of an individual with confirmed or suspected COVID-19 up to 48-hours before the individual started showing symptoms. Workers who have been exposed but are not showing symptoms can work, but should have their temperatures monitored before starting their shifts, and the worker should wear a face mask. Workers who become symptomatic during the day should be sent home immediately. The work site should compile information on other workers in close contact with an exposed worker being monitored. In the case that a worker becomes sick, other workers who had close contact with that worker should be considered exposed.

In workplaces where critical infrastructure workers were exposed to COVID-19 but remain asymptomatic, the employer and worker should adhere to the following practices prior to and during their work shift:

  • Pre-screen: Employers should measure the worker’s temperature and assess symptoms prior to them starting work. Ideally, temperature checks should happen before the individual enters the facility.
  • Regular monitoring: As long as the worker is asymptomatic (no temperature or symptoms), the worker should self-monitor under the supervision of the employer’s occupational health program.
  • Wear a mask: The worker should wear a face mask at all times while in the workplace for 14 days after last exposure. Employers can issue face masks or can approve worker’s supplied cloth face coverings in the event of shortages.
  • Social distance: The worker should maintain a six-foot distance from others (social distancing) as work duties permit in the workplace.
  • Disinfect and clean work spaces: The employer should ensure that shared common areas (offices, bathrooms, break rooms) and electronic equipment are cleaned and disinfected regularly.

Generally under OSHA’s recordkeeping requirements, COVID-19 is a recordable illness, and employers are responsible for recording cases of COVID-19 if the case is confirmed, and the case is work-related. However, in a guidance memo issued on April 10, 2020, OSHA advised that in areas where there is ongoing community transmission of COVID-19, it will not require other employers (other than health care, emergency response, and corrections) to make the same work-relatedness determinations unless there is objective evidence that a COVID-19 case may be work-related. This evidence could include a cluster of COVID-19 cases without an alternate explanation that develop among workers in close proximity or who share common areas, or could include information given to the employer by employees or in the ordinary course of managing its business and employees. This loosening is because employers, other than those in health care, emergency response, and corrections may have difficulties determining whether a worker contracted COVID-19 at work. This guidance is limited to the current public health crisis.

For more information, contact:

  • Division of Public Affairs, Centers for Disease Control & Prevention, 1600 Clifton Road, Atlanta, Georgia 30329-4027; 404-639-3286; Fax: 404-639-7394; Email: media@cdc.gov; Website: https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/businesses-employers.html
  • Elizabeth Grossman, Director of the Office of Statistical Analysis, Occupational Safety and Health Administration, Department of Labor, 200 Constitution Avenue Northwest, Washington, District of Columbia 20210; 202-693-2225; Website: https://www.osha.gov/SLTC/covid-19/

On April 3, 2020, California launched Project Roomkey, an initiative to use hotel and motel rooms to isolate homeless individuals deemed extremely vulnerable to COVID-19 in an effort to limit the spread of the disease. Additionally, the state has also contracted with Chef José Andrés’s World Central Kitchen to provide three meals a day to select Project Roomkey hotels through a statewide contract to support local efforts as needed. The goals of Project Roomkey are to protect public health by isolating the medically vulnerable, reducing the shelter population for social distancing, slowing the rate of spread of COVID-19 and, in turn, flattening the curve.

The state secured approval from the Federal Emergency Management Agency (FEMA) for a 75% federal cost share for the rooms, and wraparound supports such as meals, security, and custodial services. Counties will pay the remaining 25% of the cost, as well as cover the cost of case managers and counselors. The state has distributed $150 million to counties to help pay for the rooms and other homelessness services.

Project Roomkey isolation units are intended for the following populations experiencing homelessness:

  • Individuals who are asymptomatic, but at high risk, such as people over 65 or who have certain underlying health conditions. The goal is to move them into motel or hotel units where they can more safely self-isolate and avoid exposure to COVID-19.
  • Individuals who have been exposed to COVID-19 or are COVID-19 positive (as documented by a state or local public health official, or medical health professional) who do not require hospitalization, but need isolation or quarantine to avoid further spread of COVID-19 in congregate shelter settings or homeless encampments.

The initiative targets hotels in counties with significant homeless populations that are also experiencing high concentrations of COVID-19 transmission. The state seeks to secure up to 15,000 rooms for this purpose. Some of the leases being negotiated include an option for the state or county to purchase the entire hotel/motel property to provide for permanent homeless housing. However, no information has been released about the status of these negotiations.

Local governments to date have secured 6,867 hotel and motel rooms for Project Roomkey. However, state and local health officials have not released a comprehensive list of participating hotels/motels. The local governments are responsible for identifying which shelter clients or encampment residents are selected for these hotel isolation placements and transporting them to the hotels for intake. The counties can contract with a provider organization to manage the isolation placements. As of early April, counties had moved 869 homeless individuals off the street and/or out of shelters into isolation. Essential behavioral health and health care services are being provided by the local governments and community partners, as needed.

For more information, contact: 

  • California Governor Gavin Newsom, 1303 10th Street, Suite 1173, Sacramento, California 95814; 916-445-2841; Fax: 916-558-3160; Website: https://govapps.gov.ca.gov/gov40mail/

The President’s 2021 budget proposal for the Department of Health and Human Services (HHS) includes five provisions intended to expand behavioral health services. However, overall, the HHS budget request of $94.5 billion is about 10% lower than the 2020 enacted level of funding. The HHS budget proposes $1.6 trillion in net mandatory health savings and reducing longer-term deficits by eliminating wasteful spending.

The federal budget proposal was released on February 10, 2020, as “A Budget For America’s Future, Fiscal Year 2021.” A fact sheet about the budget highlighted the following provisions affecting behavioral health:

  • Combat the opioid epidemic. The budget allocates $5 billion to fund research, surveillance, prevention, treatment, access to overdose reversal drugs, and recovery support services. This funding includes $1.6 billion, an $85 million increase from the 2020 enacted level, for State Opioid Response grants, which support prevention, treatment, and recovery support services. States are also given flexibility to use these funds to address emerging drug issues, such as the increasing number of overdoses related to psychostimulants, including methamphetamines.
  • Fund Certified Community Behavioral Health Clinics (CCBHC) expansion grants. The budget includes $225 million for the CCBHC expansion grants and extends, through 2021, the CCBHC Medicaid demonstration programs to improve community mental health services for the eight states currently in the demonstration.
  • Fund mental health prevention and screening. The budget allocates $125 million to help schools, community organizations, first responders, and other entities identify mental health issues and help affected youth and other individuals get the needed treatment.
  • Fund primary health care services for homeless individuals. The budget allocates $25 million to expand primary care services for homeless individuals in cities with high rates of homelessness.
  • Modify the Medicaid funding exclusion on Institutions of Mental Disease (IMDs) to allow states flexibility to use IMDs to provide inpatient mental health services to Medicaid beneficiaries with serious mental illness (SMI) as part of a comprehensive strategy that includes improvements to community-based treatment. In 2018, 47.6 million adults had a mental illness, of whom 11.3 million had SMI, meaning their mental illness substantially interfered with or limited major life activities.

The fact sheet and a summary of the major savings and reforms called out additional proposals affecting the health and social service field. They address Medicare, Medicaid, rural health access, public health, and child welfare.

Medicare

  • Eliminate wasteful Medicare spending, and incentivize quality and efficiency. The budget proposes to align payments for the four main post-acute care settings (skilled nursing facilities; home health provider organizations; inpatient rehabilitation facilities; and long-term care hospitals) and transition to site-neutral payments over five years (with certain exceptions for long-term care hospitals). Currently each setting uses a different prospective payment system. It revives a proposal to pay physicians the same fee whether services are provided by a hospital outpatient facility or a private practice.
  • Reform uncompensated care payments by removing the payment from the Medicare payment system, moderating the rate of growth of spending, and establishing a new process to distribute uncompensated care amounts to hospitals based on their share of charity care and non-Medicare bad debt.
  • Implement bipartisan drug pricing proposals. The budget supports legislative efforts to improve the Medicare Part D benefit by establishing an out-of-pocket maximum, improving incentives to contain costs, and reducing out-of-pocket expenses for seniors. It also calls on Congress to pass legislation to reduce the prices paid for prescription drugs. The administration also supports changes to Medicare Part D to reduce the cost of generic and biosimilar drugs. The budget proposal calls for spending $130 billion less for Medicare prescription drugs.
  • Allow people age 65 or older to opt out of Medicare entirely. Additionally, Medicare beneficiaries enrolled in a high-deductible health plan would be allowed to accumulate more tax-free savings for health expenses.

Medicaid

  • Improve consistency between work requirements in federally funded public assistance programs, such as Medicaid and Temporary Assistance for Needy Families (TANF). All able-bodied, working-age individuals, aged 18 to 65 years old and with or without children in the home, would be required to find employment or participate in individualized work activities for a minimum of 20 hours per week, in order to receive welfare and Medicaid benefits, unless they fall into an exempt category or have an individual or geographic hardship.
  • Create a permanent Money Follows the Person option, giving states flexibility to provide additional transitional services to promote care in the community. States with high rates of institutionalization would receive time-limited enhanced funding to support necessary structural changes.
  • Allow states to consider savings and other assets in determining Medicaid eligibility. The goal is to focus Medicaid spending on individuals who lack significant assets.

Rural health

  • Expand access to telemedicine services by offering increased flexibility to provider organizations who serve predominantly rural or vulnerable populations, including Indian Health Service (IHS) provider organizations and those participating in Medicare payment models requiring financial risk.
  • Modify payments to Rural Health Clinics to ensure that Medicare beneficiaries continue to benefit from primary care services in their communities.
  • To address the trend of rural hospital closures, the budget proposes to allow critical access hospitals to voluntarily convert to rural standalone emergency hospitals and remove the requirement to maintain inpatient beds.
  • Maintain funding for Rural Health Outreach grants in the Health Resources Services and Administration (HRSA).

Public health

  • Fund the initiative to end the HIV epidemic. The budget allocates $716 million for the initiative’s second year. The avocation includes $371 million for the Centers for Disease Control (CDC) and $302 million for Health Resources and Services Administration (HRSA) to deliver HIV care through the Ryan White HIV/AIDS Program and to supply testing, evaluation, prescription of PrEP, and associated medical costs through the Health Centers program; $27 million to the Indian Health Service (IHS) to tackle the epidemic in American Indian and Alaska Native communities; and $16 million for the National Institutes of Health (NIH) for evaluation activities to identify effective interventions to treat and prevent HIV.
  • Fund initiatives to improve maternal health. The budget allocates $74 million in new resources to reach the following goals: achieve healthy outcomes for women of reproductive age by improving prevention and treatment; prioritizing quality improvement for prenatal care and birth services; optimize postpartum health; and improve data and support research.

Other social services

  • Reduce the TANF block grant by 10%, and eliminate the TANF Contingency Fund, as it fails to provide well-targeted counter-cyclical funding to states. Add a requirement that states spent at least 30% of all TANF funds on activities that directly promote work. All TANF spending would be limited to families with income below 200% of the federal poverty line (FPL). All work-eligible individuals receiving TANF cash assistance would be expected to participate in individualized work activities a minimum of 20 hours per week, unless they fall into an exempt category or have individual or geographic hardship. New proposals require that TANF expenditures be directly related to achieving TANF’s purposes and by phasing out the ability for states to use TANF funds for, “activities authorized solely under prior law,” an outdated expenditure category; states would be accountable for achieving employment outcomes to incentivize cooperation and service integration between TANF and programs through the Workforce Innovation and Opportunity Act to promote work. All states
  • Eliminate funding for the Social Services Block Grant (SSBG). The budget notes that the administration believes that the SSBG lacks strong performance measures, is not well targeted, and is not a core function of the federal government. It funds services that are also funded through other federal programs, such as early childhood education.

For more information, contact:

  • The White House, 1600 Pennsylvania Avenue Northwest, Washington, District of Columbia 20500; 202-456-1414; Website: https://www.whitehouse.gov/

On March 6, 2020, the Oklahoma Health Care Authority (OHCA) announced it had submitted a Medicaid state plan amendment to expand eligibility to the new adult group ages 19 to 64 with incomes at or below 133% of the federal poverty level. The requested effective date is July 1, 2020, contingent upon approval by the Centers for Medicare & Medicaid Services (CMS). The state is also developing plans for SoonerCare 2.0, (Oklahoma’s Medicaid program) which is based on implementing the new Medicaid Healthy Adult Opportunity waiver in a five-year demonstration, no sooner than July 1, 2021. OHCA estimates that 220,000 people will be eligible, and that 81% will ultimately enroll. The cost of the expansion is estimated at $1.24 billion annually. Currently, Oklahoma’s SoonerCare Choice programs offer managed care delivery of enhanced primary care case management.

On March 17, 2020, OHCA released a draft copy of the SoonerCare 2.0 Healthy Adult Opportunity Section 1115 Demonstration Application, and following a series of public virtual meetings, anticipates submitting the application in mid-April 2020. OHCA intends to implement outcome and value-based care coordination strategies for SoonerCare 2.0, introduce “private insurance concepts,” and include community engagement requirements. The plans will integrate physical and behavioral health services. Through its outcome-based payment model, OHCA anticipates improving member health outcomes, and focusing on quality improvement in specific population health goals. OHCA also anticipates that it will provide better care coordination by using modern technology and methods by building upon its successful Patient Centered Medical Home model. Everyone who meets the income guidelines of SoonerCare 2.0 is eligible for enrollment. The key provisions in the SoonerCare 2.0 plan are as follows:

Introduce private insurance concepts in a managed care plan design, such as premiums and commercial-like benefit packages to prepare members to move off Medicaid and into private coverage.

  • The amount of the premium will be linked to household income. Failure to pay the premium for three consecutive months will trigger an OHCA review to determine if the individual qualifies under another Medicaid eligibility category. If not, the member’s enrollment will be terminated. Anyone who is disenrolled due to non-payment will be permitted to reapply for coverage at any time. They will not be required to pay the unpaid premiums.
  • Some SoonerCare 2.0 members (those with HIV/AIDS, SUD, or SMI) will be exempt from premium payments, regardless of their household income. They will, however, be responsible for paying copayments for their services, as described in the state plan.
  • Two optional Medicaid benefits will be eliminated: non-emergency medical transportation (for most individuals), and Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits for members aged 19 to 21. Members who have a demonstrated need for non-emergency medical transportation in accordance with their care coordination assessment and care plan will have access to the service on a case-by-case basis.
  • Eliminate retroactive coverage and hospital presumptive eligibility.
  • Implement an $8 copayment for non-emergency use of the emergency department to encourage appropriate use of urgent care and primary care providers.

Implement community engagement requirements.

  • Require individuals ages 19 through 60 to participate in paid or unpaid community engagement activities for at least 80 hours per month. Eligible activities include work, volunteering, and educational activities.
  • Adults ages 61 through 64; pregnant women; a parent or caretaker of a child under the age of six or of an incapacitated person; those participating in a substance use disorder rehabilitation program; individuals with a serious mental illness who are actively participating in behavioral health treatment; those unable to work because of a disability; and members of an American Indian/Alaska Native federally recognized tribe will be exempt from this requirement. Other exceptions are also outlined in the HAO application, as well as good cause exceptions.
  • Individuals recently released from jail or prison incarceration within six months prior to their application date will have a nine-month grace period to start reporting their community engagement activities.
  • The reporting requirement will be phased in during the first year with quarterly increases rising from no hours for the first quarter, 10 for the second, 15 for the third, 20 for the fourth, and 80 hours for each subsequent quarter.
  • Non-exempt SoonerCare 2.0 members who fail to comply with the reporting requirement will have eligibility terminated effective the first day of the month following the month in which the state determined the member was non-compliant with the number of community engagement hours required.

OHCA anticipates that the service delivery model will encourage members to increase use of preventive, primary, urgent, and specialty care, and decrease their reliance on emergency departments for services that could be better provided in less resource intensive care settings. Because OHCA will implement care coordination strategies for the SoonerCare 2.0 population, the state anticipates that members will have more timely access to care and a better consumer experience.

For more information, contact:

  • Katelynn Burns, Senior Public Information Representative, Oklahoma Health Care Authority, 4345 North Lincoln Boulevard, Oklahoma City, Oklahoma 73105; 405-443-9415; Email: katelynn.burns@okhca.org; Website: http://www.okhca.org/soonercare2/.

On January 28, 2020, Michigan enacted Public Act 12 of 2020 (formerly House Bill 4051), which calls for creation of a statewide mental health hotline – the Michigan Crisis and Access Line (MCAL) – effective April 26, 2020. The law codifies a requirement in Michigan’s Mental Health Code for the Michigan Department of Health and Human Services (MDHHS) to contract with a vendor to develop and operate the hotline. The hotline will be available for anyone in the state in need of immediate mental health or addiction services. The hotline is to be staffed 24 hours a day, seven days a week. Information about a potential request for proposals (RFP) related to the hotline is not yet available.

Hotline operators are to refer and connect callers with local care providers and resources, including up-to-date availability of psychiatric and substance abuse services offered to the community. The hotline is to uphold caller privacy and information security practices; however, the hotline may collect general information for evaluation and quality management purposes, track the hotline’s success, and to identify trends in service needs and outcomes. MDHHS is to develop a “relationship management database infrastructure” to track, monitor, assign, follow up, and report on access line operations. This consumer relationship management database infrastructure must provide appropriate community and provider access.

Information about mental health professionals providing mental health services, and providers of substance use disorder treatment and rehabilitation services, will be obtained from the Department of Licensing and Regulatory Affairs internal state databases, and other publicly available resources such as the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Services Locator). MDHHS is to have operational oversight for the hotline, including access to and utilization of, the relationship management infrastructure. MDHHS’ contracted prepaid inpatient health plans and community mental health services programs will also utilize the consumer relationship management database infrastructure to optimize hotline operations and to facilitate more efficient programmatic compliance and communication with MDHHS (e.g., service inventory profiles, consumer service issues, certification/credentialing requirements, service applications).

A link to the full text of “Michigan House Bill 4051 Of 2020” (now known as “Michigan PA 12 of 2020”) may be found at www.openminds.com/market-intelligence/resources/012820mihb4051mhhotline.htm.

For more information, contact:

  • Bob Wheaton, Public Information Officer, Michigan Department of Health and Human Services, Post Office Box 30195, Lansing, Michigan 48909; 517-284-4974; Email: WheatonB@michigan.gov; Website: https://www.michigan.gov/

The federal Department of Justice (DOJ) concluded Maine’s system of services for people with intellectual/developmental disability (I/DD) violates the Americans with Disabilities Act (ADA) because it limits access to home- and community-based services (HCBS) under its Section 21 waiver. On February 10, 2020, the DOJ responded to a complaint filed in May 2018 by a Maine resident with I/DD. The DOJ concluded that Maine failed to provide necessary services in the most integrated setting appropriate to the individual’s needs. The Maine Department of Health and Human Services (DHHS) is determining how to respond.

The DOJ advised DHHS to promptly remedy the situation and prevent ADA civil right violations of people receiving Section 21 services by taking the following steps:

  1. Modify the Section 21 waiver’s 84-hour cap on Home Care Quarter Hour services by establishing and implementing a process for individuals to obtain an exception to the cap, such that individuals can receive Section 21 waiver services in the most integrated setting appropriate to their needs unless the provision of such services would constitute a fundamental alteration.
  2. Modify the Section 21 waiver’s service planning process to ensure that the services a member receives, and the setting(s) in which they are received, are determined by the member’s individual needs and preferences, rather than by provider organization preference.
  3. Inform individuals currently receiving, or who may be eligible to receive, Section 21 waiver services, including individuals currently receiving services in agency placements, those receiving Quarter Hour services, and those receiving Medicaid services in intermediate care facilities (ICFs) who may be eligible for Section 21 waiver services, about the exceptions process and providing personal planning that is sufficiently focused on the member’s individual needs and preferences.
  4. Inform state employees, agents, and contractors, including case managers, as well as others, including provider organizations, who serve on personal planning teams, and employees implementing the exceptions process, about the modifications implemented, including the exceptions process, how to apply for an exception under the process, and how the exceptions and personal planning processes should operate to ensure that individuals can receive services in the most integrated setting appropriate to their needs.
  5. Ensure that the state has sufficient provider capacity to fulfill the individual’s authorized Section 21 waiver service hours.
  6. Pay compensatory damages to the individual for injuries caused by the state’s actions.
  7. Provide the DOJ with written status reports delineating all steps taken to comply with these requirements, including the date(s) on which each step was taken, and, where applicable, information sufficient to demonstrate compliance.

Maine’s Medicaid Section 21 waiver provides comprehensive services for people with I/DD and autism who live in their own homes or in another home in the community, but not necessarily with their families. The available services include assistive communication assessment/technology, career planning, community support, counseling, crisis assessment and intervention services, employment specialist services, home accessibility upgrades, in-home support, medical equipment and supplies, therapy (occupational, physical, or speech), residential services, respite, shared living services, transportation, and work support.

The individual at the center of the DOJ complaint is an adult with several disabilities who lives with his parents. Since 2009 he has received Section 21 waiver home support services, which include personal assistance with activities of daily living and instrumental activities of daily living. In 2014, the state capped the individual’s service hours at 84 per week, citing the state’s cap on services Section 21 waiver recipients can receive while living in their own (or family) homes. The family challenged the denial. The state contested the challenge but acknowledged that the individual needed 168 hours of services per week. The DOJ noted that the state’s failure to provide needed in-home services resulted from the state’s service planning process, which determined his placement/services based on provider organization preference, rather than identifying the most integrated setting appropriate.

In February 2017, the administrative challenge was concluded, and the state cut the individual’s service hours to 84 per week. However, in March 2019, the state granted an exception to the cap during the DOJ investigation. The exception permitted the individual to receive 168 hours per week of home support services in his home; however, the 84-hour cap otherwise remained in force. Further the state failed to ensure that the licensed service provider organization actually fulfills the authorized hours, and the state failed to identify additional provider organizations to fill the gaps. Despite the exception, the individual continues to receive about 84 hours per week of in-home services.

As a result, the individual is at risk of being institutionalized to receive the needed services. The only alternative placements he has been offered are an ICF or a in a multi-person group home. An ICF is considered an institutional setting. If the individual lived in an ICF or a group home, he would not have access to the community at the same level as living at home with adequate services.

A link to the full text of “The United States’ Findings & Conclusions Based On Its Investigation Of The State Of Maine Under Title II Of The Americans With Disabilities Act” may be found at www.openminds.com/market-intelligence/resources/021020dojadaltrmaineiddhcbs.htm.

For more information, contact:

  • Jackie Farwell, Communications Director, Maine Department of Health and Human Services, 109 Capitol Street, 11 State House Station, Augusta, Maine 04333; 207-446-3319; Email: Jackie.Farwell@Maine.gov; Website: https://www.maine.gov/dhhs/.

Community reentry following incarceration is more likely to be successful if the reentry interventions address dynamic factors that affect the overall success of reentries, according to a study by The Harvard University Institute of Politics. These dynamic factors include health, employment, housing, skill development, mentorship, and social networks.

Health

Community-based organizations should prioritize providing reentering citizens with quality health care that properly addresses any mental and physical health conditions and addiction. This is especially important for female reentering citizens, who often have greater health-related needs than the general reentering population. The researchers recommend that organizations should specifically target services to women, especially in the form of trauma and counseling services.

Employment

Community-based programs are most effective when they provide training and placement services to returning citizens, using a holistic approach focused on both training and job placement. The success of these services also depends largely on the job opportunities available in the neighborhoods into which their clients are reentering. The researchers recommend that community organizations should partner with prisons to better advise incarcerated individuals on which neighborhoods to return to.

Housing

Community-based organizations that offer transitional housing, with the end goal of eventually securing an independent living situation, are effective at improving outcomes. Those programs that also provide housing in combination with other services (such as employment services, health services, and socio-emotional development) are also successful at improving outcomes. The researchers recommend that organizations and programs focus on communities with the highest risk of homelessness, namely women, Black and Hispanic individuals, and the elderly. For women, additional concern may be needed when children are involved in the reentry.

Skill Development

Assistance with both education and interpersonal skills (such as anger management, time
management, goal setting, and parenting) should be provided to those reentering the community. For education, the researchers recommend that community-based organizations should provide a variety of educational programs (such as employment training programs, college enrollment assistance and referrals, GED preparation, testing referrals, and vocational training), and these programs should be tailored to the unique education needs of different age demographics. For interpersonal skills, programs should target the skills listed above, target antisocial peer relationships, and offer appropriate cognitive behavioral programs.

Mentorship

The researchers recommend that community-based organizations that offer reentry services should also prioritize mentorship programs which match reentering citizens with mentors who share similar backgrounds. These matches could be based on gender, racial and ethnic identities, and age-related priorities.

Social Networks

The researchers also recommend programs that emphasize the role of family connection and cohesiveness, especially for young reentering individuals. Reentry programs should specifically address such needs through services that support building stronger familial ties and provide therapy, mentorship, life skills training, domestic violence education, and safe homes. They also recommend that programs subsidize or cover travel and communication costs to connect with family members when necessary.

These recommendations were presented in “Successful Reentry: A Community-Level Analysis” by researchers affiliated with the Harvard University Institute of Politics Criminal Justice Policy Group. The report focuses on how various factors significantly affect successful reentry and how existing community-based organizations tailor interventions to address those factors. The report also provides recommendations for the best practices community-based reentry programs can follow. The researchers analyzed a number of reentry case studies, social theory papers, and programs across the United States. The goal was to determine the ideal circumstances for successful outcomes for those exiting jails and prisons, and acclimating to community life.

The full text of “Successful Reentry: A Community-Level Analysis” was published in December 2019 by The Harvard University Institute of Politics’ Criminal Justice Policy Group. A copy is available online at https://iop.harvard.edu/sites/default/files/sources/program/IOP_Policy_Program_2019_Reentry_Policy.pdf.

For more information, contact: 

  • Institute of Politics, Harvard University, 79 John F. Kennedy Street, Cambridge, Massachusetts 02138; 617-495-1360; Fax: 617-496-4344; Email: ioppolicy@gmail.com; Website: https://iop.harvard.edu/

On February 27, 2020, BlueCross BlueShield of Western New York (BCBSWNY) announced that it entered into a value-based reimbursement (VBR) arrangement with Value Network, LLC, IPA, a network of behavioral health provider organizations in Western New York. The contract includes an upside-risk agreement. Thomas Schenk, M.D., senior vice president and chief medical officer at BCBSWNY, said it is the organization’s “first payment model designed to directly enhance quality care for our members with mental health and/or substance use disorder diagnoses.”

The VBR arrangement with Value Network is based on the BCBSWNY “Best Practice” model, a consumer-centered, population-based care model that reimburses provider organizations based on the full scope of care management. The model uses a per member per month capitated payment along with some fee-for-service payments, specifically in preventive care. The capitation payments are based on historical claims and nontraditional consumer engagement methods such as telehealth. Provider organizations who serve consumers that require more complex care receive additional compensation. Value Network is eligible for bonus payments based on quality outcomes performance. A BCBSWNY spokesperson said the quality targets and metrics for the agreement are based on industry benchmarks around behavioral health care.

Value Network was formed in June 2017, and achieved state approval to become an Independent Practice Association (IPA) in January 2018. It is a collaborative of 23 provider organizations licensed through the New York State Office of Mental Health or New York State Office of Addiction Services and Supports, as well as designated home- and community-based service provider organizations. The network was founded by Howard Hitzel, chief executive officer (CEO) of BestSelf Behavioral Health; Anne Constantino, CEO of Horizon Health; Bruce Nisbet, CEO of Spectrum Health and Human Services; and Elizabeth Mauro, CEO at Endeavor Health Services.

The network has 65 other partners, including hospitals, primary care partners, prevention agencies, care coordination entities, and other organizations. Andrea J. Wanat, vice president of operations for Value Network, said the arrangement aligns with its mission to “design and implement a health service delivery system that improves the quality, cost effectiveness, and overall experience of care in Western New York.” Value Network serves about 70,000 people annually.

For more information, contact:

  • Amber M. Hartmann, Public Relations Manager, Marketing and Communications, BlueCross BlueShield of Western New York, 257 West Genesee Street, Buffalo, New York 14202; 716-887-8962; Fax: 716-887-7911; Email: Hartmann.Amber@bcbswny.com; Website: https://www.bcbswny.com/
  • Bruce Nisbet, Value Network Co-founder, and President and Chief Executive Officer, Spectrum Health and Human Services, 2040 Seneca Street, Buffalo, New York 14210; 716-539-5329; Email: nisbetb@shswny.org; Website: https://shswny.org/

As of September 2019, approximately 25% of provider organization revenue was via a value-based payment (VBP) arrangement; however the amount of revenue linked to VBP arrangements varied by organization type. For hospitals and health systems, VBP ranged from 11.7% to 37.9% of revenue. About 23.2% of physician groups’ revenue was via VBP arrangements.

Researchers found that the majority of provider organizations plan to enter into a VBP arrangement, or expand an existing one, in the next two years. About half of respondents expect VBP to become the primary revenue model by 2025. Better incentives and mandatory participation are the top factors that will drive higher participation and investment in VBP models.

Additional findings, as of September 2019, include:

  1. About 19% of respondents thought that VBP quality has improved significantly, while about 50% thought quality has improved moderately.
  2. About 2% of respondents thought that VBP financials have improved significantly, and about 43% thought that financials improved moderately.
  3. About 62% of respondents participate in an accountable care organization.
  4. About 51% of respondents participate in Medicare episode-specific bundled payment models.
  5. About 35% of respondents participate in a patient-centered medical home (PCMH).
  6. About 29% of respondents receive a capitated rate.

These findings were reported in “Market Report: The Next Leap In Value-Based Care” by researchers with Sage Growth Partners for DataGen. In September 2019, Sage Growth Partners surveyed 102 executives of hospitals, health systems, and physician groups located in 38 states about their views of VBP. The goal was to gain insight on the future of VBP.

The full text of “Market Report: The Next Leap In Value-Based Care” was published March 10, 2020, by DataGen. A copy is available online at https://images.magnetmail.net/images/clients/HANYS_HSI/attach/DataGen_Papers/DataGen_MarketReport.pdf

For more information, contact: 

  • Vanessa Ulrich, Contact point for DataGen, DataGen, One Empire Drive, Rensselaer, New York 12144; 410-534-1161; Email: vulrich@sage-growth.com; Website: http://datagen.info/

The Kentucky Medicaid program is rebidding its managed care organization (MCO) contracts to have them in place for a January 1, 2021 start date. The contracts will run through December 31, 2024, followed by six additional two-year periods. The request for proposals (RFP 2000000202) was released on January 10, 2020, and proposals were due by February 7, 2020. The plans are at-risk for all Medicaid physical health, behavioral health, and pharmacy services.

The state’s current Medicaid managed care contracts are with Anthem, Aetna Better Health of Kentucky (formerly Coventry Cares), Humana, Passport Health Plan, and WellCare. The contracts are set to expire on June 30, 2020, but the state intends to extend them until the new contracts go live. About 1.3 million beneficiaries are enrolled in one of the Medicaid managed care plans.

On December 23, 2019, Kentucky’s new Governor Andy Beshear canceled the state’s award of five Medicaid managed care contracts, valued at approximately $8 billion. The contracts had been awarded on November 26, 2019, by outgoing Governor Matt Bevin, to five Medicaid MCOs: Aetna Better Health of Kentucky; Humana Health Plan, Inc.; Molina Healthcare of Kentucky; UnitedHealthcare, dba, UnitedHealthcare Community Plan of Kentucky; and WellCare Health Insurance of Kentucky.

However, on December 7, the last day of Governor Bevin’s tenure, members of the State’s Government Contract Review Committee unanimously voted to reject the new contracts. According to Governor Beshear, the contracts were canceled due to concerns about how the award process was handled. Both Anthem and Passport Health Plan filed protests over the November awards. Governor Beshear also ended community engagement provisions of the Kentucky HEALTH 1115 Medicaid waiver that required beneficiaries to meet certain work or volunteer requirements to maintain health care coverage. The previous contracts had included provisions relevant to the now-vacated community engagement requirements.

PsychU last reported on this topic in “Kentucky Announces Cancellation Of Medicaid Managed Care Contracts; To Be Rebid In January,” which published on February 10, 2020. The article is available at https://www.psychu.org/kentucky-announces-cancellation-of-medicaid-managed-care-contracts-to-be-rebid-in-january/.

For more information, contact:

  • Office of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-564-7042; Website: https://chfs.ky.gov/agencies/os/oc/
  • Amy Monroe, Director, Division of Goods & Services Procurement, Kentucky Finance and Administration Cabinet, Office of Procurement Services 702, Capitol Annex, Room 096, Frankfort, Kentucky 40601; 502-564-8624; Fax: 502-564-6013; Email: Amy.Monroe@ky.gov; Website: https://finance.ky.gov/

According to the U.S. Government Accountability Office (GAO), the Department of Veterans Affairs (VA) spending on long-term care services rose by 33%, from $6.8 in 2014 to $9.1 billion in 2018. During this period, the number of veterans using VA long-term care services rose by 14%, from 464,071 in 2014, to 530,327 veterans in 2018. Veteran eligibility for long-term care is primarily based on the extent of a service-connected disability. The VA projects that demand will continue to increase and that spending will double from about $6.9 billion in 2017, to about $14.3 billion by 2037.

VA-provided care ranges from assistance with daily activities of living, to clinical care for spinal injuries or dementia. The VA’s Geriatrics and Extended Care office (GEC) provides, or pays for, long-term care through three institutional programs, and 11 noninstitutional programs. Institutional programs typically provide more acute skilled nursing care in a residential facility. Noninstitutional programs provide care to veterans in their homes or communities. All veterans enrolled in the VA health care system are eligible for the VA’s basic medical benefits package, which includes certain institutional and noninstitutional long-term care services.

Additional findings include:

  • In fiscal years 2014 through 2018, the average daily census increased for two of VA’s three institutional programs: Community nursing homes increased by 26% (from 7,771 to 9,808); and state veterans homes increased by 1% (from 23,176 to 23,423).
  • In fiscal years 2014 through 2018, five of the 11 noninstitutional programs experienced increases in their workload over this period, ranging from 8% to 48%.
  • In fiscal years 2014 through 2018, institutional program obligations declined as a proportion of total obligations, from 74% to 67%, while the proportion of noninstitutional program obligations rose from 26% to 33%.

The GAO concluded that the VA must improve plans for providing long-term care to aging veterans. VA identified that there is not yet a consistent approach to managing the 14 long-term care programs; VA also identified an inconsistent approach in determining the amount of noninstitutional services veterans need, and has developed but not yet implemented a tool for VA medical centers to use to improve that consistency.

VA currently faces three key challenges meeting the growing demand for veteran long-term care: workforce shortages, geographic alignment of care (particularly for veterans in rural areas), and difficulty meeting veterans’ needs for specialty care. Therefore, VA must also develop measurable goals for addressing these challenges in meeting the demand for long-term care.

The GAO also recommended three executive actions to the Secretary of VA. These include:

  • Direct GEC leadership to develop measurable goals in effort to address the three key long-term care challenges listed previously.
  • Direct GEC leadership to set implementation time frames, and successfully implement a consistent GEC structure at VA Medical Centers.
  • Direct GEC leadership to set time frames for, and implement a VAMC-wide standardization of the tool for assessing the noninstitutional program needs of veterans.

These findings were reported in “VA Health Care: Veterans’ Use of Long-Term Care Is Increasing, and VA Faces Challenges in Meeting the Demand,” by the GAO. Researchers for the GAO analyzed VA data and documents on the long-term care programs that are overseen by VA’s GEC for fiscal years 2014 through 2018. VA also conducted interviews with VA officials about the programs. The goal was to describe the use of and spending for VA long-term care.

A link to the full text of “VA HEALTH CARE: Veterans’ Use Of Long-Term Care Is Increasing & VA Faces Challenges In Meeting the Demand” may be found at www.openminds.com/market-intelligence/resources/021920gaovaltc.htm.

For more information, contact:

  • Chuck Young, Managing Director, Public Affairs, U.S. Government Accountability Office, 441 G Street Northwest, Room 7149, Washington, District of Columbia 20548; 202-512-4800; Email: youngc1@gao.gov; Website: http://www.gao.gov/

From 2013 to 2016, private equity firms acquired 355 physician practices. This breaks down to 59 practices in 2013, 72 practices in 2014, 88 practices in 2015, and 136 practices in 2016. These acquisitions included 1,426 sites and 5,714 physicians. There are approximately 18,000 unique group medical practices in the U.S. Each practice has one or more sites.

Additional findings include:

  • The most commonly acquired medical groups were anesthesiology (19.4%), multispecialty (19.4%), emergency medicine (12.1%), family practice (11.0%), and dermatology (9.9%).
  • Within the acquired practices, anesthesiologists represented about 33.1% of all physicians; emergency medicine specialists represented 15.8%; family practitioners represented 9.0%, and dermatologists represented 5.8%.

The researchers concluded the results of their analysis support equity firms’ typical investment strategy of acquiring “platform” practices. These practices have large community footprints (with several sites and many physicians). Equity firms then increase the value of the acquisitions by recruiting additional physicians, acquiring smaller groups, and expanding market reach. They suggest further research to understand the effect of acquisitions by equity firms, and to mitigate unintended consequences of these acquisitions.

These findings were reported in “Private Equity Acquisitions of Physician Medical Groups Across Specialties, 2013-2016” by Jane M. Zhu, M.D., MPP, MSHP; Lynn M. Hua, BA; and Daniel Polsky, Ph.D., MPP. The researchers identified acquisitions by private equity firms through the Irving Levin Associates Health Care M&A data set, then lined those acquisitions to the SK&A data set, a commercial data set of verified physician- and practice-level characteristics for U.S. office-based practices. The goal was to report on acquisitions by private equity firms.

The full text of “Private Equity Acquisitions of Physician Medical Groups Across Specialties, 2013-2016” was published February 18, 2020 by JAMA Network. An abstract is available online at https://jamanetwork.com/journals/jama/fullarticle/2761076.

For more information, contact:

  • Jane M. Zhu, M.D., MPP, MSHP, Assistant Professor, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, Oregon, 97239; Email: zhujan@ohsu.edu; Website: https://ohsu.pure.elsevier.com/en/persons/jane-zhu

The city of Denver’s new strategic framework for improving behavioral health calls for a greater use of data to guide policy to ensure that communities promote well-being, broadly improve access to care, provide early crisis services, and provide integrated and coordinated care. The goal is to improve existing services, systems, and responses to ensure they provide consistent and comprehensive care.

The framework recommends building on the Colorado Health Observation Regional Data Service (CHORDS), a regional partnership among the metro-Denver area public health departments that uses electronic health record data to aggregate medical and behavioral health data from provider organizations. CHORDS uses the data to support public health evaluation and monitoring efforts. To further leverage data to guide behavioral health policy, the framework recommends the following:

  • Develop data collection mechanisms for behavioral health status at the population level, including positive outcomes, as well as data by race, ethnicity, and gender and for people across the lifespan, new parents, immigrants and refugees, and individuals with intellectual/developmental disabilities (I/DD).
  • Develop an official data set for Denver that captures available addiction treatment services and the demand for those services.
  • Improve care coordination by implementing a data-sharing system among providers of mental health care, physical health care, jails, and social services.
  • Enact data sharing agreements that allow multiple stakeholders, including hospitals, medical professionals, and first responders, to enable secure and timely treatment.
  • Increase family and consumer support and education for understanding health data sharing, privacy, and release of information forms.

To improve access to services, the recommendations were as follows:

  • Create a platform for Denver residents to find and access support services based on unique circumstances. Build upon existing tools such as 211 and Colorado Crisis Services.
  • Train community members (e.g., schools, religious groups, workplaces) to recognize behavioral issues in themselves and others and how to engage appropriately.
  • Collaborate with employer groups to implement workforce supports and training.
  • Expand access to supportive services such as housing assistance, food, and transportation.
  • Identify and develop care navigation and coordination plans that address the needs of specific populations.
  • Increase funding opportunities for behavioral health services and other support services to share spaces.

To increase access to integrated, coordinated care, the recommendations were as follows:

  • Expand and support Denver’s behavioral health workforce through multiple strategies, including retain existing clinical professionals; train clinical professionals to offer trauma-informed services that meet the cultural and linguistic needs of different groups; identify pathways to hire individuals with lived experience with mental health and addiction; and boost access to effective supervision models and resiliency and peer support training.
  • Develop a center to provide 24/7 care for people with behavioral health conditions, including access to treatment, social support services, legal services, and transportation.
  • Provide an accessible continuum of addiction treatment that stretches from prevention to treatment to community-based recovery.
  • Align with efforts underway through the Denver Opioid Response Strategic Plan to increase access to harm reduction services and treatment on demand.
  • Eliminate systems-level barriers to providing comprehensive care, such as reimbursement and payment structures that prioritize treating one health issue instead of the whole person, and lack of training in treating addiction and mental health issues together.
  • Promote broad adoption and use of standardized screening and processes for mental health and addiction by all health care facilities in Denver, including primary care, school-based clinics, and emergency departments.
  • Identify and fund supportive, creative strategies that build trust and strengthen relationships between city residents and service provider organizations.

To ensure that crisis behavioral health services are provided early and in appropriate settings, the recommendations were as follows:

  • Establish a first response mechanism that is distinct from law enforcement, fire, and emergency medical professionals to connect people experiencing behavioral health crises with behavioral health provider organizations directly.
  • Support legislation to allow for diversion of people in crisis to appropriate treatment and care rather than sending them to jail or the emergency room.
  • Invest in and adopt alternative crisis response models.
  • Increase the availability and integration of peer support services.
  • Expand training in trauma-informed care for law enforcement, people who work in the criminal justice system, first responders, and others who make up Denver’s behavioral health crisis response system.

The recommendations were issued in “Road To Wellness: A Strategic Framework to Improve Behavioral Health in Denver.” The goal is to provide a roadmap for stakeholders in the behavioral health community to help navigate towards shared objectives around building a healthy community. The city began developing the plan in October 2018 when the mayor convened a steering committee. The committee was charged with scanning the current state of behavioral health services in Denver, identifying gaps, examining best practices, and providing recommendations. During the process, more than 100 individuals and 50 organizations participated to provide input.

A link to the full text of “Road To Wellness: A Strategic Framework to Improve Behavioral Health in Denver” at www.openminds.com/market-intelligence/resources/011420denverroadtowellness.htm.

For more information, contact:

  • Theresa Marchetta, Director, Strategic Communications and Media Policy, City and County of Denver and the Denver Health and Hospital Authority, 1437 North Bannock Street, Room 350, Denver, Colorado 80202-5390; 720-865-9000; Email: Theresa.Marchetta@denvergov.org; Website: https://www.denvergov.org/.

In most community mental health centers and federally qualified health centers that had telehealth capabilities in 2018, telepsychiatry was used as an adjunct to in-person care. In a study that included 20 health centers, all offered any telepsychiatry services, and 13 offer telepsychiatry as an adjunct to in-person care. When services could be provided either in person or via telehealth means, the health centers often considered consumer preference, acuity, and insurance status to decide whether to offer telepsychiatry services.

For those health centers that offered telepsychiatry services, the main reason given is that they were unable to recruit or maintain in-person clinical professionals. Some centers said that the decision to offer these services was to address a vacancy caused by the departure of a clinical professional, or to continue working with a clinical professional who moved out of state.

For those health centers that do not offer telepsychiatry, the primary reason given is that they are able to meet consumer demand for care without it. Therefore, these centers instead recruit and retain providers for in-person services. Additional reasons for not offering telepsychiatry services included potential technical difficulties that would create a bad experience for consumers, potentially high no-show rates, belief that mental health therapy should be offered in person to establish good relationships, and concerns about maintaining information confidentiality and safety.

The researchers concluded that many drawbacks to telepsychiatry may be somewhat mitigated by offering telepsychiatry as an adjunct to in-person care. Examples of this include requiring all intake interviews be conducted in person prior to telepsychiatry use, and requiring occasional in-person visits when telepsychiatry is used by a consumer.

These findings were reported in “Use of Tele–mental Health in Conjunction With In-person Care: A Qualitative Exploration of Implementation Models” by Lori Uscher-Pines, Ph.D.; Pushpa Raja, M.D.; Nabeel Qureshi; Haiden A. Huskamp, Ph.D.; Alisa B. Busch, M.D.; Ateev Mehrotra, M.D. The researchers analyzed data from the 2018 Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Services Locator database, and solicited participation from varied health centers in 20 states across the U.S. Twenty health centers in 14 states participated in an interview regarding the use of telehealth. The goal was to determine trends in telehealth use in these locations.

The full text of “Use of Tele–mental Health in Conjunction With In-person Care: A Qualitative Exploration of Implementation Models” was published January 30, 2020 by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900386.

For more information, contact: 

Lori Uscher-Pines, Ph.D., Policy Researcher, RAND Corporation, Post Office Box 2138, Santa Monica, California 90401-2138; 703-413-1100; , ext. 5167; Email: Lori_Uscher-Pines@rand.org; Website: https://www.rand.org/about/people/u/uscher-pines_lori.html

Out-of-network (OON) primary care is associated with higher median quarterly costs for Medicare beneficiaries attributed to a Medicare Shared Savings Plan (MSSP) accountable care organization (ACO). Median per-beneficiary spending for ACO beneficiaries was $401 per quarter between 2012 and 2015. Each percentage point increase in OON primary care spending was associated with a $10.97 increase in total quarterly spending per beneficiary. Additionally, each percentage point increase in OON primary care was associated with quarterly per-beneficiary increases in outpatient costs, skilled nursing facility costs, and emergency department costs. Changes in OON specialty care were not significantly associated with total spending or spending in any specific setting.

About 82% of specialist care for ACO beneficiaries takes place OON. Some ACOs have focused on reducing specialty care. However, the researchers said their findings suggest that ACO administrators may have overlooked the impact of OON primary care in their efforts to reduce OON specialty care.

These findings were reported in “Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs,” by Sunny C. Lin, Phyllis L. Yan, Nicholas M. Moloci, Emily J. Lawton, Andrew M. Ryan, et al. The researchers analyzed national Medicare data between 2012 and 2015 from 1,604,809 unique beneficiaries. The goal was to determine the relationship between out-of-network care and spending.

The full text of “Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs” was published in the February 2020 issue of Health Affairs. An abstract is available online at https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00181.

For more information, contact:

  • John M. Hollingsworth, M.D., MS, Associate Professor of Urology, Management and Policy, School of Public Health, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Room 112W, Ann Arbor, Michigan 48109; 734-763-2797; Fax: 734-232-2400; Email: kinks@med.umich.edu; Website: https://sph.umich.edu/faculty-profiles/hollingsworth-john.html

To improve behavioral health in the United States, Well Being Trust recommends that policymakers adopt a new framework with five engagement points to increase the frequency of behavioral health assessments and better facilitate access to care. The framework includes recommendations to promote mental wellness, prevent and/or treat mental illness, and maintain mental wellness. The five engagement points are health systems, judicial systems, education systems, workplace and unemployment, and “the whole community.” In this framework, promotion and prevention are supported by seven community conditions that provide civic belonging, a thriving natural world, reliable transportation, lifelong learning, meaningful work and wealth, humane housing, and basic needs for health and safety. The framework identifies barriers to behavioral wellness including stigma, cost, social isolation, and problems accessing behavioral health services.

The framework recommends that the federal government take the following five actions:

  1. Ensure that hospital payment models and quality programs encourage a mental health assessment at every interaction, not only during wellness visits. This should include integrating screening and treatment into episode-based payment models for health conditions for which there are frequent mental health co-morbidities, such as cardiovascular diseases, cancers, and pulmonary diseases.
  2. Provide long-term funding for states to continue programs such as Money Follows the Person and the Balancing Incentive Program to ensure that people with intellectual/developmental disabilities (I/DD) and behavioral health conditions have consistent access to comprehensive, high-quality services and support outside of institutional settings.
  3. Increase incentives for individuals to join the mental health workforce and for training programs to actively recruit and effectively train diverse individuals to meet underserved needs and provide more culturally competent care.
  4. Create a seed fund that supports primary care provider organizations, especially Federally Qualified Health Centers and Rural Health Centers, in developing the necessary capacity to begin seeking sustainable reimbursement for integrated mental health care services.
  5. Create incentives in funding programs for municipalities that have created effective policies or strategies for ensuring access to affordable housing.

Additionally, the framework recommends that special considerations be given to focus populations, as follows:

  1. Create incentives for policy reforms that improve school culture and/or student mental health and provide additional financing for schools that implement effective strategies that reduce disparities in belonging and safety for students who identify as LGBTQ, including specialized services for suicide prevention.
  2. Make Medicaid coverage for women up to one-year postpartum a mandatory eligibility category for coverage and include measures of screening and effective coordination of care for maternal behavioral health in hospital incentive programs for care transitions and quality/safety.
  3. Ensure that the Indian Health Service and the Veteran’s Health Administration are engaged in the same reform efforts as the Centers for Medicare & Medicaid Services for mental health and increase funding to build capacity.
  4. Make it impermissible that any information related to the seeking of behavioral health treatment be used in any aspect of immigration enforcement and provide funding to disseminate this information to immigrants and for education about the availability of behavioral health services as part of immigration services.
  5. Allow Medicaid funds to reimburse for the education of housing authorities concerning the risks of housing insecurity and what resources are available to meet those needs.

These recommendations were issued in “Healing the Nation: Advancing Mental Health and Addiction Policy” by Well Being Trust. The framework focuses on multiple angles for engagement with a specific emphasis on five main entry points for policy. It also specifically highlights populations that have been impacted differently by current mental health and addiction treatment crises. In total, the report makes 50 recommendations.

Well Being Trust is a national foundation focused on advancing mental, social, and spiritual health. The organization was created to include participation from organizations across sectors and perspectives to innovate and address mental health challenges facing America, and to transform individual and community well-being.

The full text of “Healing the Nation: Advancing Mental Health and Addiction Policy” was published in January 2020 by Well Being Trust, available online at https://healingthenation.wellbeingtrust.org/.

For more information, contact:

  • Benjamin F. Miller, Psy.D., Chief Strategy Officer, Well Being Trust, 436 14thStreet, Suite 1120, Oakland, California 94612; Email: ben@wellbeingtrust.org; Website: https://healingthenation.wellbeingtrust.org/

On February 14, 2020, a federal circuit court in Washington, D.C., ruled that the federal Department of Health and Human Services (HHS) acted capriciously when it approved Medicaid waivers submitted by Arkansas and Kentucky to impose community engagement and work requirements as a condition of Medicaid eligibility. The Circuit Court upheld a District Court ruling that vacated HHS approval for the waivers.

The District Court for the District of Columbia had previously held that HHS had acted in an arbitrary and capricious manner because it failed to analyze whether the waiver demonstrations would promote Medicaid’s primary objective of furnishing medical assistance. Kentucky subsequently ended its demonstration project in late 2019. The Arkansas Works demonstration is ongoing, and requires beneficiaries to participate in at least 80 hours of work or community engagement activities monthly, and to report those hours in a timely manner. Failure to meet the threshold or to report for three continuous months results in loss of Medicaid eligibility for the rest of the year. During the first five months of Arkansas Works, about 25% of those subject to the work requirement lost coverage, representing more than 18,000 people.

The Circuit Court considered whether the HHS authorization of the Arkansas demonstration was legal, and agreed with the District Court that approval of the plan was arbitrary and capricious. The ruling noted that HHS prioritized a non-statutory objective to the exclusion of the statutory purpose of Medicaid. Because the HHS approval of the Arkansas waiver was deemed as such, the Circuit Court affirmed the district court judgment vacating HHS approval.

The Circuit Court noted that instead of analyzing whether the demonstrations would promote Medicaid’s primary objective of providing coverage for health care services, HHS identified the following three alternative objectives:

  1. Whether the demonstration as amended was likely to assist in improving health outcomes;
  2. Whether it would address behavioral and social factors that influence health outcomes; and
  3. Whether it would incentivize beneficiaries to engage in their own health care and achieve better health outcomes.

The opinion noted that while the three alternative objectives point to better health outcomes as the objective of Medicaid, the current Medicaid statutes do not mention that objective, and specifically address only coverage. Additionally, both Arkansas and HHS characterized the HHS approval letter as stating that transitioning beneficiaries away from governmental benefits through financial independence or commercial coverage as an objective promoted by the Arkansas Works demonstration. The Circuit Court said that argument misrepresents the HHS Secretary’s approval letter, which has a section for the determination that the project will assist in promoting the objectives of Medicaid. The letter cites the health outcome goals, but does not mention transitioning beneficiaries away from benefits. The letter has no reference to commercial coverage. The only reference to beneficiary financial independence is in a section summarizing public comments. The letter does not justify the approval based on a belief that the demonstration will help Medicaid-eligible people gain sufficient financial resources to be able to purchase private insurance. The Circuit Court said that while it is not arbitrary or capricious to prioritize one statutorily identified objective over another, it is an entirely different matter to prioritize non-statutory objectives to the exclusion of the statutory purpose.

PsychU last reported on this topic in “From June To November 2018, 17,000 People Lost Arkansas Medicaid Benefits Over Failure To Meet Work Requirements,” which published on February 18, 2019. The article is available at https://www.psychu.org/june-november-2018-17000-people-lost-arkansas-medicaid-benefits-failure-meet-work-requirements/.

PsychU last reported on Kentucky’s effort to implement community engagement requirements in the following articles:

  • “Under Kentucky Medicaid Work Requirements, About 15% Of Non-Exempt Beneficiaries Would Fail To Meet Criteria,” which published as a News Report on September 9, 2019, at https://www.psychu.org/under-kentucky-medicaid-work-requirements-about-15-of-non-exempt-beneficiaries-would-fail-to-meet-criteria/.
  • “Kentucky Announces Cancellation Of Medicaid Managed Care Contracts; To Be Rebid In January,” which published as a News Report on February 10, 2020, at https://www.psychu.org/kentucky-announces-cancellation-of-medicaid-managed-care-contracts-to-be-rebid-in-january/.

For more information about Gresham v. Azar, contact:

  • Andy Diantonio, Communications Associate, National Health Law Program, 1444 I Street NW, Suite 1105, Washington, District of Columbia 20005; Email: dantonio@healthlaw.org; Website: https://healthlaw.org/
  • Kevin De Liban, Attorney and Economic Justice Practice Group Leader, Legal Aid of Arkansas – West Memphis, 310 Mid-Continent Plaza, Suite 420, West Memphis, Arkansas 72301; 870-732-6370, ext. 2206; Email: kdeliban@arlegalaid.org; Website: http://arlegalaid.org/
  • Trevor Hawkins, Staff Attorney, Legal Aid of Arkansas, 714 South Main Street, Jonesboro, Arkansas 72401; 870-972-9224, ext. 6313; Email: thawkins@arlegalaid.org; Website: http://arlegalaid.org/

On February 3, 2020, the Texas Department of Family and Protective Services (DFPS) reported that turnover for its Adult Protective Services (APS) caseworker fell from 25.2% in fiscal year 2018, to 20.7% in fiscal year 2019. Based on data from the first quarter of fiscal year 2020, DFPS believes that turnover could be 17% or lower in fiscal year 2020.

DFPS believes that the decrease in turnover can be partially attributed to three events:

  • A recent legislative decision to provide APS caseworkers and front-line supervisors a raise of $750 a month.
  • More than 40 caseworkers were added to the statewide workforce, and placed in areas with the most need.
  • A mentorship program for APS caseworkers was implemented in the state.

As of August 31, 2019, APS had 512 caseworkers on staff. Of these caseworkers, 97 had been hired within the year prior, 142 had been on staff for one to three years, and 273 had been on staff for more than three years. The Arlington region had the most active caseworkers (103), followed by Houston (97), San Antonio (64), and Austin (56). During fiscal year 2019, both the Beaumont and Tyler regions had 0% turnover. El Paso region (4.8%, with just 1 turnover out of 20.8 average active caseworkers) and Lubbuck (7.1%, with just 2 turnovers out of 28.3 average active caseworkers) join these regions in the lowest turnover rates in the state.

DFPS maintains an interactive webpage with statistics at https://www.dfps.state.tx.us/About_DFPS/Data_Book/Employee_Statistics/APS/Staff_Turnover.asp.

For more information, contact: 

  • Patrick Crimmins, Media Relations Manager, Texas Department of Family and Protective Services, Post Office Box 149030, Austin, Texas 78714-9030; Email: patrick.crimmins@dfps.state.tx.us; Website: http://www.dfps.state.tx.us/

On February 24, 2020, a representative from Northern Maine Medical Center (NMMC) confirmed that a “Meds-to-Beds” program is in the process of being launched. The program will ensure that a consumers prescriptions for post-discharge medications are filled, and delivered to his or her room, before the consumer leaves the hospital. Upon the consumer’s request, these prescriptions will be delivered by a staff member during business hours, and a pharmacist will counsel consumers on the medication. After business hours, consumers can pick up their prescription at NMMC’s Pharmacy. Additionally, before discharge, NMMC pharmacy staff will conduct a consumer medication reconciliation to reduce the risk of duplicate or missing medications.

Prescriptions filled by the Meds-to-Beds program are considered an outpatient pharmacy service. Payment, or an insurance copay, is collected when services are rendered. NMMC will bill insurance provider organizations directly for the prescription. If there are financial issues that may prevent a consumer from filling their needed prescription(s), the NMMC pharmacist can access financial resources and troubleshoot by making a referral to the Patient Financial Advocate, prior to the consumer leaving the hospital.

In May 2018, Northern Maine Medical Center purchased a retail pharmacy, MADRx. Through this integration, NMMC has access to consumer clinical records, lab work, hospital medications, discharge medications, and original home medications, which will support the Meds-to-Beds program.

For more information, contact:

  • Amy Vaillancourt, Pharmacist, Northern Maine Medical Center, 194 East Main Street, Fort Kent, Maine 04743; Email: amy.vaillaincourt@nmmc.org; Website: https://www.nmmc.org/

A recent report revealed that from 2010 to 2017, the number of nurse practitioners (NPs) increased from about 91,000 to 190,000, which resulted in the RN workforce contracting by as much as 80,000. RNs returning to school to become NPs is a phenomenon occurring in every region of the country. At the same time, more than one million RNs are approaching retirement.

Additional findings in the report include:

  1. Employment for NPs was concentrated in hospitals, physician offices, and outpatient care centers.
  2. The fastest growth for NP employment overall was in outpatient care centers, which also had the highest salaries.
  3. Growth of NPs was most rapid in the east south-central region of the country, which includes Alabama, Kentucky, Mississippi, and Tennessee.
  4.  It is projected that there will be two NPs for every five physicians in 2030, compared to one NP per five physicians in 2016.

The researchers concluded that hospitals must determine and test new ways to replace RNs who have left their positions to become NPs. Hospitals must also determine solutions in response to low, or fluctuating, RN staffing.

These findings were reported in “Implications Of The Rapid Growth Of The Nurse Practitioner Workforce In The US” by David Auerbach, Peter Buerhaus, and Douglas Staiger, as published in Health Affairs. The researchers analyzed occupational data from the Census Bureau’s American Community Survey (ACS).

The full text of “Implications Of The Rapid Growth Of The Nurse Practitioner Workforce In The US” was published in February 2020 by Health Affairs. An abstract is available online at https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.00686.

PsychU last reported on this topic in “Nurse Practitioners May Represent 27% Of The Family Practice Workforce By 2025,” which published on May 23, 2018. The article is available at https://www.psychu.org/nurse-practitioners-may-represent-27-family-practice-workforce-2025/.

For more information, contact: 

  • David I. Auerbach, Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University, Anna Pearl Sherrick Hall, Bozeman, Montana 59717; Email: davea@alum.mit.edu; Website: http://healthworkforcestudies.com/about/auerbach.html

Jane Guo, MBA, PharmD, is a Managed Market Liaison­, Northeastern Region, with Otsuka. Her career started in retail pharmacy. She then moved over to managed care at Express Scripts as a Pharmacist Supervisor in front-end operations. At Otsuka, she works on the managed care side as well, focusing on relevant products and on-demand resources. Guo graduated from the Albany College of Pharmacy and Health Sciences with a Doctor of Pharmacy degree, and she has a Master of Business Administration degree from The College of William and Mary.

Guo agreed to be interviewed by PsychU about the clinical and payer implications of the study outlined in “Telemedicine Provision: One State as Case Study,” based on research conducted in Minnesota.

The conversation has been edited for clarity and brevity.

PsychU: What is the hope of telemedicine? What do we want it to do for us?

Guo: Mostly it is the convenience factor. Individuals who live in rural areas and those who seek specialists face difficulty gaining access to services. Telemedicine allows them to connect with a medical professional able to provide quality care.

Also, we are seeing a newer generation of individuals who grew up with technology, and telemedicine may seem natural to them. You have a new mother with a baby, and she can connect with someone who will prescribe antibiotics for an ear infection. She doesn’t have to schedule an appointment and wait a day or more for it, then get in the car, or go to urgent care and sit there for an hour or two. So ease of access and convenience are definitely key.

From a payer perspective, it’s a long-term investment. You have to look at it from that vantage point because you’re seeking to improve overall health by providing better access, which hopefully will lead to lower costs because you have a healthier population.

PsychU: The research study referenced in the summary found that telemedicine was used differently in metropolitan versus rural regions. Could you speak to that?

Guo: Sure. In non-metropolitan areas, it is more about access to specialists, particularly psychiatrists and other mental health care professionals—there is a well-known shortage of them. When I am out in the field, in more rural areas, I hear, “We don’t have the clinicians we need.”

In metropolitan regions, it’s the opposite. In New York City, for instance, what I hear instead is there are plenty of providers, but sometimes it’s just difficult to schedule an appointment and then take time out of your day to go to it. In the city, telemedicine tends to be more about improving access to primary care. The convenience factor, for people on the go.

Another difference the study found was that in rural areas, telemedicine tends to be real-time provider-initiated care; in metropolitan areas, consumers are more likely to initiate the encounter.

In both metropolitan and non-metropolitan locales, I think telemedicine will play a large role in coordinating care.

PsychU: That’s interesting. As you know, our theme for 2020 is bridging the care continuum. How does telemedicine close care gaps and become part of integrated care?

Guo: Well, telemedicine allows a doctor or nurse practitioner to easily put a patient in touch with a specialist. It can be a warm handoff, as opposed to a primary care provider writing a referral to a specialist. That’s when you sometimes lose that patient. By supplementing care—rather than supplanting it—telemedicine care help bridge care gaps.

PsychU: Would you say that alternative payment models that require providers to take on financial risk, such as accountable care organizations (ACOs), foster innovative uses of telemedicine?

Guo: I don’t know if those payment models do or not, but from a quality standpoint, there is an incentive to use telemedicine to improve continuity of care, thereby improving quality of care. When you improve care and outcomes, while managing costs, you get a bigger reward in the form of a better quality ranking or bigger bonus reimbursement from the government.

PsychU: What do you see ahead?

Guo: Increasing buy-in from both patients and providers. For anyone, really, the focus is “What can this do for me?” I think clinicians will increasingly see how telemedicine can improve outcomes efficiently, while being convenient. And it is likely to increase patient satisfaction, another positive attribute. If reimbursement increased, that obviously would drive adoption.

As for individuals, convenience is key. Ease of use will encourage more individuals to try it and hopefully like it.

During 2019, merger and acquisition volume within the United States health care sector dropped by 1.5%, from 1,239 in 2018 to 1,221 in 2019. Total deal value was $91.2 billion in 2019. This is a 26.6% decrease from $66.9 billion in 2018. Health service sub-sectors analyzed include hospitals, home and hospice business, managed care plans, rehabilitation, physician medical groups labs, behavioral care, and “other services.” No definition for “other services” is provided.

Additional findings include:

  • “Hospitals” was the only sub-sector whose volumes grew on a year-over-year basis in each of the last three quarters of 2019. However, the home health and hospice, and managed care plans subsectors also finished the year with a stronger positive volume growth.
  • Three sub-sectors grew in terms of both volume and value: Managed care, long-term care, and hospitals. Additionally, Labs, MRI, and Dialysis deal value grew 503%; however, volume was flat.
  • Four sub-sectors experienced deal value declines: Physician medical groups, other services, behavioral care, and home health and hospice.

These findings were reported in “US Health Services Deals Insights Year-End 2019 Online Report” by PwC. The researchers analyzed publicly announced merger and acquisition transactions in specified sub-sectors. The goal was to compile data metrics and analysis of the announced 2019 mergers and acquisitions in the U.S. health care sector.

The full text of “US Health Services Deals Insights Year-End 2019,” was published in January 2020 by PwC. A free copy is available online at https://www.pwc.com/us/en/industries/health-industries/library/health-services-quarterly-deals-insights.html

For more information, contact:

  • Nick Donkar, Partner and West Region Health Services Deals Leader, PwC US, PricewaterhouseCoopers LLP, 300 Madison Avenue, New York, New York 10017; Website: https://www.pwc.com/us/en/industries/health-industries/health-research-institute.html. 

The number of announced behavioral health acquisitions slowed by 21% between the third and fourth quarters of 2019, from 19 in the third quarter to 15 in the fourth quarter. The fourth quarter 2019 deal volume was 46% below the 28 deals announced for the fourth quarter 2018.

Discovery Behavioral Health was the most active acquirer during the quarter, with a total of three transactions targeting companies specializing in drug and alcohol treatment programs: Authentic Recovery Center in Los Angeles, California; Casa Palmera in San Diego, California; and New Life Addiction Counseling & Mental Health Services in Pasadena, Maryland. Of the 15 announced transactions in the fourth quarter, only one disclosed a transaction price: Thomas H. Lee Partners acquired Centria Healthcare from Martis Capital and Lorient Capital for $415 million.

These findings were reported in “The Behavioral Health Care Acquisition Report 2019” by Irving Levin and Associates. The researchers analyzed publicly announced merger and acquisition transactions and pricing statistics. The goal was to compile data metrics and analysis of the 2019 mergers and acquisitions market.

For more information, contact: 

  • Irving Levin Associates, Inc., 268 ½ Main Avenue, Norwalk, Connecticut 06851; 203-846-6800; Fax: 203-846-8300; Email: info@levinassociates.com; Website: https://www.levinassociates.com/

On January 21, 2020, the California Department of Corrections and Rehabilitation (CDCR) and the California Correctional Health Care Services (CCHCS) began screening inmates at all 35 state institutions for an enhanced integrated substance use disorder treatment (ISUDT) program. The program will offer participants medicated assisted treatment (MAT), comprehensive cognitive behavioral interventions, and safe, therapeutic housing. This initiative will focus on whole-person treatment from incarceration through return to the community.

During roll out, CDCR is focusing on three priority populations; however, an individual not identified in one of these groups can request assessment and treatment. At full capacity, the program will be available to any inmate needing treatment for addiction disorder. The three priority populations are:

  • Those currently receiving MAT
  • Those leaving within 15 to 24 months
  • Those considered high risk due to previous overdose, current clinical symptoms, Hepatitis C, or infections

The ISUDT provides services within the state facilities. CCHCS and CDCR have hired new staff to administer the program, and current staff are also being trained. Contracted cognitive behavioral intervention counselors will use a standardized curriculum based on the American Society of Addiction Medicine criteria.

The CDCR’s plans for ISUDT were noted in “CDCR Vision, Mission, Values, and Goals.” The program is just one method CDCR will use to continue toward the goal of “reflecting the joint priorities of creating a prison environment that provides the incarcerated population with the tools necessary to be drug-free, healthy, and employable members of society upon their release.” Additional steps the CDCR has taken to uphold this goal include:

  • Addressing criminality: The CDCR has increased capacity in cognitive behavioral intervention (CBI) programs focused on criminal thinking, anger management, family relationships, and victim impact by almost 300% since 2015.
  • Career training: The CDCR has more than doubled the capacity of career technical education opportunities for real-world job skills. They have also launched “Microhome” initiatives at the Correctional Training Facility in Soledad, and Folsom State Prison in Sacramento, which provide training for in-demand trades and careers to help individuals succeed when they return to society.
  • College education: The CDCR offers face-to-face community college programming in 34 prisons. A total of 740 people have enrolled, with an additional 200 enrolled in distance learning courses. Face-to-face instruction at Kern Valley State Prison, offered through Bakersfield College, has served 498 individuals.
  • Restorative justice: In 2019, The CDCR awarded grants to eligible non-profit organizations to implement victim impact programs in California prisons. These programs share a common goal of giving victims the opportunity for their voices to be heard, and for incarcerated men and women to fully understand the consequences of their actions.
  • Reentry: Since 2014 and 2015, The CDCR has increased its “Transitions” reentry program capacity 753% from 2,430 to 20,734. Transitions is a five-week program, provided near the end of an individual’s incarceration, to focus on their community reentry needs (such as financial literacy, job search skills, and community resources).
  • Community partnerships: The CDCR cultivates relationships with community partners throughout the state. Through a partnership with CAL FIRE, California Conservation Corps, and the Anti-Recidivism Coalition, CDCR opened an innovative firefighter training program for recently-paroled individuals who served as firefighters while incarcerated.

The full text of “CDCR Vision, Mission, Values, and Goals” was published January 7, 2020. An online copy is available at https://www.cdcr.ca.gov/about-cdcr/vision-mission-values/.

For more information, contact:

  • Krissi Khokhobashvili, Chief, External Communications, Office of Public and Employee Communications (OPEC), California Department of Corrections and Rehabilitation, 1515 S Street, Sacramento, California 95811; 916-445-4950; Email: OPEC@cdcr.ca.gov; Website: https://www.cdcr.ca.gov/
  • Elizabeth Gransee, Communications, California Correctional Health Care Services, Post Office Box 588500, Elk Grove, California 95758; 916-691-6714; Fax: 916-691-6183; Email: Lifeline@cdcr.ca.gov; Website: https://cchcs.ca.gov/

About 20% of emergency departments in the United States use some form of telepsychiatry, according to a national survey. In a separate survey, about 59% of emergency departments that use some form of telepsychiatry reported that telepsychiatry is their emergency department’s only form of emergency psychiatric services. About 25% of emergency departments that use some form of telepsychiatry reported that they have individuals that receive services at least once a day.

Additional findings include:

  • Characteristics associated with higher likelihood of emergency department telepsychiatry receipt included higher annual total visit volumes, rural location, and designation as a Critical Access Hospital (i.e., very small health care locations that provide “critical access” to people who live in remote areas).
  • Characteristics associated with lower likelihood of telepsychiatry receipt included being an autonomous freestanding emergency department.

The researchers concluded that telepsychiatry is used to fill a critical need in emergency departments. They recommend additional research to identify barriers to implementing telepsychiatry in emergency departments that do not have access to emergency psychiatric services.

These findings were reported in “National Study of Telepsychiatry Use in U.S. Emergency Departments” by Rain E. Freeman, MPH, Krislyn M. Boggs, MPH, Kori S. Zachrison, M.D., M.Sc., Rachel D. Freid, MPH, Ashley F. Sullivan, MS, MPH, Janice A. Espinola, MPH, and Carlos A. Camargo Jr., M.D., Dr.P.H. The researchers surveyed 5,375 emergency departments in the United States to characterize emergency care in 2016. Fifteen percent of those emergency departments that reported receiving telepsychiatry services were randomly re-surveyed to confirm telepsychiatry use in 2017, and to collect data on emergency psychiatric services and applications of telepsychiatry in each emergency department. The goal was to investigate the prevalence and applications of telepsychiatry in general emergency departments in the U.S.

The full text of “National Study of Telepsychiatry Use in U.S. Emergency Departments” was published February 5, 2020 by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900237.

For more information, contact: 

  • Carlos A. Camargo, Jr., M.D., Dr.P.H., Professor, Department of Epidemiology, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, Massachusetts 02114; 617-726-5276; Email: ccamargo@partners.org; Website: https://www.hsph.harvard.edu/carlos-camargo/

On December 4, 2019, the New Mexico Human Services Department (HSD) announced it had settled with the last five of the 10 behavioral health provider organizations that sued the state because their Medicaid reimbursements were frozen in June 2013 due to allegations of fraud by the previous administration of Governor Susana Martinez. The five organizations are Santa Maria El Mirador (formerly Easter Seals El Mirador); Border Area Mental Health Services; Southwest Counseling Center, Inc.; Southern New Mexico Human Development, Inc.; and Families and Youth, Inc. They agreed to share a settlement of $10 million.

In 2013, the Martinez administration hired an independent auditor that estimated that 15 behavioral health provider organizations had been overpaid by $36 million over a three-year period. The state said this represented a “credible allegation of fraud” and imposed a Medicaid payhold. The payhold meant that the organizations could not bill for any new Medicaid claims and would not be paid for $11.5 million in unpaid claims submitted before the payhold was imposed. Without the state Medicaid payments, many of the organizations could not sustain operations and went out of business within a few months. In 2015, 10 of the provider organizations sued the state to protest the audit methodology. As of June 2017, HSD, the state Medicaid agency, had held fair hearings with eight of the organizations. An HSD spokesperson said these hearings “established in excess of $5 million in overpayments.” On July 7, 2017, the governor’s office alleged that at least $9.4 million in overpayments were received by the provider organizations. By July 2017, the attorney general’s investigations had cleared each of the organizations; the investigations alleged approximately $1.16 million in overbilling by the organizations, but found no evidence of fraud. The investigation findings were forwarded to HSD for further action.

In 2019, the newly-elected administration of Governor Michelle Lujan Grisham reached agreements with the behavioral health provider organizations. In the settlements, the state admitted no liability, and each organization agreed that it would not appeal or otherwise revive its lawsuit. Additionally, Governor Grisham charged HSD with fixing New Mexico’s “broken” behavioral health care system by working with the New Mexico Behavioral Health Collaborative to build a new behavioral health provider network, develop community-based mental health services for children and families, effectively address addiction disorder, and effectively address the behavioral health needs of justice-involved individuals.

The provider organizations agreed to settle their lawsuits, and to share a $10 million settlement. In addition to the settlement agreement/addendum, three of the organizations will receive additional funds. The settlements are as follows:

  • Santa Maria El Mirador (formerly Easter Seals El Mirador) will receive 29.4% of the $10 million settlement. The organization and its attorneys Davis & Gilchrist, P.C. will also receive $127,240.40.
  • Border Area Mental Health Services will receive 21.4% of the settlement. The organization and its attorneys Davis & Gilchrist, P.C. will also receive $96,201.73. Another $226.27 in fee-for-service amounts will be paid to HSD.
  • Southwest Counseling Center, Inc., will receive 21.4% of the settlement.
  • Southern New Mexico Human Development, Inc., will receive 10.4% of the settlement. The organization and its attorneys Davis & Gilchrist, P.C. will also receive $88,239.79. Another $157.21 in fee-for-service amounts will be paid to HSD.
  • Families and Youth, Inc. will receive 17.4% of the settlement.

For more information, contact:

  • Jodi McGinnis-Porter, Director, Communications, New Mexico Human Services Department, Post Office Box 2348, Santa Fe, New Mexico 87504; 505-476-7203; Email: McGinnis-Porter@state.nm.us; Website: https://www.hsd.state.nm.us/default.aspx
  • Angie Carreón, Executive Assistant, Families and Youth, Inc., 1320 South Solano Drive, Las Cruces, New Mexico 88001; 575-522-4004; Email: acarreon@fyinm.org; Website: https://www.fyinm.org/
  • Southern New Mexico Human Development, Inc., 820 Highway 478, Anthony, New Mexico 88021; 575-882-5101
  • Kathy Luzmoor, Board Chair, Southwest Counseling Center, Inc., 2300 Foothill Boulevard, Rockwell Springs, Wyoming 82901; 307-352-6677; Fax: 307-352-6614; Email: kluzmoor@swcounseling.org; Website: http://www.swcounseling.org/
  • Border Area Mental Health Services, 315 North Hudson Street, #6, Silver City, New Mexico 88061; 575-388-4497; Email: mbonacci@bamhs.com; Website: https://www.facebook.com/nmbamhs/
  • Patsy Romero, Chief Executive Officer, Santa Maria El Mirador, 10 A Van Nu Po, Santa Fe, New Mexico 87508; 505-424-7707; Email: info@eselm.org; Website: https://www.santamariaelmirador.com/

The first-known telepsychiatry-enabled model of perinatal integrated care resulted in a 100% perinatal/postpartum depression screening rate, and a higher than expected treatment engagement rate. About 19% of the mothers screened were found to have perinatal depression and/or behavioral health needs, and about 96% of them started treatment. Available data indicate that only 15% to 20% of mothers receive routine perinatal depression screening, and that of those identified, only 60% start treatment. Perinatal depression is defined as depression during pregnancy or up to one year after giving birth.

The telehealth-enabled integrated care model was implemented within a specialty obstetrics clinic serving an at-risk, socioeconomically disadvantaged population. It consisted of three components:

  • Universal depression screening: The Edinburgh Postnatal Depression Scale (EPDS) was administered at a post-natal appointment for all consumers, and the two-question Patient Health Questionnaire (PHQ-2) was administered at all other perinatal visits.
  • Virtually embedded behavioral health clinical professional (BHC): A BHC was embedded at the clinic via video conferencing to oversee the perinatal screenings, follow up on positive screens and other referrals, support coordination of virtual psychiatric consultation, provide brief intervention and treatment as needed, and refer and coordinate ongoing behavioral health and social services.
  • Virtual integration of telepsychiatry services into an evidence-based collaborative care model in primary care: The BHC served as the coordinator across the care team, consulting with the care team to make diagnostic and medication-related recommendations.

Additional findings include:

  • Under the telepsychiatry-enabled model, 12% of non-twin infants of mothers with perinatal depression were born at a low birth weight. Nationally, about 23.5% of infants of mothers with perinatal depression are born at a low birth weight.
  • Positive intervention outcomes have provided new support for the expansion of telepsychiatry-supported models of integrated care from primary care into specialty care settings.
  • There was evidence demonstrating a bidirectional relationship such that depression was associated with lower rates of breastfeeding. Among those mothers who attended their six-week postnatal visit and were able to breast feed, 85% engaged in breastfeeding.

The researchers concluded that the program improved screening and diagnosis of perinatal behavioral health issues, increased access to treatment and consumer engagement, and improved consumer outcomes. The researchers also noted that telepsychiatry is a potentially effective tool for expanding models of perinatal-integrated care.

These findings were reported in “Evaluation of Telepsychiatry-Enabled Perinatal Integrated Care” by Jay H. Shore, M.D., MPH., Maryann Waugh, M.Ed., Jacqueline Calderone, M.D., Amy Donahue, M.D., Jennifer Rodriguez, LCSW, Danielle Peters, LCSW, Marshall Thomas, M.D., and Alexis Giese, M.D. The researchers collected behavioral health screening data from 712 consumers at an urban women’s clinic, as well as in-depth process and outcome measures for 135 consumers from this same clinic. The goal was to describe the implementation of the first known telepsychiatry-enabled model of perinatal integrated care and to report initial results following implementation.

The full text of “Evaluation of Telepsychiatry-Enabled Perinatal Integrated Care” was published February 5, 2020 by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900143.

For more information, contact: 

  • Jay H. Shore, M.D., Director of Telemedicine, Helen and Arthur E. Johnson Depression Center, University of Colorado Anschutz Medical Campus, 13199 East Montview Boulevard, Suite 330, MS F550, Aurora, Colorado 80045; Email: depression.center@ucdenver.edu; Website: https://ttspsworld.com/jay-h-shore-md-mph

Federal legislation signed into law on March 6, 2020 to address national preparation and response to 2019-Novel Coronavirus (COVID-19) includes provisions that waive Medicare restrictions on telehealth for care related to COVID-19. The bill, House Resolution (HR) 6074 – Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, provides a total of $8.3 billion, with $7.76 billion to federal, state, and local agencies to combat the virus and authorizes an additional $500 million to pay for the waivers of Medicare telehealth restrictions. About $2.2 billion is earmarked for activities to prevent virus spread, and another $3 billion is earmarked for vaccine research.

COVID-19 is a new virus that presents with a fever and respiratory symptoms, similar to influenza, from two to 14 days after exposure. The symptoms range from mild to severe. It emerged in Wuhan City, Hubei Province, China. The first infections were linked to a live animal market; however, the virus is now spreading person-to-person. The Centers for Disease Control and Prevention (CDC) says that the virus seems to be spreading easily in the community, meaning that people are infected, but it is not sure how or where they were exposed. Globally, as of March 9, 2020, there had been 109,578 confirmed cases and 3,809 deaths, a death rate of 3.5%. Cases had been identified in 105 countries/territories. On March 13, 2020, the United States declared a national state of emergency due to COVID-19.

The legislation will allow Medicare fee-for-service beneficiaries living in a COVID-19 emergency area (or a portion of such an area) to receive telehealth services related to coronavirus during any portion of any emergency period. Services related to COVID-19 include a virtual check-in to discuss possible COVID-19 symptoms that the beneficiary may be experiencing. If the beneficiary shows more physical symptoms, a subsequent virtual check-in can allow a health care professional to offer recommendations about next steps and precautions that the beneficiary should take before visiting a physician office or hospital. The goal is to keep beneficiaries with mild symptoms in their homes, while increasing access to health care professionals. However, for any other services not specifically related to potential symptoms of COVID-19, Medicare’s normal telehealth restrictions apply. Medicare beneficiaries living in rural areas can continue to use communication technology to have full visits with their health care professionals.

Prior to this bill, Medicare limited payment for telehealth visits to services furnished to beneficiaries in certain types of health care facilities located in rural areas. Beneficiaries in rural areas could not receive telehealth visits in their home except under certain exceptions for the treatment of addiction or a co-occurring mental health disorder, or for monthly clinical assessments related to end-stage renal disease (ESRD).

The telehealth virtual check-ins for COVID-19 are billable services, and the Medicare coinsurance and deductible would apply to these services. The virtual check-ins must be provided by a clinical professional who has an established relationship with the beneficiary or who is in the same practice as the professional who has that relationship. Covered telehealth services can be provided via a smartphone with audio and video capabilities sufficient to provide two-way, real-time interactive communication. Physicians and other authorized clinical professionals may bill for these virtual check-in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010).

Medicare also pays for beneficiaries to communicate with their physicians by using online consumer health portals. The individual communications, like the virtual check ins, must be initiated by the beneficiary; however, health care professionals may educate beneficiaries on the availability of this kind of service prior to initiation. The communications can occur over a seven-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable. The Medicare coinsurance and deductible would apply to these services.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
  • Center for the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Email: ncirddvdinquiry@cdc.gov; Website: https://www.cdc.gov/ncird/index.html; or Michelle Bonds, Director, Division of Public Affairs, Office of the Associate Director for Communication, Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, MS D-25, Atlanta, Georgia 30333; Email: Media@cdc.gov; Website: https://www.cdc.gov/media/subtopic/contact.htm

On January 1, 2020, Blue Cross and Blue Shield of North Carolina (Blue Cross NC), in collaboration with Quartet Health, launched a new value-based payment model called Blue Premier Behavioral Health. Behavioral health professionals who meet or exceed quality benchmarks will be able to earn higher reimbursement rates. Independent, outpatient behavioral health professionals who serve members of Blue Cross NC commercial (non-government) plans may enroll by May 31, 2020.

Behavioral health professional performance will be evaluated on a series of measures in three domains: Access, communication with primary care, and health outcomes. The participants can receive a maximum bonus payment of up to 10% of their total behavioral health service reimbursement for the year. For those with quality scores greater than 95%, Blue Cross NC will offer an additional $5,000 bonus. This new value-based payment program is part of Blue Premier, an initiative launched by Blue Cross NC in 2019 to enhance primary care services, integrate behavioral health into primary care, and move to reimbursement based on performance.

This Blue Cross NC value-based payment initiative is using the Quartet Health technology platform to measure quality of behavioral health care. Participating professionals will use Quartet’s technology to facilitate referrals and enable data collection and measurement of quality outcomes. Physicians and case managers can refer consumers for mental health care through the platform. The platform facilitates on-going communication between primary care physicians and behavioral health professionals.

In 2019, Blue Cross NC began efforts to better integrate behavioral health with physical health and to transform health care through value-based payments. This new approach also integrates with Blue Premier, the company’s value-based care program that holds network provider organizations and Blue Cross NC jointly accountable for improving care and lowering costs. As part of the integration efforts in 2019, Blue Cross NC began offering Quartet’s services to primary care and behavioral health provider organizations free of charge.

Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. It serves more than 3.9 million members, including approximately 1.1 million served on behalf of other Blue plans. Kate Hobbs Knutson, M.D., Blue Cross NC head of behavioral health said, “Blue Premier Behavioral Health will expand access, improve coordination with primary care, and help achieve better health outcomes.”

PsychU last reported on this topic in “Sutter Health Teams Up With Quartet Health To Better Integrate Mental & Physical Health Care,” which published on October 16, 2017. The article is available at https://www.psychu.org/sutter-health-teams-quartet-health-better-integrate-mental-physical-health-care/.

For more information, contact:

  • Kevin Kumler, Chief Operating Officer, Quartet Health, 119 West 40th Street, 5th Floor, New York, New York 10018; Email: help@quartethealth.com; Website: https://www.quartethealth.com/
  • Susan Foosness, Senior Business Operations Advisor, BlueCross BlueShield of North Carolina, 1965 Ivy Creek Boulevard, Durham, North Carolina 27707; 984-960-3697; Email: susan.foosness@bcbsnc.com; Website: https://www.bluecrossnc.com/

During 2019, salaries for assisted living community administrators averaged $100,622, up 3.6% over the 2018 average salary of $97,126, according to a year-to-year trend analysis for facilities that participated in salary surveys in both 2018 and 2019. Across all facilities that reported in 2019, the national average administrator salary was $76,939. Across the states, average administrator salaries ranged from $63,452 in North Carolina to $97,349 in Maryland.

At smaller facilities (74 beds or less), administrator salaries averaged $71,882. At facilities with 75 or more beds, administrator salaries averaged $80,676. At for-profit facilities, administrator salaries averaged $74,933. At non-profit facilities, administrator salaries averaged $87,380.

These statistics were reported in the 22nd annual “Assisted Living Salary & Benefits Report” by Hospital & Healthcare Compensation Service. The report was published in cooperation with LeadingAge and supported by the National Center for Assisted Living. The report covers 20 management and 29 non‐management positions. In total, 1,360 assisted living communities participated in the study and provided data for over 87,400 employees. The report includes data from communities structured as assisted living facilities (80%), personal care facilities (5%), and residential care facilities (16%). The data are reported according to for‐profit (86%) and non-profit (14%) status, revenue size, unit‐size, state, and geographic region.

The full text of “Assisted Living Salary & Benefits Report” was published by Hospital & Healthcare Compensation Service. It can be purchased at https://www.hhcsinc.com/hcs-reports.html.

For more information, contact:

  • Rich Cioffe, Client Services, Hospital Healthcare & Compensation Service, Post Office Box 376, Oakland, New Jersey 08436; 201-405-0075, ext. 10; Email: rjcioffe@hhcsinc.com; Website: https://www.hhcsinc.com/

The Arizona Health Care Cost Containment System (AHCCCS) and the three Medicaid managed care organizations (MCOs) for the Arizona Long Term Care System (ALTCS) are implementing initiatives to increase the size of the state’s Medicaid long-term care workforce. The MCO contracts require the MCOs to build a long-term care workforce within their AHCCCS networks.

The ALTCS MCOs are Mercy Care, Banner-University Family Care, and United Healthcare Community Plan. The three organizations were awarded contracts in 2017. ALTCS provides acute care, long term care, behavioral health, home- and community-based services, and case management for two Medicaid populations that are served through separate contracting arrangements. AHCCCS requires in contract that each MCO hire a Workforce Development Administrator to routinely assess the capacity and capabilities of the contracted health care workforce, produce a Workforce Development Plan, and create and support workforce development initiatives that strengthen the long-term care workforce.

The ALTCS population includes nearly 56,000 beneficiaries who are aged 65 and older, blind, or disabled and who are at risk of institutionalization. More than 30,000 ALTCS beneficiaries have developmental disabilities. Their services are provided by UnitedHealthcare Community Plan and Mercy Care under contracts with the Arizona Department of Economic Security (DES) Division of Developmental Disabilities (DDD) effective October 1, 2019. AHCCCS also requires the DDD to have a workforce development administrator to build the long-term care workforce.

The state’s goal is “to ensure that Arizona is prepared to meet the projected need for licensed and unlicensed” caregivers in the coming decades, according to AHCCCS spokeswoman Heidi Capriotti. Ms. Capriotti said the MCO initiatives include supporting innovative high school-based technical education programs, developed by the Arizona Department of Education, that prepare graduating seniors to enter the long-term-care workforce. She also added that AHCCCS supports legislation to require training and testing of direct-care workers and assisted-living caregivers to help increase career mobility and decrease training and hiring costs..

PsychU last reported on this topic in “Arizona Medicaid Announces ALTCS Managed Long-Term Care Contract Awards,” which published on April 3, 2017. The article is available at https://www.psychu.org/arizona-medicaid-announces-altcs-managed-long-term-care-contract-awards/.

For more information, contact:

  • Heidi Capriotti, Media Relations and Public Information Officer, Arizona Health Care Cost Containment System, 801 East Jefferson Street, Phoenix, Arizona 85034; 602-417-4729; Email: Heidi.Capriotti@azahcccs.gov; Website: www.azahcccs.gov.

The Texas Health and Human Services Commission (HHSC) is expanding its Texas Targeted Opioid Response (TTOR) Emergency Medical Service (EMS) Emergency Response pilot program into the Austin area. TTOR uses emergency response services to connect opioid overdose survivors to integrated services needed for long-term recovery. These services include providing individuals, their families, and supportive allies with overdose reversal medication, as well as information on how to reverse an overdose. Those served are offered same-day initiation of medications used to treat opioid use disorder and alleviate withdrawal symptoms. Paramedics and peer recovery coaches also provide ongoing support to individuals to assist in their recovery and engagement in long-term treatment. Paramedics and peer recovery coaches can refer individuals to outside services when needed.

HHSC is working with Austin-Travis County Emergency Medical Services (ATCEMS) to help provide TTOR services. On September 19, 2018, the Substance Abuse and Mental Health Administration (SAMHSA) awarded Texas $46.2 million in State Opioid Response (SOR) funds to extend and expand HHSC’s response to the opioid crisis. On May 6, 2019, the state received a $24.1 million supplemental award under this grant bringing total potential SOR funding to over $116 million over the two-year period.

Since 2018, the state has implemented TTOR in Bexar, Harris, and Williamson counties. Each site receives about $500,000 annually from the HHSC to fund the pilot services. The pilot sites are selected according to various characteristics such as overdose rates, existing community resources, existing infrastructure, and population, to test models that could be easily replicated in other counties. HHSC said in Harris County, 85% of the program’s 500 participants received and remained in treatment for more than 30 days. HHSC will select nine additional pilot sites based on community need, interest, and the ability to implement the program, however a timeline for future implementation has not been established.

The TTOR program was originally created in May 2017. TTOR funding comes to HHSC through federal grants awarded by SAMHSA. Federal grant funding covers the cost of the evidence-based prevention, treatment, and recovery support strategies. As soon as a person participating in an EMS Opioid Response pilot program transitions from the treatment induction phase into long-term treatment, a determination is made whether the cost of long-term treatment is covered by private health care insurance, Medicaid, or if the person is eligible for state-funded treatment. TTOR encompasses four grant opportunities from SAMHSA totaling more than $176 million over the expected funding periods. The funding for all grants is awarded evenly on an annual basis, with the ability to extend contingent on availability of federal funds. The grants include:

  1. State Targeted Response (STR) funds: $54,724,714. This was a two-year grant in effect from May 1, 2017 to April 30, 2019.
  2. SOR funds: $116,589,770. This is a two-year grant in effect from September 30, 2018 to September 29, 2020.
  3. The Texas Strategic Prevention Framework for Prescription Drugs (SPF-Rx) grant: $1,858,080. This is a five-year grant in effect from September 1, 2016 to August 31, 2021.
  4. The Texas First Responders – Comprehensive Addiction and Recovery Act (FR-CARA) grant: $3,200,000. This is a four-year grant in effect from September 30, 2017 to September 29, 2021.

For more information, contact: Lisa Ramirez, Director, Texas Targeted Opioid Response, Texas Health and Human Services Commission, 4900 North Lamar Boulevard, Austin, Texas 78751-2316; 512-380-4955; Email: Lisa.Ramirez@hhsc.state.tx.us; Website: https://hhs.texas.gov/

On February 3, 2020, Epic, an electronic health record (EHR) vendor, asked its health system clients to sign on to a letter urging the federal Department of Health and Human Services (HHS) to modify a pending federal interoperability rule to address concerns about consumer privacy, non-standardized data exchange, lack of protection of the intellectual property of EHR developers, and the proposed implementation timeline for fines. The letter says, “While we support HHS’ goal of empowering patients with their health data and reducing costs through the 21st Century Cures Act, we are concerned that ONC’s Proposed Rule on interoperability will be overly burdensome on our health system and will endanger patient privacy. Specifically, the scope of regulated data, the timeline for compliance, and the significant costs and penalties will make it extraordinarily difficult for us to comply.” Some 60 health systems signed the letter, which was then sent to the federal Department of Health and Human Services (HHS).

HHS is preparing to release two interoperability rules, one from the Office of the National Coordinator of Health Information Technology (ONC) and the other from the Centers for Medicare & Medicaid Services (CMS) to support the 21st Cures Act and MyHealthEData. The ONC proposed rule was released in March 2019; the final rule is expected in early 2020. It had not been released as of February 16, 2020. ONC proposed adopting Health Level Seven’s (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standards as the standard to which developers must certify their application programming interfaces (APIs) and proposes language to support an ecosystem for the secure flow of information. The goal is to promote secure and more immediate access to health information for consumers and their health care professionals. Use of standardized APIs is intended to allow individuals to use smartphones and other mobile devices to easily and securely access structured and unstructured electronic health information.

In the letter, Epic and the health systems recommended that HHS make the following changes to the proposed rule:

  • Allow health systems to hold companies that seek access to consumer data to the same privacy and security standards elsewhere in the health care industry. Health information about family members should not be used or disclosed by non-HIPAA regulated organizations without family members’ knowledge and permission.
  • Standardize data exchange, and focus the rule on the medical and financial data that is most useful to the consumer and can be exchanged in a standardized format. The rule should not require exchange of non-standardized data, even if there are existing APIs.
  • Protect the intellectual property of EHR developers to allow them to continue to innovate for health systems and consumers.
  • Give organizations at least 12 months to prepare before information blocking is enforced and 36 months for development of new technology required by the rule. Further, HHS should allow a grace period for education before fines are levied.

Epic’s letter was signed by the following health systems: Access Community Health Centers; Community Health Center Network, Alameda Health Consortium; Altru Health System; Atrius Health; Adventist Health Portland; Affirmant Health Partners; Lovelace Health System; Arc; UT Health Athens; Ardent Health Services; Bay Health; Buffalo Medical Group; Christie Clinic; Deaconess Health System; Genesis Healthcare System; Catholic Health; Community Health Network; Exact Sciences, Group Health Cooperative, South Central Wisconsin; Charlotte Eye Ear Nose & Throat Associates; Confluence Health; Fresenius Medical Care; Gundersen Health System; Guthrie; HonorHealth; Institute for Family Health; Mercy; UnityPoint Health-Meriter Hospital; Hospital Sisters; HSHS Wisconsin; Iowa Specialty Hospitals & Clinics; Mercy Care; VHS; HSHS St. Clare Memorial Hospital; HSHS St Joseph’s; HSHS Illinois; Mary Washington Healthcare; Mercy Health Services; Middlesex Health; Beth Israel Lahey Health, Mt. Auburn; NYU Langone Health; PeaceHealth; Piedmont Healthcare; Northshore’s Evanston Hospital; OhioHealth; Pembia County Memorial Hospital; Pine Rest Christian Mental Health Services; Norton Healthcare; Parkview Health; Permanente Dental Associates; Prevea Health; River Valley Primary Care Services; Singing River Health System; University Health System; Vancouver Clinic; Riverside; Southcoast Health; Titus Regional Medical Center; UT Health San Antonio; Wellstar Medical Group; Self Regional Healthcare; SSM Health; UHS Inc. and UHS Hospitals; UW Health; and West Virginia University Health System.

PsychU reported on the ONC proposed rule in “HHS Issues A Proposed Rule For API Standards For Electronic Health Information,” which published on April 1, 2019. The article is available at https://www.psychu.org/hhs-issues-a-proposed-rule-for-api-standards-for-electronic-health-information/.

For more information, contact:

  • Epic Systems, 1979 Milky Way, Verona, Wisconsin 53593; 608-271-9000; Fax: 608-271-7237; Email: info@epic.com; Website: https://www.epic.com/
  • Peter Ashkenaz, Media Contact, Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services, 330 C Street Southwest, Floor 7, Washington, District of Columbia 20201; 202-260-6342; Email: peter.ashkenaz@hhs.gov; Website: https://www.healthit.gov/topic/laws-regulation-and-policy/notice-proposed-rulemaking-improve-interoperability-health
  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

On November 21, 2019, the U.S. Department of Justice (DOJ) indicted four former employees of Outcome Health—including the two co-founders and two former executives—for defrauding the company’s clients, lenders, and investors of an estimated $1 billion. Prior to January 2017, the company was known as ContextMedia. It sold digital advertising in physician offices; most of its clients were pharmaceutical companies. The defendants are accused of selling millions of dollars of advertising inventory from 2011 to 2017 that did not exist, which inflated its financial statements. The DOJ alleged that the former executives used the inflated financials to raise nearly $1 billion in debt and equity financing in 2016 and 2017.

Outcome Health itself is not under indictment; it entered a Non-Prosecution Agreement (NPA) with the DOJ on October 30, 2019. After the fraud surfaced, Outcome Health engaged in “extensive remedial measures” including requiring the co-founders to give up all financial interests in the company or representation on the company’s board, and retaining a new management team. Additionally, Outcome Health provided more than $65 million in restitution to its client pharmaceutical companies.

The company provided physician practices with free waiting-room video screens, consumer-education tablets, wallboards, wi-fi access points, and free health education content. The platform provided consumers at the physician practices with health care information and advertising. The content library included assessments, 3D anatomical models, recipes for healthy living, and information about treatment options. ContextMedia/Outcome Health generated revenue by selling ads on the platform.

The DOJ alleged that Outcome sold advertising inventory—digital tablets in physician offices—that the company did not have, and then under-delivered on its advertising campaigns. Outcome allegedly invoiced its clients as if it had delivered in full. The indicted former executives and employees are accused of concealing the under-deliveries by falsifying affidavits and proofs of performance to make it appear that Outcome was meeting its contract requirements. The defendants allegedly inflated consumer engagement metrics for how frequently consumers in the physician offices engaged with Outcome’s tablets that provided health education and targeted advertising. Additionally, some of the contracts included return on investment (ROI) guarantees. One of the defendants is accused of altering studies presented to clients to make it appear that the digital campaigns were more effective than they actually were.

The under-delivery resulted in a material overstatement of Outcome’s revenue for 2015 and 2016. The company’s outside auditor signed off on the 2015 and 2016 revenue numbers because the indicted individuals fabricated data to conceal the under-deliveries from the auditor. The inflated revenue figures in Outcome’s 2015 and 2016 audited financial statements were allegedly used to raise $110 million in debt financing in April 2016, $375 million in debt financing in December 2016, and $487.5 million in equity financing in early 2017. The co-founders were allegedly paid dividends totaling $37.7 million on the $110 million debt financing. The $487.5 million equity financing allegedly resulted in a $225 million dividend to the co-founders.

On November 7, 2017, the investors sued the founders of the Company and related entities following a report that from 2014 through 2016 the company misled advertisers about the number of physician offices using the health education platform. The lawsuit, Global Private Opportunities, et al., v. Rishi Shah; Outcome Holdings, LLC; ContextMedia Health Holdings, LLC; Outcome, Inc.; Gravitas Holdings, LLC; and Shradha Agarwal, came after the company had announced on September 27, 2017 that its network included more than 140,000 installed devices, and that it had also recently received independent certification from BPA Worldwide iCompli that the platform size estimates and audience qualification complied with industry standards. On October 19, 2017, Outcome Health announced it was taking steps to ensure transparent and accurate impression measurement. On November 15, 2017, the company announced it had joined the IAB, a large trade association for digital advertising and marketing comprised of more than 650 media and technology companies that sell, deliver, and optimize digital advertising and marketing campaigns.

A link to the full text of “October 17, 2019 Letter From the DOJ Regarding Outcome Health” may be found at www.openminds.com/market-intelligence/resources/101719dojletterreoutcomehealth.htm.

A link to the full text of “Department Of Justice Indictment Of Former Outcome Health Employees” may be found at www.openminds.com/market-intelligence/resources/112119outcomehealthindictment.htm.

A link to the full text of the 2017 investor lawsuit, “Global Private Opportunities, et al., v. Outcome Health, et al.,” may be found at www.openminds.com/market-intelligence/resources/110717lawsuitoutcomehealth.htm.

For more information about Outcome Health, contact:

  • Kendall Day, Partner, Gibson, Dunn & Crutcher, LLP, 1050 Connecticut Avenue Northwest, Washington, District of Columbia 20036-5306; Email: kday@gibsondunn.com; Website: https://www.gibsondunn.com/lawyer/day-m-kendall/.

For 2020, about 2% of eligible clinical professionals participating in the Medicare Merit-based Incentive Payment System (MIPS) earned a negative payment adjustment ranging from -0.01% to -5.00%. The remaining 98% of MIPS participants received a positive or neutral payment adjustment, ranging from 1.68% to 0.00%, based on their 2018 MIPS performance data. The Centers for Medicare & Medicaid Services (CMS) noted that the positive payment adjustment received in 2020 is modest because under current law, the positive and negative payment adjustments must be budget-neutral. In general, if a clinical professional is eligible for MIPS, they will choose whether to participate at the individual or group level.

CMS reported the 2018 Quality Payment Program (QPP) performance results and payment adjustments in a January 6, 2020 blog post. In total, 889,995 clinical professionals received a MIPS payment adjustment in 2018, either positive, neutral, or negative. Of the total number of clinical professionals receiving a payment adjustment, 872,148 MIPS eligible clinical professionals will receive a neutral or positive payment adjustment through their individual, group, or Alternative Payment Model (APM) participation.

In total, 183,306 eligible clinical professionals earned Qualifying APM Participant (QP) status under the Advanced APM track of the QPP. Another 47 eligible clinical professionals received partial QP status during 2018. In 2017, the number of eligible clinical professionals who met QP status was 99,076 and partial QP status was 52.

CMS noted significant successes in MIPS participation during the second year of the program. The MIPS participation rate was higher in 2018 than in 2017, which was the first year of the program. More clinical professionals avoided a negative payment adjustment, 2% in 2018 compared to 5% in 2017. The overall national average and median MIPS scores increased from 2017. Additionally, those who participated in MIPS through an APM had a mean score of 98.77 and a median score of 100.

Based on MIPS 2018 data, the payment adjustments were as follows:

  • 84% of MIPS eligible clinical professionals received an additional adjustment for exceptional performance (with scores of 70.00 to 100.00 points). The minimum payment adjustment for this group was 0.21% and the maximum was 1.68%.
  • 13% of MIPS eligible clinical professionals received a positive adjustment for earning between 15.01 and 69.99 points. The minimum payment adjustment was 0.00% and the maximum was 0.20%.
  • No MIPS eligible clinical professionals earned 15.00 points to earn a neutral payment adjustment of zero.
  • 2% of MIPS eligible clinical professionals earned 0 points to receive a negative payment adjustment ranging from -0.01% to -5.00%.
  • 97% of MIPS eligible clinical professionals in rural practices received a positive payment adjustment, compared to 93% in 2017.
  • 84% of MIPS eligible clinical professionals in small practices received a positive payment adjustment, up from 74% in 2017.

MIPS is one track of the QPP established to implement certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MIPS requires eligible clinical professionals to submit performance data on certain measures and activities in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. Performance in the four categories determines whether participating MIPS eligible clinical professionals receive a positive, neutral, or negative adjustment to their Medicare part B allowed charges for covered professional service under the Physician Fee Schedule. Three of the four performance categories allow the MIPS eligible clinical professional to choose the measures and activities they report. In the 2017 and 2018 performance years, MIPS eligible clinical professionals included physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, osteopathic practitioners, and chiropractors who billed Medicare Part B covered professional services. MIPS eligible clinical professionals who did not participate in MIPS for the 2017 performance period were subject to a negative 4% payment adjustment in 2019.

The CMS announcement is posted online at https://www.cms.gov/blog/2018-quality-payment-program-qpp-performance-results (accessed January 22, 2020).

For more information, contact

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: https://www.cms.gov/.

Serious mental illness (SMI) is a disabling condition—and because it develops early in life, it brings with it a lifetime of costs. But while researchers have long believed that early intervention for SMI has lifelong benefits for patients, there has been little evidence that weighs whether these efforts can be considered cost effective.

This led a team of researchers and scientists to employ a simulation model to attempt to estimate the lifetime costs of SMI for patients diagnosed by age 25. In “Measuring the Lifetime Costs of Serious Mental Illness and the Mitigating Effects of Educational Attainment,” these scholars provide current outcome statistics and present their methodology and the conclusions for measuring the potential economic effect of early intervention.

SMI’s Effects and the Intervention Opportunity: A Quick Overview

As noted, serious mental illness (SMI)—including psychoses, major depressive disorder, and bipolar disorder—is disabling and costly, with an economic impact that is similar to that of cancer and diabetes. And since it is often diagnosed between the ages of 15 and 30, SMI carries other costs, too. It impacts educational attainment and dropout rates, employment status, annual earnings, and even life expectancy, with previous reports documenting anywhere from 10 to 30 years of potential life lost.

But the trend toward early diagnosis and treatment of SMI as a means to improve patient-based and economic outcomes has continued to grow. Potential strategies integrate patient-centered interventions—such as addressing substance use disorders and relationship issues—with clinical trials that demonstrate the benefits of early interventions like medication management, family involvement, and education/employment support. Indeed, a variety of studies have shown such positive early intervention outcomes as:

  • Improved quality of life
  • Reduced depression
  • Increases in academic enrollment, course completion, and employment

However, evidence that defines the economic impact of these interventions has been limited.

Research Aimed at “Filling the Gap”

Based upon findings of various studies, it might be logical to infer that intervention strategies resulting in increased educational attainment and employment could improve the quality of life and reduce the lifetime financial burden of people with SMI. In fact, policy makers in the United States have been actively exploring potential strategies.

But efforts may be hindered because long-term benefits of these strategies have not been measured—and there is limited evidence of these interventions’ long-term return on investment (ROI). Researchers Seth A. Seabury et al. have thus attempted to fill that gap by providing new data on the lifetime benefits of improving educational or employment outcomes for people who experience SMI early in life, using a research model to project the impact on health and economic outcomes.

A Brief Look at Methodology

With the growing emphasis on early identification and treatment of mental illness to help improve long-term health and economic outlooks, the research team sought to obtain evidence via simulated differences in life expectancy, quality of life, medical spending, and economic outcomes.

The research team simulated lifelong outcomes using the Future Americans Model (FAM), a dynamic microsimulation model that uses data on Americans ages 25 and older to project health, medical spending, social service use, and economic outcomes over time. FAM builds estimates based on the paths of individual health and economic outcomes rather than on average characteristics—thus allowing for more accurate estimations.

FAM combines data from several large, nationally representative surveys. As a result, it enabled the research team to:

  • Estimate transitions between health state;
  • Project health care spending; and
  • Assess quality of life.

FAM also allowed the team to compare people with a self-reported diagnosis of SMI by age twenty-five to those without a diagnosis of SMI by age twenty-five, including those diagnosed later in life.

How FAM Was Used

The model measured transition probabilities for specified health states based upon predictors such as age, gender, and health condition as derived from questions in the nationally representative Panel Study of Income Dynamics (PSID).

Detailed information on simulation scenarios, trial details, and study limitations can be found in the report referenced below.

Simulation Revealed Key Findings

While outcomes varied based upon educational attainment, the overall findings during one year of simulation showed that those with an SMI diagnosis by age 25:

  • Have lower educational attainment. In the simulation, about 23.4% had less than a high school diploma, compared to 11.3 percent for those who never developed SMI.
  • A re more likely to be female and white. They also had more restrictions to activities of daily
  • Have a lower life expectancy. The average life expectancy from age 25 was 45.7 years—10.4 years (19%) lower than those without SMI by age
  • Have substantially higher lifetime medical spending. Total lifetime medical spending was $96,500 (24%) higher, even though people with SMI are much more likely to be on Medicaid or uninsured.
  • Earn substantially less over their lifetime. Earnings were an average of $537,100 (48%) less per person, with 2 (55 %) fewer years of full-time work. This also corresponded to increased lifetime benefit payments of 500% for Social Security Disability Insurance and 809% for Supplemental Security Income (SSI).

What Comes Next?

While early intervention to improve the educational attainment of people with SMI has clear benefits, interventions can be costly. But at the same time, a significant number of Seabury et al.’s simulations also demonstrated that, at least in part, early intervention can reduce the high economic burden.

Recap: The Opportunities and the Challenges

Overall, the simulation’s findings highlight both the opportunities and the challenges to improve SMI’s economic outcomes.

The Good News

  • An estimated $1.85 million per-patient cost can be reduced by $73,600 through use of an education-based intervention. Indeed, SMI patients as a whole experience nearly a quarter of a trillion dollars in economic burden, and improvement in educational attainment would reduce that by over $8.9 billion.
  • Relatively low-cost interventions that focus on helping young SMI patients enroll in school and have accommodations from/interaction with teachers and administrators can have large impacts on school participation.

The Challenge

While intervention can flexible and implemented across a variety of geographic settings (urban, suburban, and rural), these gains would be spread across many years, which suggests:

  • The potential need for public investment or subsidy
  • The hiring and training of additional providers

Many assessments of intervention programs focus on outcomes that can’t easily measure long-term effects, but Seabury et al.’s work has provided new evidence.

And resulting from their generally optimistic findings, the Seabury et al. team urges that future interventions and evaluations should use objective and clearly defined outcome measures that can be linked to publicly available data sources.

This, in turn, could foster additional measurement of the long-term economic impact of early interventions—and, potentially, provide further evidence that supports their adoption and leads to lifelong benefits for SMI patients.

This summation was developed independently of the authors.

In 2017, states spent 17% of state-generated funds on Medicaid, which represents a 41% increase from 2000 to 2017. The states spent $0.17 of every state-generated dollar on Medicaid in 2017, up from $0.12 per dollar in 2000.

Every state except Illinois spent a larger share of its own dollars on Medicaid in 2017 than in 2000. The state with the largest increase was Louisiana, at 11.5 cents higher than 2000, spending 22% of its revenue (or 22 cents per state-generated dollar) on Medicaid in 2017. Illinois spent the same on Medicaid in 2017 as it did in 2000, largely due to extreme delays in payments to health care provider organizations.

Medicaid provides medical coverage for eligible groups of children, adults, people with disabilities, and the elderly. Medicaid is most states’ largest expense, following education expenses. Medicaid is paid for by both the state, and the federal government. However, in 2017, states collectively spent $228.2 billion of their own resources to provide health benefits for 73.8 million Medicaid recipients. Additional findings include:

  • Besides Illinois, three states had increases of less than one cent per state-generated dollar spent on Medicaid since 2000: Tennessee (0.7 cent), Michigan (0.8 cent), and Hawaii (0.9 cent).
  • Besides Louisiana, just one other state had an increase of more than 10 cents per state-generated dollar spent on Medicaid since 2000: Alaska (10.5 cents).
  • The 13 states where Medicaid in 2017 was at its highest level since 2000 were Arkansas, Colorado, Delaware, Kentucky, Massachusetts, Mississippi, Nebraska, New Hampshire, North Dakota, Oklahoma, Vermont, Virginia, and Wyoming.

The states that spent the lowest share of their own dollars on Medicaid in 2017 were Utah (5.8%), Hawaii (8.2%), Nevada (9.4%), and Idaho (9.9%).

These findings were reported in “States Collectively Spend 17 Percent of Their Revenue on Medicaid” by Barb Rosewicz, Justin Theal, and Katy Ascanio for Pew Charitable Trusts (Pew). Researchers at Pew analyzed data from the Centers for Medicare & Medicaid Service (CMS), the National Association of State Budget Officers, and the U.S. Census Bureau. The goal was to highlight trends in state Medicaid spending, relative to states’ own revenue, to allow policymakers to examine budgetary implications of their Medicaid programs over time.

The full text of “States Collectively Spend 17 Percent of Their Revenue on Medicaid” was published January 9, 2020 by The Pew Charitable Trusts. The content is available online at https://www.pewtrusts.org/en/research-and-analysis/articles/2020/01/09/states-collectively-spend-17-percent-of-their-revenue-on-medicaid (accessed January 27, 2020).

For more information, contact:

  • Jim Gavin, Director of Communications and Media, Indiana Family and Social Services Administration, 402 West Washington Street, W461, Indianapolis, Indiana 46204-2739, Phone: 317-234-0197, Fax: 317-233-4693, Email: Jim.Gavin@fssa.IN.gov, Website: https://www.in.gov/medicaid/

The year after Cascadia Behavioral Healthcare (Cascadia) implemented a certified Community Behavioral Health Clinic (CCBHC) integrated care model, the number of emergency department (ED) visits was reduced by 18% and inpatient admissions by 23% among individuals who’d previously utilized the ED or inpatient facilities. Before implementing the CCBHC integrated care model in 2017, Cascadia reported 3.74 ED visits/inpatient admissions per consumer for April 2016 through April 2017. After becoming a CCBHC, Cascadia reported 3.07 ED visits/inpatient admissions per consumer for 2018. Cascadia reported the outcomes on December 17, 2019.

Cascadia anticipates that the reduction will result in substantially lower annual health care costs. The cost savings estimates are based on data from HealthShare, one of the state’s Medicaid coordinated care organizations (CCO). The CCO tracks ER utilization for adults age 18 and older with mental illness as a quality measure to reduce disparity in outcomes. The goal is to reduce the disproportionately higher emergency department utilization among those experiencing mental illness by increasing awareness and engagement with appropriate points of primary and mental health care. ED visits for mental health and chemical dependency services are not included in the ED visit count.

As a CCBHC, Cascadia introduced care coordination and primary care services to its continuum of care. Cascadia currently serves over 3,700 consumers.

Cascadia’s Chief Medical Officer Jeffrey Eisen said “These are significant results that support the need for continued funding for the CCBHC model, which has enabled an integrated care approach for our clients. By providing preventative and proactive services, we can significantly change quality of care and health outcomes for individuals, as well as reduce financial strain on our health care system and our payers.” Cascadia is continuing to refine its integrated model through population health efforts that emphasize diabetes management, chronic pain management, decreased emergency department utilization and medical admissions, and tobacco cessation.

For more information, contact:

  • Jennifer Moffatt, Senior Director of Communications, Cascadia Behavioral Healthcare, Post Office Box 8459, Portland, Oregon 97207; 503-402-8117; Email: jennifer.moffatt@cascadiabhc.org; Website: https://cascadiabhc.org/

Cigna reports its commercial members with integrated medical, pharmacy, and behavioral benefits had annual medical costs of averaging $207 less per covered life than members enrolled in non-integrated plans. For Cigna members with health improvement opportunities (such as weight management and smoking cessation), being enrolled in a plan with integrated benefits reduced annual medical costs by an average of $850 per person.

Per-person savings were realized for members with more intensive health needs who were enrolled in a combined plan. Per-person savings attributable to the combined plan totaled $7,372 for members with conditions requiring a specialty medication. For members with an oncology diagnosis, per-person savings totaled $11,679 and their inpatient oncology costs were 24% lower.

Members of Cigna’s integrated plans also were found to have:

  • 17% higher engagement in wellness programs including counseling for conditions such as diabetes and heart disease; lifestyle or wellness coaching to help with weight management and smoking cessation; and personal case management for complex conditions such as rheumatoid arthritis or cancer.
  • 32% lower mental health readmission rates.
  • 18% fewer out-of-network behavioral claims.
  • 5% higher utilization of in-network high-performing provider organizations.
  • 4% lower out-of-network claims.
  • 15% higher treatment rate for opioid misuse, and 30% reduction in subsequent post-treatment overdoses compared to the previous year.

Cigna reported these findings as the key outcomes of its fourth annual 2019 Value of Integration report. These findings are based on a two-year internal analysis of more than 2.3 million claims from Cigna customers who receive coverage through their employer. Half of the population had comprehensive medical, behavioral, and pharmacy benefits administered by Cigna, while the other half had only medical benefits with minimal behavioral benefits administered by Cigna. Customers were matched between the two groups on key attributes, including demographics, health condition, access to health improvement services, plan design, and geographies. The study methodology was reviewed and validated by KPMG LLP in 2018. However, KPMG did not conduct an independent analysis to verify any results, and KPMG did not audit the data or the programming code used to conduct the study.

Based on the findings, Cigna asserts that with connected medical, pharmacy, and behavioral health benefits customers are more engaged in their health and well-being and are more likely to stay in-network for their care. Cigna also believes that consumers enrolled in a plan with integrated benefits are more informed about their care options.

Cigna reported the 2019 Value of Integration report findings at https://www.cigna.com/newsroom/news-releases/2020/combining-medical-pharmacy-and-behavioral-benefits-delivers-annual-savings-of-more-than-850-per-customer-with-an-identified-opportunity (accessed January 23, 2020).

For more information, contact:

  • Meaghan MacDonald, Enterprise Media Relations, External Communications, Cigna Corporation, 3 Waterside Crossing, Windsor, Connecticut 06095; 860-226-0576; Email: Meaghan.MacDonald@cigna.com; Website: https://www.cigna.com/

A new U.S. Department of Veterans Affairs (VA) five-city pilot program pairs older veterans with volunteer “companions” to help these veterans remain in their homes, rather than move into health care institutions. The program is being piloted in five locations: San Antonio, Texas; Colorado Springs, Colorado; Las Vegas, Nevada; Pittsburgh, Pennsylvania; and Glendive, Montana.

The program called “Choose Home Initiative” relies on Senior Corps volunteers from the Corporation For National and Community Service (CNCS). The program partnership was first announced on June 27, 2019.

VA invested seed money to recruit and train about 250 volunteers, aged 55 or older, to help veterans in their homes. Senior Corps volunteers receive training about Veteran-specific concerns, including suicide awareness and prevention, before providing services in veterans’ homes. CNCS volunteers then assist veterans with activities of daily living, such as light housekeeping and preparing meals. They may also offer companionship and alert family members if issues arise. Respite care services are available through the volunteers who can stay with the veteran so the family caregiver can take time away from home. CNCS estimates the volunteers will serve approximately 600 households over a three-year period.

CNCS is the federal agency that leads national volunteering and service efforts. Senior Corps is a nationwide network of service programs for volunteers who commit their time to a wide range of community needs. CNCS mobilizes Senior Corps volunteers to provide homemaker and in-home respite care services to eligible veterans, so those veterans can remain in their own homes, live more independently, and stay close to their families, caregivers, and support services.

For more information, contact:

  • Samantha Jo Warfield, Media Contact, Corporation for National and Community Service, 250 E Street Southwest, Washington, District of Columbia 20525; 202-606-6775; Email: info@cns.gov; Website: https://www.nationalservice.gov/
  • Public Relations, U.S. Department of Veterans Affairs, 810 Vermont Avenue Northwest, Washington, District of Columbia 20420; 202-461-7600; Email: va.media.relations@va.gov; Website: https://www.va.gov/

On December 11, 2019, the Naat’áanii Development Corporation (NDC), a federally chartered business development arm of the Navajo Nation, announced plans to contract with Molina Healthcare, Inc. to create an Indian Managed Care Entity (IMCE) health care offering under New Mexico’s Centennial Care Medicaid program. Molina will provide full-risk plan operations for the IMCE, including a full array of Medicaid managed care services.

The IMCE is a program authorized under the state’s most recent Medicaid 1115 waiver. NDC will provide direction for the IMCE to determine its priorities, engage Navajo stakeholders, and ensure that the program includes Navajo culture. NDC will also lead education and marketing for the program. The IMCE differs from other Medicaid managed care plans in that it is uniquely tailored to Navajo health priorities.

In a statement about the arrangement, an NDC spokesperson said the organization selected Molina based on Molina’s experience serving New Mexico’s Medicaid beneficiaries for two decades and its dedication to serving Native Americans in the state. About 75,000 Medicaid-eligible Navajos live in New Mexico.

In December 2018, the Centers for Medicare & Medicaid Services (CMS) approved the New Mexico Human Services Department (HSD) Centennial Care 2.0 waiver program renewal, which included plans for an IMCE. In January 2019, the NDC responded to an HSD request for information seeking proposals on how an IMCE could be established. In September 2019, HSD issued an outline of the plans in “The New Mexico Naat’áanii IMCE Program: Improving Access & Outcomes for the State’s American Indians / Alaska Natives.” In October 2019, HSD held a tribal consultation with the Navajo Nation about the NDC IMCE. This consultation focused on benefit design, delivery model, quality measurements, and enrollment methodology. On December 2, 2019, the Navajo Nation Council began considering legislation to request the State of New Mexico to issue all necessary approvals to the NDC and Molina Healthcare, Inc. to launch an IMCE using a passive enrollment system. The legislation passed two Committees of the Navajo Nation Council, and is slated to be reviewed by the full sub-Committee, before the legislation becomes the Navajo Nation governing body’s official position. Additional details about the planned NDC-Molina IMCE are as follows:

  • Coverage will be geographically focused on the Northwest corner of New Mexico but will cover members wherever they travel in the Navajo Nation, which includes parts of Arizona and Utah.
  • All New Mexico Medicaid Centennial Care benefits will be covered, including key tribal services such as traditional healing, tribal care coordinators within Indian Health Service facilities, and tribal peer specialists. Programs will be developed to address key social determinants of health, such as housing, employment, food insecurity, and enhanced transportation. The plans also will offer enhanced dental benefits, wellness incentives for diabetes and cancer screenings, diabetes food boxes, workforce development and employment counseling services, enhanced transportation services, and free school physicals.
  • The IMCE will provide members with comprehensive access to a statewide provider organization network in New Mexico. The network will include primary care, specialists, hospitals, core service agencies, and will also allow members to have direct access to Indian Health Services facilities and professionals.

A link to the full text of Navajo Nation Legislation titled, “An Action Relating To Health, Education & Human Services & Naabik’íyáti’ Committee To Launch The Naat’áanii Development Corporation – Molina Healthcare, Inc. Indian Managed Care Entity” can be viewed online at http://dibb.nnols.org/PublicViewBill.aspx?serviceID=9cb3afd7-c3b8-47ec-b013-c3cefcebad98  (accessed January 20, 2020).

For more information, contact:

  • Robert Joe, MEB, Interim Chief Executive Officer, Naat’áanii Development Corporation, Post Office Box 4560, Window Rock, Arizona 86515, Phone: 520-301-8111
  • Mellor C. Willie, Public Affairs, Naat’áanii Development Corporation, Post Office Box 4560, Window Rock, Arizona 86515, Phone: 505-870-2006, Email: mwillie@cheeconsulting.com
  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802, Phone: 562-951-1588, Email: Caroline.Zubieta@molinahealthcare.com, Website: https://www.molinahealthcare.com/members/common/enUS/abtmolina/compinfo/newsmed/Pages/newsmed.aspx
  • Jodi McGinnis Porter, Director of Communications, External Affairs, New Mexico Human Services Department, Post Office Box 2348, Santa Fe, New Mexico 87504, Phone: 505-476-7203, Fax: 505-827-6286, Email: Jodi.McGinnis-Porter@state.nm.us, Website: https://www.hsd.state.nm.us/Default.aspx
  • Theresa Belanger, Acting Native American Liaison, New Mexico Human Services Department, Post Office Box 2348, Santa Fe, New Mexico 87504, Phone: 505-827-3122, Email: theresa.belanger@state.nm.us, Website: https://www.hsd.state.nm.us/Native_American_Liaison.aspx
  • Megan Pfeffer, Deputy Director, New Mexico Department of Health, 1190 South Saint Francis Drive, Santa Fe, New Mexico 87505, Email: megan.pfeffer@state.nm.us, Website: https://nmhealth.org
  • David Morgan, Media & Social Media Manager, Office of the Secretary New Mexico Department of Health, 1190 South Saint Francis Drive, Santa Fe, New Mexico 87505, Phone: 575-649-0754, Email: David.Morgan@state.nm.us, Website: https://nmhealth.org/

On December 11, 2019, Blue Cross Blue Shield of Michigan (BCBSM) announced a new “Blueprint for Affordability” payment model. Under the model, seven preferred provider organizations (PPOs) that provide care to BCBSM members will share financial risk for consumer care and consumer outcomes.

The risk-sharing agreements became effective January 1, 2020 and cover Blue Cross Commercial PPO and Medicare Advantage PPO plans. “Blueprint for Affordability” participating organizations represent approximately 30% of the state’s total Commercial PPO and Medicare Advantage market. The seven PPOs include:

  • Ascension Michigan (Genesys Provider Health Organization physician-hospital organization (PHO), Partners in Care, St. Mary’s PHO)
  • Henry Ford Health System
  • Michigan Medicine
  • Oakland Southfield Physicians
  • The Physician Alliance
  • Trinity Health – Michigan (Saint Joseph Mercy Health System, Mercy Health, Mercy Health Physician Partners, Integrated Healthcare Associates)
  • United Physicians

The goals of the Blueprint for Affordability payment model include: improve quality of care; avoid unnecessary tests, scans, and emergency room visits; reduce complications and rehospitalizations; and better coordinate consumer care across all points of service. Under the model, health systems and physician organizations agree to annual targets for the cost of providing care to Blue Cross members. Aggregate costs that come in below those financial targets will result in financial rewards for the provider organizations involved. If costs cannot be managed within the target, the provider organization will rebate Blue Cross, and ultimately its consumers, a portion of the amount spent beyond the target. This enables costs to be predictable for Blue Cross customers, and encourages the provider organizations to improve care delivery cost, quality, efficiency, and coordination.

For more information, contact: 

  • Meghan O’Brien, Public Relations & Social Media Manager, Blue Cross Blue Shield of Michigan
    600 East Lafayette Boulevard, Detroit, Michigan 48226-2927, Phone: 313-549-9884, Email: newsroom@bcbsm.com, Website: https://bcbsm.com/

Approximately 87.8% of workers with disabilities had health insurance in 2017. This was a 7.9 percentage point increase from 79.9% in 2009, prior to the implementation of the Patient Protection and Affordable Care Act (PPACA). Despite coverage gains, cost-related barriers to accessing medical care did not change much after the PPACA for any group. Workers with disabilities experienced an increase in structural access barriers, from 18.4% before PPACA to 24.8% after PPACA. People with disabilities are defined as those who report being limited in the type or amount of work they can perform due to a physical, mental, or emotional problem.

The increase in health insurance for workers with disabilities was the result of an 11 percentage point increase in the share of that population with Medicaid coverage between 2014 and 2017 (compared with 2001 through 2009), and a five percentage point increase in privately purchased coverage over those periods. These increases were accompanied by an 11 percentage point decline in the share with employer-sponsored coverage.

Researchers concluded that the gain in insurance coverage for workers with disabilities is an important benefit of the PPACA. However, they recommended more investigation and monitoring to understand whether PPACA coverage will translate into improvements in access to needed health care.

These findings were reported in “Insurance Coverage And Access To Care For Workers With Disabilities, 2001–2017” by Anna Hill, M.H.A., Ph.D.; and Jody Schimmel Hyde, Ph.D. The researchers analyzed data from 2007 through 2017 from the National Health Interview Survey. The goal was to determine how PPACA changed insurance coverage and access to care for workers with disabilities, and compare those changes to changes among other groups.

The full text of “Insurance Coverage And Access To Care For Workers With Disabilities, 2001–2017” was published in January 2020 by Disability and Health Journal. An abstract is available online at https://www.sciencedirect.com/science/article/pii/S1936657419301530 (accessed January 20, 2020).

For more information, contact:

  • Jody Schimmel Hyde, Ph.D., Researcher, Mathematica Policy Research, 1100 First Street Northeast, 12th Floor, Washington, District of Columbia 20002, Email: jschimmel@mathematica-mpr.com, Website: https://www.mathematica.org/

On January 1, 2020, Indiana implemented a Medicaid waiver amendment that will allow the state to receive reimbursement for short-term services for people age 19 to 64 with serious mental illness (SMI) who are treated at privately run institutions for mental disease (IMD). The waiver excludes treatment provided at Indiana’s six state-operated psychiatric hospitals. This waiver amendment augments an earlier waiver approved on February 1, 2018, that allows the Indiana Family and Social Services Administration (FSSA) to reimburse for inpatient treatment in private IMDs for Medicaid members with a primary diagnosis of an addiction disorder. FSSA implemented that waiver’s IMD provisions in early 2018, and according to an interim evaluation released in October 2019, by the end of calendar year 2018, there were 17 Medicaid-enrolled IMDs that provided addiction treatment to 4,026 beneficiaries. Without the waivers, Medicaid statutes prohibit federal reimbursement for services provided in an IMD, which is defined as any hospital, nursing facility, or other institution with more than 16 beds that provides treatment primarily for people with mental illness.

Under this new waiver amendment, the IMD services will be covered for beneficiaries with SMI who are primarily receiving withdrawal management services or short-term inpatient or residential treatment for an addiction disorder. The goal is to create consistency in treatment for the 25% of beneficiaries with SMI with a co-occurring addiction disorder.

FSSA can claim federal financial participation (FFP) for individual stays of up to 60 days, as long as by a mid-point assessment at December 31, 2022, the state can show that the average length of stay (ALOS) is 30 days or less. If the state does not meet the ALOS target by the assessment, FSSA will only be able to claim FFP for stays of up to 45 days until it meets the ALOS target.

Special terms and conditions (STCs) of the waiver require FSSA to ensure that psychiatric hospitals provide intensive pre-discharge, care coordination services to help beneficiaries transition into appropriate community-based outpatient services. The STCs include the following requirements:

  • Involve community-based provider organizations in transition efforts, such as allowing initial contact with a community-based provider organization while the beneficiary is still at the IMD, or by hiring peer support specialists to help beneficiaries connect with available community-based provider organizations and make plans for employment.
  • Assess the housing situation of a beneficiary transitioning to the community, and connect those who are homeless or who have unsuitable or unstable housing with provider organizations that coordinate housing services.
  • Require psychiatric hospitals to have protocols in place to ensure contact is made by the treatment setting with each beneficiary within 72 hours of discharge, and ensure follow-up care is accessed by those individuals by contacting them directly and by contacting the community-based provider organizations to which they were referred.
  • Implement strategies to prevent or decrease the length of stay in emergency departments (EDs) among beneficiaries with SMI/serious emotional disturbance (SED) or SED. This could include the use of peers and psychiatric consultants in EDs to help with discharge and treatment referral.
  • Develop and enhance interoperability and data sharing between disparate physical, addiction treatment, and mental health provider organizations to enhance coordination and improve clinical outcomes for beneficiaries with SMI/SED or SED

The STCs require FSSA to increase access to a continuum of care, including crisis stabilization services by doing the following:

  • Establish a process focused on crisis stabilization services to annually assess the availability of mental health services throughout the state. The assessment must provide updates on steps taken to increase availability.
  • Commit to implementing the SMI/SED financing plan included in the approved waiver.
  • Improve the state’s capacity to track available inpatient and crisis stabilization beds to help connect individuals in need with that level of care as soon as possible.
  • Require provider organizations, plans, and utilization review entities to use an evidence-based, publicly available consumer assessment tool, preferably endorsed by a mental health provider organization association to determine appropriate level of care and length of stay.

Further, FSSA must implement strategies to facilitate earlier identification and engagement in treatment for those with SMI/SED or SED, as follows:

  • Identify and engage adolescents and young adults in treatment earlier through supported employment and education programs.
  • Increase integration of behavioral health care in non-specialty care settings including schools and primary care practices, to improve early identification and improve awareness of and linkages to specialty treatment provider organizations.
  • Establish specialized settings and services, including crisis stabilization services, focused on the needs of young people.

The intent of the waiver amendment is to shift services for beneficiaries with SMI from less appropriate settings to facilities such as hospitals and larger mental health treatment facilities. As a result, FSSA anticipates that costs related to lack of access to appropriate care settings and overuse of the emergency department for mental health problems and psychiatric crises will decrease. The IMD services will be for eligible individuals with SMI who are primarily receiving short-term treatment and withdrawal management services.

FSSA had submitted the “SMI/SED Amendment Request for the Healthy Indiana Plan (HIP) Section 1115 Waiver (Project Number 11-W-00296/5)” on June 24, 2019. FSSA data indicates that in state fiscal year 2019, about half of Indiana’s traditional Medicaid members receiving inpatient psychiatric services received them at an IMD.

For more information, contact:

  • Jim Gavin, Director of Communications and Media, Indiana Family and Social Services Administration, 402 West Washington Street, W461, Indianapolis, Indiana 46204-2739, Phone: 317-234-0197, Fax: 317-233-4693, Email: Jim.Gavin@fssa.IN.gov, Website: https://www.in.gov/medicaid/

On January 1, 2020, Optum Maryland went live as the administrative services organization (ASO) for the Maryland public behavioral health system, replacing Beacon Health Options. The contract, valued at $198 million, has a five-year base period, followed by one two-year option. The ASO is responsible for managing behavioral health services for individuals with Medicaid eligibility, as well as certain uninsured and grant-funded individuals. The ASO also will manage the provider organization network and service utilization for the Applied Behavioral Analyst (ABA) program for children and youth with autism.

The Maryland Department of Health (MDH) released the request for proposals (RFP MDH/OPASS 20-18319) on November 29, 2018, seeking an ASO for the state’s public behavioral health system. The ASO manages behavioral health authorizations, utilization control, claims processing, health care professional education, training, compliance, and auditing functions. The ASO also provides reimbursement for recovery and support services, including mental health case management, mobile treatment/assertive community treatment, psychiatric rehabilitation, residential rehabilitation, supported employment, rehabilitation services, and specific addiction treatment services.

By the due date of January 22, 2019, MDH had received proposals from Optum Maryland and Beacon Health Options. Optum’s total evaluated bid price of $188.4 million was 27% lower than Beacon’s evaluated bid price of $260.5 million. MDH ranked Optum’s technical proposal higher than Beacon’s. The contract was approved by the Maryland Board of Public Works on July 24, 2019.

The award amount and total evaluated price are different. The total evaluated price was based upon a model for firm fixed prices for the six different parts of the contract:

  1. Implementation
  2. Medicaid enrollees
  3. Non-Medicaid services
  4. Cost-based pool
  5. Provider organization quality incentive pool
  6. Optional features or services

For evaluation purposes, the optional features or services were weighted at 20%. However, MDH included the full amount of the optional features or services in the award amount, based on the decision to accept those features and services into the contract. Three major optional services outlined in the contract are provider quality incentives, flexible funds for specialty services not otherwise covered, and developing the crisis response system. All three optional services would require additional budget initiatives and utilize Optum’s national and Maryland-specific experience. These initiatives will largely be informed by the work MDH has done in its System of Care Workgroup with managed care organizations and behavioral health provider organizations.

For more information, contact:

  • Deidre McCabe, Director of Communications, Maryland Department of Health, 201 West Preston Street, Baltimore, Maryland 21201-2399; 410-767-3536; Email: deidre.mccabe@maryland.gov; Website: https://health.maryland.gov/
  • Gwen Holliday, External Communications, Optum, 11000 Optum Circle, Eden Prairie, Minnesota 55344; 202-549-3429; Email: gwen.m.holliday@optum.com; Website: https://www.optum.com/
  • Chris Curran, Brand Strategy, Beacon Health Options, 200 State Street, Boston, Massachusetts 02109; 857-243-0472; Email: chris.curran@beaconhealthoptions.com; Website: https://www.beaconhealthoptions.com/

During the last decade, the number of states that have moved to include behavioral health in their Medicaid health plan contracts has almost doubled. In 2011, only 15 (25%) states included behavioral health in their health plan contracts. And, at that time, 29 states (48%) had a primary Medicaid behavioral health carve-out.

 

Currently, 31 states have included behavioral health in their health plan contracts and 17 states (28%) have a primary Medicaid behavioral health carve-out (i.e., primary carve-out to a Medicaid fee-for-service or care management organization). Approximately 34.9 million (48%) of the 72.8 million Medicaid beneficiaries are enrolled in Medicaid health plans with integrated behavioral health financing, according to a new report, State Medicaid Behavioral Health Carve-Outs: The OPEN MINDS 2020 Annual Update. And another 3 million (6% of total Medicaid beneficiaries) are enrolled in vertical consumer-specific specialty carve-out plans for individuals with serious mental illness.

In the last year, there have been a few interesting developments. One state, Washington, completed the transition to integrated financing from a traditional specialty carve-out (see Washington State To Launch Behavioral Health System Transformation). Additionally, integration efforts in three states with traditional specialty carve-outs stalled or ended. North Carolina suspended the move to integrated financing indefinitely. And, Michigan cancelled integrated financing pilots due to disagreements over the model but is working to implement specialty integrated plans (see Michigan Cancels Behavioral Health Integration Pilots). Finally, Pennsylvania’s integration efforts ended before the state proposed an official plan.

So what does the integration of behavioral health in Medicaid health plans look like? Ohio’s system provides a good example. In 2018, Ohio officially integrated behavioral health financing into Medicaid health plans. As a result, Medicaid beneficiaries’ traditional and specialty behavioral health services are provided by one of the five health plans.

Strategies for behavioral health provider organizations serving Medicaid beneficiaries are dependent on the state Medicaid plan’s decisions about behavioral health benefits – and the selection of primary contractors that control the Medicaid behavioral health spending. Medicaid plans are now relying on health plans and provider organizations to make integrated care coordination models work and deliver comprehensive behavioral health services. Going forward, it is important to consider how health plan policies, procedures, and financial alignment initiatives differ by state.

 

On December 23, 2019, Kentucky Governor Andy Beshear announced the cancellation of the state’s five Medicaid managed care contracts, valued at approximately $8 billion. The contracts had been awarded by Governor Beshear’s predecessor, then-Governor Matt Bevin on November 26, 2019. However, on December 7, the last day of Governor Bevin’s tenure, members of the State’s Government Contract Review Committee unanimously voted to reject those contracts. According to Governor Beshear, the contracts were cancelled due to concerns about how the award process was handled. Governor Beshear also ended the 1115 Medicaid waiver that required Kentuckians to meet certain work or volunteer requirements to have health care coverage.

The contracts will be rebid in January 2020. In the meantime, Medicaid managed care plans currently operated by Anthem, Aetna Better Health of Kentucky (formerly Coventry Cares), Humana, Passport Health Plan, and WellCare will remain in effect. About 1.3 million beneficiaries are enrolled in one of the Medicaid managed care plans.

The now-cancelled contracts were awarded in November 2019 to five Medicaid managed care organizations (MCOs): Aetna Better Health of Kentucky, Humana Health Plan, Inc., Molina Healthcare of Kentucky, UnitedHealthcare, dba, UnitedHealthcare Community Plan of Kentucky, and WellCare Health Insurance of Kentucky. The contracts were scheduled to start on July 1, 2020, running more than 15 years. The plans were at-risk for all Medicaid physical health, behavioral health, and pharmacy services. Both Anthem and Passport Health Plan filed protests over the November awards.

For more information, contact: Office of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-564-7042; Website: https://chfs.ky.gov/agencies/os/oc/

New technologies, changing reimbursements, and corporate consolidations are amongst the many drivers evolving the health care landscape.1 During this webinar archive, the speakers discuss strategies for future sustainability in ever-changing industry.

Featuring:

  • Kimberly Bond
    Senior Associate, OPEN MINDS
  • Paul Duck
    Senior Associate, OPEN MINDS

Kimberly Bond brings over thirty years of experience providing behavioral health treatment in the public and community settings to the OPEN MINDS team. She currently serves as the Executive Vice President of Business Development and Marketing. Prior to joining OPEN MINDS, Ms. Bond served concurrently as a Program Coordinator III and Clinical Manager of Adult Services and a Program Coordinator II and Clinical Manager of Recovery Services for the Ozark Guidance Center. In these roles, Ms. Bond was responsible for the administrative and clinical oversight of the adult outpatient and adult intensive mental health services on the Springdale Campus and the adult recovery/co-occurring services, including domestic violence and anger management treatment as well as treatment services for Drug Court.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

New technologies, changing reimbursements, and corporate consolidations are amongst the many drivers evolving the health care landscape.1 During this webinar archive, the speakers discuss strategies for future sustainability in ever-changing industry.

Featuring:

  • Kimberly Bond
    Senior Associate, OPEN MINDS
  • Paul Duck
    Senior Associate, OPEN MINDS

Kimberly Bond brings over thirty years of experience providing behavioral health treatment in the public and community settings to the OPEN MINDS team. She currently serves as the Executive Vice President of Business Development and Marketing. Prior to joining OPEN MINDS, Ms. Bond served concurrently as a Program Coordinator III and Clinical Manager of Adult Services and a Program Coordinator II and Clinical Manager of Recovery Services for the Ozark Guidance Center. In these roles, Ms. Bond was responsible for the administrative and clinical oversight of the adult outpatient and adult intensive mental health services on the Springdale Campus and the adult recovery/co-occurring services, including domestic violence and anger management treatment as well as treatment services for Drug Court.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

From 2013 to 2017, the Medicare Shared Savings Program (MSSP) generated $755 million in net savings to the Centers for Medicare & Medicaid Services (CMS). Net savings are the total savings ACOs produce, minus what CMS pays to accountable care organizations (ACOs) for reaching spending targets and quality measures. The MSSP includes 518 ACOs.

Additional findings include:

  • From 2013 to 2017, gross savings from ACOs was $3.5 billion.
  • Gross federal savings in the MSSP have increased every year that was studied. In 2013, ACOs delivered $357 million in gross savings for CMS; however, that number reached $930 million in 2017.

The analysts concluded that the over-time MSSP savings continue to increase. These savings translate to an approximate 1% to 2% savings over time, compared to spending in unattributed beneficiaries.

These findings were reported in “2017 Update: MSSP Savings Estimates; Program Financial Performance 2013-2017” by researchers with Dobson, DaVanzo & Associates. The report was commissioned by the National Association of Accountable Care Organizations (NAACOs). The researchers analyzed public files from CMS. They also built on previous analysis by adding data on provider organization participation and spending, for both assigned and unassigned Medicare beneficiaries. The goal was to present MSSP Performance Year 2017 ACO savings estimates.

The full text of “2017 Update: MSSP Savings Estimates; Program Financial Performance 2013-2017” was published December 3, 2019 by the National Association of Accountable Care Organizations. A copy is available online at https://www.naacos.com/assets/docs/pdf/2019/Final-NAACOS-AsTreatedDID-SavingsEstimateReport2017.pdf (accessed December 23, 2019).

PsychU last reported on this topic in “Physician-Led ACOs Generated Almost 7 Times More Savings Than Hospital-Led ACOs,” which published on December 2, 2019. The article is available at https://www.psychu.org/physician-led-acos-generated-almost-7-times-more-savings-than-hospital-led-acos/.

For more information, contact:

  • Dobson, DaVanzo & Associates, LLC., 450 Maple Avenue East, Suite 300, Vienna, Virginia 22180; 703-260-1760; Email: info@dobsondavanzo.com; Website: https://www.dobsondavanzo.com
  • David Pittman, Health Policy and Communications Advisor, National Association of Accountable Care Organizations, 601 13th Street Northwest, Suite 900 South, Washington, District of Columbia 20005; 202-640-2689; Email: dpittman@naacos.com; Website: https://www.naacos.com/

The Michigan Department of Health and Human Services (MDHHS) proposed integrating Medicaid physical and behavioral health services through new statewide specialty integrated plans (SIPs). SIPs will replace the state’s current behavioral health carve-out.

The proposal was released on December 4, 2019 in an MDHHS fact sheet, “Michigan DHHS Future of Behavioral Health Fact Sheet & FAQ.” Currently, Medicaid beneficiaries with significant behavioral health needs or developmental disabilities have two managed care plans, a Medicaid health plan (MHP) for physical health and a prepaid inpatient health plan (PIHP) for behavioral health.

The SIPs will be provided by qualified managed care entities including health plans, provider organizations, hospitals, public behavioral health authorities, or new partnerships between these organizations. MDHHS intends to seek public input on application requirements to ensure that each organization has the needed expertise and commitments. They will receive a capitated risk-based payment for every enrolled member. The SIP will provide all services currently provided through the MHP and PIHP systems, including support services and investments to address social determinants of health, not just traditional medical services. In this model, non-Medicaid safety net behavioral health services for any Michigander in need will continue to be funded and managed through the Community Mental Health Services programs (CMHs). MDHHS intends to ensure that a clearly defined set of core CMH services will be available everywhere with separate dedicated funding to support the services.

MDHHS developed the new proposal after negotiations collapsed in October 2019 on pilots for a financial integration model. The pilots were called the Section 298 model (named for a section of the state budget) in which the state sought to include individuals with behavioral health needs in the MHPs, which would have managed all funds and have responsibility for care management. The new SIP concept differs from the Section 298 model in that it establishes new entities that combine the skills of the MHPs and the expertise and enhanced services of behavioral health organizations. In the new plan, a more diverse set of organizations will have the opportunity to lead. At least one plan is expected to be led by the public behavioral health authorities.

During January 2020, MDHHS will schedule four open forums to solicit public comment. MDHHS will work with the legislature to identify needed statutory changes and pass any necessary bills. Design decisions will be made through a collaborative process with provider organizations, payers, and consumers.

PsychU last reported on this topic in “Michigan Cancels Behavioral Health Integration Pilots,” which published on December 16, 2019. The article is available at https://www.psychu.org/michigan-cancels-behavioral-health-integration-pilots/.

For more information, contact: Lynn Sutfin, Public Information Officer, Michigan Department of Health and Human Services, Post Office Box 30195, Lansing, Michigan 48909; 517-284-4772; Email: SutfinL1@michigan.gov; Website: https://www.michigan.gov/mdhhs/0,5885,7-339-71550_2941_96949—,00.html.

Making the new gainsharing, value-based partnerships between health plans and provider organizations work requires changes from both parties, and a clear understanding of what success requires. This discussion was prompted by a new report from Harvard and UnitedHealthcare with a three-dimension framework for building these new payer/provider partnership relationships.

The framework is built on performance incentives for cost reduction, performance incentives for consumer outcomes improvement, and the provider infrastructure needed to make value-based reimbursement (VBR) work. For provider organization executives to succeed in these new relationships, that ‘provider infrastructure’ brings a few key requirements – shared data, increased care management capacity, collaborative and innovative program design, and organizational evolution and leadership.

Shared data is front and center along with providing care coordination tools for provider organization partners. But, having the data and tools is not enough for success. Provider organizations need to develop care management skills to ensure access, improve consumer outcomes, and develop a value equation (the balance between performance improvement and cost reduction). While there is ongoing contention about the responsibility for care coordination, the more provider organizations are at financial risk, the more robust provider-led care coordination is essential.

Another issue is innovation. Most executives of provider organizations that have active risk-based (particularly case rates and sub-capitated arrangements) reimbursement arrangements cite the ability to do something new and creative to improve consumer outcomes as the greatest benefit of VBR. These new provider-payer organization relationships can facilitate innovative program development by providing financial upside through aligned goals.

Finally, there is the issue of organizational change and the leadership required to implement it. Delivering on VBR requires an entirely different type of organization. Every detail of the day-to-day running of provider operations needs to be reconfigured to succeed with VBR, which is why a leadership commitment is so essential. And, many times, new approaches to care are required along with an enhanced tech infrastructure to ensure that data can be tracked and used in actionable ways. He advises executive teams to assess their capacity for success early on and ask about a range of organizational competencies – including intake and eligibility determination systems, care managers who can conduct concurrent reviews, and the ability to collect deductibles and copayments.

The move to value-based care is changing the relationship between health plans and provider organizations. Ultimately, the relationships that are most successful will have leaders (on both sides of the equation) who understand that the commodity-oriented network model of the past is (slowly) being replaced by mutually-dependent partnerships. To learn more about preparing for VBR, check out the following resources in the PsychU Resource Library:

  1. VBR @ Scale—Changes Required
  2. Crawl, Walk, Run To VBR

 Adoption of value-based reimbursement (VBR) models is glacial—slow to occur but changing the delivery system in its wake. It’s an issue we’ve written about before — VBR @ Scale—Changes Required, and Preparing For The Very Glacial VBR Rollout In Some Markets and will continue to help health and human service organizations find their footing. In the field, two different conversations are happening: Health plan executives talk about the lack of readiness of provider organizations while managers of provider organizations talk about the difficulty in moving VBR proposals forward with health plan customers. How do we make these partnerships evolve more smoothly? I think observations and advice from Alyna T. Chien, M.D., MS, Harvard Medical School, and Professor Meredith B. Rosenthal, Harvard T.H. Chan School of Public Health in the report, A 3D Model For Value-Based Care: The Next Frontier In Financial incentives And Relationship Support1 provide a great foundation for that discussion.

The authors present a three-part framework for considering the health plan shift to VBR – financial incentives for reduced spending, financial incentives for improving quality, and infrastructure support for their partner provider organizations. Their infrastructure support includes performance management information (both access to raw data and analyzed data), limitations on financial exposure from risk contracts, care coordination tools, technical assistance, and infrastructure payments.

What is interesting is that these were the very issues brought up by provider organization executives during a session at the 2019 OPEN MINDS Executive Leadership Retreat. Access to data and limitation on financial downside were high on the list.

To make this three-dimensional model for VBR a reality, there are some specific actions that managers in health plans, accountable care organizations, and state and county government can take. Two key issues stood out as potentially having the greatest impact: Increasing the amount of revenue tied to VBR and aligning performance measures across payer contracts.

One of the common concerns from provider organization executives is that the upside in the value-based contracts is not enough to justify infrastructure expenses. This is a fiscal reality at two levels in any individual payer contract. Is the incremental increased revenue of quality-based performance bonuses or shared financial savings enough to justify new operating infrastructure? Second is the volume of consumers served great enough to warrant dedicated service capacity (it’s addressing that ‘one foot in two canoes’ issue that provider organization managers face).

OPEN MINDS Senior Associate Drew Digiovanni urges industry members to walk before they run with VBR contracts that include financial risk:

Establish a pathway for providers who are entering into VBR agreements for the first time. Assess their abilities and offer limited performance measures in the first year to help them ramp up for success, before entering into more robust risk contracts.

The other issue is one that comes up every year during the OPEN MINDS Performance Management Institute – can’t health plans get together and agree on the same performance measures? From the provider organization perspective, almost every VBR-based contract is a ‘one off’ with different measures that have different definitions.

Admittedly, the adoption of NCQA HEDIS and CMS STARS are starting to create some “standardization” of measures, but provider organization managers need very flexible (and very expensive to maintain) performance reporting tools that can be customized for each contract. Almost any initiative to standardize measures would be welcome on the service delivery side of this equation.

Moving forward, how do health plan executives make their provider partnerships a success, sooner rather than later? OPEN MINDS Senior Associate Paul M. Duck suggests that transparency and investments in technology need to be front and center in VBR discussions:

Provider and payer organizations benefit from technology implementation. If a tool like a telepsychiatry platform is implemented, the payer benefits by increasing access to care, which lowers costs and prevents emergency room admissions. Provider organizations benefit by delivering a new service, which opens the door for additional revenue. It expands access for a larger population and delivers services in places where a group might not have a physical presence, such as rural communities. In other words, it’s a win-win.

For more on the path to VBR, check out:

  1. Current Insights Into Population Health Management Value-Based Models In Managing High-Risk, High-Cost Patients
  2. Structuring (& Budgeting For) Analytics

1 https://newsroom.uhc.com/content/dam/newsroom/Harvard%20Report_FINAL_0923.pdf

“Show don’t tell” is one of the first lessons journalists learn and one that’s increasingly applicable to executives of health care organizations. The increasing use of value-based contracts is changing communication between provider organizations and health plans to focus on data. Yet few executive teams harness their data in actionable ways judging by the discussion during the “Building A Data Infrastructure For Performance Management” town hall discussion at The 2019 OPEN MINDS Technology & Informatics Institute.

“With value-based purchasing, it’s even more essential for providers to understand spending patterns at the consumer level,” said Susanna Kramer, director of performance evaluation at Community Behavioral Health, a Philadelphia-based managed behavioral health organization. She stressed that using data in actionable ways is essential for success with case rates. Organizations need to identify how to optimize service delivery—the most effective processes, how to handle consumers who regularly reschedule or no-show, the best way to match consumer needs with treatment, and more—“so you can predict what your case rate payments are and what shared savings may amount to.”

Consensus from these three panelists was that provider organization managers need to understand utilization and costs to negotiate reimbursement rates and terms: Ms. Kramer provided a health plan perspective; Karen Fridg, director of EHR systems for Community Intervention Services Inc., offered a provider organization perspective; and Jaclyn O’Donnell, executive vice president for Credible Behavioral Health Software, gave a technology vendor’s perspective.

Understanding customer performance perspectives—This process starts with understanding performance expectations to improve success. “It’s key for provider organization executives to know exactly how they’re being assessed” and use those measures to improve care delivery and efficiency, said OPEN MINDS Senior Associate Joe Naughton-Travers. While most measures focus on processes, not outcomes, and reports are not public for now, executives who seek to build or retain a competitive edge understand what payers want, create data-driven cultures, and speak openly about how to improve their numbers. “We are very interested in understanding what payers are looking for and what constitutes quality of care,” said Ms. Fridg.

Start with actionable metrics—Identify a few metrics and assemble a small committee to review data and identify anomalies and solutions, Ms. O’Donnell suggested. While there’s no magic number of metrics, teams should seek metrics that are strategic and companywide. “You want to limit what you’re looking at to ensure that what you’re collecting is meaningful, informs changes, and how we look at staff,” she said.

It’s important to balance the number of metrics with diversity of delivery and service provision, added Ms. Kramer with a nod to the unique aspects of behavioral health. “It’s not like a knee operation where you know the surgery was a success because the knee healed or [the consumer] followed expected patterns of rehabilitation. However, we try to limit most providers to around three financial and quality targets outside fee-for-service (FFS) and value-based reimbursement (VBR) purchasing standards that they are required to meet.”

Start with what you have and make sure the data you’re collecting is actionable, she added. “You don’t need to have a shiny dashboard, which is great, but you can start with basic reporting. Create habits of using data and give in to that cadence. There are things you can do each day, each week to lay the framework to make that more manageable.”

Ms. Fridg agreed. “It’s never too soon to start talking about what your goals and expectations are, to see what data you have, and ask how you can utilize what’s already there.” Begin the conversation with your leadership team, start with a small set of metrics, and use that experience to develop the process of implementing from beginning to end. Then repeat the process as you identify and prioritize additional measures.

Her organization created metrics with a multidisciplinary team that sees monthly reports for the performance of its six affiliated organizations. It started with a scorecard created by the chief executive officer with more than 200 metrics in four domains (clinical, finance, people, and growth). The clinical team then selected three key metrics deemed to be most meaningful and actionable.

Being data-driven requires internal transparency—Making data visible and public was an important step for the Community Intervention Services team. Selected performance metrics were used to create standardized dashboards and presented organization-wide during monthly meetings, which allowed each team to benefit from the experience and success of others. “Managing by metrics has proven to be very effective” because it informs team members about their status and how to improve, said Ms. Fridg.

This type of transparency is key to gaining staff buy-in, said Ms. O’Donnell, who explained that more than half the company’s partners use a business intelligence reporting tool that allows organization-wide data sharing. “The ones who are most successful make data transparent, they build a data culture and show that data is not to be feared.” Her advice: Acknowledge failures but focus on lessons learned and steps to improve. “You use it like a tool,” she added.

Townhall panelists wrapped up the session with a discussion of organizational competency in measuring performance, driving performance improvement, and public transparency of data. Improving operational efficiencies and clinical outcomes, regardless of reimbursement model, was at the top of their list for areas of focus but they all agreed that value-based reimbursement will increasingly drive strategy. On the transparency side, health plans and third parties are making provider organization performance and fee information public. This will emphasize the importance of data and the need for a data-driven culture will rise to a whole new level.

Get more information on using data for strategic success with these PsychU resources:

  1. The Age Of Priceline Health Care
  2. Is ‘Unblackboxing’ The Key To Reducing Health Care Costs?
  3. Why Guidelines Matter
  4. How Do You Measure Access?

On November 25, 2019, the Centers for Medicare and Medicaid Services (CMS) Innovation Center released a request for applications (RFA) for its “Direct Contracting” initiative. For this initiative, CMS is inviting health care professionals to participate in Direct Contracting agreements with CMS. Direct Contracting is a set of three voluntary payment model options aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS). The payment model options available under Direct Contracting test new risk- sharing arrangements to produce value and high quality health care. Direct Contracting model options build on lessons learned from initiatives involving Medicare accountable care organizations (ACOs), such as the Medicare Shared Savings Program (MSSP) and the Next Generation ACO (NGACO) Model, and approaches from Medicare Advantage and private sector risk-sharing arrangements.

The Direct Contracting RFA seeks direct contracting entities (DCEs) to participate in direct contracting through two models: professional payment models, and global payment models. These two models will start with an initial implementation period in 2020 with a five-year performance period that begins in 2021. More information about a third model, the geographic model, will be released during 2020.

DCEs are similar to Medicare Advantage plans and ACOs in that the DCEs are risk-bearing entities managing the care of a panel of Medicare beneficiaries. However, similar to an ACO, the DCEs will manage only FFS Medicare beneficiaries. Like a Medicare Advantage plan, the DCEs will receive upfront, at-risk, capitated payments to pay their downstream provider organizations and suppliers for services, allowing the DCE to better coordinate care delivery. The DCEs’ financial methodology uses a benchmark based on the Medicare Advantage rate book; the DCEs also have a new risk-adjustment strategy that mitigates coding intensity and improves the accuracy of risk adjustments for complex, high-risk beneficiaries.

Applications will be accepted through February 25, 2020. In the spring of 2020, CMS will release an application for organizations interested in starting in the first performance year. Direct Contracting aims to reduce administrative burden, support a focus on complex, chronically ill beneficiaries, and encourage organizations to participate that have not typically participated in Medicare FFS or CMS Innovation Center value-based models.

Direct Contracting is part of the Medicare Primary Cares Initiative announced in April 2019. Direct Contracting is a six-year demonstration with three contracting options that will begin in January 2020. The other Primary Cares Initiative is called Primary Care First, a five-year multi-payer demonstration with two options that will also begin in January 2020.

The DCE must be a legal entity that contracts with Direct Contracting participant provider organizations, an entity that is a Medicare-enrolled provider organization or supplier and is identified by CMS as a participant provider organization. Current Medicare ACOs interested in continuing and deepening their participation in Medicare risk arrangements will be eligible to participate in all three Direct Contracting payment model options. The DCE may also contract with preferred provider organizations and professionals, entities that are Medicare-enrolled provider organizations or suppliers and are identified by CMS as Direct Contracting participant provider organizations.

Direct Contracting participants may include, but are not limited to, physicians or other clinical professionals in group practices; networks of individual practices of physicians or other clinical professionals; and hospitals employing physicians or other clinical professionals. A DCE is not required to be a Medicare-enrolled provider organization or supplier in order to apply to participate in Direct Contracting; however, each participant and preferred provider organization under the DCE must be a Medicare-enrolled provider organization or supplier by no later than June 30, 2020.

There will be three types of DCEs:

  • Standard DCEs are comprised of organizations that generally have experience serving Medicare FFS beneficiaries, including dual eligible beneficiaries. These organizations may have previously participated in section 1115A models involving shared savings or the Shared Savings Program. New organizations composed of existing Medicare FFS provider organizations and suppliers may be created in order to participate as this DCE type. Beneficiaries will be aligned to Standard DCEs through voluntary alignment and claims-based alignment.
  • New Entrant DCEs are organizations that have not traditionally provided services to a Medicare FFS population and that will primarily rely on voluntary alignment. Claims-based alignment will also be utilized.
  • High Needs Population DCEs serve Medicare FFS beneficiaries with complex needs, including dual eligible beneficiaries, who are aligned to the DCE through voluntary alignment or claims-based alignment. These DCEs are expected to use a model of care designed to serve individuals with complex needs, similar to the Programs of All-Inclusive Care for the Elderly (PACE), to coordinate care for their aligned beneficiaries.

There are two voluntary risk-sharing payment model options, as well as a third payment model option for which CMS will release more information later this year. Additional information about the two risk-sharing models is as follows:

  • Professional offers the lower risk-sharing arrangement and provides Primary Care Capitation, a capitated, risk- adjusted monthly payment for enhanced primary care services.
  • Global offers the highest risk-sharing arrangement and provides two payment options: Primary Care Capitation or Total Care Capitation, capitated, risk-adjusted monthly payment for all services provided by DPC participants and preferred provider organizations with whom the DCE has an agreement.

CMS will link a meaningful percentage of the DCE benchmark to performance on quality of care to help ensure that care quality improves and beneficiary choice and access are protected. CMS will also monitor to ensure that beneficiaries’ access to care is not adversely affected as a result of the model. With the new payment model options, CMS seeks to test novel methods for organizations to manage Medicare FFS expenditures.

For more information, contact: Direct Provider Contracting, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Email: DPC@cms.hhs.gov; Website: https://www.cms.gov/.

On October 30, 2019, the Tennessee Division of TennCare released a request for information (RFI 31865-00702) seeking comments regarding its plans for the next statewide Medicaid managed care re-procurement. The Division is preparing to rebid its Medicaid managed care organization (MCO) contracts. Responses to the RFI were due by November 22, 2019. The current MCO contract expires on December 31, 2020. The state did not indicate when during 2020 the TennCare RFP might be released.

The RFI sought information about how to promote quality and innovation in long-term services and supports, delivery system transformation, and quality and access to care. The information requested seeks improvements to clinical models of care, with a focus on integration, addressing social determinants of health, ensuring efficiency in pharmacy, and achieving administrative simplification.

The state will not release the RFI responses until after the state completes its evaluation of any responses to the (as of December 6, 2019 unreleased) MCO procurement. If for some reason, the state chooses not to go further in the procurement process and responses are never evaluated, the responses to the RFI will be considered confidential. TennCare is the state of Tennessee’s Medicaid program that provides health care for approximately 1.4 million Tennesseans and operates with an annual budget of roughly $12 billion.

For more information, contact:

  • Matt Brimm, Director of Contracts, Division of TennCare, Tennessee Division of Health Care Finance and Administration, 310 Great Circle Road, Nashville, Tennessee 37243; Email: Matt.Brimm@tn.gov; Website: https://www.tn.gov/tenncare/
  • Sarah Tanksley, Director of Communications, Division of TennCare, Tennessee Division of Health Care Finance and Administration, 310 Great Circle Road, Nashville, Tennessee 37243; Email: sarah.tanksley@tn.gov; Website: https://www.tn.gov/tenncare/

The Blue Cross Blue Shield Association (BCBSA) is creating a national provider organization network composed of health care provider organizations and professionals who routinely offer high quality care at lower prices. BCBSA announced the new network on November 13, 2019. The network will be called Blue High Performance Network (HPN); it is slated to launch in January 2021 in 55 markets.

Blue HPN is designed for large national and regional employers. It is expected to reach more than 185 million people. BCBSA represents 36 independent Blue companies. The goal is that Blue HPN will provide more consistent pricing to help large employers control medical costs and enhance care for their workers. About 16% of large employers have built a high performance network into their health plan. BCBSA predicts that Blue HPN could generate more than 10% average cost savings on top of the savings already offered by the existing BCBS preferred provider organization network.

In June 2019, BCBSA issued an infographic explaining how it defines a high-performance network. Provider organizations will be selected for Blue HPN by the independent Blue plans based on existing quality measures and relationships. About 70% of the 74 million BCBS members are already in a value-based contract. Provider organizations selected for Blue HPN will be provided with data and insights; BCBSA will also align financial incentives for the participating provider organizations.

BCBSA released the full text of “Defining High-Performance Networks” and the info graphic in June 2019. A free copy is available online at https://www.bcbs.com/smarter-better-healthcare/infographic/defining-high-performance-networks (accessed December 10, 2019).

For more information, contact: Tess Thomson, Media Contact, Blue Cross Blue Shield, 225 North Michigan Avenue, Chicago, Illinois 60601; 202-942-1082; Email: press@bcbsa.com; Website: https://www.bcbs.com/

On November 19, 2019, the North Carolina Department of Health and Human Services (DHHS) suspended implementation of managed care because the General Assembly adjourned without providing required new spending and program authority for the transition. As a result, managed care will not go live on February 1, 2020. The wind-down process began November 20, 2019. DHHS stated that it will not decide on a new go-live date until it has program authority within a budget that supports its ability to provide critical oversight and accountability of managed care.

Open enrollment, which had launched statewide in October, is suspended. The Medicaid Managed Care Call Center will remain open to answer questions through December 13, 2019. DHHS will send notices to beneficiaries to inform them to continue accessing services as they currently do. North Carolina Medicaid will continue to operate under its current fee-for-service model. Behavioral health services will continue to be provided by Local Management Entities/Managed Care Organizations. All current Medicaid-enrolled provider organizations and clinical professionals will continue to bill the state through NCTracks.

A recently issued request for proposals (RFP), released on November 5, 2019, that was linked to implementation of managed care and approved in the same 1115 Medicaid waiver has not been suspended or canceled. NC DHHS released the RFP (RFP 30-2019-052 DHB) seeking contractors to serve as Lead Pilot Entities as part of the Healthy Opportunities Pilot in up to three geographic areas of the state. The pilot is intended to test evidence-based interventions to reduce costs and improve health by addressing housing instability, transportation insecurity, food insecurity, interpersonal violence, and toxic stress for eligible Medicaid beneficiaries. The competitive bidding process is continuing, and proposals are due January 21, 2020. It is possible, however, that awards may be impacted by the suspension of Medicaid Managed Care.

The transition to Medicaid managed care began in 2015, when the North Carolina General Assembly enacted legislation directing DHHS to shift Medicaid and NC Health Choice from fee-for-service to managed care, and ended the state’s behavioral health carve-out. The plan called for Standard Plans to integrate physical health, behavioral health, long-term services and supports (LTSS), and pharmacy services for the general Medicaid population. Tailored Plans, vertical health plans, for the subset of beneficiaries with behavioral health disorders and/or developmental disabilities would provide integrated physical health, LTSS, pharmacy unmet resource needs services, plus a more robust behavioral health and I/DD benefit package than the Standard Plans.

DHHS submitted a 1115 Medicaid waiver, which was approved on October 19, 2018 by the Centers for Medicare & Medicaid Services (CMS). The five-year waiver went into effect on November 1, 2019, and runs through October 31, 2024. In addition to implementing integrated managed care via Standard and Tailored Plans, the waiver permitted DHHS and managed care plans to cover services provided in institutions of mental disease (IMD). It also permitted the state to implement Healthy Opportunities Pilots to address social determinants of health, such as housing, food, transportation, employment, and interpersonal safety services.

On February 4, 2019, DHHS selected one regional and four statewide prepaid health plan (PHP) contractors to operate Standard Plans for the general Medicaid population. Statewide PHP contracts were awarded to AmeriHealth Caritas North Carolina, Inc.; Blue Cross and Blue Shield of North Carolina; UnitedHealthcare of North Carolina, Inc.; and WellCare of North Carolina, Inc. Carolina Complete Health, Inc., a Provider-Led Entity PHP, was awarded two regional contracts for Regions 3 and 5 in February, and subsequently awarded Region 4 as part of a settlement agreement associated with protest of the Department’s awards. Standard Plans in two regions were to begin transitioning to managed care in November 2019; the remaining four regions were to transition in February 2020. The Tailored Plans were slated to go live in 2021.

PsychU last reported on this topic in “North Carolina Medicaid Selects Five Health Plans—One Regional & Four Statewide,” which published on March 4, 2019. The article is available at https://www.psychu.org/north-carolina-medicaid-selects-five-health-plans-one-regional-four-statewide/.

PsychU also reported on this topic in “CMS Approves North Carolina’s 1115 Medicaid Managed Care Waiver, Ending The Behavioral Health Carve-Out,” which published on December 8, 2018. The article is available at https://www.psychu.org/cms-approves-north-carolinas-1115-medicaid-managed-care-waiver-ending-behavioral-health-carve/.

For more information about the suspension, contact: Chris Mackey, Office of Communications, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina, 27699-2000; 919-855-4840; Fax: 919-733-7447; Email: news@dhhs.nc.gov; Website: https://www.ncdhhs.gov/

For more information about the RFP for the Healthy Opportunities Pilot, contact: Division of Health Benefit, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina, 27699-2000; 919-527-7236; Fax: 919-733-7447; Email: Medicaid.Procurement@dhhs.nc.gov; Website: https://www.ncdhhs.gov/

Care coordination models matter. The approach that a payer takes to care coordination fundamentally changes the service delivery system—and provider reimbursement. For specialty provider organization executive teams, understanding the care coordination models preferred by payers is critical to strategy, referral generation, revenue and growth, reimbursement, and marketing planning.

The OPEN MINDS team conducted an analysis of the Medicaid care coordination models used in each state in their report, State Medicaid Care Coordination Initiatives: The 2019 Update. They looked at seven models ranging from models that change provider roles within the existing system such as patient-centered medical homes (PCMH), health homes, and certified community behavioral health centers (CCBHCs) to models that restructure the basic financing of benefits like accountable care organizations (ACOs), managed long-term services and supports (MLTSS) plans, dual eligible integration initiatives, and vertical/specialty health plans.

What did they find? The most common model was PCMHs in 30 state Medicaid plans. There are MLTSS plans in 22 states and health homes in 21 state Medicaid plans. The models that are least common are Medicaid ACOs, dual demonstration initiatives, and CCBHCs (note that CCBHCs are limited to the states that received grants).

What is the general direction of Medicaid care coordination? There are a few recent developments to consider. First, four states (Arkansas, California, West Virginia, and Illinois) added specialty consumer health plans in the last year. Funding for CCBHCs keeps getting short-term extensions, but we are still waiting to see if Congress will expand the program.1 An increase in “health homes” is likely with the child-focused health home initiative starting in late 2022.

Each of the integration models adopted by Medicaid have specific opportunities and strategic challenges for specialty provider organizations. The creation of new health plans—MLTSS plans, specialty consumer plans, and Medicare-Medicaid dual plans—bring new consumers into the managed care-oriented service delivery systems. This increases the share of health care spending in local markets that is controlled by health plans. The expansion of ACOs typically shifts health care spending to hospital systems, and the expansion of medical homes and health homes concentrates care coordination in a smaller group of provider organizations.

To learn more about each of the care coordination models, check out these resources in our PsychU Resource Library:

  1. Patient-centered medical homes – see Integration Strategies For The Complex Consumer Market1
  2. Certified community behavioral health centers – see What Is The Future Of The CCBHC?2 and Successfully Managing Bundled Rates—The Voice Of Experience3
  3. Accountable care organizations – see ACOs Saved Medicare $1.7 Billion In 20184 and The Growing Push For Medicaid ACOs5
  4. Medi-Medi dual eligible integration initiatives – see The Path Forward In Serving The Dual Eligible Population6 and CMS Forwarding Three Opportunities For State Integrated Care For Dually Eligible Individuals7

 

During the 2020 Medicare Advantage enrollment season, a total of 3,148 plans are available to beneficiaries. For the 2020 plan year, there are 15% more plans (414 more plans) for beneficiaries to choose from. The average beneficiary will be able to choose from 28 Medicare Advantage plans offered by seven insurers. About 90% of the plans will include prescription drug coverage. About two-thirds of plans (64%) are structured as health maintenance organizations (HMOs).

In metropolitan counties, beneficiaries can choose from an average of 31 plans. Beneficiaries in non-metropolitan counties can choose from an average of 16 plans.

  • In the 10% of counties that account for 40% of Medicare enrollment, beneficiaries have a choice of more than 30 plans. In 131 counties, beneficiaries have a choice of more than 40 plans. In four Ohio counties (Mahoning, Medina, Trumbull, and Summit) and two Pennsylvania counties (Bucks and Lancaster), more than 60 plans will be available.
  • In 6% of counties, accounting for just 1% of Medicare enrollment, beneficiaries can choose from two or fewer Medicare Advantage plans. This includes 59 counties in which only one plan will be available. In 77 counties, no Medicare Advantage plans are available. Additionally, no Medicare Advantage plans are available in territories other than Puerto Rico.

More than 100 insurers are offering Medicare Advantage plans in 2020. UnitedHealthcare and Humana have the most Medicare Advantage enrollees, and each offers plans in most counties. UnitedHealthcare offers plans in 60% of counties, while Humana offers plans in 83% of counties. Both offer plans in 53% of counties. About 85% of Medicare beneficiaries have access to at least one Humana plan, and 82% have access to at least one UnitedHealthcare plan.

Thirteen plan sponsors are offering Medicare Advantage plans for the first time in 2020. Each of these new entrants is offering plans in one of these 10 states: Florida, Illinois, Louisiana, Michigan, North Carolina, New York, South Carolina, Tennessee, Texas, and Virginia. These new sponsors are:

  1. ApexHealth, Inc., offering plans in North Carolina, South Carolina, Tennessee, and Virginia.
  2. Clarion Health, offering one plan in Florida.
  3. Community Health Choice, offering a plan in Texas.
  4. Dignity Health Plan, offering one plan in Louisiana.
  5. El Paso Health Advantage, offering one plan in Texas.
  6. Experience Health, Inc., offering one plan in North Carolina.
  7. Mary Washington Medicare Advantage, offering two plans in Virginia.
  8. MoreCare, offering four plans in Illinois.
  9. Oscar, offering two plans in New York and in Texas.
  10. PHP Medicare, offering six plans in Michigan.
  11. Reliance Medicare Advantage, offering two plans in Michigan.
  12. Troy Medicare, offering one plan in North Carolina.
  13. Zing Health, offering one plan in Illinois.

These statistics were reported in “Medicare Advantage 2020 Spotlight: First Look” by Gretchen Jacobson, Meredith Freed, and Tricia Neuman of the Kaiser Family Foundation, and Anthony Damico, an independent consultant. The plan numbers exclude employer or union-sponsored group plans. The count also excludes Special Needs Plans (SNPs), which are only available to select populations. During 2020, 855 SNPs will be available, up 19% from the 717 offered in 2019.

The full text of “Medicare Advantage 2020 Spotlight” was published October 24, 2019 by Kaiser Family Foundation. An abstract is available online at https://www.kff.org/report-section/medicare-advantage-2020-spotlight-first-look-data-note/ (accessed November 27, 2019).

For more information, contact: Chris Lee, Senior Communications Officer, Kaiser Family Foundation, 1330 G Street Northwest, Washington, District of Columbia 20005; Email: clee@kff.org; Website: http://www.kff.org/.

On November 1, 2019, the Centers for Medicare & Medicaid Services (CMS) began enrolling opioid treatment programs (OTPs) as Medicare provider organizations to receive payment for a new Medicare addiction treatment benefit that begins on January 1, 2020. Medicare will pay OTPs through bundled payments for opioid use disorder (OUD) treatment services in an episode of care provided to people with Medicare Part B. OTPs must be enrolled in the Medicare program to receive reimbursement for services provided to beneficiaries.

CMS finalized the episode of care as one continuous seven-day period, in part because OTPs already are paid by weekly episodes and have billing processes in place. There is no maximum on the number of episodes. Each weekly bundle can consist of a range of service frequencies, depending on whether the beneficiary is at the initial phase or maintenance phase of treatment. CMS will consider the requirements to bill for the full weekly bundle to be met if the beneficiary is receiving the majority of the services identified in their treatment plan at that time. For the purposes of valuation, CMS assumed one addiction counseling session, one individual therapy session, and one group therapy session per week and one toxicology test per month.

OTP treatment services for OUD include the following:

  • Dispensing and administration of medication assisted treatment (MAT), if applicable.
  • Addiction counseling by a professional to the extent authorized under state law to furnish such services.
  • Individual and group therapy with a physician or psychologist (or other mental health professional to the extent authorized under state law).
  • Toxicology testing.
  • Other items and services that CMS determines are appropriate (but in no event to include meals or transportation).

The details of the new OTP benefit were finalized in the Calendar Year (CY) 2020 Physician Fee Schedule final rule. CMS estimates that there are about 1,700 certified and accredited OTPs eligible for Medicare enrollment. All states except Wyoming have OTPs. Over the next three years, another 200 OTPs are projected to become certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) at a pace of roughly 67 per year, bringing the total amount of OTPs eligible to enroll in Medicare to approximately 1,900 over the next three years. OTPs provide treatment with opioid agonist and antagonist medications (including oral, injected, or implanted versions) that are approved by the Food and Drug Administration (FDA).

To enroll as an OTP service provider organization with Medicare, the OTP must have current, valid, and full certification by SAMHSA, and meet all SAMHSA criteria. These criteria include Drug Enforcement Administration (DEA) registration, state licensure, and accreditation. OTPs must submit an application to their regional Medicare Administrative Contractor (MAC). The MAC will verify the SAMHSA certification on the SAMHSA OTP directory. The OTP must send its letter of certification from SAMHSA with the Medicare provider enrollment application. MACs will not accept applications without full SAMHSA certification and will deny applications for OTPs with “provisional” SAMHSA certification status.

Enrollment information is available at the OTP webpage https://www.cms.gov/Center/Provider-Type/Opioid-Treatment-Program-Center.html (accessed November 27, 2019).

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Email: press@cms.hhs.gov; Website: https://www.cms.gov/.

On October 29, 2019, the California Department of Health Care Services (DHCS) formally released the California Advancing & Innovating Medi-Cal (CalAIM) proposal. CalAIM is a multi-year initiative to prepare for renewing the state’s current 1115 and 1915(b) Medicaid waivers, which expire in 2020. By January 2021, DHCS proposes to standardize managed care plan benefits such that all Medicaid managed care plans provide the same benefit package. The plans will carve-in institutional long-term care and major organ transplants, and carve-out pharmacy. By 2026, managed long-term-services and supports will be implemented statewide in Medicaid managed care. These plans will replace the current variety of 1915(b) Medicaid waiver plans, which have capped enrollment and are not statewide.

DHCS intends for the CalAIM initiative to serve as a framework for the upcoming waiver renewals. The state seeks to improve the quality of life and health outcomes of Medicaid beneficiaries by implementing broad delivery system, program, and payment reform across the Medi-Cal program. The proposals address homelessness, behavioral health access, clinical needs of justice-involved individuals, children with complex medical conditions, and the needs of adults aged 65 and older. Through the CalAIM workgroup process, DHCS intends to explore the following five key issues:

  1. Requiring Medi-Cal managed care plans to submit population health management strategies and moving to annual Medi-Cal managed care plan open enrollment.
  2. Adding a new enhanced care management benefit and a set of “in lieu of” services, designed to focus on critical populations such as children, high-cost/high-need populations, and the homeless.
  3. Behavioral health payment reform and delivery system transformation.
  4. Requiring Medi-Cal managed care plans to obtain accreditation from the National Committee on Quality Assurance (NCQA).
  5. Considerations for creation of full integration plans where one entity would be responsible for the physical, behavioral, and oral health needs of their members.

DHCS introduced the CalAIM proposal at the Stakeholder Advisory Committee (SAC) and Behavioral Health Stakeholder Advisory Committee (BH-SAC) meetings. Throughout the remainder of 2019 and 2020, DHCS will conduct extensive stakeholder engagement for both CalAIM and the renewal of the state’s Medicaid 1115 and 1915(b) waivers. The major components of CalAIM build upon the successful outcomes of various pilots (including, but not limited to, the Whole Person Care Pilots, Health Homes, and the Coordinated Care Initiative) from the previous federal waivers. This will result in better quality of life for Medi-Cal members as well as long-term cost savings/avoidance.

DHCS has three primary goals for CalAIM:

  • Identify and manage member risk and need through the Whole Person Care pilot approaches and addressing social determinants of health
  • Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility
  • Improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems, and payment reform

Whole Person Care Approaches

DHCS proposed the following recommendations that use a whole person care approach that address beneficiary needs in terms of physical, behavioral, and non-medical social determinants of health. The goal is to improve quality of life and reduce overall costs for the Medi-Cal population. The recommendations are as follows:

  1. Require plans to submit local population health management plans.
  2. Implement new statewide enhanced care management benefit.
  3. Implement in lieu of services (e.g., housing navigation/supporting services, recuperative care, respite, sobering center, etc.).
  4. Implement incentive payments to drive plans and provider organizations to invest in the necessary infrastructure, build appropriate enhanced care management, and in lieu of services capacity statewide.
  5. Evaluate participation in the federal Institutions for Mental Disease Serious Mental Illness/Serious Emotional Disturbance Section 1115 Expenditure Waiver. Counties would participate on an opt-in basis.
  6. Require screening and enrollment for Medi-Cal prior to release from county jail.
  7. Pilot full integration of physical health, behavioral health, and oral health under one contracted entity in a county or region.
  8. Develop a long-term plan for improving health outcomes and delivery of health care for foster care children and youth.

To transition Medicaid managed care plans to a standardized benefit package with integrated long-term services and supports (LTSS), DHCS proposed discontinuing the Cal MediConnect pilot program at the end of calendar year 2022. Cal MediConnect is the state’s dual eligible demonstration project operating in eight counties; it is part of the state’s Connected Care Initiative (CCI). The CCI is a Medicaid LTSS program available in all counties. Enrollment in CCI or Cal MediConnect is mandatory for people eligible for both Medicare and Medicaid. DHCS proposes to transition from the pilot approach of the CCI to standardized mandatory enrollment of people dually eligible for Medicare and Medicaid into a Medicaid managed care plan for Medicaid benefits and integration of long-term care into managed care for all Medi-Cal populations statewide. DHCS anticipates two phases:

  • By January 2021, the CCI will continue, but Multipurpose Senior Services Programs will be carved out, and all institutional long-term care services will be carved into managed care for all populations statewide.
  • By January 2023, the CCI will fully transition to mandatory managed care enrollment into managed care in all counties and plan models. Medicaid managed care plans will be required to operate Medicare Dual Special Needs Plans.

For more information about CalAIM, contact: California Department of Health Care Services, 1501 Capitol Avenue, MS 0000, Post Office Box 997413, Sacramento, California 95899; Email: calaim@dhcs.ca.gov; Website: https://www.dhcs.ca.gov/calaim.

Following-up to the 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd Edition, Deb Adler and Paul Duck discuss trends and shifts in the market and the impacts on population health management. From 2017 to 2019, specialty care coordination programs increased by 50%, behavioral health readmissions prevention programs increased by 74%, and emergency department diversion programs for behavioral emergencies increased by 43% for all health plans1. Service provider organizations are adapting to this shift by utilizing peer support specialists, adopting telehealth, and increasing consumer engagement via emails and text messages.

Featuring:

  • Deb Adler, CPHQ
    Senior Associate at OPEN MINDS
  • Paul Duck
    Senior Associate at OPEN MINDS

Deb Adler, CPHQ, has more than 20 years of experience in executive health care roles, serving in a variety of capacities, including network executive, quality management executive, and COO. She is the former Senior Vice President of Network Strategy for Optum, where she was responsible for behavioral health network development, contracting, and strategy for over 185,000 providers. In this role, she developed the largest performance-tiered behavioral health network, the largest telemental health network, and the largest medication-assisted treatment (MAT) network. She was also responsible for implementing network initiatives to promote medical/behavioral integration, improve member outcomes, and reduce total cost of care through collaborative care models. Currently, she serves as a Senior Associate at OPEN MINDS. Ms. Adler earned her MA in psychology and evaluation from Catholic University of America and is a Certified Professional in Health Care Quality (CPHQ).

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management, focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

Following-up to the 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd Edition, Deb Adler and Paul Duck discuss trends and shifts in the market and the impacts on population health management. From 2017 to 2019, specialty care coordination programs increased by 50%, behavioral health readmissions prevention programs increased by 74%, and emergency department diversion programs for behavioral emergencies increased by 43% for all health plans1. Service provider organizations are adapting to this shift by utilizing peer support specialists, adopting telehealth, and increasing consumer engagement via emails and text messages.

Featuring:

    • Deb Adler, CPHQ
      Senior Associate at OPEN MINDS
  • Paul Duck
    Senior Associate at OPEN MINDS

Deb Adler, CPHQ, has more than 20 years of experience in executive health care roles, serving in a variety of capacities, including network executive, quality management executive, and COO. She is the former Senior Vice President of Network Strategy for Optum, where she was responsible for behavioral health network development, contracting, and strategy for over 185,000 providers. In this role, she developed the largest performance-tiered behavioral health network, the largest telemental health network, and the largest medication-assisted treatment (MAT) network. She was also responsible for implementing network initiatives to promote medical/behavioral integration, improve member outcomes, and reduce total cost of care through collaborative care models. Currently, she serves as a Senior Associate at OPEN MINDS. Ms. Adler earned her MA in psychology and evaluation from Catholic University of America and is a Certified Professional in Health Care Quality (CPHQ).

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management, focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

On October 21, 2019, the Michigan Department of Health and Human Services (MDHHS) announced that it canceled plans for pilots to integrate Medicaid behavioral health specialty services and physical health services. The state, the health maintenance organizations (HMOs) for physical health services, and the regional behavioral health authorities were unable to reach an agreement on the financial model. MDHHS still intends to pursue improvements and changes to the Medicaid system that will promote physical and behavioral health integration.

MDHHS Director Robert Gordon said, “These pilots were supposed to be built on agreement among all participants. After years of work to reach consensus, it has become clear that agreement will not be reached. We remain committed to making our behavioral health system work better for all Michiganders, and it is time to look for new ways to achieve this goal.”

The initiative began with a provision in Section 298 of the Governor’s 2016 executive budget, which started a statewide discussion on the best approach for integrating physical and behavioral health services. A task force was created to make recommendations to fix the system. The Michigan Legislature used the task force recommendations to direct MDHHS to develop a set of recommendations regarding the most effective financing model and policies for behavioral health services for individuals with mental illnesses, intellectual and developmental disabilities, and addiction disorders. The 2017 budget revised Section 298 to direct MDHHS to create up to three pilots to test the financial integration of Medicaid-funded physical health and specialty behavioral health services. In March 2018, MDHHS selected community mental health centers to participate in the pilots.

Pilot implementation was set to initially begin on October 1, 2019. However, in June 2019, MDHHS delayed implementation until the following year to allow more time to design a financial integration model. The pilots were canceled because the parties could not agree on two issues: start-up costs and automatic statewide scaling of the model.

PsychU last reported on this topic in “Michigan DHHS Announces Delay In Pilot Of Integrated Physical Health Services & Specialty Behavioral Health Services,” which published on August 5, 2019. The article is available at https://www.psychu.org/michigan-dhhs-announces-delay-in-pilot-of-integrated-physical-health-services-specialty-behavioral-health-services/.

For more information, contact: Lynn Sutfin, Public Information Officer, Michigan Department of Health and Human Services, Post Office Box 30195, Lansing, Michigan 48909; 517-284-4772; Email: SutfinL1@michigan.gov; Website: https://www.michigan.gov/mdhhs/.

On October 25, 2019, officials with Universal Health Services (UHS) told investors that the company wrote off $147 million of the value of its addiction treatment unit, Foundations Recovery Network LLC (Foundations). UHS had acquired Foundations in 2015 for $350 million. UHS asserts that since 2015, payer control over treatment has been increasing and fewer consumers are covered for out-of-network services. Additionally, consumers are less willing to travel to obtain addiction treatment services.

When UHS acquired Foundations, there were four Foundations inpatient facilities with a total of 322 beds operating in California, Georgia, and Tennessee, and eight outpatient centers. In addition to limited coverage and fewer consumers traveling for services, Steve Filton, chief financial officer of UHS, said the marketing model that Foundations used was not a good fit with current UHS payer practices. Foundations had focused on involving direct-to-consumer marketing, consumer travel for treatment, and seeking insurance coverage for out-of-network services.

UHS operates 350 inpatient acute care hospitals and behavioral health facilities, as well as 30 outpatient and other facilities located in 37 states, Washington, D.C., Puerto Rico, and the United Kingdom. The organization serves more than 2.6 million health care consumers per year. UHS reported $97.2 million in net income on $2.8 billion in revenue in the quarter ending September 30, compared with $171.7 million in net income on $2.6 billion in revenue in the same period of 2018.

PsychU last reported on this topic in “Universal Health Services Creates Primary Care Service Line With Vera Whole Health,” which published on May 29, 2019. The article is available at https://www.psychu.org/universal-health-services-creates-primary-care-service-line-with-vera-whole-health/.

For more information, contact: Jane Crawford, Director, Corporate Public Relations, Universal Health Services, Inc., Post Office Box 61558, King of Prussia, Pennsylvania 19406; 610-382-4830; Email: jane.crawford@uhsinc.com; Website: https://www.uhsinc.com

The National Quality Forum (NQF) has recommended policy alignment, payment innovation, and standardizing data collection in effort to address social determinants of health (SDOH). NQF is a non-profit, nonpartisan, membership-based organization that gives health care stakeholders a voice in driving improvement of measurable health outcomes. Specifically, the recommendations include: aligning policy and payment across public and private stakeholders; improving the use and collection of standardized SDOH data; and designing incentives to address SDOH. The recommendations are as follows:

  1. Align policies, funding, and reimbursement across private and public payers, community-based organizations, social services entities, health systems, and provider organizations. This will improve data collection, system integration, workforce development, and the capacity to address SDOH.
  2. Develop consistent measures for SDOH. Selected measures should be shared by health care and community-based organizations, This will allow for communities to prioritize specific population subgroups based on their most pressing needs and largest health disparities.
  3. Execute the recommendations from the Social Determinants of Health Action Team to capture meaningful, standardized, and locally actionable data; enable data exchange and interoperability; enable collaboration at all levels, especially at the community level; and monitor progress using a standardized set of community and clinical outcome measures.
  4. Provide funding to test, collect data, assess, and measure the feasibility and effectiveness of community-based SDOH models and targeted interventions to improve health outcomes. Funding should support sustainable financing for community-based organizations and pay for social services that address SDOH. Organizations should share and apply data to enable continuous quality improvement and build a real-world evidence base for effective initiatives.
  5. Provide incentives and rewards for addressing and improving SDOH. Incentives may include payment, contracting, and non-financial rewards. Actions should help communities in which the health system operates, and a percentage of payment to health systems and clinicians should be tied to collaborating with the community-based workforce.

The recommendations were offered in “A National Call to Action: Quality And Payment Innovation In Social Determinants Of Health” by NQF and were released at a Congressional Hill Briefing on October 24, 2019. Through an initiative supported by Aetna Foundation, NQF collaborated with nearly 60 health care stakeholders from across the United States at the SDOH Payment Summit in August 2019. At the summit, the group discussed national strategies, barriers, and recommendations for addressing social determinants through payment and quality innovation.

The full text of “A National Call to Action: Quality And Payment Innovation In Social Determinants Of Health” was published October 22, 2019 by NQF. A copy is available online at http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=91325 (accessed November 18, 2019).

For more information, contact: Information Office, National Quality Forum, 1099 14th Street Northwest, Suite 500, Washington, District of Columbia 20005; 202-783-1300; Fax: 202-783-3434; Email: info@qualityforum.org; Website: http://www.qualityforum.org/

Medicaid health plans are moving ahead with the shift to alternate payment methodologies (APM) at a relatively rapid rate. Twenty-two states require health plans to move to value-based reimbursement and eleven states use Medicaid accountable care organizations.

Is Medicaid financing for physical health, behavioral health, and pharmacy properly aligned for value-based reimbursement (VBR)? If integrated care coordination and VBR are going to have a meaningful impact on “bending the cost curve”, financial alignment is important. The more fragmented the financing, the less impact care coordination can have on consumer resource use.

Of the 49 states with a fee-for-service (FFS) system, 39 align all services – physical health, behavioral health, and pharmacy. In those FFS systems, 10 align physical health and pharmacy services, but not behavioral health services.

Of the 41 states with Medicaid managed care, financial alignment is less uniform. In 26 states, the Medicaid health plans are financially responsible for all services – physical health, behavioral health, and pharmacy. In the other states with Medicaid health plans, two states align physical and behavioral health, but not pharmacy; seven align physical health and pharmacy only, two align behavioral health and pharmacy, and two have no alignment of any services. Additionally, there were two states (Hawaii and Maryland) that align physical health and physical health pharmacy and then separately finance, but align behavioral health and behavioral health pharmacy.

Why financial alignment matters is clear. Care coordination and incentives based on ‘total cost of care’ are possible where financial risk is aligned. Setting targets for reduction of total spend is not possible if those funding streams aren’t aligned. In states where behavioral health is not in same financial pool as physical health, it is not possible to incentive behavioral health provider organizations on medical cost-offset as a ‘value measure’.

Overall, Medicaid plans are increasingly eliminating ‘carve outs’ of behavioral health and pharmacy benefits and relying on health plans to make integrated care coordination models work. Going forward, it is health plan policies and initiatives that are going to determine the incentives in pay-for-value arrangements. Whether those models work is a subject for a different analysis. For a current snapshot of health plan practices, see 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd Edition.

During 2018, the 548 Medicare accountable care organizations (ACOs) collectively saved Medicare $1.7 billion. After accounting for shared savings bonuses and collecting shared loss payments, net savings were $739 million. ACOs that received shared savings payments had decreases in inpatient, emergency room, and post-acute care spending and utilization. ACOs that increased spending relative to their targets tended to show increases in these areas.

Of the 548 ACOs in 2018, 205 ACOs generated savings and 70 generated losses; the remaining 273 generated no savings or losses. In total, 205 ACOs earned savings; 11 ACOs had losses (negative earned savings), and 332 ACOs had no earned savings or losses.

In a blog post about the 2018 ACO financial results, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma wrote that CMS analyzed the data to sort ACOs into low-revenue and high-revenue groups according to the Pathways to Success final rule. The low-revenue ACOs outperformed high-revenue ACOs in terms of their average spending reduction relative to their targets. The majority of low-revenue ACOs are physician-led. The majority of high-revenue ACOs are led by hospitals.

The low-revenue ACOs had an average reduction of $180 per beneficiary, compared to $27 per beneficiary for high-revenue ACOs. CMS concluded that ACOs led by physicians outperformed ACOs led by hospitals. Ms. Verma wrote, “Given the success of low-revenue ACOs to date, the Pathways to Success final rule provides these ACOs with the option to elect more time under one-sided risk (generally three years), before requiring them to take on downside risk, to encourage their participation in the Shared Savings Program.”

In the post, Ms. Verma noted that ACOs responsible for downside risk performed better than ACOs that did not accept risk. ACOs taking on downside risk showed an average reduction in spending, relative to their targets, of $96 per beneficiary, compared to $68 for ACOs that did not take on downside risk.

The CMS ACO MSSP Public Use File for 2018 is posted online at https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/2018-Shared-Savings-Program-SSP-Accountable-Care-O/v47u-yq84/data (accessed November 4, 2019).

Seema Verma’s statements were in a blog post “Interest In ‘Pathways To Success’ Grows: 2018 ACO Results Show Trends Supporting Program Redesign Continue” published September 30, 2019, by Health Affairs. A copy is available online at https://www.healthaffairs.org/do/10.1377/hblog20190930.702342/full/ (accessed November 4, 2019).

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Email: press@cms.hhs.gov; Website: https://www.cms.gov/

Physician-led Medicare accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) achieved nearly seven times more Medicare savings per beneficiary than hospital-led ACOs. For all ACOs in 2018, aggregate savings per-beneficiary totaled $73.23. Physician-led ACOs, which tend to be “low revenue” ACOs, generated savings of $180.41 per Medicare beneficiary. Hospital-led ACOs, which tend to be high revenue, generated savings of $26.76 per Medicare beneficiaries.

MSSP ACOs continue to achieve higher savings the longer they participate in the program. Overall in 2018, ACOs in their first performance year had higher per-beneficiary spending. However, those that had been in the program longer had spending lower than baseline each year, and the savings increased.

  • Per beneficiary spending for first year ACOs was $20.20 higher than the baseline; however, for those in the second year, per-beneficiary spending was lower than baseline by $56.41.
  • In the third year, spending was $50.30 lower than baseline, representing an 11% change from the previous year savings.
  • In the fourth year, spending was $84.51 lower than baseline, representing a 68% change from the previous year savings.
  • In the fifth year, per-beneficiary spending was $122.68 lower, representing a 45% change from the previous year savings.
  • In the sixth year, per-beneficiary spending was $141.48 lower for ACOs in their sixth year, representing a 15% change from the previous year savings.

These findings were reported in “Physician-Led Accountable Care Organizations Outperform Hospital-Led Counterparts” by researchers with Avalere. They analyzed data from the Centers for Medicare & Medicaid Services (CMS) 2018 Shared Savings Program Accountable Care Organizations Public Use File (PUF). For the analysis, they estimated the net impact on Medicare spending from the MSSP and aggregated the results across the program by each ACO’s experience with the program, performance year, and CMS categorization of “low revenue” and “high revenue.” Under the Medicare Pathways to Success changes to the MSSP, CMS designates an ACO as “low” or “high” revenue based on a threshold of Medicare Parts A and B revenue associated with the ACO’s assigned beneficiaries.

In 2018, 548 MSSP ACOs provided care to over 10 million Medicare beneficiaries and reduced Medicare spending by $739 million. In 2018, 235 ACOs (43%) were considered low revenue and 313 ACOs (57%) were considered high revenue.

The full text of “Physician-Led Accountable Care Organizations Outperform Hospital-Led Counterparts” was published October 15, 2019. A copy is available online at https://avalere.com/press-releases/physician-led-accountable-care-organizations-outperform-hospital-led-counterparts (accessed November 4, 2019).

For more information, contact:

  • John Feore, Associate Principal, Avalere Health, 1350 Connecticut Avenue Northwest, Suite 900, Washington, District of Columbia 20036; 202-207-1300; Email: jfeore@avalere.com; Website: https://avalere.com/
  • Gabe Sullivan, Consultant I, Avalere Health, 1350 Connecticut Avenue Northwest, Suite 900, Washington, District of Columbia 20036; 202-207-1300; Email: gsullivan@avalere.com; Website: https://avalere.com/

 

Payers use a variety of methods to control prescription drug costs including different financing arrangements, prior authorization, preferred drug lists, and co-payments – each of which target a different part of the financing and delivery system. This week, our team examined the uniform preferred drug list (PDL).

What exactly is a PDL and what is a uniform PDL? A PDL is list of medications that a payer or health plan “prefers” and therefore will cover without prior authorization (these medications may still be subject to quantity and dosage limits or safety edits). Typically, medications that are preferred are either a generic formulation or the payer has been able to negotiate a major discount on the cost by listing the medication as preferred. Generally, the PDL is broken up by class of drugs: for example, antipsychotics vs. antidepressants vs. steroids vs. beta blockers. Payers can include all drug classes on the PDL or choose to exclude certain classes. In general, when a class is excluded, all drugs in that class are considered preferred.

While PDLs are used by all payers—Medicare, Medicaid, and commercial—the uniform PDL is unique to Medicaid. When a state Medicaid program puts a uniform PDL in place, it standardizes the preferred drugs across the Medicaid health plans and the fee-for-service (FFS) program. In states without a uniform PDL, the PDL can vary between the FFS plans and the health plans. A variety of names are used to describe this practice including single PDL, statewide PDL, and unified PDL.

What are the advantages of a uniform PDLs? For provider organization clinical teams, uniform PDLs for Medicaid can simplify the process for prescribing medications. Instead of checking the PDL of each health plan, prescribers can be fairly confident in knowing the availability and access to medications for all Medicaid beneficiaries. For consumers, uniform PDLs can help eliminate some of the confusion with choosing a health plan and can make switching between health plans less complicated.

How many state Medicaid programs have uniform PDLs? Of the 30 states with Medicaid managed care, 13 use a uniform PDL. All of these states include at least one mental health and addiction drug class on the uniform PDL. There are no states that have uniform PDLs only for mental health drugs. In 2019, seven of the 13 states with uniform PDLs set their own prior authorization requirements, clinical criteria, and other restrictions.

During the last couple of years more states have moved to a uniform PDL. Between 2017 and 2019, Arkansas, Louisiana, Minnesota, and Virginia added a uniform PDL (note that West Virginia ended its integrated financing arrangement for pharmacy). In the future, at least two states are planning to implement uniform PDLs. Ohio plans to implement a uniform PDL for its health plans on January 1, 2020 (see Unified Preferred Drug List)1. Pennsylvania is also planning to implement a uniform PDL for its health plans on January 1, 2020.2

In 2018, Medicare beneficiaries over age 65 with UnitedHealthcare commercial insurance who saw high-value physicians for more than 75% of their care had about 21% lower risk-adjusted spending compared to beneficiaries who saw physicians who were not considered “high-value.” UnitedHealthcare defines a high-value physician as one that meets the quality and cost-efficiency criteria established by the UnitedHealth Premium Program. Members who saw high-value physicians had 64% fewer inpatient hospital days, and 35% fewer emergency department visits. As a result, their risk-adjusted spending was $95 lower per member per month.

These findings were reported in “High-Value Physicians Can Save the Medicare Program over $286 Billion in Health Care Costs” by researchers with UnitedHealth Group. The UnitedHealth Premium Program draws upon quality metrics from the National Quality Forum, the National Committee for Quality Assurance (NCQA), and other leading clinical quality organizations. Cost-efficiency measures are based on local market benchmarks for cost-efficient use of resources and referral patterns in providing care.

Additional findings include:

  • The greatest average per-consumer or per-episode Medicare savings for those who saw high-value physicians was for those who saw nephrology professionals, which totaled 11.8% in savings. This was followed by those who saw neurology professionals (11.1% in savings), and those who saw cardiology professionals (10.1% in savings).
  • Of all specialties evaluated, primary care physicians saw the highest volume of consumers (58.7%). Improving the cost-efficiency of these physicians represents the greatest total savings opportunity of an estimated $14.5 billion in 2020, and $202.9 billion by 2029, for those who already meet the quality criteria.
  • Improving the cost-efficiency of cardiologists, neurologists, and pulmonologists who already meet the quality criteria could save seniors and the Medicare fee-for-service program $4.3 billion in 2020, and $61.2 billion by 2029.

The full text of “High-Value Physicians Can Save The Medicare Program Over $286 Billion In Health Care Costs” was published September 25, 2019 by UnitedHealth Group. An abstract is available online at https://www.unitedhealthgroup.com/newsroom/posts/2019-09-24-high-value-physicians-medicare-costs.html (accessed October 28, 2019).

To learn more about the criteria for the UnitedHealth Premium Program, go to https://www.uhcprovider.com/en/reports-quality-programs/premium-designation.html (accessed October 28, 2019).

PsychU last reported on this topic in “Medicare Fee-For-Service Spending For Primary Care Ranges From 2% To 5%,” which published on September 23, 2019. The article is available at https://www.psychu.org/medicare-fee-for-service-spending-for-primary-care-ranges-from-2-to-5/.

For more information, contact: Eric Hausman, Corporate Communications, UnitedHealth Group, Post Office Box 1459, Minneapolis, Minnesota 55440-1459; 952-936-3963; Email: eric.hausman@uhg.com; Website: http://www.unitedhealthgroup.com/

The top three factors associated with higher dual eligible enrollment in financial alignment plans (FAI) are passive enrollment, alignment with existing state Medicaid managed long-term services and supports (MLTSS) programs, and beneficiaries’ relationships with care coordinators. Across the ten states with FAI plans, plan enrollment among eligible beneficiaries ranged from a high of 67% in Ohio to a low of 4% in New York. The participating states are California, Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, Texas, and Virginia.

Researchers concluded that higher enrollment rates are dependent upon strategic passive enrollment and marketing the alignment of key design features between the state’s dual demonstration and Medicaid MLTSS programs. To increase enrollment, the researchers made two suggestions for state policymakers. First, state policymakers should conduct passive enrollment at the start of a program and on a rolling basis each month with newly eligible beneficiaries. The second, state policymakers should align the design of state MLTSS and Medicare–Medicaid integrated care programs so that dually eligible beneficiary groups, state regions, and participating plans are the same in both programs.

These findings were reported in “Enticing Dually Eligible Beneficiaries to Enroll in Integrated Care Plans” by Debra J. Lipson and Erin Weir Lakhmani of Mathematica. The report was published by Milbank Memorial Fund. The researchers conducted a study on FAI enrollment with support from the Medicaid and CHIP Payment and Access Commission. Also called the “duals demo,” FAI is a 10-state demonstration as part of an effort to improve the quality of care and lower spending for low-income people who are dually-eligible for both Medicare and Medicaid.

Through the FAI, each of the states and the Centers for Medicare and Medicaid Services (CMS) contracted with integrated Medicare–Medicaid plans (MMPs). The MMPs are paid a fixed monthly rate for each member to provide and coordinate Medicare and Medicaid benefits. The researchers focused primarily on passive enrollment and demonstration/MLTSS alignment as program-level factors that affect enrollment.

Passive Enrollment:

All 10 participating states used passive enrollment, in which states automatically enroll eligible beneficiaries into an MMP. Enrollment in all 10 states typically spiked during or immediately after the implementation of a passive enrollment “wave.” States that continuously conducted monthly passive enrollment for individuals who became newly dually eligible during the course of the demonstration had higher participation rates than those that conducted annual passive enrollment. States with higher participation rates were more likely to passively enroll dually eligible people who were already enrolled in a Medicare Advantage plan, if the plan’s parent company also sponsored an MMP.

Alignment with Medicaid Managed Long-Term Services & Supports:

The researchers found that higher enrollment in MMPs was associated with greater alignment of key design features between the state’s dual demonstration and its Medicaid MLTSS program. By sharing the same eligibility criteria, geographic areas of operation, and participating health plans, the state agencies and health plans were able to communicate more effectively the advantages of choosing one plan to provide both Medicare and Medicaid services.

Degree Of Program Feature Alignment Between State FAI Duals Demonstrations & MLTSS Programs
Ohio California Illinois Massachusetts Michigan New York Rhode Island Texas
Same program name for demonstration and MLTSS Yes No No No No No Not completely No
Rolled out demonstration and MLTSS simultaneously Yes Yes No No No No No No
Eligible populations are identical Yes Not completely Yes No Not completely Not completely Not completely Not completely
Participating counties identical for both programs Yes Yes Not completely Not completely Not completely Not completely Yes Not completely
Same health plans offer MMP and MLTSS plans in each demonstration county Yes Not completely Not completely Not completely No Not completely Yes Yes

The table includes eight of the 10 FAI demonstration states whose MLTSS programs have run concurrently with the demonstration. South Carolina did not operate a concurrent MLTSS program, and Virginia’s MLTSS program began after the state’s FAI demonstration ended.

The full text of “Enticing Dually Eligible Beneficiaries to Enroll in Integrated Care Plans” was published in October 2019 by Millbank Memorial Fund. A copy is available online at https://www.milbank.org/publications/enticing-dually-eligible-beneficiaries-to-enroll-in-integrated-care-plans/ (accessed October 28, 2019).

For more information, contact: Debra J. Lipson, Senior Fellow, Mathematica, 1100 First Street Northeast, 12th Floor, Washington, District of Columbia 20002-4221; 202-238-3325; Email: dlipson@mathematica-mpr.com; Website: https://www.mathematica.org/

State Medicaid plan costs to implement and administer work requirements range from $6.1 million in New Hampshire to $271 million in Arkansas, according to early data from the first five states that have implemented them. The five states include Kentucky, Wisconsin, Indiana, Arkansas, and New Hampshire. Since January 2019, these five states that received approval for work requirements from the Centers for Medicare & Medicaid (CMS) reported a range of up-front costs for administrative activities.

Estimated Cost To Administer Medicaid Work Requirements For First Five States With Waivers As Of November 2018
State Number of Beneficiaries Subject to Requirements Estimated Costs (dollars in millions) Estimated Federal Share (percentage)
Kentucky 620,000 $271.6 87%
Wisconsin 150,000 $69.4 55%
Indiana 420,000 $35.1 86%
Arkansas 115,000 $26.1 83%
New Hampshire 50,000 $6.1 79%

 

These findings were reported in “Medicaid Demonstrations: Actions Needed to Address Weaknesses in Oversight of Costs to Administer Work Requirements” by the United States Government Accountability Office (GAO). In the report, the GAO examined the states’ estimates of costs of administering work requirements To examine these estimates, the GAO reviewed state data and documentation for the five selected states that had received approval as of November 2018. The data included estimates of the administrative costs for implementing and administering work requirements over the course of the three-to-five year demonstration approval including the states’ estimates of federal and non-federal costs.

The estimates were based on information the states had readily available, such as the costs of contracted activities for information technology (IT) systems and beneficiary outreach. Additionally, the estimates primarily reflect up-front costs.

Breaking down the costs:

  • Kentucky’s estimated costs of $271.6 million included $220.9 million in IT costs for the Medicaid demonstration as a whole, including work requirements, for fiscal years 2019 and 2020. The estimate also included $50.7 million in payments for managed care organizations’ cost to administer work and other beneficiary requirements for the period of July 2018 through June 2020. The estimate does not include expected costs for evaluating work requirements. Expenditures from the application date in August 2016 through 2018 equaled more than $99.5 million.
  • Wisconsin’s estimated costs of $69.4 million included $57.3 million for beneficiary outreach, evaluation, and other services from July 2019 through June 2021, and $12.1 million in fiscal year 2019 for IT systems changes for the Medicaid demonstration as a whole. There were no expenditures reported from the time of application through 2016.
  • Indiana’s estimated costs of $35.1 million included $14.4 million for IT systems for fiscal years 2018 through 2021, and $20.7 million for managed care organizations’ activities in 2019. Expenditures from the application date in July 2017 through 2018 equaled more than $800,000.
  • Arkansas’s estimated costs of $26.1 million included contracts in place from July 2017 through June 2019 for IT systems, beneficiary outreach, and other activities, such as data analysis. Expenditures from the application date in June 2017 through 2018 equaled more than $24.1 million.
  • New Hampshire’s estimated costs of $6.1 million included $4.5 million for IT system and other contracts in place from July 2018 through June 2019, and $1.6 million for evaluation activities from 2019 through 2025. Expenditures from the application date in October 2017 through 2018 equaled more than $4.4 million.

Factors such as differences in changes to information technology systems and numbers of beneficiaries subject to the requirements may have contributed to the variation in estimates. The estimates do not include all costs, such as ongoing costs states expect to incur throughout the demonstration. All five selected states expected to receive federal funds for the majority of estimated costs and expenditures for implementing work requirements.

PsychU last reported on this topic in the following articles:

For more information, contact:

  • Carolyn L. Yocom, Media Contact, United States Government Accountability Office, 441 G Street Northwest, Washington, District of Columbia 20548; 202-512-7114; Email: yocomc@gao.gov; Website: https://www.gao.gov/index.html
  •  Chuck Young, Office of Public Affairs, United States Government Accountability Office, 441 G Street Northwest, Washington, District of Columbia 20548; 202-512-4800; Email: youngc1@gao.gov; Website: https://www.gao.gov/index.html

Social factors are primary impediments to managing care for high-cost Medicaid beneficiaries. These factors create barriers that impede beneficiary participation in care management services, creating challenges for states trying to improve outcomes and reduce costs for high-expenditure Medicaid beneficiaries. The biggest barriers include lack of transportation to medical appointments, lack of stable housing, and inconsistent access to food and other basic resources. Additional barriers to effective care management include staff shortages in rural areas and state or Medicaid managed care organization (MCO) difficulties contacting beneficiaries due to outdated contact information or limited beneficiary mobile phone minutes.

A review of seven state Medicaid program care management strategies to manage costs and care for high-expenditure beneficiaries found mixed results. The review was conducted by the Government Accountability Office (GAO); the outcomes were reported in “Efforts to Identify, Predict, or Manage High-Expenditure Beneficiaries.” It briefly mentioned barriers cited by the states and MCOs to beneficiary engagement with care management but did not go into detail to analyze the impact of the barriers on outcomes or costs.

Six of the seven states reported on their assessment of care management program efforts to manage costs and care for high-expenditure beneficiaries. Four of the states—Pennsylvania, South Dakota, Vermont, and Washington—said their assessment showed positive results, such as cost savings or reductions in the use of expensive services. The Indiana and Nevada Medicaid agencies reported mixed or inconclusive findings related to the impact on cost or quality of their programs for high expenditure Medicaid beneficiaries. In addition to providing care management services, some states (South Carolina, Nevada, Pennsylvania, and Indiana) used additional strategies, such as coverage policy changes, payment incentives, and restrictions on the use of provider organizations.

The GAO examined state and federal efforts to manage costs and improve care coordination for high-expenditure Medicaid beneficiaries. For this performance audit, the GAO interviewed officials from the Centers for Medicare & Medicaid Services (CMS), Medicaid officials from the seven states, and officials from five Medicaid managed care organizations (MCOs) operating in Indiana, Nevada, Pennsylvania, South Carolina, and Washington; and Vermont’s all-payer accountable care organization (ACO). The MCOs were not named in the report. South Dakota does not use managed care. For this report, the GAO defined “high-expenditure” as the subset of beneficiaries who account for a disproportionately large share of Medicaid expenditures, or are at-risk for doing so in the future. The goal was to report on approaches the states have used to identify or predict high-expenditure Medicaid beneficiaries; strategies used to manage beneficiaries’ health care costs while ensuring quality of care; and resources to help states identify, predict, or better manage high-expenditure beneficiaries.

For this report, the GAO defined care management programs as an effort to manage the cost and quality of health care services delivered to high-expenditure Medicaid populations with the goal of both improving health outcomes and achieving cost savings. The GAO included any programs that provided care coordination, case management, and/or disease management to assess consumer need and to coordinate care across multiple health care professionals.

Four states—Pennsylvania, South Dakota, Vermont, and Washington—reported positive outcomes, as follows:

  • Pennsylvania: The state’s Integrated Care Plan program for high-expenditure beneficiaries with persistent serious mental illness resulted in improvements in utilization, including reductions in inpatient hospitalizations and readmissions.
  • South Dakota: For 2017, health home participants cost $204 less per month than a comparison group, and had an 8% decline in emergency room visits from the prior year, compared to a 10% increase for the comparison group.
  • Vermont: The state reported in 2018 that the rate of inpatient visits per thousand beneficiaries in care management decreased from 600 to 393, and the annual rate of emergency visits per thousand beneficiaries decreased from 1,536 to 1,003.
  • Washington: The Health Homes program for dual eligible saved $107 million over its first 42 months.

Two states—Indiana and Nevada—reported mixed outcomes, as follows:

  • Indiana: The Right Choices Program generated low cost savings, with the exception of pharmacy costs, which were lower among beneficiaries with addiction disorders.
  • Nevada: The fee-for-service (FFS) care management organization (CMO) appeared to achieve some cost savings, but had little effect on quality of care after the program was implemented in 2013.

All seven states, the five MCOs, and the ACO used at least one approach to identify or predict high-expenditure beneficiaries. Some used more than one approach. States said they used various approaches to identify high-expenditure beneficiaries among different Medicaid population segments, such as FFS beneficiaries, or those with certain chronic conditions. The approaches included risk scores, statistical outliers, diagnosis type, service utilization and claims expenditure thresholds, and clinical judgment.

Officials in each of the selected states, the MCOs, and the ACO identified barriers to implementing care management for some high-expenditure Medicaid beneficiaries. In addition to noting the barriers posed by social determinants of health, the officials said missing outdated contact information for beneficiaries was a problem. They also noted that staff shortages in rural areas interfered.

For more information, contact: Carolyn L. Yocom, U.S. Government Accountability Office, 441 G Street, NW, Room 7149, Washington, District of Columbia 20548; 202-512-7114; Email: yocomc@gao.gov; Website: http://www.gao.gov/; or Chuck Young, Managing Director, Public Affairs, U.S. Government Accountability Office, 441 G Street, NW, Room 7149, Washington, District of Columbia 20548; 202-512-4800; Email: youngc1@gao.gov; Website: http://www.gao.gov/. 

There is great debate over whether consumers shop for health care services; like comparing prices and using performance and quality data to make decisions. A recent story about a man who drove five hours for hernia surgery because he discovered a cost difference of $30,000 versus $3,000 (see Man Drives Five Hours For Surgery Insurance Won’t Cover)1 and news that about 1.9 million Americans have become medical tourists to get cheaper care (see U.S. Medical Tourists Seek Cheap Health Care Abroad)2 make me believe we’re entering a new phase of health care consumerism.

While price transparency is a priority (see Presidential Order Requires Price Transparency For Hospital Charges And Out-Of-Pocket Expenses), there is controversy over mandates for transparency and experts question why consumers are not really shopping to get the best prices.

What’s causing the delay? One health care executive, quoted in a Los Angeles Times story, said, “We overestimated the ability of consumers to be good stewards of their health care dollars.”

We may need more time to see a real shift from a doctor-knows-best environment to one in which consumers, like the Texas man noted above, look at health care like other purchases.

There are a few trends that might support more active consumerism. First, employers like Walmart are taking action to steer employees to specific physicians in its markets based on quality data. And Walmart is not alone. An increasing number of employers and health plans are implementing strategies to influence consumer health choices with value-based benefit designs and decision support tools (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System).

The Center for Medicare & Medicaid Services (CMS) has several new initiatives that are focused on engaging consumers in health care decisions. CMS implemented a new rating system for nursing homes this month, Nursing Home Compare (try out the tool: https://www.medicare.gov/nursinghomecompare/search.html). And starting October 23, CMS will add a graphic alert to listings for nursing homes cited for abuse, neglect or exploration.

CMS is also requiring health plans to use its star ratings, which are influenced by consumer satisfaction, on health insurance exchanges (see CMS Requiring Star Ratings Displayed For Health Plans Sold On 2020 Health Exchanges). And it’s planning to update and expand the Hospital Compare site in 2021 based on public hearings and other stakeholder input.

When you combine these efforts with existing NCQA, HEDIS and health plan efforts to highlight health provider performance ratings, consumers will have more information at their fingertips. We see evidence that out-of-pocket costs will increasingly influence consumer choice (see News Reports about a Weakening Economy Impacting How Some Patients Seek Medical Treatment)3 and lead them to use these tools. The bigger question is how do we teach consumers how to use this information the same way they use Rotten Tomatoes to assess movie choices and Yelp when looking for restaurants?

“We are moving quickly toward Priceline health care,” said OPEN MINDS Senior Associate, Paul Duck. As consumers gain a better understanding of their options, shopping will become more common, which is why he advises executives to prepare. A few approaches to consider:

  • Review your organization’s ratings from health plans and independent organizations.
  • Assess how consumers find you online.
  • Review the consumer experience on your website.
  • Assess wait times for consumers scheduling appointments on the phone.

Learn more in upcoming coverage of the consumerism issue and check out these resources in the PsychU Resource Library:

  1. The Next Wave Of Consumer Price Shopping For Health Care
  2. Considering Cash & Consumerism in Service Line Planning
  3. Integration, Interoperability & Consumer Engagement
  4. The Big Rewards Of Health Care Through The Consumer Lens
  5. Answering The Question – Who Can Afford Their Health Services?

1 https://www.cbsnews.com/news/man-drives-five-hours-for-surgery-insurance-wont-cover-hernia-surgery-central-texas-2019-10-11/

2 https://newsroom.transunion.com/news-reports-about-a-weakening-economy–impacting-how-some-patients-seek-medical-treatment/

Between 2017 and 2018, the rate of health insurance coverage in the U.S. dropped from 92.1% of the 325.14 million population to 91.5% of the 327.16 million population in 2018. The uninsured rate rose from 7.9% to 8.5%; this rate counted people who had no insurance for any part of the year. Between 2017 and 2018, the U.S. population rose by 0.4%, from 322.5 million in 2017 to 323.7 million in 2018.

Of the total population, for all or part of 2018, about 67.3% was covered by a private health plan, such as employment-based coverage, direct-purchase coverage, or VA TRICARE. About 55.1% of the total population was covered by an employer-sponsored plan for all or part of the year. In 2017, 55.4% were covered by an employer-sponsored plan for all or part of the year.

Another 34.4% was covered for all or part of 2018 by a publicly funded health plan (Medicare, Medicaid, and VA or CHAMPVA). The share of people covered by a publicly funded health plan declined slightly from 34.8% in 2017 to 34.4% in 2018. About 17.8% of the population was covered by Medicare, up from 17.4% in 2017. About 17.9% were covered by Medicaid, down by 0.7 percentage points from 18.6% in 2017.

These findings were reported in “Health Insurance Coverage in the United States: 2018” by the U.S. Census Bureau. This report presents statistics on health insurance coverage in the U.S. based on information collected in the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) and the American Community Survey (ACS). The goal was to report trends in health insurance coverage in the U.S.

Additional findings include:

  1. In 2018, about 8.5% percent of people, or 27.5 million, did not have health insurance at any point during the year.
  2. Of the subtypes of health insurance coverage, employer-based insurance was the most common in 2018, covering about 55.1% of the population for all or part of the calendar year.
  3. Between 2017 and 2018, the percentage of people with employment-based coverage, direct-purchase coverage, TRICARE, and VA or CHAMPVA health care did not show a statistically significant change.
  4. Between 2017 and 2018, the percentage of people without health insurance coverage at the time of the interview decreased in three states (New York, South Carolina, and Wyoming), and increased in eight states (Alabama, Arizona, Idaho, Michigan, Ohio, Tennessee, Texas, and Washington).

PsychU last reported on this topic in “Medicaid Covered 19.6% Of Americans In 2015,” which published on January 17, 2017. The article is available at https://www.psychu.org/medicaid-covered-19-6-americans-2015/.

For more information, contact: Public Information Office, United States Census Bureau, 4600 Silver Hill Road, Washington, District of Columbia 20233; 301-763-3030; Email: pio@census.gov; Website: https://www.census.gov/.

The number of primary Medicaid behavioral health carve-outs is on the decline. In our annual analysis, we’ve seen a decrease in the number of states with behavioral health carve-outs and an increase in the number of states with integrated financing. While the trend is toward integrated financing for physical and behavioral health services, does this apply to pharmacy benefits?

In a recent OPEN MINDS report, State Medicaid Mental Health Pharmacy Carve-Outs, they analyzed the market. Before diving into the findings, it is important to level set on exactly what we mean by integrated financing versus carve-outs for pharmacy benefits. State Medicaid financing of pharmacy benefits can take one of three forms:

  1. The pharmacy benefit can be integrated with financing for physical health across the plan (either within the fee-for-service [FFS] plan or a Medicaid health plan)
  2. The entire pharmacy benefit can be separately managed and/or financed via a primary carve-out for all pharmacy
  3. A portion of the pharmacy benefit—such as mental health pharmacy—can be separately managed and/or financed via a primary carve-out for behavioral health pharmacy (some states have primary carve-outs for other specialty drugs, but they are not the focus of this report)

OPEN MINDS found that in 2019, 44 states have integrated financing models for pharmacy benefits (either integrated in the FFS plans or in the Medicaid health plans) and 10 states have primary carve-outs. (Note, the total exceeds the number of states because some states utilize more than one financing arrangement.) Of those states with a primary carve-out, four had a primary carve-out for all pharmacy and six had a primary carve-out for mental health pharmacy only.

How does this compare with the past? There is not much change overall from a national perspective. Since 2017, one state has moved from an integrated financing model to a primary carve-out for all pharmacy. One state moved from a primary carve-out for all pharmacy to integrated financing in health plans and one state moved from a primary carve-out for mental health pharmacy to integrated financing with health plans.

Essentially, Medicaid pharmacy benefits are all over the place. Some states are integrating pharmacy benefits while others are instituting carve-outs. Three states have announced plans to implement primary carve-outs of pharmacy benefits. California plans to implement a carve-out for prescription drugs by 2021, Michigan released a notice to implement a carve-out for prescription drugs by December of this year, and North Dakota plans to implement a primary carve-out for pharmacy for the Medicaid expansion population in January 2020 (see New California Governor Orders Medi-Cal To Move Pharmacy To FFS Carve-Out Model.

What does this mean for provider organizations managing complex consumer populations? On one level, the move toward managing pharmacy benefits through a primary carve-out arrangement can simplify the administration of benefits. All Medicaid consumers will have exactly the same benefit and prior authorization requirements – regardless of the consumer’s health plan. On the other hand, the use of a primary carve-out might make it more difficult to coordinate benefits. Provider organizations’ clinical teams might have to take a more active role in making sure services and medications are coordinated.

There are a couple other factors to consider. On a more global basis, pharmacy benefit carve-out models make it more difficult to use total medical spend as a performance measure in value-based contracts. And, aside from the more common use of carve-out models and pharmacy benefit managers, we’re seeing the first states using value-based reimbursement contracts with specific manufacturers for specific medications. The effects of these models are still unknown, but could change how pharmacy benefits are delivered.

On September 13, 2019, three addiction and mental health treatment centers sued United Behavioral Health (UBH), UnitedHealthcare’s mental health subsidiary. The centers alleged that UBH wrongfully denied $5 million in behavioral health treatment claims for self-insured and fully insured employer health plans for residential and outpatient treatment from 2011 to 2017. The case involves claims for 157 employer group health plan members, including children.

The complaint claims that UBH guidelines for coverage are overly restrictive and violate federal and state law. Meridian Treatment Services; iRecover Treatment, Inc.; and Harmony Hollywood Treatment Center of California are listed as the primary plaintiffs. They allege that UBH used a cost-focused method of deciding whether to grant or deny pre-authorizations, and to grant or deny coverage for services that did not require pre-authorization. The plaintiffs asked the U.S. District Court of Northern California to have a neutral third party re-process the claims believed to be wrongfully denied.

The case stems from two consolidated class action lawsuits filed against UBH in 2014. The consolidated case went to trial in October 2017 before U.S. Chief Magistrate Judge Joseph Spero in San Francisco. The case was subsequently granted class-action status on September 16, 2016, in conjunction with these earlier lawsuits. In the current suits, the plaintiffs are asking the court to certify two classes—one covering residential treatment claims, and one class encompassing outpatient and intensive outpatient treatments that were not covered. The plaintiffs claim that as many as 3,000 health plans and 10,000 care facilities could be involved in the resulting complaints.

Meridian Treatment Solutions, Inc., offers sub-acute treatment for individuals suffering from mental health, addiction, and other co-occurring disorders in Lauderdale-By-The-Sea, Florida. Meridian provides mental health and addiction treatment to those covered under health insurance plans sold or administered by UBH.

iRecover Treatment Inc., dba, Serenity Palms Detox, offers sub-acute treatment for individuals suffering from mental health, addiction, and other co-occurring disorders in Palm Desert, and Cathedral City, California. Serenity provides mental health and addiction treatment services to those covered under health insurance plans sold or administered by UBH.

Harmony Hollywood offers sub-acute treatment for individuals suffering from mental health, addiction, and other co-occurring disorders in Los Angeles, California. Harmony provides mental health and addiction treatment services to consumers covered under health insurance plans sold or administered by UBH.

PsychU last reported on this topic in “Four Provider Organizations File $40 Million Lawsuit Against BCBS Of Michigan For Underpayment Of Out-Of-Network Addiction Treatment Claims,” which published on September 30, 2019. The article is available at https://www.psychu.org/four-provider-organizations-file-40-million-lawsuit-against-bcbs-of-michigan-for-underpayment-of-out-of-network-addiction-treatment-claims/.

For more information about the plaintiffs’ claims, contact: Napoli Shkolnik, PLLC, 360 Lexington Avenue, 11th Floor, New York, New York 10017; Email: info@napolilaw.com; Website: https://www.napolilaw.com/

For UBH, contact: Maria Gordon Shydlo, Media Contact for Employer & Individual, United Healthcare, Post Office Box 1459, Minneapolis, Minnesota 55440-1459; 612-486-4361; Email: maria_g_shydlo@uhc.com; Website: https://www.unitedhealthgroup.com/

On October 1, 2019, the Alabama Medicaid Agency implemented the Alabama Coordinated Health Network (ACHN) to replace its Medicaid health home program and three other care coordination programs. The ACHN is a single care coordination delivery system intended to link consumers, primary care physician (PCP) groups, and community resources in each of seven newly-defined regions. In this new program, the regional networks and PCP groups are incentivized to achieve quality goals in the areas of childhood obesity, infant mortality rates, and addiction disorders. The ACHN does not change Medicaid benefits, and delivery of medical services is not the program focus. The state will continue to pay provider organizations directly. The goal is to improve the quality of care provided to Medicaid recipients, and to drive better health outcomes.

The ACHN will serve approximately 750,000 Alabama Medicaid recipients. The ACHN is for full-benefit, non-institutionalized children, pregnant women, and aged/blind/disabled beneficiaries in the Patient 1st population, maternity care population, and Plan First (family planning) population. Excluded populations include people dually eligible for Medicare and Medicaid, those in an institutional setting (including prison or jail), those enrolled in the state’s home- and community-based services waiver, children in custody of the Department of Youth Services, and people using hospice services.

Previously, Alabama operated four programs that each included care coordination functions. For the ACHN, the state selected seven primary care case management entities (PCCM-Es) in April 2019 to manage regional care coordination in the new regions. The aggregate value of the first-year PCCM-E contracts is about $40.9 million; the maximum contract values for each of the seven regions range from $5.5 million to $6.6 million. The PCCM-Es are as follows:

  • My Care Alabama for three regions: Northwest, Central, and East.
  • Alabama Care Network for two regions: Midstate and Southeast.
  • North Alabama Community Care for the Northeast region.
  • Gulf Coast Total Care for the Southwest region.

Participating PCPs will qualify for Participation Rates (enhanced payments for certain services) and bonus payments. To be eligible for these enhanced rates and bonus payments, the PCPs must also do the following:

  • Actively participate with the network entity in developing individualized and comprehensive care plans
  • Participate in the ACHN entity’s Multi-Disciplinary Care Team
  • Participate in program initiatives centered around quality measures, reviewing data provided by the ACHN entity to help achieve state and region quality goals
  • Participate in person in at least two quarterly medical management meetings and one webinar/facilitation exercise with the ACHN entity’s medical director over a 12-month period

In year one, all PCPs working toward patient centered medical home (PCMH) recognition will receive a bonus payment. In year two, all PCPs who have achieved PCMH recognition at any level will continue to receive the bonus payment.

Cost effectiveness bonus rates will be calculated to reward PCPs who control costs. Bonus participation is based on the risk-adjusted, average monthly cost of members attributed to the PCP provider organization group when compared to other similar PCP provider organization groups. Members who do not receive services are excluded from the calculation. Bonuses for improving quality will be awarded based on the achievement of certain scores on nationally recognized quality metrics.

Members will be attributed to the PCP based on the members’ primary care utilization over the past two years. This review will include preventative and regular office visits along with prescriptions for chronic care. A score will be calculated for each member/PCP combination. More recent claims and preventive care visits will receive higher values. The member will be attributed to the PCP with the highest score. Attribution will be updated quarterly.

PCP groups were required to complete an ACHN enrollment agreement with the Alabama Medicaid Agency before July 1, 2019 to avoid any delay in receiving ACHN bonus and participation payments. Care coordination referrals may be requested by provider organizations, recipients, or community sources. The care coordination services can be provided in a setting of the recipient’s choice to include provider organization offices, hospitals, ACHN-entity offices, public locations, or in the recipient’s home. Federally Qualified Health Clinics and Rural Health Clinics can participate in the regional AHCNs. If FQHCs and RHCs contract with their regional PCCM-E, their PCPs will also be eligible for bonus payments based on quality, cost effectiveness, and Patient Centered Medical Home (PCMH) recognition. Participating in the ACHN will not affect the prospective payment system reimbursement for FQHCs and RHCs.

PsychU last reported on this topic in “Alabama Medicaid Awards Contracts For Alabama Coordinated Health Network,” which published on July 8, 2019. The article is available at https://www.psychu.org/alabama-medicaid-awards-contracts-for-alabama-coordinated-health-network/.

For more information, contact: Melanie Cleveland, Communications Director, Alabama Medicaid Agency, 501 Dexter Avenue, Montgomery, Alabama 36104; 334-353-9363; Email: Melanie.cleveland@medicaid.alabama.gov; Website: https://medicaid.alabama.gov/content/5.0_Managed_Care/default.aspx.

More than half of physicians (53.8%) participated in an accountable care organization (ACO) during 2018, up from 44.0% in 2016. Of those physicians that participated in an ACO, 38.2% of participated in a Medicare ACO in 2018, 26.3% participated in a Medicaid ACO, and 39.0% participated in a commercial ACO. A subset participated in two or three ACO types. 31.9% worked in a practice that belonged to a medical home.

These findings were reported in “Policy Research Perspectives: Payment and Delivery in 2018: Participation in Medical Homes and Accountable Care Organizations on the Rise While Fee-for-Service Revenue Remains Stable” by Apoorva Rama for the American Medical Association (AMA). Ms. Rama analyzed 2012 through 2018 data from the American Medical Association’s (AMA) Physician Practice Benchmark Surveys. These surveys contain physician-level data on involvement with various care delivery models and payment methods. The goal was to determine physician involvement in ACOs, fee-for-service (FFS), and alternative payment methods (APMs). APMs included pay-for-performance, bundled payments, shared savings, and capitation.

Additional findings include:

  1. Among physicians in solo practices, 11.1% belonged to a medical home; 22.6% belonged to a Medicare ACO; 14.6% belonged to a Medicaid ACO; and 27.2% belonged to a commercial ACO.
  2. Participation rates for each ACO model were between 6 and 14 percentage points higher for physicians in single specialty practices compared to solo practices.
  3. Participation in medical homes and ACOs was 26 percentage points higher among physicians in practices that had at least some primary care physicians (40.8%), compared to those in practices without any primary care physicians (14.5%).
  4. Approximately 63.1% of physicians worked in practices that received at least some revenue from an APM.
  5. About 43.1% of physicians were unaware of their practice’s participation in at least one of the three ACO types (Medicaid ACOs, commercial ACOs, or Medicare ACOs).
  6. An average of 70% of practice revenue came from FFS, while only 30% came from APMs.

The full text of “Policy Research Perspectives: Payment and Delivery in 2018: Participation in Medical Homes and Accountable Care Organizations on the Rise While Fee-for-Service Revenue Remains Stable” was published in September 2019 by the American Medical Association. A copy is available online at https://www.ama-assn.org/system/files/2019-09/prp-care-delivery-payment-models-2018.pdf (accessed October 14, 2019).

PsychU last reported on this topic in “71% Of Physician Practice Revenue In Fee-For-Service,” which published on February 21, 2018. The article is available at https://www.psychu.org/71-physician-practice-revenue-fee-service/.

For more information, contact: Carol Kane, Director of Economic and Health Policy Research, American Medical Association, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885; 312-464-4819; Email: carol.kane@ama-assn.org; Website: https://www.ama-assn.org/

While most executive teams focus planning time on ‘the next big thing’ to position their organizations for the future (see Coming Up With The Next Big Thing, that future is dependent on having a better bottom line for investment. Revenue cycle management is critical to that bottom line to make sure your organization is paid for every eligible service it delivers. Learning how to “beef up” reimbursement was the focus of the “Executive Strategies To Optimize Reimbursement In A Changing Marketplace” session led by Matthew Zabolotny, Netsmart’s Vice President/General Manager of Revenue Cycle Practice during the 2019 OPEN MINDS Executive Leadership Retreat.

How does revenue cycle management help you optimize performance and margins with your current services? It is the process for capturing consumer service revenue, a process that extends from the “first contact” with consumers, such as appointment scheduling and eligibility determination to point-of-service and service authorizations through service coding, billing, and collections (see Have You Mastered These 4 Financial Management Skills For VBR?). Mr. Zabolotny discussed three key elements for ensuring success with service revenue collections: The right people, real-time information for eligibility determinations and service authorizations, and a data-driven approach to managing claims denials.

Right people today, right people tomorrow: No matter what tools provider organizations invest in for revenue cycle management, they all need people who can use those tools effectively and understand the billing and collections process. And, due to high turnover rates for experienced billing team members, Mr. Zabolotny discussed the importance of creative incentive plans and the ability to scale up capacity with contract help when needed. Organizations that want to maximize their investments in revenue cycle management need to start with staffing plans that include better training, incentives, and/or outsourcing.

Eligibility verification and service authorizations in real time: One big factor in improving collections is improving the care authorization process. More than 25% of denied claims stem from authorization issues – making processes for real-time benefit eligibility verification an essential ingredient for success. Mr. Zabolotny also discussed the need to structure (and frequently update) processes and information about the prior authorization process for each payer including benefit coverage and medical necessity documentation requirements.

Data-driven management of claims denials: The key to managing claims denial rates is to prevent claims denials. While a speedy and reactive approach to responding to each denied claim is essential, the ‘big win’ comes with using data to improve the process. Having data to understand which claims are denied and why helps your organization continuously improve its revenue cycle management process.

As provider organization executives look to the future, optimizing revenue cycle management in the here and now can improve margins – and support the resources needed for future growth. For more on improving service revenue collections, check out these resources in the OPEN MINDS Industry Library:

  1. Have You Mastered These 4 Financial Management Skills For VBR?
  2. The Coordination Of Benefits Issue: A Sticky Wicket For Some

Blue Shield of California Promise Health Plan and L.A. Care Health Plan are planning to invest $146 million in expanding Community Resource Centers (CRC) in Los Angeles County, California. The program is part of a five-year commitment to expand CRCs across the county. Currently, the health plans operate seven CRCs and at full expansion, they will jointly operate 14. The expansion plans call for L.A. Care and Blue Shield Promise to jointly open seven new CRCs, remodel four existing centers, and relocate three other existing CRCs to larger locations.

The CRCs will connect members from both Blue Shield Promise and L.A. Care health plans, and the Los Angeles community, to classes and personalized services that foster community connections, address social needs, and keep them active, healthy, and informed. CRCs offer:

  • Fitness and health education classes
  • Preventive health, training and screenings
  • Nutrition and healthy cooking classes, and a registered dietitian onsite
  • Social service assistance (housing, financial literacy, food insecurity)
  • Support groups
  • On site Department of Public Social Services worker

The new CRCs will continue to offer services that are currently available at existing locations, as well as new services for health plan members such as telehealth, digital applications support, and care management. The centers will provide previously-offered preventative health screenings and new on-site care management for health plan members. The centers will also offer on-site support from community social service organizations focused on addressing social needs of health, such as food and income insecurity. Child care is offered at no cost to ensure that parents in each community can take full advantage of the classes.

L.A. Care currently serves approximately 2.2 million members in four product lines, one of which (Medi-Cal) is contracted with Blue Shield of California Promise Health Plan. Each new center will serve approximately 72,000 people per year when services and staff are fully built out, serving more than one million Angelenos annually. Both L.A. Care and Blue Shield Promise will have staff at the CRCs. Additionally, local community-based organizations will be invited to provide social services support as appropriate. Services and free classes, such as Zumba and Pilates, will be offered to the community. Members can be referred by a physician, but it is not a requirement in order to attend.

For more information, contact:

  • Kellie Todd Griffin, Senior Director, Community and Provider Engagement, Blue Shield of California Promise Health Plan, 601 Potrero Grande Drive, Monterey Park, California 91755; 800-605-2556; Email: Kellie.ToddGriffin@blueshieldca.com; Website: https://www.blueshieldca.com/promise/
  • Francisco Oaxaca, Senior Director, Communications and Community Relations, L.A. Care Health Plan, 1055 7th Street, Los Angeles, California 90017; 213-694-1250; Email: foaxaca@lacare.org; Website: https://www.lacare.org/.

On September 17, 2019, The Alliance for Addiction Payment Reform (Alliance) announced value-based pilot projects underway in five states and Washington D.C. One of the first projects includes a statewide rollout in North Carolina of Eleanor Health, a new integrated health provider organization that treats addiction disorders with a “whole-person” approach, and manages addition as a chronic disease.

On September 4, 2019, Eleanor Health announced its first location in Mooresville, North Carolina. Additional sites will open first in North Carolina, and then at yet-to-be-announced locations across other markets in the United States. Specific dates for these additional locations have not been announced; however, market expansion is planned during 2020.

Eleanor Health is a member of the Alliance and has committed to implementing a related value-based payment program built from principles within the Addiction Recover Medical Home – Alternative Payment Model (ARMH-APM). A spokesperson for the Alliance said the additional projects are being developed by other Alliance members—Anthem, Superior Health Plans, Amerihealth Caritas, and Select Health. Each is exploring projects that would launch in late 2019 or early 2020.

The ARMH-APM elements address payment, quality measures, integrated care, long-term recovery, and treatment and recovery planning. The goal is to holistically address the clinical and non-clinical factors of managing addiction and recovery.

The Eleanor Health treatment model starts with an initial meeting between the consumer and the organization’s clinical professionals, therapists, and community recovery partners. The team will develop a personalized “whole-person” treatment plan, specific to the needs of the individual. Treatment plans will include a combination of medical services, individual and group therapy, and community-based support services. Comprehensive treatment support will be offered in-person and via treatment technology, including medication assisted treatment (MAT) for opioid use disorder and other addiction disorders. The length of treatment will depend on the needs of the individual.

The payment model uses a blend of capitation/bundled payments to reward the provider organization for its performance on recovery-linked quality measures. The capitated/bundled payments support the provision of more integrated and personalized care. A portion of the capitated/bundled payment is tied to achievement of successful consumer outcomes. The provider organization may be eligible to share in additional savings created from better coordinating care across all health care services, including addiction, behavioral, and physical services.

Eleanor Health launched operations on September 4, 2019, in North Carolina. The company is led by Corbin Petro as chief executive officer; Ms. Petro co-founded Eleanor Health with the assistance of venture capital investment firms Oxeon and Town Hall Ventures. Mosaic Health Solutions, a subsidiary of Blue Cross and Blue Shield of North Carolina (Blue Cross NC) invested in Eleanor Health in a July 2019 funding round. Blue Cross NC is also collaborating with Eleanor Health to expand access to Eleanor Health’s comprehensive treatment services.

The Alliance is comprised of dozens of health care institutions and professionals. The Alliance developed a value-based alternative payment model, the ARMH-APM, to establish a structure that promotes the type of integration and consumer care capable of producing improved outcomes for consumers, payers, and health systems long-term by aligning all incentives. The 2018 ARMH-APM was initially developed by a multi-sector process convened by Leavitt Partners, Facing Addiction with the National Council on Alcoholism and Drug Dependence, Inc. (NCADD), and Third Horizon Strategies. In 2019, Third Horizon Strategies continued to manage the work on behalf of the Alliance and released an updated paper coinciding with the announcement of pilot explorations of the model in local markets.

The full text of the “Addiction Recovery Medical Home – Alternative Payment Model” 2019 update was released on September 24, 2019. A copy is available online at https://www.incentivizerecovery.org/ (accessed September 17, 2019).

PsychU last reported on this topic in “New Health Care Alliance Launches Addiction Medical Home Model,” which published on November 26, 2018. The article is available at https://www.psychu.org/new-health-care-alliance-launches-addiction-medical-home-model/.

For more information about the Alliance for Addiction Payment Reform, contact: Greg Williams, Managing Director, Alliance for Addiction Payment Reform; Third Horizon Strategies, 444 North Michigan Avenue, Chicago, Illinois 60611; 312-374-8934; Email: greg@thirdhorizonstrategies.com; Website: https://www.incentivizerecovery.org/.

During the 2019 OPEN MINDS Executive Leadership Retreat in Gettysburg, they discussed the was struck by the many challenges that health and human service organization executive teams face in building the organizational size and scale needed for success. Most often, the discussion focuses on getting more “revenue”—almost all discussions of scale are posed in terms of revenue. But to make that revenue growth happen, there is also the parallel challenge of building the administrative infrastructure needed to support the scale—human resources, financial, marketing, technology, regulatory compliance, and more.

One option in a high-change, high-growth environment is for those executive teams to consider using outsourcing to build capacity in non-core service areas, allowing them to focus on building more service revenue. How to consider the outsourcing option and make it happen was the focus of Hope Winkowski, Vice President of Product Services at Credible Behavioral Health Software, in her presentation Opting To Outsource: An Executive’s Guide To Identifying, Selecting & Managing A Vendor For Outsourced Services.

First, provider organization executive teams need teed to consider the pros and cons to outsourcing. Positives include cost saving opportunities, better efficiency, greater operations transparency, an easy way to “adopt” best practices, and keeping organizational focus on core competencies. But there are a few downsides that need to be kept in mind. There is the issue of control and customization. And, there can be liability issues (which party is “responsible” when something goes wrong) and likely higher costs.

What should you look for when outsourcing services and how do you make your decision? Ms. Winkowski recommends using a request-for-proposal (RFP) process. The RFP should include expected performance metrics, clarify any shared risk, establish communication expectations, and establish criteria for terminating the outsourcing relationship. The RFP process—the response, presentations, and negotiations—will provide an opportunity to negotiate costs, confirm all service delivery assumptions, and provide insights into the vendors’ processes..

Outsourcing is a potential tool for rapid growth and achieving operational scale. Executive teams should consider the many outsourcing options as part of their strategic growth plans. For more on outsourcing and vendor selection, check out these resources from The PsychU Resource Library:

  1. A Chaotic Environment Demands Fluid Strategic Planning
  2. Building Your Foundation & Your Castle
  3. What Should Your Organization Be Spending On Tech?

On September 3, 2019, UCHealth in Colorado announced plans to invest at least $100 million over five years to enhance its behavioral health services. As part of this effort, within six months, UCHealth plans to launch virtual behavioral health services in its emergency departments. Within the next year, UCHealth anticipates collocating behavioral health workers in pilot primary care locations.

A key goal of the investments is to provide earlier detection and treatment for consumers with addiction and mood disorders, and increase access to new addiction treatment services. UCHealth intends to remove barriers by providing the right care at the right time. The funding will be used for the following three initiatives:

  • Integrating behavioral health with primary care: Teams of licensed clinical social workers and psychologists will work hand-in-hand with primary care physicians to provide immediate resources to the largest number of consumers in need.
  • Tele-behavioral health consultation services: When consumers and clinical professionals in emergency departments, primary care clinics, or inpatient hospitals need consultations with a psychiatrist, UCHealth’s Virtual Health Center will provide the video connection.
  • A new inpatient behavioral health unit: The expansion of the University of Colorado Hospital will enable a new inpatient behavioral health unit to expand the services already available in other UCHealth locations. The new inpatient behavioral health unit will likely open in late 2023.

For more information, contact: Dan Weaver, Vice President, Communications, UCHealth University of Colorado Hospital, 12605 East 16th Avenue, Aurora, Colorado 80045; 720-848-7852; Email: dan.weaver@uchealth.org; Website: https://www.uchealth.org/

When you ask about the state of payer/provider organization partnerships—with innovative programming and value-based reimbursement (VBR)—executives on both sides of the equation say there is more talk than action. Yet several examples of success were shared during The Innovative Treatment Programs For Value-Based Partnerships: An OPEN MINDS Summit. Executives who attended this first summit, held two weeks ago at The 2019 OPEN MINDS Executive Leadership Retreat, learned firsthand from executives who are making these partnership work:

  • Marie Wenzel, PEACE Program Director of Horizon House, developed early psychosis intervention services paid with a bundled rate in partnership with a payer.
  • Andrew F. Vitullo, Vice President of Development of Kolmac Outpatient Recovery, which provides an outpatient addiction treatment detoxification and rehabilitation program using a bundled payment.
  • Brandi Phillips, Chief Executive Officer of Allegheny HealthChoices, is private non-profit that performs oversight of a local Medicaid behavioral health managed care program that uses alternative payment models to fund ACT services.
  • Lee Anne Langhurst, Vice President, Account Management at Talkspace and Kathleen Mahieu, Lead Business Consultant for Strategy & Innovation for Aetna Behavioral Health, providing a virtual behavioral health service for Aetna members.

Throughout the day of detailed discussion, there were three common elements to the successful payer/provider organization partnerships—bringing innovative program ideas to payers that answer some very specific questions; having a plan to take pilot programs to scale; and doing what is needed to create a true partnership.

Think big and bring innovative program ideas to payers that answer some very specific questions

One key element in making payer/provider organization partnerships work is innovation paired with data. Payers are looking for innovations that increase their value, which means addressing issues like consumer access, tracking key performance metrics, accepting VBR, and managing across the health and human service continuum.

All the provider organization executives presented impressive performance data, which was a key component to partnering with payers. I touched base with Ken Carr, Senior Associate, OPEN MINDS, after the event and he emphasized the value of payer and provider organization representatives working collaboratively to innovate new approaches to care, agree on how success will be measured, and deliver services in consumer-centric ways.

Mr. Carr added that while networking is critical to getting a foot in the door with health plans, provider organization representatives need to do two things: Identify the person highest up at the organization you can talk to and have the data to “prove” your solution works.

All of the provider organization executives presented impressive performance data. Ms. Wenzel illustrated the value of data to moving to a value-based reimbursement model for PEACE. Initially, her organization wasn’t positioned to do this. But, they are systematically measuring performance – measures like their 80% decrease in number of participants hospitalized at 6-month follow-up; their 88% decrease in hospital days at 6-month follow-up; and consumer employment rates increased by 133% at 12-month made that possible.

Ms. Wenzel noted: “To build those relationships, you have to know who to talk to and have the meat and potatoes to show that you are really doing this. Also, define everything for yourself. If we have something that is proven to work, that takes the burden off the managed care organization to define things.”

Have a plan to bring the innovative program to scale

Often the only way in the health plan door is to conduct a “pilot” of an innovative treatment program for a health plan. But often, those pilots are not profitable —getting “to scale” is often a key to sustainability.

On the health plan side, a service delivery network model that can incorporate innovative programming with alternative reimbursement models is necessary. On the provider organization side, having an innovative program with a defined clinical model driven by decision support tools, as well as an administrative model that can grow with volume, is necessary.

Mr. Vitullo noted: “Payer organizations aren’t afraid to think big. They see the need for best practices to expand. Understand what your service delivery is and understand if it is replicable. How do you quantify the outcomes, how do you track it, and how do you agree on it with your payer-partner?”

Do what is needed to create a relationship that is a partnership

Finally, to make partnerships work in the long run, creating the framework for a partnership is key. Mr. Vitullo spoke of the need to start with aligned incentives – the consumer, the payer, and the provider organization.

Ms. Mahieu spoke to the period when Aetna Behavioral Health began talks to partner with Talkspace, Aetna came to the table with a key question—when you are approached every day with a new solution by a new potential partner, what is actually valuable to their members and what solves the problems you are trying to address? Talkspace’s value includes reaching 70% of consumers who reported they wouldn’t have sought face-to-face services, and a 50-57% symptom reduction in depression or anxiety after 3 months.

Ms. Mahieu also noted, “As we investigate the new solutions and partners, they all sound great. One of the key challenges is to determine how they work together to support our members across the continuum of care. How do we create the right ecosystem so that they all make sense to the member? We don’t all know the answers so we value our strong partnerships so we can solve it together.”

If the future of health and human services is value-based, then the future requires a different relationship between health plans and the provider organizations serving their members – a relationship based on partnership. For provider organization executives who see these relationships in their future, innovation, performance metrics, scalability, and new account management model are minimum requirements for success.

Over the years, we’ve written about the federal Certified Community Behavioral Health Clinic (CCBHC) initiative (see CCBHCs Are Moving Forward – What This Means If Your State Isn’t Moving Forward, Are You Ready To Be A Certified Community Behavioral Health Center?, CCBHCs In 8 States Projected To Serve 380,000 Individuals In First Year). And this summer, the demonstration was slated to end, leaving states, Congress, and provider organizations scurrying to figure out what to do next. So where are states now and what does the future look like?

As a reminder, CCBHCs are behavioral health provider organizations that receive a prospective payment rate for delivering care in return for meeting six key criteria related to staffing mix; service access and availability; coordination of services; scope of services; quality improvement and reporting; organizational, authority, governance, and accreditation. In order to help states prepare for the demonstration, planning grants were awarded to 24 states in 2015 and then eight states were selected to actually participate in the demonstration. Those states are Minnesota, Missouri, Nevada, New York, New Jersey, Oklahoma, Oregon, and Pennsylvania.

Technically, the demonstration ended on June 30, 2019 after two years. In August, Congress extended funding for the demonstration to September 13, 2019, and in September the Senate cleared a short-term spending bill that includes an extension of the CCBHC until November 21. Continued funding for the program is included in the President’s budget and is expected to have bipartisan support.

Regardless of the decisions at the federal level, six of the eight states are committed to continuing to fund the program. Only Pennsylvania and New Jersey are awaiting federal funding to make their decision to continue the program. In order to continue the demonstration, most states are submitting state plan amendments (SPA) to the Centers for Medicaid & Medicare Services (CMS).

  1. Minnesota- Continued payment for the CCBHC program was included in the state’s 1115 demonstration waiver approved in June 2019. The approval is for one year in order to allow the state to submit the necessary SPAs and documentation to continue the program (see Minnesota Medicaid To Expand Addiction Treatment Via CCBHCs & Short-Term Residential Treatment Benefit).
  2. Missouri – In June, the state received approval of their SPA to continue the CCBHC program (see Missouri Medicaid To Continue Prospective Payments To 15 CCBHOs).
  3. Nevada – The state plans to continue paying a bundled rate for services and will certify seven additional clinics. Until the SPA is approved, the three clinics will receive about 75% of their average monthly billing.
  4. New York – Official documents on the continuation of the program is not available, however the state is expected to submit a state plan amendment.
  5. Oklahoma – CMS approved Oklahoma’s SPA to continue the CCBHC program on July 1, 2019. The state plans to certify new CCBHCs.
  6. Oregon – The state has indicated that they plan to submit a SPA right.

Overall, the fact that six states are planning to permanently continue to the CCBHC program is promising. It indicates that they are committed to new model for delivering and financing behavioral health services. For provider organizations, who do not serve these states, the results of the demonstration are still relevant. CCBHCs really serve as a model for the future, the key competencies required of the organizations include the adoption of technology, tracking of outcomes, new financing models, and coordination of services. Organizations can use the CCBHC model as a benchmark for their organization and as a model for developing core competencies for operating in a value-based environment.

As the primary care industry moves toward value-based payment (VBP), primary care practices participating in risk-based models will need additional staff who offer a richer skill mix. The additional skills include consumer education, care planning and coordination of care, as well as support for community services to meet needs of consumers with complex health and behavioral health conditions. Pharmacists, behavioral health professionals, nutritionists, and social workers may be needed to support community services. As a result, a practice participating in a risk-based model could need registered nurses (RNs), licensed practical nurses (LPNs), medical assistants (MAs), behavioral health social workers, nutritionists, and pharmacists.

Currently, fee-for-service (FFS) practices rely on RNs, LPNs, and MAs. The majority of practices, (54%) are staffed with a combination of nurses (either RNs only or LPNs only), plus MAs. About 24% of practices are staffed with all three current staff types including RNs, LPNs, and MAs. About 22% use an MA-only staffing model.

These findings were reported in “Optimizing Primary Care Model Design to Improve Performance” by researchers with Premier Inc. The researchers analyzed Premier’s database of physician practice information, which includes more than 30,000 clinical professionals. They benchmarked 2018 data from 257 family medicine and primary care practices comprised of more than 885 physicians and 1,445 staff. The report noted that for most of the practices, FFS revenue represents the majority of revenue. However, the report did not split out results by level of FFS revenue or risk-based revenue. The goal of studying current staffing models was to gain insight on how clinical staffing variation can help physician practices design the most effective staffing model.

Supported by the data gathered from the physician practice database, Premier made the following observations about aligning primary care practice staffing and effectiveness with payment model design.

  • Physician practices should understand where they are on the journey to value-based care and be intentional about moving toward staffing models that will support that path, such as leveraging staff in relation to volume. Value-based arrangements require specific clinical, technical, and administrative capabilities; as primary care practices move further along the value chain, they will likely need a higher level of staff skill mix to support more proactive coordination of care for consumers.
  • Consumer education, care planning, and coordination of care for the highly complex or vulnerable populations will further improve efficiency and effectiveness in a VBP model.
  • Provider organizations that are not interested in participating in VBP, or other advanced models of care, may want to reconsider their staffing models if they currently have staff with a richer skill mix (RNs and LPNs) since this model may only be contributing to higher practice expense and ineffective use of resources relative to licensed staff.
  • The MA-only staffing model may be the most practical and cost-effective option for primary care provider organizations intending to remain in FFS. Compared to nurses, MAs have similar productivity, but have lower wage costs.

Productivity of the current primary care staffing models was measured in terms of work relative value units (wRVUs) associated with each medical code. RVUs are set by the Centers for Medicare & Medicaid Services (CMS). The value is based on how much effort CMS believes is required to perform a service. In the current FFS practice models, wRVUs were very similar for the three staffing models, as follows:

  • The wRVUs for the MA-only model averaged 4,763 per professional.
  • The wRVUs for the nurse (RN or LPN) plus MA model averaged 4,536 per professional.
  • The wRVUs for the RN, LPN, and MA model averaged 4,786 per professional.

The researchers concluded that the staff skill mix was not a determining factor in overall professional productivity in the three models. Further, clinics with MA-only models and comparable staff to physician clinical full-time equivalent (CFTE) ratios were just as likely to achieve top quartile performance as higher skill mix models inclusive of RNs. The highest performing clinics (in terms of productivity) had more numbers of support staff per physician CFTE than clinics in the bottom quartile. The overall staff cost per wRVU falls as the practices achieve economies of scale.

  • The RN, LPN, and MA model in the top quartile had 2.4 staff per physician CFTE at a cost of $17 per wRVU, compared to 1.7 at a cost of $23 per wRVU in the bottom quartile
  • The RN or LPN plus MA model in the top quartile had 2.2 staff per physician CFTE at a cost of $13 per wRVU, compared to 1.7 at a cost of $31 per wRVU in the bottom quartile.
  • The MA model in the top quartile had 1.8 staff per physician CFTE at a cost of $9 per wRVU, compared to 1.3 at a cost of $18 per wRVU in the bottom quartile.

The researchers concluded that movement towards value-based payment requires primary care provider organizations to consider alternative care delivery and payment model options. They said that primary care provider organizations will need to methodically adjust their staffing models to include staff with a richer skill set that can support a more coordinated model of care. The researchers concluded that a richer skill mix is a cost-effective option in the shift to value-based payment.

The full text of “Optimizing Primary Care Model Design to Improve Performance” was published in August 2019 by Premier Inc. A copy is available online at http://offers.premierinc.com/2019-08-WC-PH-PES-WP_Landing-Page.html?utm_source=pinc&utm_medium=public_relations&utm_content=whitepaper&utm_campaign=WC_2019_08_PH_PES_Whitepaper (accessed September 20, 2019).

For more information, contact: Morgan Guthrie, Media Contact, Premier, Inc., 13034 Ballantyne Corporate Place, Charlotte, North Carolina 28277; 212-901-1356; Email: Morgan_Guthrie@PremierInc.com; Website: https://www.premierinc.com/.

What a week at the 2019 OPEN MINDS Executive Leadership Retreat! They covered a lot about the challenges of value-based reimbursement (VBR) to non-profit board governance, the rising proportion of chief executive officers (CEO) of specialty provider organization executives getting ready to retire, the challenges of bringing trauma-informed care to scale, and much more. And, in a sense, these topics were the focus of Monica Oss’s closing keynote, The Complexity Leadership Challenge: How To Prepare Your Organization—& Yourself—For Success In A New Era. Ms. Oss reviewed the structural changes shaping the field, the implications for strategy, and how best to position specialty provider organizations for the future. And, then she asked the audience the question—how prepared are they as executives to lead this change?

The challenge is that many fundamentals—the business models for behavioral health and primary care, reimbursement models, consumerism, and technology—are in motion. What is obvious is that most organizations will need new service lines and new market positioning for long-term sustainability.

While the specifics of that new market positioning will vary based on the consumers served and their service needs, the successful sustainable services will be the services with the highest value equation. Those services will most likely be community-based, tech-enabled, and consumer-centric. And the design, delivery, and management of those services will be driven by performance metrics, with performance defined by payer, health plan, and consumer customers.”

We’ve written a lot about how to plan for this “big leap” in market positioning. Essentials include a new approach to organizational strategy for sustainability and a rigorous approach to strategy implementation (see Coming Up With The Next Big Thing and Adjust Your Strategic Sails!). But, having the plan and preparing the organization for a successful evolution is only part of what is required. I’m a big believer in the Peter Drucker observation, “Strategy is a commodity and execution is an art.” The question for every executive is: are you also prepared to provide the strategic leadership needed for this transitional phase of your organization’s existence?

Strategic leadership is defined as the ability to handle complex problems for which there is no obvious short-term solution. While most executives in the health and human service field got to their current positions because of great transaction leadership skills success in the new environment requires new leadership talents. Strategic leadership—the ability to transform organizations in a complex environment—is key.

The good news is that strategic leadership can be learned and improved. Executives can practice the strategic leadership—and build their strategic leadership “muscle.” This is based on the concept of neuroplasticity, in which the brain can change, and self-directed neuroplasticity, or that we can make brain changes happen.

Ms. Oss find that practiced and disciplined behavior, meditation, mindfulness, and visualization are keys to building your leadership skills. The issue for executives is how assess where they are with core strategic leadership practices and if they want to put in the hard work to move their leadership skills from the transactional to the transformational. If the answer is yes, there are some specific actions in decision making and management that can enhance their strategic leadership skill set.

The fate of many organizations in the field will rise or fall based on the strategic leadership skills of their executive teams. Keep in mind the adage of Malcolm Forbes, “An organization can never rise above its leader.” For more on leadership topics, check out these articles and presentations in the PsychU Resource Library:

  1. Are You A Change Agent Leader? Take The Test
  2. The Complexity Challenge Keeping You Up At Night? Former Execs Advise. . .
  3. Long-Distance Leadership
  4. Staff Not Performing? What Does That Mean?

At the 2019 OPEN MINDS Executive Leadership Retreat Ray Wolfe J.D. and George Braunstein, Senior Associates at OPEN MINDS, presented a seminar on Aligning Non-Profit Health & Health Human Service Boards for Sustainability With The New Market Landscape.

For governing boards of provider organizations, new reimbursement models can be challenging. This is especially true considering a third of non-profit board members are unsatisfied with how the board evaluates organizational performance, and over a quarter of board directors believe their fellow associates lack an understanding of the organizational mission and strategic plan. For a provider organization to meet change successfully, the board members, structures, and operations must align with the organization’s mission—either the old mission, or a VBR-defined mission.

The board must be more educated and do more evaluation, in terms of financing and risk. For education, board members must understand the changing reimbursement models and obtain the necessary skills to support an organization with a VBR model. And for evaluation, the board needs to do more in planning and evaluating itself in terms of the skills that are required for optimal functioning, the expectations of commitment from each member, and the overall processes of the board, with feedback provided as needed.

Historically, the role of board members hasn’t focused on the challenges of managing financial risk and variable revenue streams. Mr. Wolfe discussed how traditional boards operate with a few very active members meeting at a regular time, often two or three months apart. This is not effective in a value-based world where the financial issues can change unexpectedly, and timely judgment calls are necessary. Put simply, traditional models of governance are not effective.

So, how does board governance need to change? Board members need an understanding of value-based reimbursement models and potential risk; they need a more operational understanding of how consumer care and coordination of services works; and they need different financial data.

Understanding value-based reimbursement models and potential risk—Board members must have an understanding of the changes in health care, different reimbursement models, and financing, particularly in the context of a value-based health care model. Boards must understand the coordination of services and care, how clinical professionals and provider organizations are paid based on consumer health outcomes, and how provider organizations are reimbursed for improved outcomes. Mr. Wolfe discussed:

A significant problem with board members is their lack of knowledge of a value-based reimbursement model as well as the changes in health care. As changes emerge when adopting these new models, this change places tension between the board and the organization. Models can have moderate risk to high risk, but how many board members have this understanding of health care financing? If board members don’t have that type of background or education, they need to have an expert or someone who is able to provide the support and advice on which contracts to sign, or not sign.

Operational understanding of consumer care and coordination of services—In the process of building a team for a governing board, a board should consist of a diverse group of individuals who are able to bring their different backgrounds and different perspectives together on the same issues. To best serve and understand what consumers truly need, the board needs to be composed of community leaders, social service and health care leaders, individuals and families who are directly impacted, and business leaders. But this should also be representative of the community—diverse in gender, ethnicity, and age. Mr. Wolfe discussed:

Consumerism is the driver of the shift to VBR. To truly understand consumerism, collaboration among individuals from diverse backgrounds is needed on the governing board. It’s not enough to just match a skill set to the board, it’s necessary to find the right people who are willing to have the education and the skill sets that are needed to fulfill the functions and the mission of the organization. Boards should be composed of family members who will be directly affected, persons in the community who can offer their perspective, and experts with specific clinical and business knowledge. A diverse group of board members can provide their unique skill sets along with their unique perspectives.

Financial data to measure organizational performance—For organizations that have shifted to value-based contracts, a shift also needs to occur from traditional reports. In the context of risk calculation and monitoring of income, traditional means of reporting are not able to provide the level of detail for VBR. For the governing board of a provider organization with a VBR model, “best practice” starts to look different. New skill sets are needed to support the changing reimbursement model including ensuring a quality assurance process is in place for measuring performance. This means embracing different techniques to identify and stratify risk, making informed decisions, and taking appropriate action based on the strategic analysis. Mr. Wolfe discussed:

The shift to a value-based contract isn’t just an incentive to do better, it shifts the risk onto the organization that is providing care. These levels of risk need to be analyzed for proper maintenance, which needs to be effectively conducted by the board members. Boards need to determine how much risk is on the company, and traditional means of analysis simply don’t provide enough detail when determining if there is too much risk on the company. The income statement and metrics are important, along with income monitoring. Contracts are written around the possibility that reductions are taken out, and then given back only if those performance outcomes are met; risk calculation has to be determined with a close monitoring of cash, 60 to 90 day cash projections, and an income statement broken down by value-based and non-value-based structures, as well as the metrics and impact of the metrics as they presently stand. Without this, it would essentially be impossible to successfully oversee the financial operations of the organization.

The key to sustainable success with VBR begins with organizational leadership, and this requires acceptance at the level of the governing board members. The modern health care board is changing with the shift to VBR, and the board requires a new set of unique perspectives and skill sets across the continuum of the health care system.

 Attributes of a good board member—A good starting point lies in the personality characteristics and attributes of the board members that are sought out during the recruitment process. This requires a focus on aligning the attributes of each board member to the mission and expectations of the organization and leadership. And it’s not just about matching specific skill sets to the board, it’s about finding the right people who are motivated and willing to build the necessary skills through education, which includes having the ability and willingness to see the changing market in new ways. Good board members should be motivated to preserve the mission; however, they should also know the difference between when to pursue it, and when to redefine it.

In the context of strategy, leaders have to embrace the change (and the risk) that comes with this constantly changing environment. Aligning this new strategy with board leadership and the changing reimbursement methods will be the ultimate driver in reaching optimal organizational performance.

Check out these resources from the PsychU Resource Library.

  1. Have You Mastered These 4 Financial Management Skills For VBR?
  2. The Strategic Challenges On The Road To Value-Based Reimbursement
  3. From An Extension Of Government Policy To Competitive Service Providers – The Strategy Evolution For Non-Profit Executives

On August 1, 2019, New York City launched “NYC Care”, a health care program to provide access to health care services for uninsured city residents. Enrollment in the Bronx began on August 1. All services are provided by NYC Health + Hospitals. NYC Care will be expanded city-wide by the end of 2020. At full-scale, the program will cost approximately $100 million annually.

NYC Care member benefits include:

  • Primary care, and members who are new to NYC Health + Hospitals will be able to secure a primary care appointment within two weeks of enrollment.
  • Mental health services and addiction treatment services.
  • A 24/7 customer assistance line where members can ask questions about NYC Care and speak to an on-call clinical professional for all of their needs, including prescription refills.
  • 24/7 access to medications in the Bronx. This includes expanded pharmacy hours at the five NYC Health + Hospitals pharmacies in the Bronx.

NYC Health + Hospital has a multi-pronged strategy to reach NYC Care-eligible residents, including partnerships with the New York City Mayor’s Office of Immigrant Affairs and New York City Mayor’s Fund to Advance New York City. NYC Health + Hospitals is also leveraging GetCoveredNYC’s existing outreach to uninsured New Yorkers in the Bronx to refer eligible people to NYC Care for enrollment. In addition, New Yorkers who apply for public health insurance through MetroPlus, and are found ineligible or are unable to afford any options, will be directed to NYC Care. The health system has contracted with five community-based organizations to facilitate outreach. These organizations will identify, recruit, and refer uninsured New Yorkers for screening and enrollment in NYC Care. The five organizations are BronxWorks, Emerald Isle, Northwest Bronx Community and Clergy Coalition, Mekong NYC, and Sauti Yetu Center for African Women.

For more information, contact:

  • Press Office, The Office of the New York City Mayor Bill de Blasio, City Hall, New York, New York 10007; Email: pressoffice@cityhall.nyc.gov; Website: https://www1.nyc.gov/office-of-the-mayor/index.page
  • Chris Miller, Media Contact, NYC Health+Hospitals, 125 Worth Street, New York, New York 10013; 347-396-4177; Email: PressOffice@health.nyc.gov; Website: https://www.nychealthandhospitals.org/.

On July 31, 2019, four Michigan addiction treatment centers sued Blue Cross Blue Shield of Michigan (BCBSM), alleging that they have been underpaid for their out-of-network claims for addiction treatment for Blue Cross Blue Shield (BCBS) commercial members. The four provider organizations are Serenity Point Recovery, Inc.; Forever Recovery; Behavioral Rehabilitation Services; and Best Drug Rehabilitation. The organizations allege that from April 2016 and forward, claims that were wrongfully denied, underpaid, or incorrectly processed by BCBSM total not less than $40 million. The plaintiffs requested a jury trial.

The case is the Serenity Point Recovery, Inc, et al. v. Blue Cross Blue Shield of Michigan (case number 19-cv-00620) in the U.S. District Court for the Western District of Michigan. The centers have no written agreement with BCBSM or any BCBS plan, although one of the plaintiffs, Best Drug Rehabilitation, joined BCBSM’s Traditional Network of participating provider organizations. The plaintiffs provide 1,000 beds for residential addiction and mental health treatment. The lawsuit involves claims related to at least 4,066 consumers purportedly covered by BCBSM. The plaintiffs alleged that each consumer who received or currently receives treatment at the plaintiffs’ facilities was asked to execute a notarized, durable power of attorney and endorse a separate assignment of benefits form to the respective facility. Based on these documents, the facilities claim the same rights as the health plan members to appeal, litigate, and receive payment under the health plan benefits.

The treatment centers allege that BCBSM failed to process their out-of-network claims and often rejected them even when the consumers were covered by an out-of-state BCBS “home plan,” other than BCBSM that explicitly provided benefits to be paid to out-of-network provider organizations. They further allege that BCBSM lacked staff, processes, and systems to accept claims for out-of-state members with out-of-network benefits and process them through the Blue Card program. As a result, the plaintiffs said, BCBSM simply denied the claims. After negotiation, BCBSM allegedly agreed to process claims submitted by mail. The plaintiffs said they were not permitted to submit claims electronically.

The treatment centers allege that between April and July 2016, BCBSM cut reimbursement for their daily inpatient rates from $900 per day to $150 per day. The plaintiffs asserted that in March 2017, BCBSM informed them that the lower rates were the standard “in-network rates” that would be paid, regardless of network status. Additionally, BCBSM allegedly told the plaintiffs that it would no longer reimburse at a per diem rate. Instead, the plaintiffs said BCBSM told them they would be required to submit unbundled billing for each service provided during the day. Further, the plaintiffs allege that some claims were wrongfully denied. After the reimbursements were cut, the treatment centers billed the consumers for the difference.

On August 26, 2019, BCBSM requested a pre-motion conference for the purpose of filing a motion to dismiss the lawsuit by the four nonparticipating out-of-network addiction treatment facilities in Michigan, which are commonly owned by Nevada-based U.S. Addiction Inc. BCBSM alleges that the claims are vague and flawed, in part because the plaintiffs do not identify a benefit plan or policy term that entitles them to the additional payments they seek. In a statement, BCBSM noted that U.S. Addiction Inc. bases its claims on alleged “assignments” of rights from consumers, which are not valid under BCBSM policies.

On August 29, 2019, the attorneys for the plaintiffs said that three of the four facilities are incorporated under Nevada law, but they are not owned by U.S. Addictions; the fourth facility is a Michigan corporation. They clarified that the claims are not brought under “assignment” but directly by the provider organization to which BCBSM has an independent duty. The claims under the Employee Retirement Income Security Act of 1974 (ERISA) are also not an “assignment,” but are brought under the health care power of attorney designations executed by the consumers treated by the plaintiff facilities.

For more information about the plaintiffs’ claims, contact: Napoli Shkolnik, PLLC, 360 Lexington Avenue, 11th Floor, New York, New York 10017; Email: info@napolilaw.com; Website: https://www.napolilaw.com/

For more information about BCBSM policies, contact: Blue Cross Blue Shield of Michigan, 600 East Lafayette Boulevard, Detroit, Michigan 48226-2927; 313-549-9884; Email: newsroom@bcbsm.com; Website: https://bcbsm.com/

The Oregon Department of Human Services (DHS) and the Family Independence Initiative (FII) launched a pilot project to support self-sufficiency among low-income families in Jefferson and Lincoln counties. Across the two counties, up to 900 families can participate. FII’s contract for the two new counties started in May 2019, and will expire on October 31, 2020.

The 12-month FII program consists of facilitated group meetings among small participant groups, and participant use of an online platform called UpTogether to support community building. The participating families can earn up to $800 over the course of the 12-month partnership. The goal is to reduce poverty in Oregon and stop the cycle of poverty for the next generation.

Funding is provided from a combination of DHS funding and grant funding procured by DHS. The total program budget is more than $1.4 million. About 65% of the pilot costs are covered by DHS SSP funds. The funds from DHS cover the cost of one full-time FII staff member who manages the pilot, and the DHS funds are used for direct cash investments in families. FII-National is contributing the remaining 35% of funding, which will be used to cover the direct project operation costs in Jefferson and Lincoln counties. FII contracted staff monitor the cohorts.

Families that are part of the DHS SSP Job Participation Incentive (JPI) will be invited to attend a FII information session. After attending the FII information session, families interested in participating in FII are asked to invite a small group of friends (up to six) to join them and form a cohort for a one-year engagement. These friends do not have to be part of the JPI, just members of the participant’s social network. In addition to in-person meetings, the cohort participants will use the UpTogether online platform to share strengths and build community so that the participants feel comfortable turning to their cohort for support and inspiration. The UpTogether platform also provides access to a journal platform for the participants to tell FII about the different initiatives the participant families are taking toward self-sufficiency to build their well-being. The journal platform also allows participants to provide mutual support to their personal cohort and to the wider FII UpTogether community. The goal is that the FII participants will serve as a resource for each other on how to manage their financial situations, health, education needs, and housing needs and challenges.

The FII program has two key objectives. Firstly, FII seeks the participants’ feedback on what does and does not work to deploy a strength-based approach to developing self-sufficiency. Secondly, FII seeks to identify trends around the initiatives families take to improve their lives, to learn how families prioritize goals for the adults and children in the household, to identify early signals in changes in the financial health of families, and to learn how families are supporting each other. FII will track these trends on a daily basis using UpTogether, and will report the trend findings to DHS quarterly. The report will discuss the collective and aggregate trends among the Jefferson and Lincoln county participants, and will discuss the participants’ progress.

More information about DHS interest in self-sufficiency programs was presented to the legislature in February 2019 in “Oregon DHS Presentation To The Human Services Subcommittee: Self-Sufficiency Programs Committed To Long-Term Success.” DHS provides a variety of programs and partnerships to build self-sufficiency. The presentation noted that, in most Oregon counties, a family of three with an income at 185% of the federal poverty level is not able to be self-sufficient.

In 2016, FII partnered with the Oregon DHS to test new ideas for self-sufficiency. The state was exploring a redesign of how it deployed Temporary Assistance for Needy Families (TANF) funds, with a long-term goal of transforming delivery of human services. FII operated a pilot during fiscal years 2017 and 2018 in Multnomah County, which encompasses the Portland metro area. The Multnomah County pilot enrolled more than 100 families across eight jurisdictions in the county. During the first project year, the participating families experienced a 26% increase in income and a 130% increase in assets.

A FII project fact sheet issued by Multnomah County noted that the implementation was supported through a public-private partnership with DHS TANF Reinvestment funds and Meyer Memorial Trust funds, totaling $456,860. The program focused on Multnomah County families who were long-term TANF participants and who were either newly employed, living at or below 37% of the federal poverty level, or at-risk of enrolling in or returning to TANF.

FII was founded in 2001 in Oakland, California. FII has also partnerships in the following cities: Austin, Texas; Albuquerque, New Mexico; Boston and Cambridge, Massachusetts; Chicago, Illinois; Cincinnati, Ohio; Detroit, Michigan; New Orleans, Louisiana; and Oakland, California. For the year ended December 31, 2018, FII reported $7.6 million in revenue and nearly $7.3 million in expenses, with $5.8 million in program expenses.

For more information, contact:

  • Ashley Conners Sherwin, Vice President of External Affairs, Family Independence Initiative, Post Office Box 301764, Jamaica Plain, Massachusetts 02130; 617-935-7566; Email: ashley@fii.org; Website: https://www.fii.org/
  • Jennifer Grentz, Information Strategist, Self-Sufficiency Programs, Oregon Department of Human Services, 500 Summer Street NE, E48, Salem, Oregon 97301; 503-884-9071; Email: Jennifer.Grentz@state.or.us; Website: https://www.oregon.gov/DHS/

There are many factors driving the increased use of value-based reimbursement. Payers are facing cost pressures and as a result are focusing on driving better value through integrated care. Competition between health plans is creating the need for better synergy with their contracted provider organizations. Finally, the volume of new technologies that allow for new treatment modalities and better administrative functions mean that reimbursement models that leverage these technologies are needed.

As the largest health care payer organization, the Center for Medicare & Medicaid Services (CMS) has set the tone for VBR and their policies are a big driver in the shift. In Medicare, there are 518 Shared Savings accountable care organizations serving 10.9 million beneficiaries.1 There is the expansion of the bundled rate program (see HHS To Launch New Mandatory Bundled Payment Models). There are pending new models for reimbursing primary care. In Medicaid, there are an increasing number of mandates for Medicaid health plans to use alternative payment methodologies (APMs)–either performance-based or value-based reimbursement models–to reimburse their provider networks.

The state-specific mandates to Medicaid health plans to use APMs in provider reimbursement the focus of recent report published by Open Minds.2 The report looks at which state Medicaid programs require the Medicaid health plans to implement APMs and what that mandate exactly means.

What did they find? The number of states with APM requirements for health plans continues to increase. When OPEN MINDS completed the report in 2017 of the 38 states with managed care, 22 required the use of APMs. In 2019, that number has increased to 28 of 40 states with managed care.

The six states that added APMs in the past year and a half include California, Colorado, District of Columbia, Kansas, Louisiana, and Wisconsin. Additionally, there are three states with active plans to add APMs in the next two to three years. Those states include Kentucky, North Carolina, and Virginia.

States with especially notable APM requirements include Washington and New York both of which have value-based roadmaps intended to drive changes in financing in delivery. New York plans to have 80-90% of payments in VBR arrangements by the end of 2020 and Washington plans to have 75% of payment in VBR by the end of 2019 and 90% in 2021. While Arizona, Pennsylvania, and New Mexico do not have requirements to move such a high percentage of payments to APMs in the near term, these states have specific requirements around the inclusion of behavioral health provider organizations in APMs.

At the state level, the implications for provider organizations varies by state like so many market factors. Typically, the mandates are not particularly prescriptive. Health plans are given the opportunity to decide the types of payment arrangements and the types of provider organizations they would like to contract with. Additionally, there is the issue of how the state is “counting” APMs. It can be the number of contracts with APMs, the percent of medical expenditures in APMs, or the number of enrollees who receive a service that is paid for using an APM.

At the macro level, the increase in the number of states offering these arrangements and the increasingly percentage of payments in APMs is indicative of the trend that VBR is reshaping the health and human services landscape. The pressure for VBR is not only coming from the state and government, but also from private sector as health plans work to implement these initiatives with or without a mandate. Provider organizations regardless of the state they operate in need to at minimum begin readying their organization for VBR. For more on this check out these resources:

  1. The Four-Part Checklist For VBR Success
  2. VBR @ Scale—Changes Required
  3. Crawl, Walk, Run To VBR
  4. Successfully Managing Bundled Rates—The Voice Of Experience
  5. Developing Case Rates? Better Find Your ‘Single Source Of Truth’

For the 2020 Medicare Part D plan year, the Centers for Medicare & Medicaid Services (CMS) will increase the total out-of-pocket (OOP) threshold to increase by 24.5%, from $5,100 in 2019 to $6,350 in 2020. The OOP threshold is the point at which the Part D catastrophic coverage for medications takes effect and the beneficiary is no longer responsible for cost sharing. Since 2007, the OOP threshold has increased 64.9% (from $3,850 in 2007). The OOP threshold does not include monthly premiums or non-formulary purchases.

CMS finalized the OOP increase in “Contract Year 2020 Medicare Advantage and Part D Flexibility Final Rule (CMS-4185-F)” on April 5, 2019. Formulas that set the OOP threshold are set by Congress, and CMS is required to implement the applicable increase. For 2020 and subsequent years, the Social Security Act requires the OOP threshold to be calculated as if the OOP threshold for years 2014 through 2019 had been subject to the respective annual percentage increase (API) values. For 2014 and 2015, the Act required that the OOP threshold be updated by the API minus 0.25 percentage points. For contract years 2016 through 2019, the Act required that the OOP threshold be updated from the previous year by the lesser of the API, or two percentage points plus the annual percentage increase in the Consumer Price Index (CPI). For 2020, the OOP threshold is increased from $5,100 in 2019 and rounded to the nearest multiple of $50.

The change in the OOP threshold for 2020 was calculated using the 2013 threshold value of $4,750 as the starting point. The calculation is as follows:

  1. The starting point is the 2013 OOP threshold of $4,750.
  2. The published API for 2014 was applied, as this is the percentage that would have been applied absent the modification.
  3. The resulting value is rounded to the nearest $50.
  4. Each of the first three steps is repeated for each subsequent year through 2019.
  5. The 2020 API is then applied, and the result rounded to the nearest $50, resulting in the $6,350 out-of-pocket threshold value for 2020.

For 2020, the total covered Part D spending at OOP threshold for applicable beneficiaries is $9,719.38. The figure is calculated given the following basic assumptions:

  1. Beneficiary cost-sharing in the deductible phase: 100%
  2. Beneficiary cost-sharing in the initial coverage phase: 25%
  3. Beneficiary cost-sharing for non-applicable drugs purchased in the coverage gap phase of the benefit: 25%
  4. Cost-sharing for the ingredient cost and sales tax for applicable drugs purchased in the coverage gap phase of the benefit: 95% (25% beneficiary coinsurance and 70% Coverage Gap Discount Program discount)
  5. Cost-sharing for the dispensing and vaccine administration fees for applicable drugs purchased in the coverage gap phase of the benefit: 25%

A line graph showing the rise in Part D OOP is posted online at https://q1medicare.com/PartD-The-MedicarePartDOutlookAllYears.php (accessed September 4, 2019).

PsychU last reported on this topic in “CMS Final Rule Codifies Existing Policy On Step Therapy For Part D Protected Drug Classes,” which published on July 8, 2019. The article is available at https://www.psychu.org/cms-final-rule-codifies-existing-policy-on-step-therapy-for-part-d-protected-drug-classes/.

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore 21244; Maryland; 202-690-6145; Website: press@cms.hhs.gov; Website: https://www.cms.gov/newsroom/fact-sheets/contract-year-2020-medicare-advantage-and-part-d-flexibility-final-rule-cms-4185-f

On August 28, 2019, Nevada submitted a Medicaid state plan amendment (SPA) to transition its Certified Community Behavioral Health Centers (CCBHCs) to become a Medicaid provider organization type. On July 16, 2019, the Nevada Department of Health and Human Services (DHHS) issued the proposed SPA documents. A public hearing was scheduled for August 27, 2019.

After the Centers for Medicare & Medicaid Services (CMS) approves the SPA, Nevada’s goal is to develop a directed payment in cooperation with CMS for the CCBHCs and incorporate the directed payment into the rates and contract in or after 2021. Once this goal is achieved, the CCBHC model will again be part of the Nevada managed care system.

Nevada is one of eight states participating in the two-year grant-funded federal CCBHC demonstration program, which was recently extended through federal legislation. DHHS is currently working with CMS to find the best solution for Nevada’s program during this extension and transition. The other grant-funded states are Minnesota, Missouri, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania.

Nevada has three CCBHCs: Bridge Counseling Associates in Las Vegas, New Frontier Treatment Center in Fallon, and Vitality Unlimited in Elko. DHHS seeks to have the program fully transitioned by October 1, 2019. In the interim, DHHS reached an agreement with its three CCBHCs to fund the clinics at about 75% of their average monthly billing. The CCBHC services include the following:

  1. Crisis mental health services
  2. Screening, assessment, and diagnosis
  3. Consumer-centered treatment planning
  4. Outpatient mental health and addiction treatment services
  5. Screening and monitoring of health risks and status; targeted case management
  6. Psychiatric rehabilitation
  7. Peer and family support services

Nevada is continuing to move forward with its previously announced plans to add seven more CCBHCs. The clinics will be reimbursed with a clinic-specific daily rate. Each clinic has an individual prospective payment based on the anticipated cost of their program.

For more information, contact: Sarah Dearborn, Social Services Program Specialist 3, Behavioral Health Outpatient/ Rehabilitative Services, Nevada Department of Health and Human Services, 4126 Technology Way, Suite 100, Carson City, Nevada 89706-2009; 775-684-3732; Email: sdearborn@dhcfp.nv.gov; Website: http://dhhs.nv.gov/ ; or Shannon Litz, Public Information Officer, Director’s Office, Nevada Department of Health and Human Services, 4126 Technology Way, Carson City, Nevada 89706-2009; 775-684-4000; Email: sdlitz@dhhs.nv.gov; Website: http://dhhs.nv.gov/

On August 5, 2019, the Kentucky Cabinet for Health and Family Services (CHFS) announced the launch of a new Medicaid program to help employed Medicaid beneficiaries transition from Medicaid to employer-sponsored health insurance (ESI) benefits while still retaining access to Medicaid wraparound services. The Kentucky Integrated Health Insurance Premium Payment (KI-HIPP) program will pay the employee share of premium costs for beneficiaries eligible to enroll in their ESI plan. The Medicaid individual/family will not be responsible for paying the ESI copayment and deductible amount if they see an in-ESI network and/or Medicaid provider organizations. KI-HIPP will not cover services delivered by provider organizations out-of-network with the ESI or services provided by non-Medicaid provider organizations.

Kentuckians qualify for KI-HIPP if they or a member of their household are eligible for Medicaid and have access to comprehensive and cost-effective health insurance through their job. When a member enrolls, KI-HIPP pays them for their share of the cost of the insurance premium. The premium, deductible, and copayments of the ESI plan must cost the state less than the cost to cover a member in a Kentucky Medicaid managed care organization. Members who choose to enroll in the program do not lose their Medicaid benefits. The types of insurance coverage that qualifies for KI-HIPP include the following:

  • Insurance through a comprehensive ESI plan that covers at least one benefit from each of the 10 essential health benefit categories
  • Insurance through a parent’s ESI plan
  • Coverage from United Mine Works, Retiree Health Plan, or Consolidated Omnibus Budget Reconciliation Act (COBRA)

CHFS quietly launched the KI-HIPP program on May 6, 2019 by offering enrollment to about 9,000 Medicaid beneficiaries who reported access to or enrollment in ESI. Expanded outreach started in August 2019.

On August 6, 2019, the Kentucky Hospital Association hosted a webinar about KI-HIPP. CHFS anticipates that KI-HIPP may make family coverage more affordable by reimbursing the employee’s share of a premium for more extensive coverage plans. Further, it may widen the health care network available to beneficiaries by providing access to physicians through the full traditional Medicaid network. On August 5, 2019, CHFS notified about 35,000 beneficiaries who have reported full-time employment. On September 4, 2019, another 38,000 beneficiaries with full-time work will be notified about the program. On November 4, 2019, another 10,000 non-Medicaid policy holders with at least one Medicaid beneficiary in the policy will be notified about KI-HIPP.

The Kentucky Hospital Association webinar presentation about KI-HIPP was released August 6, 2019. A copy is available online at http://www.new-kyha.com/Portals/5/NewsDocs/KI-HIPPBriefing.pdf (accessed September 4, 2019).

For more information, contact:

  • Kentucky Integrated Health Insurance Premium Payment (KI-HIPP), Kentucky Cabinet for Health and Family Services, 275 East Main Street, 6C-A, Frankfort, Kentucky 40621; 855-459-6328; Email: KIHIPP.Program@ky.gov; Website: https://chfs.ky.gov/
  • Christina Dettman, Executive Director of Public Affairs, Office of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-229-2791; Email: christina.dettman@ky.gov; Website: https://chfs.ky.gov/; or Jordan Rowe, Director of Strategic Communications, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-352-3977; Email: jordan.rowe@ky.gov; Website: https://chfs.ky.gov/.

Behavioral health provider organizations have long understood that biopsychosocial factors have a significant impact on behavioral health. In 1943, the humanist psychologist Abraham Maslow introduced the concept of a hierarchy of needs.1 In general, Maslow believed that in order for individuals to reach their full potential, their more basic needs must be met. Many of these needs are primarily physiological such as food, water, and sleep. Basic needs extend to safety and the need to belong. Safety needs include a safe environment, housing, and employment.2 Today these factors are referred to as social determinants of health (SDoH). The World Health Organization defines SDoH as “the conditions in which people are born, grow, live, work, and age”.3 There is a growing recognition of the impact that a lack of social determinants, such as safe affordable housing, transportation, and access to nutritional foods, has on health outcomes and health care spending. Social determinants also impact how and if individuals access health care and the quality of health care services that they receive.4

Despite Maslow’s recognition of social determinants on human growth, it is only more recently that the U.S. health system, both payers and providers, has become focused on social factors outside of direct health care services. In fact, it is estimated that medical care accounts for only 10% – 20% of the modifiable contributors to healthy outcomes.4

Medicaid, Medicare, and commercial insurers are increasingly focused on factors beyond direct medical services which impact their covered populations’ overall health. A recent survey of health plans and health plan executives that is highlighted in the Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide), found that all payers, to varying degrees, have developed strategies to address an array of SDoH.5

Access to safe housing, transportation, affordable childcare, and healthy and nutritious foods are social determinants significantly impacted by poverty. As the primary payer for individuals living at or below the poverty level and for individuals with serious mental illness, Medicaid is leading the way in addressing social determinants with a strong focus on coordinating with social services to help address unmet needs. Increasingly, state Medicaid programs are adding requirements around SDoH in their contracts with managed care plans and are using the flexibility under Section 1115 Medicaid Demonstration waivers (1115 waivers) to address SDoH. For example, Texas allows Medicaid health plans to cover transportation and activities to promote healthy lifestyles, Massachusetts allows Medicaid ACOs to pay for traditional non-reimbursed services to address health related social needs, and North Carolina as part of their 1115 waiver is requiring health plans to screen for social determinants.5 Under their 1115 waiver, North Carolina is launching Healthy Opportunity pilots that will require health plans to coordinate and pay community-based organizations and social service agencies to address housing, food insecurity, transportation, and interpersonal violence. Medicaid managed care contracts in California and the District of Columbia require the identification of health disparities and plans to address them, and Kansas requires that health risk assessments contain questions about domestic violence, housing, and employment.6

Resources for Human Development (RHD), a human services company that has nationwide expertise in providing innovative supportive housing programs for individuals with serious mental illness and individuals with intellectual and development disabilities, has begun to demonstrate the power of housing as a health care strategy. They have developed a model to serve high-cost Medicaid enrollees in a supported housing setting with an array of community-based supports and the goal of reducing the total cost of health care for this population. The program model leverages overall health care savings to payback social investors who provide loans to RHD which are used to cover expenses related to program enrollee housing. A pilot of this model is in development in Philadelphia, Pennsylvania where RHD will support 50 individuals who each have health care costs in excess of $80,000 annually.7 A similar project already underway in Kansas has produced a 64% decrease in emergency room use and a 38% decrease in psychiatric hospitalization for individuals housed for 6 months.8

Commercial plans are also increasingly focused on the SDoH. Over the past several years, some of the largest national payers, such as Blue Cross Blue Shield, UnitedHealthcare, Aetna, and Kaiser Permanente, have developed new partnerships and have invested hundreds of millions of dollars on various factors that impact access to health care and health outcomes. UnitedHealthcare is partnering with the American Medical Association to launch almost two dozen new International Statistical Classification of Diseases & Related Human Problems (ICD) 10th revision (ICD-10) codes to capture unmet SDoH information regarding their members.9 According to UnitedHealthcare, this work on coding allows the insurer to better track patients and their needs.9 Having this type of readily reportable information can help a payer better track the needs of their population and support referral to appropriate community support. In addition to this effort, UnitedHealthcare has invested $350 million in housing projects across 14 states since 2011.10 In 2018, Kaiser Permanente announced that they will invest up to $200 million to help address housing stability and homelessness in their communities. The initial focus of their funding is to help prevent displacement or homelessness of lower- and middle-income households in rapidly changing communities; reduce homelessness by ensuring access to supportive housing; and making affordable homes healthier and more environmentally sound.11

Payers are increasingly partnering with non-health care providers to address barriers to health care and activities that support wellness. The ridesharing company Lyft is partnering with a number of the nation’s largest health plans to provide transportation services to their members.12 Lyft began a collaboration with the Blue Cross Blue Shield Institute in 2017 to provide rides to their Medicare Advantage members to medical appointments. They have since expanded to allow members to access rides to pick up prescriptions and will be adding rides to fitness centers as a benefit. Lyft has entered in to similar partnerships with Humana and Cigna-Health Spring.12 Lyft cites that 36% of riders who have used their service to get to medical appointments report that they go to urgent care less often.12 Beyond health plans, Lyft has partnered with Allscripts to develop a feature within their EHR that allows a physician to order transportation for a patient.

It can be anticipated that as greater percentages of health care spending are tied to outcomes, health plans and health systems will continue to look to address social determinants as a strategy for improving member outcomes and reducing costs of care. While both payers and providers are finding and investing in innovative ways to address social determinants, the challenge remains of determining return-on-investment and developing long-term, sustainable solutions. For additional information and insights into how various payer are approaching SDoH and other health care trends across the nation, please see the Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System.

About The Guide
The Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide) provides information and insights into the multi-layered United States behavioral health system. The Guide includes an in-depth view of current statistics, prevailing issues, and emerging trends in order to inform the discussions, debates and decision-making of policy-makers, payers, providers, advocates and consumers. The Guide addresses current behavioral healthcare trends topics, including:

• A look at the national policy that is shaping the U.S. health and human services market
• A view of the state behavioral health delivery systems that were created by a combination of historical practices, federal and state policy, and market factors over recent years
• An examination of the practices of 1,265 health plans that manage both physical and behavioral healthcare for the vast majority of the U.S. population
• A deep-dive into behavioral healthcare access and delivery of care from the consumer perspective

During a recent presentation on building partnerships with payers, which featured OPEN MINDS Senior Associate Deb Adler and Yanick Hazlewood, Esq., Vice President, Third Party Payer Contracting, LifeStance Health, said health plan contracts should be reviewed and revisited every year; March to July is best contract renegotiation window; rate increases tend to be no more than 3% in any given year; access is the number one health plan “pain point”; and good negotiators ask 2.5 times as many questions as average negotiators, and share a third of the data.

To negotiate effectively, these elements need to be incorporated in a framework for success. To build a contract negotiation plan, Ms. Hazlewood presented six key principles—position your product and service; understand your capabilities; establish high targets; satisfy customer needs over customer wants; manage information skillfully; and concede according to plan.

Position your product and service—First, what are you offering? Payers have a small window of time to speak to a provider organization, and your answer needs to be quick. When you approach them, they want to know who you are, what you do, and what you want. Ms. Adler explained it this way:

You must be able to basically say your elevator pitch and highlight the unique value you bring as a provider organization. If you haven’t built a pitch with one, or a maximum of two slides, do that immediately. As the saying goes, ‘Be brief, be right, be gone.’ You have very little time to highlight what is different about you. What are the quality and value and cost differences that you bring? The more you can learn from payers and what they are struggling with, the more you can shape your programs to address what they need. Finally, you need to have a plan. That sounds so basic and simple, but many organizations show up with a 65-page deck and just wing it.

Understand your capabilities—Knowing yourself thoroughly is key to being able to explain the true difference between your services and the services of the competition down the road—what is also known as competitive intelligence. This is also a strength because it gives you both a solid ground to stand on in negotiations, as well as the confidence to know exactly what you are bringing to the table.

Establishing high targets—The saying to “shoot for the stars and hit the moon” will only work if you truly understand your capabilities and trust in your value story. But if you do, there is no reason not to aim high. For example, even if you must come down from your original expectations lower than you originally wanted, you are still positioned to get more than you would have starting low.

Satisfy customer needs— Focus on what the “customer” needs and wants. Depending on the situation, it might be the consumer and it might be the payer. In a negotiation, it comes down to what can you offer the customer so that it’s a win-win for everyone. Think about what they need and what can you give them to satisfy that need. This means developing relationships with each health plan at multiple levels. Ms. Adler noted:

I don’t know if there is any magic bullet. The more you can get to know the people on the payer side the better. One person can lead you to a door, then to another door, then to another door. If you get in the door, make sure you are using that time wisely. If you don’t know who your network manager is, you need to find out and get to know your network representative. Who signed your contract? If they aren’t there anymore, find out who replaced them and work your way through the system. 

Manage information skillfully—If you like to negotiate, you will prepare your value story, figure out the payer, the market, and published rates where available (e.g., Medicaid). If you don’t like to negotiate, you may not prepare as thoroughly and that is a mistake. No matter where you sit with the negotiating, you must prepare, whether you like it or not. And remember that patience is also key to preparation. Payers usually have the advantage for time. When you are preparing yourself, you must look at how much time you can spend on the negotiation and understand there is a significant return on investment. Ms. Adler noted:

Patience is a virtue is an old adage that is absolutely true when it comes to contract negotiation. Payers are very busy with generally few staff to support the contract negotiation efforts. The payer is very much outnumbered. The level of attention that you will get will depend on how much your program can fulfill an important unmet need (e.g., access to an important specialty service). Be prepared for a 6-month or longer process for a fee-for-service arrangement and 12 months for a more complex value-based agreement.

Concede according to plan—No one wants to concede anything, but chances are you are going to have to. With that in mind, it pays to know exactly what you can give up and still look like you are committed to making the deal. If you have a bunch of things you are asking for, conceding a little on some of them will help show your willingness to achieve a win-win.

This framework emphasizes the importance of planning from concept to final contract terms—and having a person (or team) dedicated to managing and improving the contractual relationships with health plans and other payers. That goes hand-in-hand with another big takeaway from the day—the importance of brand building. In the coming years, networks will get smaller and smaller over time. If you want to be the preferred provider organization, you need to tie these negotiations to your marketing and business developing efforts. Brand messaging helps to support consumer and health plan executive perceptions of your value proposition. You need a consistent stream of normative messages establishing the value for what you do.

For more on this exciting topic, check out these resources from the PsychU Resource Library:

  1. Health Plan Relationship Building Skills Key To VBR Success
  2. Adjust Your Strategic Sails!
  3. The Five-Step Process To Demonstrate Your “Performance” To Health Plans
  4. Becoming A ‘Blue Chip’ Provider Organization

Care provided by primary care professionals accounts for a small percentage of total spending among Medicare beneficiaries. Depending on whether “narrow” or “broad” definitions of primary care professionals and services are used, primary care spending represents 2.12% to 4.88% of fee-for-service (FFS) Medicare beneficiaries’ total medical and prescription spending. The study classified primary care professionals according to a narrow definition that included only family practice, internal medicine, pediatric medicine, and general practice physicians, and a broad definition that included the professionals in the narrow, as well as nurse practitioners, physician assistants, geriatric medicine, and gynecology. Primary care spending represented 2.12% of medical and prescription spending under the narrow definition of primary care professionals. Spending totaled 4.88% when using the broad definition. The study also classified primary care services using a narrow definition, which includes office visits and preventive care, and a broad definition, which includes any service provided by a primary care professional.

These findings were reported in “Primary Care Spending in the Fee-for-Service Medicare Population” by Rachel Reid, M.D., MS; Cheryl Damberg, Ph.D.; and Mark W. Friedberg, M.D., MPP. The researchers analyzed Medicare claims and enrollment data for all Medicare beneficiaries who were aged 65 years and above in 2015 and who had Parts A and B fee-for-service coverage as well as Part D prescription coverage for all of 2015, which totaled 16,244,803 beneficiaries. The researchers used data from the Medicare Data on Provider Practice and Specialty File for professional characteristics. The goal of the study was to provide a national estimate for primary care spending among Medicare fee-for-service beneficiaries, and to examine how spending varies by different demographics and by state.

The researchers found primary care spending, as a percentage of total medical and prescription spending, varied by state and beneficiary characteristics. Across all definitions, primary care spending percentages were lower than the overall low-end average among the following sub-populations:

  • Those who were older, at 1.76% for those aged 85 and above by the narrow professional and service definition.
  • Those who were black or North American Native, at 1.76% and 1.51% respectively by the narrow professional and service definition.
  • Those who were dually eligible for Medicare and Medicaid, at 1.64% by the narrow professional and service definition.
  • Those with most chronic medical conditions, varying from 1.08% for hip or pelvic fracture to 2.13% for hyperlipidemia for the narrow professional and service definition.
  • Primary care spending percentages also varied by state and definition. For the narrow primary care, the primary care spending percentage ranged from 1.59% in North Dakota to 3.18% in Hawaii. While the narrow professional and broad service definition, the primary care spending percentage ranged from 2.92% in the District of Columbia to 4.74% in Iowa.

According to the study’s lead author, Dr. Reid, there is currently no consensus on what the optimal percentage of spending is for primary care services. However, estimates are important reference points to consider for potential policy changes around primary care payment and investment.

The full text of “Primary Care Spending in the Fee-for-Service Medicare Population” was published April 15, 2019, by JAMA Internal Medicine. An abstract is available online at https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2730351 (accessed August 26, 2019).

For more information, contact: Rachel Orler Reid, M.D., MS, Physician Policy Researcher, RAND Corporation, 20 Park Plaza, Suite 920, Boston, Massachusetts 02116; Email: rreid@rand.org; Website: https://www.rand.org/.

On August 8, 2019, the Department of Veterans Affairs (VA) announced it had selected TriWest Healthcare Alliance (TriWest) as the Community Care Network (CCN) contractor for CCN Region 4. The Region 4 contract is valued at $25.9 billion over one base year and seven option years. The territory covers all or portions of the following states: Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Texas, Utah, Washington, and Wyoming. VA’s CCN will allow veterans who are unable to receive care at the local VA medical center, either due to a lack of availability, long transit, or long wait times, to receive care from high-performing licensed civilian health care professionals and provider organizations that provide medical, dental, and pharmacy services, including mental health and addiction treatment services.

TriWest previously administered the Veterans Choice Program (VCP), which ended on June 6, 2019. It currently holds a contract to administer the Patient-Centered Community Care (PC3) program, which serves as a transition program before the CCN is fully implemented.

VA issued the initial CCN request for proposals (VA79116R0086) on December 28, 2016. VA said it would award the six regional contracts to up to four organizations. On May 8, 2018, VA issued an amended notice (36C10G18R0189) that it intended to re-solicit the CCN Region 4 requirement, and make a single contract award. Under these contracts, the CCN regional administrators will develop regional networks of high-performing licensed civilian health care professionals and provider organizations who will work together with VA health care professionals to deliver services.

On December 28, 2018, VA awarded three of the six regional CCN contracts to Optum Public Sector Solutions (also known as OptumServe). Optum’s contracts have an aggregate value of $55 billion for Regions 1, 2, and 3. The contracts have an initial base term of one year followed by seven individual option years. Contract awards for Regions 5 and 6 are expected by end of calendar year 2019.

PsychU last reported on the VA CCN transition plan in “VA Expands Private Provider Options For Veterans Under MISSION Act,” which published on July 14, 2019. The article is available at https://www.psychu.org/va-expands-private-provider-options-for-veterans-under-mission-act/.

PsychU reported on the earlier contract awards in “Veterans Affairs Awards 3 Community Care Regional Contracts To OptumServe,” which published on February 25, 2019. The article is available at https://www.psychu.org/veterans-affairs-awards-3-community-care-regional-contracts-optumserve/.

For more information, contact:

  • TriWest Healthcare Alliance, Post Office Box 42049, Phoenix, Arizona, 85080-2049; 602-564-2000; Email: media@triwest.com; Website: http://www.triwest.com/
  • Public Relations, U.S. Department of Veterans Affairs, 810 Vermont Avenue Northwest, Washington, District of Columbia, 20420; 202-461-7600; Email: va.media.relations@va.gov; Website: https://www.va.gov/

On July 1, 2019, the AIDS Healthcare Foundation (AHF) became a full-risk California Medicaid managed care plan for beneficiaries age 21 or older in Los Angeles County who have a prior diagnosis of Stage 3 HIV infection (AIDS). AHF previously operated as a Medicaid primary care case management (PCCM) plan called PHC California. The transition was announced by the California Department of Health Care Services (DHCS).

PHC California is a California Medicaid special needs managed care plan for people who have a prior AIDS diagnosis. AHF has operated PHC California since 1995. As a PCCM, PHC California received a per member per month (PMPM) capitated payment to cover primary medical care, specialty consultation, outpatient services, pharmaceuticals (including all psychotherapeutic and HIV/AIDS drugs), hospice, and long-term facility care. DHCS was responsible for the cost of acute inpatient services for PHC California members.

DHCS said the AIDS Healthcare Foundation (AHF) added full-risk benefits to its existing contract by meeting all DHCS readiness requirements. The transition was not required by a new contract. Full-risk requires AHF to offer all the same adult services that are required of the Two-Plan managed care plans in Los Angeles, which includes inpatient, outpatient, mild to moderate mental health benefits, and pharmacy services. As a full-risk Medicaid managed care plan, AHF receives a PMPM capitated payment that covers the cost of the previous PCCM services as well as the cost of acute inpatient services. PHC California had a total average enrollment of 703 members from October 1, 2016, through September 30, 2017.

Non-profit AHF was founded in 1987. It provides HIV treatment to more than 820,000 individuals in 39 countries. Positive Healthcare is the AHF managed care division. Since 1995, Positive Healthcare has provided an AIDS-specific Medicaid special needs plan for Medicaid beneficiaries in Los Angeles County, California. In 2008, AHF expanded its AIDS-specific Medicaid special needs plan to Florida. As of 2017, Positive Healthcare served more than 7,000 Medicaid beneficiaries in California and Florida.

For more information, contact:

  • Ged Kenslea, Senior Director, Communications, AIDS Healthcare Foundation, 6255 Sunset Boulevard, 21st Floor, Los Angeles, California 90028; 323-860-5200; Email: gedk@aidshealth.org; Website: https://www.aidshealth.org/
  • Office of Public Affairs, California Department of Health Care Services, Post Office Box 997413, Sacramento, California 95899; 916-440-7660; Email: DHCSPress@dhcs.ca.gov; Website: http://www.dhcs.ca.gov/.

The U.S. spends approximately 5% to 7% of total health care spending on primary care. The national average for primary care spending across public and private payers was 5.6% using a narrow definition, and 10.2% using a broad definition. The narrow definition focuses on spending related to primary care physicians in offices and outpatient settings. The broad definition includes all of the above, plus other members of the primary care clinical team, including nurses, nurse practitioners (NPs), physician assistants (PAs), OB/GYNs, and behavioral health professionals (i.e., psychiatrists, psychologists, and social workers). No specific dollar values are offered regarding health care spending. Overall, the U.S. falls well below the 14% average spent on primary care in other countries

These findings were reported in “Investing in Primary Care: A State-Level Analysis” by Yalda Jabbarpour, M.D.; Ann Greiner, MCP; Anuradha Jetty, MPH; Megan Coffman, MS; Charles Jose, M.D.; et.al. The researchers analyzed data from the 2011-2016 Medical Expenditure Panel Survey (MEPS) to examine and compare cross-sectional variation in primary care investment at the state level. Due to MEPS data limitations, results for 29 of the 50 states were reported. The goals of the study were to report a national average for primary care spending; understand differences across states and payer types; determine investment in primary care and its association with key consumer outcomes; and analyze 10 recent state legislative and regulatory efforts to invest more in primary care.

Additional findings include:

  • For the narrow definition, Minnesota had the highest percentage of primary care spending (approximately 7.6%), and Connecticut had the lowest (approximately 3.5%).
  • In total, 11 states were above the national average for primary care spending using the narrow definition: Alabama, California, Florida, Georgia, Minnesota, North Carolina Oklahoma, Texas, Virginia, Washington, and Wisconsin.
  • For the broad definition, Minnesota had the highest percentage of primary care spending (approximately 14.0%), and New Jersey had the lowest (approximately 8.2%).
  • In total, 10 states were above the national average for primary care spending using the broad definition: Alabama, California, Colorado, Connecticut, Massachusetts, Minnesota, Montana, Oklahoma, Oregon, and Wisconsin.

The full text of “Investing in Primary Care: A State-Level Analysis” was published July 17, 2019, by the Patient-Centered Primary Care Collaborative. A copy is available online at https://www.pcpcc.org/sites/default/files/resources/pcmh_evidence_report_2019.pdf (accessed August 26, 2019).

For more information, contact: Yolanda Raine, Senior Manager of Communications, Patient-Centered Primary Care Collaborative, 601 13th Street Northwest, Washington, District of Columbia 20005; 202-417-2075; Email: yraine@pcpcc.org; Website: https://www.pcpcc.org/

On August 6, 2019, Healthy Alliance Independent Practice Association (IPA) and insurer MVP Health Care announced a first-of-its-kind partnership to provide funding to community-based organizations (CBOs) that provide social services in the Capital Region of New York. Approximately $800,000 will be distributed to a select group of CBOs for the purpose of addressing social determinants of health. Through Alliance for Better Health’s Healthy Together Network, the funding will also be used to help CBOs implement the Unite Us platform, a technology platform that digitally connects the medical and social service sectors for referrals and tracking purposes. Healthy Alliance IPA and MVP Health Care will launch the program in late September to work with CBOs to help high-need MVP Health Care members obtain services such as housing, nutrition assistance, and transportation. CBOs for this specific partnership with MVP Health Care have been selected based on existing relationships. Other CBOs interested in learning more about the IPA can contact a Healthy Alliance IPA community relations specialist.

Healthy Alliance IPA is the first IPA that focused exclusively on addressing social determinants of health. The network includes primary and acute care provider organizations, behavioral health provider organizations, CBOs, and local and state government. The structure of Healthy Alliance IPA serves as a central point of contact to connect health care provider organizations, CBOs, accountable care organizations (ACOs), and managed care organizations (MCOs), such as MVP Health Care. Historically, CBOs have relied on grant funding from states, foundations, and charities to fulfill their missions. As part of Healthy Alliance IPA’s infrastructure, it will assist CBOs by aligning the CBO mission with those of MCOs who also seek to maximize innovative ways to keep their members as healthy as possible.

Healthy Alliance IPA will contract with all payers or risk-bearing provider organizations that want to incorporate social care initiatives, such as employment, education, food, housing and family support, benefits enrollment, advocacy, health education, case management, job training, enhanced pharmacy services, addiction disorder, mental health, and behavioral health, into their strategies. MVP is partnering with Healthy Alliance IPA to invest in the underlying social, economic, and environmental factors that contribute to an individual’s health, which reinforces their commitment not only to the overall health and wellness of their members but to the entire Capital Region community.

MVP Health Care is a non-profit health insurer with more than 700,000 members in New York and Vermont. Together, Healthy Alliance IPA and MVP Health Care will be responsible for social care initiatives, including but not limited to, employment, education, food, housing and family support, benefits enrollment, advocacy, health education, case management, job training, enhanced pharmacy services, addiction disorder, mental health, and behavioral health.

For more information, contact:

  • Charles Wiff, Media Contact, Alliance for Better Health, 403 Fulton Street, 2nd Floor, Troy, New York 12180; 607-743-8314; Email: charles@gramcomm.com; Website: https://abhealth.us/
  • Michelle Golden, Public Relations Professional, MVP Health Care, Post Office Box 2207, Schenectady, New York 12301-2207; 518-386-3467; Email: mgolden@mvphealth.com; Website: https://www.mvphealthcare.com/

In this webinar, Monica Oss, M.S., and Paul Duck from OPEN MINDS discuss the current state of population health in the United States. They also discuss how data analytics are utilized by payers and providers in managing population health outcomes. The presenters also discuss the history and success of the PASSE in Arkansas.

Monica Oss, M.S.  is the founder of OPEN MINDS. For the past two decades, Ms. Oss has led the OPEN MINDS team and its research on health and human service market trends and its national consulting practice. Prior to founding OPEN MINDS, Ms. Oss served as an executive with a national managed behavioral health organization, with responsibility for market development and for actuarial analysis and capitation-based rate setting. She also held a position as a vice president of the U.S. risk management and underwriting division of an international insurance company. Ms. Oss has been the keynote speaker at the conferences of dozens of national associations and has been published in a wide range of professional journals and trade publications.

Ms. Oss is a graduate of the University of Minnesota.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics.

Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

Structural changes in the health and human service value chain will make many services obsolete (or at least in need of a serious remake) over time. The growing shift in stakeholder roles—tech and pharma companies offering services, health plans providing clinical services, health systems managing health benefit plans, and national specialty contracting—is changing the “value chain.” And with it the demand for (and margins of) traditional services. For long-term sustainability, executive teams will need to look ahead and come up with the market positioning and service offerings that are in high demand and have profitability in the emerging market—the “next big thing.”

Some of the market effects of these structural changes are service specific—primary care will be redefined with new functions and delivered by different professionals in new settings. Behavioral health services will be increasingly virtual. Social services will have more funding dependent on consumer impact. Consumerism will drive transparency of price and experience information and growing non-fee for service value-based reimbursement (VBR) models will open the flood gates for tech substitution. Thinking through these changes for undiscovered market opportunities is the stuff of identifying the new market opportunities.

How does one accomplish this? Metrics-based strategy development and strategy implementation with two different areas of focus: First, optimizing the performance of current services lines and, second, developing new or enhanced services for the emerging market. Optimizing current services involves improving performance for customers and knowing when to “retire” any particular service line when it is non-performing in the portfolio. At the same time, organizations need to develop that new sustainable service line for the future.

Developing this strategic road map for future success is a challenge and implementing it even more challenging. Leading an organization that is making the shift from one business model to the next requires an executive team with the ability to manage complexity; leading operational activities and entrepreneurial initiatives at the same time. Managing in this environment requires executives who are comfortable with risk taking and uncertainty, are comfortable with tension, and—to quote Peter Drucker—”are comfortable making sacrifices of parts of the organizations for the broader enterprise.”

There are many elements to “organizational readiness” for this shift in reimbursement. OPEN MINDS Senior Associate Ken Carr provided a deep dive into that subject during a recent presentation. During the session, Mr. Carr zeroed in on one of the key elements to preparing organizations for VBR arrangements: how to build the financial management competencies needed for success. His four essentials include revenue cycle effectiveness, encounter reporting, value-based payment capabilities, and financial performance monitoring. He explained:

Assessing financial readiness for value-based reimbursement is important because moving from the fee-for-service business model to new forms of reimbursement that are tied to outcomes involves taking on new risks. Provider organizations are no longer reimbursed just for providing services. Documenting an encounter and linking it to a CPT payment code is necessary. For instance, in a pay-for-performance agreement, they need to demonstrate that they have achieved agreed upon outcomes in order to receive the maximum payment for their services, and the final payment may be delayed until the outcomes are verified by the payer. This requires the implementation of new skills sets and tools for financial managers: assessing risk, projecting cash based on new payment mechanisms, and working with the organization to support performance management around the contracted outcome goals. These four key competencies play a key role in supporting this new focus on managing financial risk:

Revenue cycle effectiveness—The ability to align operational and financial processes to assure adequate cash flow. Success relies on practicing effective processes for reconciliation of authorizations and payment verification to credentialed provider organizations. The kicker: it’s often a new and alien process to submit invoices to payers for services delivered under value-based reimbursement agreements (see Adapting Revenue Cycle Management For A VBR-Driven World).

Encounter reporting—The ability to capture, analyze, and report granular utilization data to payers and to internal teams for management. Success relies on electronically capturing and reporting reliable encounter data in the format and timeframe required by payers. The kicker: the data needs analyzed to also manage service outcomes and utilization from an in-house performance standpoint (see The Hospital Perspective On ‘Owning’ Value-Based Reimbursement and The Value Train Has Left The Station).

Value-based payment capabilities—The ability to track and manage contractual outcomes and payments. Success relies on reporting actual performance data (in the form of outcomes and financial performance) against budgets and contractual targets. The kicker: there are many types of value-based reimbursement models and different contracts require different capabilities (see Successfully Managing Bundled Rates—The Voice Of Experience).

Financial performance monitoring—The ability to monitor actual financial results against contracts, budgets, and forecasts. Success relies on a comprehensive set of key performance indicators and the ability to report incurred but not reported liabilities while monitoring service utilization and costs; with the additional ability to reconcile to service and revenue projections. The kicker: real success takes adopting a system to link population health management and value-based contracting strategies to resources planning and reporting.

For a deep dive into the many ways to understand VBR and its relationships to your current and future strategy, check out these resources from the PsychU Resource Library.

  1. The Strategic Challenges On The Road To Value-Based Reimbursement
  2. Preparing For Value-Based Reimbursement—Even Before The Contracts Are Signed
  3. Your Organization Is Ready For VBR, Now What?
  4. The Strategic Challenges On The Road To Value-Based Reimbursement

On June 17, 2019, the Centers for Medicare and Medicaid Services (CMS) approved Missouri’s application to add Certified Community Behavioral Health Organization (CCBHO) services to the state Medicaid plan. Missouri had been participating in the two-year grant-funded federal Certified Community Behavioral Health Clinic (CCBHC) demonstration program, which was to end on June 30, 2019, but was extended to September 30, 2019. Missouri submitted a Medicaid state plan amendment (SPA) to continue operating the CCBHO model. The difference between the CCHBC Demonstration project and the CCBHO SPA is mainly a change in terminology from the word “clinic” to “organization.”

The state agency will reimburse CCBHOs a clinic‐specific fee schedule rate applicable to provider organizations affiliated with the CCBHO. This funding will allow the current 15 CCBHOs to continue to receive a prospective payment for behavioral health services provided to certain Medicaid enrollees.

The CCBHO services include the following:

  1. Crisis mental health services
  2. Screening, assessment, and diagnosis
  3. Patient-centered treatment planning
  4. Outpatient mental health and substance use disorder treatment services
  5. Screening and monitoring of health risks and status
  6. Targeted case management
  7. Psychiatric rehabilitation
  8. Peer and family support services

PsychU last reported on this topic in “CCBHCs In 8 States Projected To Serve 380,000 Individuals In First Year” which published on November 26, 2019. The article is available at https://www.psychu.org/ccbhcs-8-states-projected-serve-380000-individuals-first-year/.

For more information, contact: Debra Walker, Director of Public and Legislative Affairs, Missouri Department of Mental Health, 1706 East Elm Street, Jefferson City, Missouri 65101; 573-751-1647; Email: debra.walker@dmh.mo.gov; Website: https://dmh.mo.gov/ or https://dmh.mo.gov/CertifiedCommunityBehavioralHealthClinics.htm.

On August 5, 2019, the Louisiana Department of Health (LDH) announced that it selected AmeriHealth Caritas Louisiana, Community Care Health Plan of Louisiana (Healthy Blue), Humana Health Benefit Plan of Louisiana, and United Healthcare Community Plan of Louisiana for Medicaid managed care organization (MCO) contracts for the Healthy Louisiana program. The contracts begin January 1, 2020. The initial term ends on December 31, 2022, followed by a 24-month extension option.

LDH released the request for proposals (RFP 3000011953) on February 25, 2019. Proposals were due by April 29, 2019. This is the third procurement cycle for the state’s Medicaid managed care program. The incumbents are Aetna Better Health, AmeriHealth Caritas Louisiana, Healthy Blue, Louisiana Healthcare Connections (a Centene subsidiary), and United Healthcare Community Plan of Louisiana. During fiscal year 2018, Medicaid paid the five incumbents $7.6 billion to manage care for more than 1.7 million enrollees. Their contracts expire on December 31, 2019.

On May 1, 2019, LDH stated it received six responses from the following organizations: Aetna Better Health of Louisiana, AmeriHealth Caritas Louisiana, Healthy Blue, Humana, Louisiana Healthcare Connections, and UnitedHealthCare Community Plan of Louisiana. Incumbents Aetna and Louisiana Healthcare Connections were not selected for new contracts. LDH anticipates completing negotiations and executing contracts on or about August 23, 2019. Open enrollment will begin in November 2019.

In the procurement, LDH asked the bidders to identify baseline health outcome measures and targets for health improvement; explain how they intend to measure population health status and identify sub-populations; and indicate how they would identify determinants of health outcomes and strategies for targeted interventions to reduce disparities. Additionally, LDH requested information about the proposer’s recent experience using data regarding social determinants of health to improve the health status of targeted populations. LDH asked them to describe their data collection approach and how this approach can be applied to one or more of the state’s population health priorities. LDH increased MCO requirements in terms of access to and the use of primary care, as well as the integration of physical and behavioral health care services. Additionally, LDH sought proposals for an optional community health worker pilot program with the larger focus of improving population health.

In the “Healthy Louisiana RFP 3000011953 Summary Score Sheet” the state presented each bidder’s score for each of the evaluation components. Of a maximum 1,500 points, the scores from highest to lowest were as follows:

  1. AmeriHealth Caritas Louisiana earned 867.507 points.
  2. Humana earned 818.766 points.
  3. Healthy Blue earned 711.944 points.
  4. UnitedHealthCare Community Plan earned 705.800 points.
  5. Aetna Better Health of Louisiana earned 668.601 points.
  6. Louisiana Healthcare Connections earned 621.000 points, which did not meet the minimum score. This proposal did not proceed to the Louisiana Veteran and/or Hudson Initiative evaluation, and was rejected.

PsychU last reported on this topic in “Louisiana Rebids Medicaid Managed Care Contracts,” which published on April 1, 2019. The article is available at https://www.psychu.org/louisiana-rebids-medicaid-managed-care-contracts/. For more information, contact:

  • Bob Johannessen, Communications Director, Bureau of Media & Communications, Louisiana Department of Health, Post Office Box 629, Baton Rouge, Louisiana 70821-0629; 225-342-5275; Fax: 225-342-5568; Email: robert.johannessen@la.gov; Website: http://ldh.la.gov/
  • Corporate Communications, Amerihealth Caritas Louisiana, Post Office Box 83580, Baton Rouge, Louisiana 70884; 215-863-6780; Website: https://www.amerihealthcaritasla.com/index.aspx
  • Healthy Blue Louisiana Medicaid, 4425 Corporation Lane, Virginia Beach, Virginia 23462; 757-490-6900.; Email: MPSInquiries@healthybluela.com; Website: https://www.myhealthybluela.com/la/louisiana-home.html
  • Mitch Lubitz, Corporate Communications Lead, Humana, 1863 Hendersonville Road, Asheville, North Carolina 28803; 828-772-3093; Email: mlubitz@humana.com; Website: https://www.humana.com/
  • United Healthcare Community Plan of Louisiana; 866-675-1607; Website: https://www.uhccommunityplan.com/contact-us

On July 9, 2019, MVP Health Care announced that beginning in early 2020, it will directly administer case management, utilization review, claims payment, and network management for all of its New York members that use behavioral health services. MVP Health Care currently contracts with Beacon Health Options to manage behavioral health benefits for MVP members; this contract will end. By directly managing behavioral health benefits, MVP Health Care anticipates that the new structure will best support the coordination and integration of primary care and behavioral health services.

MVP is working collaboratively with Beacon Health Options to ensure that all areas of care delivery are transitioned seamlessly, with continuity of care for members being a primary focus. Member benefits during 2019 will not be affected. During the transition period, MVP is building its own behavioral health network comprised of Beacon’s current provider organization network and other services deemed essential to MVP’s integrated health vision.

The new in-house behavioral health management will complete this launch in early 2020. MVP believes that by managing the services itself, it will be able to establish policies to strengthen coordination between medical and behavioral services, improve access to behavioral health care, provide more personalized services and supports, and streamline provider organization reimbursement.

MVP has 700,000 members across New York and Vermont. MVP Health Care’s lines of business include Medicaid, Medicare, and insurance for employer groups as well as individuals and families.

Beacon Health Options is a leading behavioral health services company that serves approximately 36 million individuals across all 50 states. Beacon works with employers, health plans and government agencies to provide robust mental health and addiction services through innovative programs and solutions that improve the health and wellness of people every day. Beacon is a national leader in the fields of mental and emotional well-being, addiction, recovery, and employee health. On June 6, 2019 Anthem Inc, announced plans to acquire Beacon Health Options from Bain Capital Private Equity and Diamond Castle Holdings. The acquisition is expected to close in the fourth quarter of 2019.

For more information, contact:

  • Michelle Golden, Public Relations Professional, MVP Health Care, Inc., 625 State Street, Schenectady, New York 12305; 518-386-3467; Email: mgolden@mvphealthcare.com; Website: https://www.mvphealthcare.com/
  • Tina Beckwith, Senior Vice President, Marketing & Communications, Beacon Health Options, 200 State Street, Boston, Massachusetts 02109; 860-338-0164; Email: tina.beckwith@beaconhealthoptions.com; Website: https://www.beaconhealthoptions.com/anthem-to-acquire-beacon-health-options/

Well, the results are in. A survey of the health plans focused on their management approaches for better serving consumers with behavioral health disorders and complex support needs brought a few results that surprised even me. The big takeaways? Specialty care coordination, access, and value-based partnerships are at the top of the list.

The survey results were published in a new report, Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System, issued from the collaborative efforts of Otsuka America Pharmaceutical, Lundbeck, and our team at PsychU Resource Library. This is the second survey of every U.S. health plan—commercial, Medicaid, and Medicare—and for strategists, a great snapshot of where health plans are now compared to just 24 months before. Here is a summary of some of the “big picture” findings.

Innovative approaches to care coordination are growing—Health plans are investing in specialized approaches to managing the care coordination of consumers with complex needs. The proportion of health plans reporting specialty care coordination programs increased from 23% to 73% in two years. There were also increased use of behavioral health readmission prevention programs (from 15% to 89%) and emergency department diversion programs for (from 15% to 58%).

Moving beyond pay-for-volume—Value-based benefit reimbursement for behavioral health and for complex consumers continued to increase. The health plans reporting using some pay-for-performance reimbursement increased from 86% of all health plans to 93%. But the more important development was in the use of reimbursement models with more risk. Bundled payments have increased from 39% to 59%; 60% of health plans reported using case rates and 64% had some form of provider capitation.

Consumer access to behavioral health is key—Developing access strategies that help consumers get behavioral health services faster is high on the list. Eighty-five percent of health plans are using telehealth and 70% have instituted “quick access” programs; 78% are providing support for appointment scheduling.

And, beyond improving access for consumers who self-identify with behavioral health needs, 84% of health plans reported having strategies to identify consumers with behavioral health needs (compared to 16% in 2017) and promote early intervention. This reflects a growing trend to use analytics to identify those consumers, with 90% of health plans making an investment in population health-focused analytic systems.

For consumer engagement, think technology—Health plans are increasing their investment in consumer engagement, with significant increases in engagement-focused technologies. Fifty-nine percent have adopted some type of engagement strategy for consumer with complex needs, 35% of health plans reported investing in on-line tools (up from 21% in 2017). Investment in mobile apps went from 9% to 38% in the same time period, and consumer self-management tools are up from 15% to 23%.

Investment in initiatives to improve quality of care for consumers with behavioral health conditions growing—In addition to these investments in care coordination, access, and engagement, health plans also reported investing in several programs to improve quality of care. Health plans reported exploring a number of concepts: behavioral health centers of excellence (85% of plans), patient-centered medical homes (86%), peer-directed service credentialing (51%), peer-directed service network inclusion (51%), provider rating transparency (53%), provider cost transparency (52%); and narrow tiered network designs (63%).

At this point in time, the programs that health plans put in place to serve consumers with chronic conditions and complex needs are critical to provider organization strategy. There are two related reasons—most of those consumers get their health services through a health plan and those consumers use about 90% of the service resources.

So, what are the implications for provider organizations strategy? First, consumer performance metrics are critical to be a preferred health plan partner—how easily (and fast) can consumers get appointments? How engaged are those consumers in managing their health? And, the ability to accept non-traditional reimbursement (performance-based, value-based, etc.) is a requirement—particularly for competing for contracts for the more innovative programs. Lastly, the impact of technology on the consumer care continuum continues, with more disruption to traditional services models ahead.

For a very deep dive, download your own copy of the new survey results—Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System. And for more on marketing to and managing your relationships with health plans, check out these resources from the PsychU Resource Library:

  1. The Impact Of Opioid Use Disorders & The National Response
  2. Adjust Your Strategic Sails!
  3. The Five-Step Process To Demonstrate Your “Performance” To Health Plans
  4. Becoming A ‘Blue Chip’ Provider Organization

Forty states and the District of Columbia (D.C.) have passed laws that expanded telemedicine coverage or reimbursement since 2017. Those states that have not expanded coverage include Alabama, Colorado, Idaho, Michigan, Montana, New Mexico, Ohio, Oklahoma, South Carolina, and West Virginia.

These findings were presented in “2019 State of the States Report: Coverage and Reimbursement,” by the American Telemedicine Association (ATA). Researchers for the ATA reviewed consumer settings, different technologies, provider organization types, and unique policies regarding reimbursement and coverage of telehealth services in the 50 states and D.C. The goal was to determine trends in telehealth coverage, parity policies, provider organization restrictions, and telehealth limitations in the U.S.

Additional findings include:

  • 36 states and D.C. have parity policies for private payer coverage; only 21 states and D.C. have coverage parity policies in Medicaid.
  • 13 states have not adopted private payer parity policies: Alabama, Florida, Idaho, Illinois, Louisiana, Massachusetts, North Carolina, Ohio, Pennsylvania, South Carolina, West Virginia, Wisconsin, and Wyoming.
  • 28 states have Medicaid payment parity policies; only 16 mandate payment parity for private payers.
  • 19 states have not adopted parity policies: Alabama, Alaska, Arizona, Connecticut, Florida, Georgia, Idaho, Illinois, Louisiana, Michigan, Montana, New Hampshire, Ohio, Oklahoma, Pennsylvania, Rhode Island, Virginia, Washington, and West Virginia.
  • The majority of states have no restrictions around eligible provider types: 10 states (Arizona, Connecticut, Delaware, Georgia, Idaho, Kansas, Kentucky, Minnesota, New York, and Wyoming) have authorized six or more types of provider organizations to treat consumers through telehealth. Some of the more common telehealth provider types include: physicians, physician assistant, nurse practitioner, licensed mental health professional, occupational therapist, physical therapist, psychologist, and/or dentist.
  • Only 16 states limit telehealth to synchronous technologies (the delivery of health information in real-time), while most of the country recognizes the benefits of remote patient monitoring (RPM) and store and forward (S&F). RPM is a technology to enable monitoring of consumers outside of conventional clinical settings. S&F is the collection of clinical information to send electronically to another site for evaluation.

The full text of “2019 State of the States Report: Coverage and Reimbursement” was published July 18, 2019 by the American Telemedicine Association (ATA). An abstract is available online at https://www.americantelemed.org/initiatives/2019-state-of-the-states-report-coverage-and-reimbursement/ (accessed August 12, 2019).

PsychU last reported on telemedicine payment coverage in “Health Plan Telemedicine Visit Volume Increased 52% Per Year Between 2005 & 2017,” which published on May 6, 2019. The article is available at https://www.psychu.org/health-plan-telemedicine-visit-volume-increased-52-per-year-between-2005-2017/.

For more information, contact: Amy Gaddis, Director, Marketing and Communications, American Telemedicine Association, 901 North Glebe Road, Suite 850, Arlington, Virginia 22203; 703-373-9600; Email: agaddis@americantelemed.org; Website: https://www.americantelemed.org/

Copayments and deductibles used to be a small issue. The $1 here or $20 there. Not anymore. Consumers now pay 30% of total health care costs.1 There are now health plans with $7,150 deductibles for individuals and twice that for families.2

3Overall consumer out-of-pocket (OOP) for hospital services rose 12% during 2018 across inpatient, outpatient, and emergency department services; average OOP costs rose from $1,813 in the fourth quarter of 2017 to about $2,030 in the fourth quarter of 2018. The share of consumers with average per-visit OOP costs above $501 also rose, from 51% in 2017 to 64% in 2018. The rising costs for all three settings were:

    1.  Inpatient OOP costs averaged $4,659 in 2018, up 14% from $4,086 in 2017.
    2.  Outpatient OOP costs averaged $1,109 in 2018, up 12% from $990 in 2017.
    3.  Emergency department visit OOP costs averaged $617 in 2018, up 7% from $577 in 2017.

One of the results of these rising consumer costs has also surprised me—Americans are using crowdfunding to pay their bills. The Los Angeles Times recently reported on one family that resorted to “T-shirt sales, a home run tournament, a benefit concert and an online GoFundMe campaign” to raise funds for a boy who needed 53 surgeries and 800 days in the hospital.4

The rise in consumer payments has also gotten the attention of legislators and policy makers, including a push in Congress “to end surprise medical bills, curb high prices for medicines, and limit prescription copays for people with Medicare”.5 The Trump Administration has also proposed new rules to provide consumers more transparency about the prices hospitals charge insurers6, while a new California policy has stopped surprise medical bills7, which are defined by The Brookings Institution as when consumers “receive care from out-of-network providers that they did not choose” and “receive a “surprise” out-of-network bill”.8

The question for many provider organization executives is how to factor a larger proportion of revenue coming from consumer OOP? How do you ensure that you can collect the payments? Most executive teams don’t think about consumers paying for services because we have long had a health care financing system that relies on third-party payment. In an environment that relies more heavily on consumer OOP, provider organizations need the ability to estimate those expenses, present a bill at the point of service, and collect immediately. Success relies on having policy and procedures in place that recognize why consumers might not pay, and identifying the right timing for the right assertiveness in collecting those payments.

How to prepare? Joseph P. Naughton-Travers, Senior Associate at OPEN MINDS noted that provider organization managers need to focus on three key elements:

Invest in a good electronic health record and billing system—Provider organizations can’t be successful at collections if they can’t keep track of exact amount consumers owe for their portions of payment.

Collect in real time—Policy and practice should be focused on collecting payment; in advance if possible, or immediately at the time of service.

Cash isn’t the only payment option—Invest in the infrastructure necessary to accept credit cards or other forms of payment. Provider organizations can also partner with a company that offers credit services to aid consumers in paying for services (this is commonly done in dentist and other doctor settings).

For more, check out these resources from the PsychU Resource Library:

    1. Integration, Interoperability & Consumer Engagement
    2. The Next Wave Of Consumer Price Shopping For Health Care
    3. Make Change Or Be Changed
    4. The Big Rewards Of Health Care Through The Consumer Lens
    5. Answering The Question – Who Can Afford Their Health Services?

Since the signing of the Patient Protection and Affordable Care Act (PPACA), accountable care organizations have grown in popularity, with 17.2 million beneficiaries in commercial ACOs and 14.6 million in Medicare ACOs. But there is another category that, while slower in growth, has gained an increasing amount of support at the state level—Medicaid ACOs.

At the start of 2018, there were 1,000 ACOs covering 32.7 million consumers—approximately 11% of the U.S. insured population (294.6 million)—under 1,477 different.1 According to a new report from Leavitt Partners, by the end of 2018 there were 1,013 ACOS, 86 of which were Medicaid ACOs and covering 3.7 million lives (or 5% of the Medicaid population.2 While this doesn’t seem like much, in the last three years the number of Medicaid ACOs has grown by 40% and are now present in 13 states.

And a quick scan of the environment finds examples of states continuing to make big investments in this model. This summer, the Oregon Health Authority (OHA) announced its intent to award 15 organizations contracts, valued at $6 billion, to serve as Medicaid coordinated care organizations (CCO) for the Oregon Health Plan. If you are unfamiliar with it, the CCO model was established in 2012; the CCOs were required to subcontract with the public behavioral health system in each county, and by 2024, 70% or more of CCO payments will be through value-based reimbursement. CCOs will also be required to spend 12% of total medical expenditures on primary care by 2023.3

In Minnesota, the Department of Human Services (DHS), Health Care Administration issued a request for proposals (RFP) to expand Medicaid Integrated Health Partnerships (IHP) with new care delivery models in new geographic regions (see Minnesota To Expand Medicaid Integrated Health Partnerships With New Care Delivery Models In New Geographic Regions). Now in its sixth year, the IHP program has grown from 11 sites and 100,000 beneficiaries, to 24 sites and 460,000 beneficiaries, as well as achieved $213 million in savings.4

Why this push? It’s in the numbers. 5According to a recent report from RTI International on states participating in the SIM Initiative, ACO programs in Maine, Vermont, and Minnesota had a positive impact on emergency department visits:

  1. Reduced the rate of overall emergency department visits by 3% (Maine), 5% (Vermont), and 7% (Minnesota)
  2. Reduced the rate of emergency department visits for beneficiaries with behavioral health conditions by 2% (Maine), 6% (Vermont), and 5% (Minnesota)

There is specific market challenge for specialty provider organizations with a high proportion of revenue from Medicaid in those states with pending Medicaid ACOs. ACO models are largely driven by hospital systems—and have a history of “building” specialty services rather than “buying” them. Executives of these specialty provider organizations will need to understand the ACO “roadmap” in their state and develop a strategy to “plug into” that new consumer service system.

For more specifics on Medicaid ACO models, see Helping ACOs Fill In The Complex Consumer Blanks. And for more on the market impact of ACOs and related market strategy, check out these resources in the PsychU Resource Library:

  1. How To Build Successful ACO Health Plan Partnerships
  2. Building The ‘Next Generation’ Behavioral & Social Service ACO
  3. New ACO Developments, Same Challenges
  4. 62% Of ACOs Launched In 2012 Implemented Behavioral Health Initiatives
  5. 61% Of ACO Contracts Only Include Upside Financial Risk
  6. Most ACOs Not Ready For Two-Sided Risk Model
  7. Half Of ACOs Consider Exiting MSSP Over New Downside Risk Rules

1 https://revcycleintelligence.com/news/after-a-slow-2017-acos-grow-and-expand-their-contracts-in-2018

2 https://leavittpartners.com/press/leavitt-partners-releases-the-medicaid-aco-landscape-white-paper/

3 https://www.chcs.org/we-need-more-data-on-medicaid-acos-to-determine-drivers-of-success/

4 https://tincture.io/sdoh-doncha-know-innovation-lessons-from-minnesotas-medicaid-aco-program-30f5ed7e6ed6

5 https://downloads.cms.gov/files/cmmi/sim-rd1-mt-fifthannrpt.pdf

In 2018, one-third of accountable care organizations (ACOs) had at least one contract with downside risk of loss if they failed to meet savings targets. In 2012, 28% of ACOs had contracts with two-sided risk. The ACOs taking on downside risk were less likely to be physician-led, and were more likely to have previous experience with risk-bearing contracts in the past.

These findings were reported in “ACO Contracts With Downside Financial Risk Growing, But Still In The Minority” by Kristen A. Peck, Benjamin Usadi, Alexander J. Mainor, Elliott S. Fisher, and Carrie H. Colla. The researchers are affiliated with Dartmouth’s Geisel School of Medicine; the study was published in the July 2019 issue of Health Affairs. The researchers analyzed the National Survey of ACOs to identify trends in ACO structure and contracts for 2012 through 2018. The survey was sent to 862 ACOs of the 1,011 operating in 2018; about 55% responded to the survey.

According to a press release issued by the Dartmouth Institute about the study findings, “In 2018, there were more than 1,000 ACOs nationally, covering an estimated 33 million lives and including more than 1,400 different payment arrangements.” The researchers found that the ACOs with two-sided risk contracts were more likely to have participating provider organizations experienced with other types of alternative payment agreements.

Between 2012 and 2018, the number of Medicare ACOs rose from 154 in 2012 to 561 in 2018. However, the share accepting downside risk has not grown at the same pace. The researchers concluded that success of the ACO model may need stronger financial incentives. They noted that the proportion of ACOs taking on downside risk is likely to increase because the Pathways to Success program requires ACOs to move toward risk bearing more quickly.

The full text of “ACO Contracts With Downside Financial Risk Growing, But Still In The Minority” was published in the July 2019 issue of Health Affairs. An abstract is available online at https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.05386?journalCode=hlthaff (accessed August 5, 2019).

PsychU reported on the new Pathways to Success model in “CMS ‘Pathways To Success’ Medicare ACO Overhaul Limits ACO Time Without Risk” on January 28, 2019. The article is at https://www.psychu.org/cms-pathways-success-medicare-aco-overhaul-limits-aco-time-without-risk/.

For more information, contact:

  • Tim Dean, Research Communications Manager, Office of Communications and Marketing, Geisel School of Medicine, 1 Rope Ferry Road, Hanover, New Hampshire 03755-1404; 603-650-1225; Email: timothy.s.dean@dartmouth.edu; Website: https://geiselmed.dartmouth.edu/
  • Sue Ducat, Director of Communications, Health Affairs, 7500 Old Georgetown Road, Suite 600, Bethesda, Maryland 20814; 301-841-9962; Email: sducat@projecthope.org; Website: healthaffairs.org/1520_staff.php

The Centers for Medicare & Medicaid Services (CMS) has changed how it will manage the overlap between the Bundled Payments for Care Improvement (BPCI) Advanced program and the Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs). For Model Year 3, which starts on January 1, 2020, provider organizations participating in both an Enhanced ACO (Track 3) and BPCI Advanced (BPCI-A), when they treat a beneficiary receiving services in a BPCI Advanced bundle, the reconciliation will attribute the beneficiary to the owner of the bundle, not to the ACO. Previously, overlap beneficiaries were attributed to the ACO.

The revision accounts for changes to ACOs due to the Pathways to Success ACO initiative and addresses how Medicare will avoid overlap and “double counting” of beneficiaries attributed to an ACO as well as who receives a BPCI-A clinical episode of care from a provider organization participating in BPCI-A. This change only affects Enhanced ACOs; NextGen ACOs will still take precedence over the BPCI-A program.

CMS discussed the changes in “Medicare Bundled Payments For Care Improvement Advanced Model Year 3: General Frequently Asked Questions (FAQ) –Update June 2019.” For purposes of Model Year 1 and 2 Reconciliation calculations, BPCI Advanced includes expenditures for items and services furnished to beneficiaries assigned to SSP Tracks 1, 1+, 2, and the Pathways to Success ACO BASIC track (all levels A through E). Items and services furnished to beneficiaries aligned to Pathways to Success Enhanced track ACOs (formerly known as Track 3) will be excluded from reconciliation calculations.

For participants with clinical episodes, the span between BPCI model years 2 and 3, CMS will apply the BPCI Advanced Model Year 1 and 2 MSSP overlap policy to clinical episodes with a date of discharge from the anchor stay or completion of the anchor procedure on or prior to December 31, 2019. BPCI clinical episodes that have a date of discharge from the anchor stay or completion of the anchor procedure on or after January 1, 2020, will fall under the BPCI Advanced Model Year 3 MSSP overlap policy.

Prior to this, clinical episodes in BPCI Advanced were excluded for Medicare beneficiaries aligned to Next Generation ACOs, ACOs participating in the Vermont Medicare ACO Initiative, Track 3 MSSP ACOs, or organizations participating as Comprehensive End Stage Renal Disease Care (CEC) Seamless Care Organizations with downside risk. The BPCI clinical episodes were not excluded for beneficiaries attributed to an ACO in tracks previously called Tracks 1, 1+, and 2.

In BPCI Advanced Model Year 3, ACOs can participate in BPCI Advanced as a Convener Participant. Health care provider organizations participating in BPCI may also add ACOs to the BPCI financial arrangements list (FAL) as an organization with which the BPCI participant has a financial arrangement. Beginning January 1, 2020, health care provider organizations participating in BPCI Advanced model year 3 will take precedence over Medicare ACOs in the enhanced track, which has the most downside risk.

Under BPCI Advanced, risk-bearing entities called Convener Participants or Non-Convener Participants enter into direct agreements with CMS. Individual “Participating Practitioners” are Medicare-enrolled physicians and non-physician clinical professionals who participate in BPCI Advanced by furnishing direct care for Medicare fee-for-service beneficiaries during a BPCI clinical episode. The Participating Practitioners enter into agreements with the Convener and Non-Convener Participants. A clinical episode generally triggers the start of the bundle.

However, not every Medicare beneficiary triggers a clinical episode because of beneficiary eligibility exclusions. BPCI Advanced excludes clinical episodes for Medicare beneficiaries covered under United Mine Workers or managed care plans; beneficiaries eligible for Medicare because they have end stage renal disease (ESRD); beneficiaries for whom Medicare is not the primary payer; and beneficiaries who die during the episode Anchor Stay or Anchor Procedure.

PsychU last reported on the ACO changes in “CMS ‘Pathways To Success’ Medicare ACO Overhaul Limits ACO Time Without Risk,” which published on January 28, 2019. The article is available at https://www.psychu.org/cms-pathways-success-medicare-aco-overhaul-limits-aco-time-without-risk/.

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Email: press@cms.hhs.gov; Website: https://www.cms.gov/

Many executive teams of specialty provider organizations are working to iron out preferred relationships with health plans – relationships that are most often anchored in some type of pay-for-performance or value-based model. Getting contracts for these new relationships is only part of the story, actually successfully managing the contracts is other half of equation.

So what is involved with success with value-based arrangements? Ken Carr, a Senior Associate at OPEN MINDS explains how to build an infrastructure that supports performance management. Mr. Carr outlines four types of outcomes that every organization needs to focus on to build a performance management infrastructure that is capable of supporting VBR.

Contract-Specific Performance Measures – These measures are the floor for success in measuring value. They will vary based on contracts with payers—and reflect what those payers see as the most important and most costly. Health plans and accountable care organizations will be focused on the outcomes they are accountable for to achieve to receive maximum reimbursement, making these measures paramount to the contact’s success. This may appear to be the most straightforward type of performance outcomes for a provider organization to track, but most organizations are working with multiple payers, health plans, and programs—each with their own set of measures. For an organization that contracts with multiple health plans and accountable care organizations; has multiple contracts with each of those health plans; manages a health home; receives grants with program-specific measures; and/or participates in other state programs—these standard contract-specific measures quickly add up. To manage these requirements, organizations need to have a robust technology and operational infrastructure in place for tracking and reporting on all these measures.

Routine Services & Transactions – Routine performance measures are about fulfilling the baseline expectations of running a successful business—making services convenient and affordable. Over the past decade, consumers have come to view health care like any other service, and this has shifted expectations. Organizations need to have services and programs that are easily accessible and meet the needs of consumers—the traditional processes and programs may no longer be what consumers want, making it necessary to adapt and meet consumers “where they are,” not where you think they should be. Organizations can measure their service offering by tracking the number of inquiries, inquiry response time, inquiry conversion rates, time to appointment, and service/program costs.

Great Customer Service – The health and human service market is increasingly driven by consumerism. As consumers are responsible for more of their health care costs, consumer price transparency is becoming the standard and consumer experience and engagement have become an essential component of service delivery. For provider organizations management teams, measuring good customer service is about keeping consumers satisfied in all their interactions with your organization so that you can create “passionate advocates” of your brand. To do this, organizations need to develop a written service strategy to ensure consistency of consumer experience and cultivate consumer loyalty. Start this process by reviewing processes and procedures to ensure that workflow is designed from a consumer experience perspective. The goal is to make consumers feel valued and satisfied in their interactions with your organizations—not like they are simply another “transaction.”

Cutting-Edge Expertise – As the “expert”, consumers expect provider organizations to be their advisor on the latest medical science and best practices. Organizations and clinical professionals have a responsibility to understand the new science in their area of specialization and to evaluate emerging treatment models and technologies in a timely manner, and wherever possible integrate those innovations into their program models. Clinical expertise and innovation is the foundation for all clinical outcome measures, with the ultimate goal that organizations can deliver a consistent treatment model that produces consistent results without unexplained variability in clinical performance outcomes.

Is your organization ready to measure and manage under this new value equation? For most specialty provider organizations, the answer isn’t simple. Many organizations have put forth a lot of effort into getting up to speed on contract-specific performance measures, leaving behind the others. But all four of these types of outcomes fold together and build on one another—and you can’t successfully manage a value-based contract without a focus on the four as a unit.

Check out some of our new resources on performance-based contracting:

  1. Successfully Managing Bundled Rates-The Voice Of Experience
  2. Where Wellness & Prevention Fit In A Value-Based World
  3. Implementing Measurement-Based Care-From Idea To Action
  4. Developing Case Rates? Better Find Your ‘Single Source Of Truth’
  5. Why Clinical Guidelines Matter More With Risk-Based Contracting
  6. Most Common Data Exchange For Office-Based Physicians – Referrals, Lab Results & Medication Lists
  7. Ready For Risk? How Would Your Team Answer That Question?

Last year, PsychU reported that voters in three states—Idaho, Nebraska, and Utah—passed ballot initiatives to fully expand Medicaid to individuals up to 138% of the federal poverty level (see Voters In Idaho, Nebraska & Utah Passed Ballot Measures To Expand Medicaid). Despite what appears to be similar initiatives, each state has chosen their own path to implement the Medicaid expansion. And what this means for provider organizations is a continued bifurcation of state Medicaid programs, bringing along its own set of challenges.

What exactly is happening?

Nebraska

Nebraska plans to extend benefits to the Medicaid expansion population beginning in October 2020. Although the state submitted a state plan amendment to the Centers for Medicare & Medicaid Services (CMS) to expand Medicaid, the state also intends to submit a 1115 waiver application. The application will create a non-traditional Medicaid expansion program based around two benefit packages – a Basic benefit package and a Prime benefit.

The Basic benefit package will include most Medicaid services except vision, dental, and over-the-counter medications. The Prime package will include these services. In order to qualify for Prime after the first year, enrollees will have participated in active care and case management, selected a primary care provider, and had a wellness check-up. In year two, individuals will need to continue to meet these requirements, as well as 80 hours of community engagement activities to retain Prime coverage. Individuals who do not meet the requirements will return to the Basic benefit.

Idaho

Idaho also intends to expand Medicaid to individuals up to 138% of the federal poverty level (FPL), but plans to allow the expansion population the choice of financing and delivery systems. The state is in the process of collecting public comments on a 1115 demonstration waiver that will allow individuals with income between 101-138% of the FPL to choose between enrolling in a health insurance marketplace plan and receiving tax credits or enrolling in traditional Medicaid. Medicaid expansion will occur on January 1, 2020 and if the waiver is not approved, everyone will be enrolled in traditional Medicaid.

Utah

Utah has a multi-step expansion plan that began on April 1, 2019 with the Bridge Plan. The state legislature chose to only expand Medicaid to individuals up to 100% of the FPL instead of the full 138% and if enrollment exceeds the state budget targets, enrollment can be closed. Currently these individuals are receiving full coverage through the fee-for-service (FFS) system. Individuals will be enrolled in the Medicaid health plans where available starting in January 2020. The state is also considering testing the integration of physical and behavioral health financing for this population. In January 2020, the state will also implement community engagement/work requirements.

This month, the state will also submit a 1115 waiver to CMS known as the Per Capita Plan. The plan will continue the expansion of Medicaid coverage to adults up to 100% FPL and will request the following provisions: work/self-sufficiency requirement, authority to cap expansion enrollment, up to 12-month continuous eligibility, required enrollment in employer’s plan with premium reimbursement, lock-out for intentional program violation, use federal funds for housing supports, and use of federal funds limited by per capita cap. If this request is not approved by CMS by January 2020, the state will submit the Fallback plan, which expands coverage up to 138% of the FPL and includes a self-sufficiency requirement, require enrollment in employer’s plan with premium reimbursement, and lock-out provision for intentional program violations. Finally, if this is not approved by July 2020 then the state will implement a traditional expansion.

While these approaches may seem disparate what they all have in common is that they put an above average administrative burden on consumers and provider organizations. In Idaho, the onus is put on the consumer to educate themselves and understand the difference between the health insurance marketplace and Medicaid. In Utah and Nebraska, not only do consumers have to apply for and maintain eligibility for services, they have to report meeting work requirements. And in Nebraska, they have to understand the point of participating in care coordination and how it effects their benefits.

Because of this increased complexity, consumer education in the selection of and use of benefit plans is needed. While the state will be required to provide some education, most of the burden will fall on provider organizations. Provider organizations first need to educate staff on these new requirements and then provide coaching and materials to staff to help explain the programs to consumers.

Finally, in the case of Utah, we are seeing the first test of a cap on the per person contribution the federal government will take towards Medicaid. Some may even argue, that is the first move towards transitioning Medicaid from an entitlement program. Whether or not the per capita cap will be approved remains to be seen (and its likely to be challenged). But, it represents the increasing bifurcation among state thinking on Medicaid and some states are pressing models that limit spending and enrollment in state Medicaid programs. For example, Tennessee is planning to seek federal approval to turn their program into a Medicaid block grant (see Tennessee To Seek Medicaid Block Grant). This will likely increase the uninsured/underinsured population and result in a higher need for safety-net services.

During the first year of the federal Comprehensive Primary Care Plus (CPC+) demonstration, which began in 2017, the median supplemental care management payments from the 63 participating payers to the 2,905 participating practices, with 13,209 clinical professionals, exceeded $32,000 per professional. For primary care practices participating in Track 1, the median care management fees exceeded $88,000, or about $32,000 per primary care professional. For practices participating in Track 2, the median care management fees exceeded $195,000, or about $53,000 per primary care professional.

For both tracks, about 76% of care management fee payments were for about 2.2 million Medicare fee-for-service (FFS) beneficiaries who represented about 36% of consumers served by the CPC+ practices. The remaining 24% of total care management fees were paid by state Medicaid plans or commercial insurers. In addition to care management fees, CMS and most other payers also provided CPC+ practices with payments to reward performance on utilization of service, cost, and/or quality-of-care measures.

These findings were reported in “Independent Evaluation of Comprehensive Primary Care Plus (CPC+): First Annual Report” by Deborah Peikes, Grace Anglin, Mary Harrington, Arkadipta Ghosh, Kristin Geonnotti, et al. This is the first-year CPC+ report submitted to CMS. The researchers focused on practice and provider organization participation, supports the practices received, how practices implemented CPC+ and changed the way they delivered services, and the impact of CPC+ on cost, service use, and limited claims-based quality-of-care outcomes for attributed Medicare FFS beneficiaries.

CPC+ is a five-year nationwide, multi-payer primary care medical home (PCMH) model that launched in January 2017. In total, 3,070 primary care practices located in the 18 CPC+ regions have joined CPC+ as well as 79 payers. During the first year, 2,905 practices participated; these practices have 13,209 primary care professionals who serve about 15 million consumers, including about 2.2 million Medicare FFS beneficiaries, and 3.3 million attributed by other payers. The remaining 9.7 million consumers were not attributed by a CPC+ participating payer, were covered by a non-participating payer, or were uninsured. The participating practices range in size from one to 80 primary care professionals.

The CPC+ participating practices help consumers, including those with serious or chronic diseases, achieve their health goals; provide consumers with 24-hour access to care and health information; deliver preventive care; engage consumers and families in self-care; and collaborate with hospitals and other clinicians, including specialists, to provide better-coordinated care. The payers have agreed to use a similar methodology to reimburse the CPC+ participants for delivering the PCMH services. The payers provided the CPC+ practices with enhanced and alternative payments, data feedback, and learning activities to support primary care transformation.

There are two CPC+ tracks. In Track 1, the participating primary care provider organizations received a per beneficiary per month (PBPM) care management fee averaging $15. In Track 2, the PBPM care management fee averaged $28, and Track 2 also receives a Comprehensive Primary Care Payment (CPCP) which replaces a proportion of their payments for some evaluation and management services upfront. Both tracks continue to receive Medicare FFS as usual. Provider organizations in either track are eligible for prospective performance-based incentive payments based on utilization, quality, and experience of care components. Compared to Track 1, practices in Track 2 are required to make more advanced care delivery changes to improve the care of complex consumers. In support of this, practices in Track 2 receive more financial support and a greater shift from FFS toward population-based payment. Track 2 requires advanced health IT capabilities.

The CPC+ practices also partnered with one or more of 66 health information technology vendors to help them use health IT to improve primary care. The five largest health IT vendors partnered with about 80% of Track 2 practices.

CMS and 90% of the other payers provided data feedback to practices on utilization of services, quality of care, and/or cost of care. The payers committed to developing a common approach to quality measurement and data feedback. By the end of 2017 payers in three regions (Colorado, Ohio/Northern Kentucky, and Oklahoma) were providing CPC+ practices with a single report or tool that presented all payer-data for the region.

CMS and 84% of the other payers provided learning support to practices. The CMS learning activities sought to provide information and resources, and to promote peer learning among the practices. These activities included webinars, a social networking platform, in-person meetings, and tailored one-to-one and small group practice coaching. CMS group learning was offered to all CPC+ practices, and in-person practice coaching was provided to 74%.

The CPC+ practices started changing care delivery during 2017. Many focused on risk stratifying consumers to identify those who needed more intensive care management, and they focused on hiring and deploying care managers, as well as integrating behavioral health into primary care. To meet the goal of providing comprehensive services, many practices used strategies consistent with the Primary Care Behaviorist model in which a behavioral health professional (psychologist or clinical social worker) is integrated into the primary care workflow through warm handoffs and co-location. Integrated behavioral health services were optional for Track 1 practices, and mandatory for Track 2 practices. Track 2 practices were also required to work on identifying and addressing consumer social needs. During 2017, 67% of the Track 2 practices reported that they incorporated screenings for social needs, such as housing, food insecurity, and transportation, into their electronic health records.

The researchers noted that as expected, during the first year, CPC+ had minimal effects on Medicare FFS beneficiaries during 2017. Compared to the prior year, and relative to a comparison group of similar practices, beneficiaries served by CPC+ practices had 1.2% to 1.6% fewer outpatient emergency department visits. They had slightly slower rates of growth in primary care ambulatory visits, at 1.6% to 1.8%. They had slightly larger improvements in claims-based quality of care measures for recommended services for beneficiaries with diabetes and for breast cancer screening compared to beneficiaries served by comparison practices. CPC+ had no statistically significant effects on acute hospitalizations, ambulatory visits to specialists, 30-day readmissions, or the proportion of beneficiaries who had hospice use or an advance care plan visit. CPC+ did not alter total Medicare FFS expenditures without the enhanced CPC+ payments. Because these findings reflect only the first year of the model, more time is needed to determine the ultimate effects of CPC+

The full text of “Independent Evaluation of Comprehensive Primary Care Plus (CPC+): First Annual Report” was published April 22, 2019, by Mathematica. An abstract is available online at https://www.mathematica-mpr.com/our-publications-and-findings/publications/independent-evaluation-of-comprehensive-primary-care-plus-cpc-first-annual-report (accessed July 29, 2019).

PsychU last reported on this topic in “CMS Selects 14 Regions For All-Payer Comprehensive Primary Care Plus Demonstration,” which published on September 7, 2016. The article is available at https://www.psychu.org/cms-selects-14-regions-payer-comprehensive-primary-care-plus-demonstration/.

For more information, contact: Deborah Peikes, Ph.D., MPA, Senior Fellow, Mathematica Policy Research, 600 Alexander Park, Suite 100, Princeton, New Jersey 08540; 609-750-2005; Email: dpeikes@mathematica-mpr.com; Website: https://www.mathematica-mpr.com/.

The World Health Organization (WHO) defines Social determinants of health (SDoH) as “The conditions in which people are born, grow, live, work and age.  Variability in the population health drivers noted above result in health inequities.  For example, lack of education or poor health and social supports –as well as access to services and transportation—can result in deteriorating health, substance use disorders and a growing number of challenges to sustain health.1

In Part II of the SDoH Series, the presenters explain how payers and providers acknowledge SDoH and provide one case study on how SDoH can be used for value-based reimbursement.

Featuring:

  • Bill Maroon, MSW
    Director of Business Development and Innovation, Resources for Human Development (RHD)
  • Deb Adler, MA, CPHQ
    Senior Associate, OPEN MINDS

Bill Maroon, MSW, is the Director of Business Development and Innovation for Resources for Human Development (RHD). Over the last 25 years, Bill Maroon has worked for various non-profits organizations at the cross-section of housing, homelessness and healthcare.  Bill has experience in street outreach, Assertive Community Treatment (ACT) teams, housing first, supportive housing, case management and integrated health care. Over the last 4 years, Bill has been an integral part of negotiating, developing and implementing 4 ACT teams, as well as other programs focusing on social determinants of health for RHD..

Mr. Maroon has a Master’s Degree in Social Work Administration from Temple University.

Deb Adler, MA, COHQ, is a Senior Associate at OPEN MINDS. Deb Adler has more than 20 years of experience in executive health care roles, serving in a variety of capacities including network executive, quality management executive and chief operating office. She is the Former Senior Vice President of Network Strategy for Optum, where she was responsible for behavioral health network development, contracting, and strategy for over 185,000 providers. In this role she developed the largest, performance-tiered behavioral health network, largest telemental health network, and largest medication assisted treatment (MAT) network. She was also responsible for implementing network initiatives to promote medical/behavioral integration, improve member outcomes, and reduce total cost of care through collaborative care models.

Ms. Adler earned her MA in psychology and evaluation from Catholic University of America and is a Certified Professional in Health Care Quality (CPHQ).

On July 9, 2019, the Oregon Health Authority (OHA) announced its intent to award 15 organizations contracts, valued at $6 billion, to serve as Medicaid coordinated care organizations (CCO) for the Oregon Health Plan (OHP). OHA is now conducting a readiness evaluation before finalizing the contracts in the fall of 2019. Eleven of the organizations were selected for five-year contracts, and four were selected for one-year contracts. The new CCO contract services start January 1, 2020. The CCOs function as Medicaid managed care organizations (MCOs) that provide coordinated physical, behavioral, and oral health care. Nearly 87% of Oregon’s 1 million OHP members are enrolled in CCOs.

OHA established the CCO model in 2012. In those contracts, the CCOs were required to subcontract with the public behavioral health system in each county. OHA released the CCO 2.0 request for applications on January 25, 2019; applications were due by April 22, 2019. The service areas in these next CCO contracts have different boundaries than the previous contracts, which followed ZIP Codes. The new CCO contracts will be primarily based on county line boundaries, which is intended to align the CCO services with the county behavioral health and public health infrastructure, school districts, and the justice system. However, OHA did allow exceptions to the county-wide service areas when applicants could demonstrate that there were benefits to members, providers and the community in granting the requested service area. Under the next CCO contracts, every county will have at least one CCO to coordinate OHP member health care. The CCOs will be fully accountable for the behavioral health benefit, including developing a person-centered mental health and addiction disorder system.

The four organizations selected for one-year contracts will initially be placed on remediation plans and will have up to one year to show they can meet the higher expectations of the new contracts; each will receive technical support from OHA. Those that meet the new contract goals will be offered extensions. The five-year contracts will run through 2024.

Oregon CCO 2.0 Contract Awardees
Awardee Contract Length Service Area
AllCare CCO, Inc. 1 year Curry, Jackson, and Josephine; partial Douglas
Cascade Health Alliance 1 year Partial Klamath County
Columbia Pacific CCO, LLC 5 years Clatsop, Columbia, and Tillamook
Eastern Oregon Coordinated Care Organization, LLC 5 years Baker, Gilliam, Grant, Harney, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, and Wheeler
Health Share of Oregon 5 years Clackamas, Multnomah, and Washington
InterCommunity Health Network, dba, InterCommunity Health Network Coordinated Care Organization 5 years Benton, Lincoln, and Linn
Jackson County CCO, LLC, dba, Jackson Care Connect 5 years Jackson County
PacificSource Community Solutions – Central Oregon 5 years Crook, Deschutes, and Jefferson; partial Klamath County
PacificSource Community Solutions – Columbia Gorge 5 years Hood River and Wasco
PacificSource Community Solutions – Lane 5 years Lane County
PacificSource Community Solutions – Marion Polk 5 years Marion and Polk
Trillium Community Health Plan Inc. (Trillium) 5 years Clackamas, Lane, Multnomah, and Washington; partial Douglas and Linn
Umpqua Health Alliance, LLC 1 year Partial Douglas County
Western Oregon Advanced Health, LLC abn Advanced Health 5 years Coos and Curry
Yamhill County Care Organization 1 year Yamhill; partial Polk and Washington

OHA rejected the application submitted by current CCO PrimaryHealth due to concerns reported in the organization’s financial review. Three new applicants were also denied contracts.

OHP members in all or part of Clackamas, Jackson (partial), Lane, Multnomah, Polk (partial), and Washington counties will have changes to their CCO choices. Current CCO Willamette Valley Community Health (WVCH), which serves OHP members in Marion and Polk counties and parts of Benton, Clackamas, Linn, and Yamhill counties, did not seek a new contract. WVCH’s contract will end December 31, 2019, and members will transfer to a new CCO.

The new CCO 2.0 contracts will focus on integrating physical, behavioral, and oral health. OHA will implement policies that expand programs that integrate primary care into behavioral health settings. Additionally, the CCOs will be required to support electronic health record adoption and access to electronic health information exchange.

The new contracts will also increase development of value-based payments (VBPs) to improve health outcomes, specifically in the areas of hospital care, maternity care, behavioral health, oral health, and children’s health care. By 2024, 70% or more of CCO payments should be through VBP arrangements, and each CCO will be required to meet annual VBP growth targets.

The CCOs will increase their investments in strategies to address social determinants of health and health equity, with the goal of eliminating systemic barriers to better health outcomes. For this effort, the partners will include the CCO members, local non-profit organizations, hospitals, local schools, and local public health departments. CCOs will be encouraged to increase their financial support of non-clinical and public health provider organizations. OHA will develop measurement and evaluation strategies to track outcomes for these investments. Community health assessments will be aligned with community health improvement plans to increase impact.

PsychU last reported on this topic in “Oregon Announces Next Medicaid Coordinated Care Organization Contracts Will Establish Service Areas Based On Counties,” which published on January 7, 2019. The article is available at https://www.psychu.org/oregon-announces-next-medicaid-coordinated-care-organization-contracts-will-establish-service-areas-based-counties/.

For more information, contact: Allyson Hagen, Strategic Communications Manager, Oregon Health Authority, 500 Summer Street NE, E-20, Salem, Oregon 97301-1097; 503-449-6457; Fax: 503-947-5461; Email: allyson.hagen@dhsoha.state.or.us; Website: https://www.oregon.gov/oha/ and https://www.oregon.gov/oha/OHPB/Pages/CCO-2-0.aspx.

On June 28, 2019, the Michigan Department of Health and Human Services (MDHHS) said it would cancel its pre-paid inpatient health plan (PIHP) contract with the Lakeshore Regional Entity (LRE) as of September 30, 2019. LRE is the PIHP for Allegan, Kent, Lake, Mason, Muskegon, Oceana, and Ottawa counties. MDHHS intends to keep the region intact, and will initiate temporary state management when the contract with LRE ends. MDHHS intends to establish a new PIHP in the region via a formal procurement process for fiscal year 2021; the estimated contract value is about $250 million.

For fiscal year 2020, which begins on October 1, 2019, MDHHS will contract with LRE’s behavioral health management subcontractor, Beacon Health Options (Beacon), to continue to provide managed care functions, such as service authorizations and utilization management support to the community mental health services programs (CMHSPs) in the region.

The Michigan PIHPs are managed care entities that administer Medicaid and other public behavioral health specialty services. LRE has contracted with Beacon since February 2019 to take over the managed care functions, while LRE provides administrative claims management, receives payments from the state, and submits service and cost data back to MDHHS.

MDHHS notified LRE of its intent to cancel the contract on April 25, 2019. MDHHS later received a response from LRE and met with multiple stakeholders in the region. However, after reviewing the response, MDHHS decided to terminate the contract. LRE expenses have exceeded its budget since 2015. MDHHS provided supplemental funding for fiscal years 2017 and 2018 when the shortfalls were $23.6 million and $15.9 million, respectively. LRE’s predicted budget shortfall for fiscal year 2019 is $16 million, which would require additional state funds. MDHHS said LRE also had performance problems that remained uncorrected, and its member outcomes were weaker than those of other regions in terms of inpatient hospitalization.

For the interim contract with Beacon, an MDHHS spokesperson said MDHHS intends to contract in a manner that would establish Beacon as a PIHP under federal regulations. The contract would include all public policy requirements currently in place for PIHPs, including consumer protections. MDHHS will establish a public board to oversee Beacon’s contract and ensure compliance and service delivery, in conjunction with MDHHS, which will hold the contract. Board membership will include representation from the community mental health centers, the counties, advocates, and individuals receiving services. The public board will ensure quality, timeliness of payments, and work with MDHHS to flag any issues as they emerge. MDHHS intends to support the board in fulfilling its oversight role for the region and quickly address any issues that may arise.

On June 28, 2019, LRE issued a critique of the MDHHS proposal and offered an alternative. LRE believes that its fiscal distress (and that of other PIHPs) is the result of systemic underfunding. It cited an analysis by the Community Mental Health Association of Michigan which found that PIHPs experiencing financial crises over the past four years received only a modest appropriation increase, although Michigan’s Medicaid expansion increased enrollment. LRE proposed that MDHHS establish a three-way contract with LRE and Beacon. The three-way contract would result in changes to the board of directors and the role of LRE staff relative to Beacon. This approach achieves MDHHS’s stated goals, and maintains the positive momentum achieved by LRE, Beacon, and the community mental health centers.

For more information, contact:

  • Lynn Sutfin, Public Information Officer, Michigan Department of Health and Human Services, Post Office Box 30195, Lansing, Michigan 48909; 517-284-4772; Email: SutfinL1@michigan.gov; Website: https://www.michigan.gov/mdhhs/
  • Marion Dyga, Executive Assistant, Lakeshore Regional Entity, 5000 Hakes Drive, Suite 250, Norton Shores, Michigan 49441; 231-769-2052; Fax: 231-769-2071; Email: mariond@lsre.org; Website: http://www.lsre.org/

Overall consumer out-of-pocket (OOP) for hospital services rose 12% during 2018 across inpatient, outpatient, and emergency department services. Average OOP costs rose from $1,813 in the fourth quarter of 2017 to about $2,030 in the fourth quarter of 2018. The share of consumers with average per-visit OOP costs above $501 rose from 51% in 2017 to 64% in 2018.

These findings were reported by TransUnion Healthcare in a presentation given at the 2019 Healthcare Financial Management Association Annual Conference, and covered in TransUnion Healthcare’s “Out-of-Pocket Costs Rising Even as Patients Transition to Lower Cost Settings of Care.” Researchers for TransUnion studied costs associated with hospital visits (inpatient, outpatient, and emergency department). The goal was to determine how hospital costs affect consumer OOP costs for consumers. Costs rose for all three settings, as follows:

  • Inpatient costs averaged $4,659 in 2018, up 14% from $4,086 in 2017.
  • Outpatient costs averaged $1,109 in 2018, up 12% from $990 in 2017.
  • Emergency department costs averaged $617 in 2018, up 7% from $577 in 2017.

The share of consumers with average per-visit OOP costs below $500 dropped from 49% in 2017 to 36% in 2018. The share  with average per-visit OOP costs between $501 to $1,000 rose from 39% in 2017 to 59% in 2018. The share with average per-visit OOP costs of $1,001 or higher rose from 5% in 2017 to 12% in 2018.

The researchers concluded that, due to the greater cost burden, consumers are now making more decisions about where they receive care based on costs instead of just the quality of care they receive. The researchers noted that consumers may face difficulties in paying their larger health care bills, and recommended that hospitals implement strategies to maximize reimbursement.

The full text of “Out-of-Pocket Costs Rising Even as Patients Transition to Lower Cost Settings of Care” was published July 22, 2019, by TransUnion Healthcare. A copy is available online at https://newsroom.transunion.com/out-of-pocket-costs-rising-even-as-patients-transition-to-lower-cost-settings-of-care/ (accessed July 9, 2019).

PsychU last reported on this topic in ”More Americans Are Underinsured In Terms Of Out-Of-Pocket Costs,” which published on March 28, 2019. The article is available at https://www.psychu.org/more-americans-are-underinsured-in-terms-of-out-of-pocket-costs/.

For more information, contact: David Blumberg, Senior Director, Public Relations, TransUnion, Post Office Box 1000, Chester, Pennsylvania 19022; 312-985-3059; Email: David.Blumberg@transunion.com; Website: https://newsroom.transunion.com/out-of-pocket-costs-rising-even-as-patients-transition-to-lower-cost-settings-of-care/

On June 28, 2019, the Centers for Medicare & Medicaid Services (CMS) approved Minnesota’s 1115 Medicaid demonstration waiver to expand addiction treatment via enhanced mental health services provided by both the state’s Certified Community Behavioral Health Clinics (CCBHCs), and short-term residential treatment benefits. The waiver allows the state Medicaid program to continue to reimburse for CCBHC services, although the federal CCBHC demonstration ended on June 30, 2019. The CCBHCs will integrate with community health care provider organizations to increase rates of identification, initiation, and engagement in treatment for addiction disorder. Minnesota’s demonstration project started on July 1, 2019, and will end on June 30, 2024.

Additionally, the provisions of Minnesota’s Section 1115 Demonstration Project Substance Use Disorder System Reform allow Medicaid reimbursement for short-term residential addiction treatment services provided by Institutions for Mental Disease (IMDs). The federal definition of an IMD is a hospital, nursing facility, or assisted living facility with more than 16 beds in which more than half of the residents between the ages of 21 through 64 have a primary or secondary mental health diagnosis. The determination about whether a facility is an IMD rests on the facility’s overall purpose, client mix, and licensing. Medicaid will not reimburse for residential medical or behavioral health care services provided by IMDs. Minnesota will aim for a statewide average length of stay of 30 days in residential treatment settings considered IMDs. To establish broader state reform efforts for a more integrated and coordinated addiction treatment delivery system, Minnesota will model its levels of care after the levels of care recommended by the American Society of Addiction Medicine (ASAM) for treating addiction, addiction-related, and co-occurring conditions.

Within 90 days after the demonstration approval date, Minnesota must submit its Opioid Use Disorder/Substance Use Disorder (OUD/SUD) Implementation Plan. The state cannot claim federal financial participation (FFP) for services provided in IMDs until CMS has approved the OUD/SUD Implementation Plan. Within 150 calendar days after the demonstration approval date, Minnesota must submit a separate monitoring protocol for the addiction treatment programs authorized by the demonstration.

The OUD/SUD Implementation Plan must address the following:

  1. Set service delivery for new benefits including residential treatment and withdrawal management.
  2. Establish a requirement that provider organizations assess treatment needs based on addiction-specific, multidimensional assessment tools, such as the ASAM Criteria or other comparable assessment and placement tools that reflect evidence-based clinical treatment guidelines.
  3. Establish a utilization management approach so that beneficiaries have access to addiction treatment services at the appropriate level of care and that the interventions are appropriate for the diagnosis and level of care, including an independent process for reviewing placement in residential treatment settings.
  4. Establish residential treatment provider organization qualifications in licensure, policy or provider manuals, managed care contracts or credentialing, or other requirements or guidance that meet program standards in the ASAM Criteria or other comparable, nationally recognized, addiction disorder-specific program standards.
  5. Establish a provider organization review process to ensure that residential treatment provider organizations deliver care consistent with the specifications in the ASAM Criteria or other comparable, nationally recognized addiction disorder program standards. The review process should address guidelines for types of services, hours of clinical care, and credentials of staff for residential treatment settings.
  6. Establish requirements that residential treatment provider organizations offer medication assisted treatment (MAT) on-site or facilitate access to off-site MAT.
  7. Assess the availability of provider organizations in the key levels of care throughout the state, or in the regions of the state participating under this demonstration, including those that offer MAT.
  8. Implement opioid prescribing guidelines along with other interventions to prevent prescription drug abuse and expand coverage of and access to naloxone for overdose reversal as well as implementation of strategies to increase utilization and improve functionality of prescription drug monitoring programs.
  9. Establish and implement policies to ensure residential and inpatient facilities link beneficiaries with community-based services and supports following stays in these facilities.

Minnesota is one of the eight states that participated in the CCBHC demonstration program, which expired on June 30, 2019. Six Minnesota CCHBCs have been delivering an enhanced set of mental health services to Medicaid beneficiaries. Within one year after the waiver approval date, Minnesota must submit the necessary state plan amendments (SPAs) and other documentation to add CCBHC services to the state’s Medicaid plan. The state must also submit a SPA to pay CCBHCs the established prospective payment system (PPS) rate through its fee-for-service (FFS) system and a preprint directed payment for managed care organization payments. In the interim, CMS granted Minnesota expenditure authority to pay the CCBHCs for services that are not currently included in the Minnesota state plan. The goal is to avoid disruption of services for people currently receiving CCBHC services.

With Minnesota’s waiver, 24 states have been approved to conduct Medicaid 1115 demonstration projects focused on treatment for addiction disorder. States with previously approved demonstration approvals include Alaska, California, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin.

For more information, contact:

  • Neerja Singh, Deputy Director, Behavioral Health Division, Minnesota Department of Human Services, 540 Cedar Street, Saint Paul, Minnesota 55151; Email: neerja.singh@state.mn.us; Website: https://mn.gov/dhs/
  • Nathaniel Dyess, Human Services Program Consultant, Minnesota Department of Human Services, 540 Cedar Street, Saint Paul, Minnesota 55151; Email: nathaniel.dyess@state.mn.us; Website: https://mn.gov/dhs/

About 39% of the 626 health care systems in the United States offered a health insurance product in 2016. Of those that offered an insurance product, about 31% offered a health maintenance organization (HMO), 31% offered a preferred provider organization (PPO), and 16% offered an indemnity fee-for-service plan.

These findings were reported in “Provider-Offered Insurance Products Among U.S. Health Systems, 2016” by the Agency for Healthcare Research and Quality (AHRQ) Comparative Health System Performance Initiative. The analysis is based on the AHRQ Compendium of U.S. Health Systems, 2016. Developed as part of the Comparative Health System Performance (CHSP) initiative, the Compendium is a resource for data and research on health systems. For the purpose of the Compendium, a health system is defined as including at least one hospital and at least one group of physicians that provide comprehensive care (including primary and specialty care) and are connected with each other through common ownership or joint management. The researchers used the 2015 American Hospital Association (AHA) Annual Survey Database to construct the measure of assessing whether a system offered any insurance product. The overall survey population included 626 health systems: 207 had one hospital, 191 had two or three hospitals, and 202 had four or more hospitals.

Additional findings were as follows:

  • The larger systems – and systems with the most physicians – were more likely to offer an insurance product. About 20% of the 207 systems with only one hospital offered an insurance product. Among the 191 systems with two-or-three hospitals, 28% offered an insurance product. Approximately 69% of the 202 systems with four or more hospitals offered an insurance product.
  • The systems that included at least one children’s hospital were more likely to offer an insurance product. Of the 549 systems without a children’s hospital, 38% offered an insurance, compared to 46% of the 50 systems that had one or more children’s hospital.
  • The systems that operated in two or more states were more likely to offer an insurance product. About 32% of the 499 systems that operated in only one state offered an insurance product. Of the systems that operated in two or more states (101 systems), 73% offered an insurance product.

For more information, contact: Lorin Smith, Health Communications Specialist, Office of Communications, Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, Maryland 20857; 301-427-1864; Email: lorin.smith@ahrq.hhs.gov; Website: https://www.ahrq.gov/

On June 3, 2019, the U.S. Supreme Court ruled that in 2014 the Centers for Medicare & Medicaid Services (CMS) impermissibly changed the reimbursement formula for disproportionate share hospital (DSH) payments for fiscal year 2012. The policy retroactively reduced Medicare DSH payments to hospitals serving a higher proportion of low-income individuals because CMS simply issued a policy change that counted Medicare Part C beneficiaries as Medicare Part A-entitled beneficiaries for purposes of DSH payment calculations. Previously, the calculation included only Part A beneficiaries. The new calculation reduced hospital DSH payments. The ruling vacated the policy; CMS has not released information about the next steps.

The Medicare DSH payments are intended to offset the cost of providing uncompensated care, and the payments are targeted to hospitals that serve a high percentage of indigent consumers. For federal fiscal year 2012, Medicare DSH payments were estimated at $10.8 billion. Federal Medicaid DSH allotments are calculated differently than the Medicare DSH; in 2012, Medicare DSH allotments to states totaled $11.3 billion.

The Medicare DSH beneficiary percentage is equal to the sum of the percentage of Medicare inpatient days attributable to beneficiaries eligible for both Medicare Part A and Supplemental Security Income (SSI), and the percentage of total inpatient days attributable to patients eligible for Medicaid but not Medicare Part A. The CMS website cites the DSH calculation as: “DSH Patient Percent = (Medicare SSI Days / Total Medicare Days) + (Medicaid, Non-Medicare Days / Total Patient Days).” In an exception, DHS payments are also available to large urban hospitals that can demonstrate that more than 30% of their total net inpatient care revenue comes from state and local governments for indigent care (other than Medicare or Medicaid).

In 2004, the agency overseeing Medicare issued a final rule declaring that it would count Part C beneficiaries in the DSH calculation. However, the rule was vacated after hospitals filed legal challenges. In 2013, CMS issued a new rule prospectively readopting the policy of counting Part C beneficiaries in the DSH calculation. However, by 2014 the rule had not been finalized. CMS posted on its website the Medicare fractions for fiscal year 2012 and noted that the calculation included Part C beneficiaries. The hospital plaintiffs, Allina Health Services and others, sued. The district court upheld the federal position; the plaintiffs appealed. On July 25, 2017, the United States Court of Appeals for the District of Columbia Circuit upheld the hospitals’ position that CMS failed to provide a notice and comment period as required by the Medicare Act. It reversed the district court judgement and sent the case back to the district court for reconsideration. The federal government appealed to the Supreme Court.

In Azar v. Allina Health Services, the plaintiff hospitals argued that the policy change to include Medicare Part C beneficiaries in the calculation altered a “substantive legal standard.” They said CMS should have used a formal notice-and-comment rulemaking required by the Medicare Act. By failing to use the notice-and-comment process, CMS received no feedback on how the change might affect hospitals, consumers, and other provider organizations. The Supreme Court agreed that this represented a change to “substantive legal standard” that required CMS to engage in formal notice and comment rulemaking. The decision has a potential impact on DSH payments to hospitals. It will also affect other changes CMS has made and will affect how CMS changes “substantive legal standards” in the future.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Email: press@cms.hhs.gov; Website: https://www.cms.gov/
  • American Hospital Association, D.C. Office, 800 10th Street, Northwest, Two CityCenter, Suite 400, Washington, District of Columbia 20001-4956; 202-638-1100; Website: https://www.aha.org/press-releases/2019-06-03-aha-statement-supreme-court-decision-azar-v-allina-health-services and https://www.aha.org/about/contact

The average cost of an emergency department visit rose by 176% between 2008 and 2017, from $503 to $1,389. During this period, overall annual emergency department utilization did not change. The average out-of-pocket cost to consumers rose from $70 in 2008 to $239 in 2017, and as a share of the overall cost rose from 18% to 26%.

These findings were reported in “10 Years Of Emergency Room Spending For The Commercially Insured” by John Hargraves and Kevin Kennedy of the Health Care Cost Institute (HCCI) in a presentation at the AcademyHealth 2019 Research Meeting in early June 2019. They analyzed insurance claims for hospital emergency department professional and outpatient facility services provided to commercially insured people under age 65 with employer-sponsored insurance enrolled in a non-capitated health plan. The data was from the HCCI claims database for 2008 through 2017. The analysis focused on claims that had one (or more) of five successive Current Procedural Terminology (CPT) codes (99281 to 99285) for an emergency department visit. These codes are used to capture the level of severity and complexity of the visit. The researchers created an estimate of emergency department visits for each of the five CPT codes. The researchers estimated spending per-person, average price, negotiated price, average charge, and average consumer out-of-pocket.

The mix of CPT codes billed for emergency department visit complexity changed during the decade to reflect greater use of high severity codes. The share of visits with a low complexity code declined, although the average prices rose for low complexity visits.

HCCI holds data on over 50 million commercially insured individuals per year (2008 to 2016), and as a Qualified Entity (QE), HCCI also has 100% of Medicare fee-for-service claims data on roughly 40 million individuals per year (2012 to 2016). The commercial health plan data is from four large insurers: Aetna, Humana, Kaiser Permanente, and UnitedHealthcare.

The full text of “10 Years Of Emergency Room Spending For The Commercially Insured” was published June 3, 2019 by the Health Care Cost Institute. A free copy is available online at https://www.healthcostinstitute.org/news/entry/hcci-will-be-presenting-at-academyhealth-s-2019-annual-research-meeting (accessed July 9, 2019).

PsychU last reported on this topic in “Employer-Sponsored Health Insurance Spending Rose 4.2% To $5,641 Per Person In 2017,” which published on March 25, 2019. The article is available at https://www.psychu.org/employer-sponsored-health-insurance-spending-rose-4-2-to-5641-per-person-in-2017/.

For more information, contact: Sally Rodriguez, Chief of Staff, Health Care Cost Institute, 1100 G Street NW, Washington, District of Columbia 20005; 202-803-5200; Email: srodriguez@healthcostinstitute.org; Website: https://www.healthcostinstitute.org/.

Montana Medicaid is exploring ways to design and implement innovations that could lead to a supportive housing services benefit as a way to reduce costs for homeless beneficiaries with the highest, 10%, of Medicaid expenditures. The Montana Department of Public Health and Human Services (DPHHS) is currently receiving technical assistance from the federal Centers for Medicare & Medicaid Services (CMS) to align policies across Medicaid and housing programs. The DPHHS Medicaid State Plan currently includes federal Medicaid reimbursement for many of the services that are provided as part of supportive housing, such as services intended to help the individual obtain and maintain tenancy. The state has released no further details about a target date for making additional improvements.

National supportive housing cost studies have documented that after one year of entering supportive housing, the participants have fewer emergency department visits, hospital overnight stays, ambulance transports, and detoxification visits. Implementing supportive housing for the high cost homeless Montana Medicaid beneficiaries is projected to have a 100% to 300% return on investment (ROI).

The 2017 point-in-time count of Montana’s homeless population identified 157 individuals ages 18 to 64 with chronic homelessness. Among the 10% (16 individuals) with the highest Medicaid costs, their average annual Medicaid costs was $53,463 per person, at $4,455 per member per month (PMPM). Additional details are as follows:

  • Supportive housing is projected to potentially reduce their Medicaid costs by up to 45%.
  • The monthly cost of supportive housing services known as “tenancy supports” is projected at $500 per person; Medicaid costs are projected to fall by $2,005 per month, with net savings at $1,505 PMPM.
  • The $500 monthly cost for tenancy supports is projected to be offset by a $2,005 reduction in Medicaid costs due to supportive housing, a 300% ROI.
  • Annual savings are estimated at $18,058 per person.

Another 1,708 individuals ages 18 to 64 were identified in the point-in-time count as having short-term homelessness. Within this group, the top 10% (171 individuals) with the highest Medicaid costs had average costs of $49,906 per person annually, and $4,159 PMPM. Additional details are as follows:

  • Supportive housing is projected to reduce their Medicaid costs by up to 24%.
  • The monthly cost of tenancy supports is projected at $500 per person; Medicaid costs are projected to fall by $998 per month, with net savings at $498 PMPM.
  • The $500 monthly cost for tenancy supports is projected to be offset by a $498 reduction in Medicaid costs due to supportive housing, a 100% ROI.
  • Annual savings are estimated at $5,977 per person.

During 2017, this group of 187 homeless Montana Medicaid beneficiaries with health care costs in the highest 10% had average annual Medicaid claims totaling $49,906 per person. If these 187 individuals had been stably housed, the state could have avoided a total of $445,766 net annual Medicaid costs, even after reimbursing supportive housing provider organizations for supportive housing services. Combined state and federal savings were estimated at $1.3 million, annually.

These findings were reported in “The Montana Business Case for a Supportive Housing Services Benefit” by the Corporation for Supportive Housing (CSH). This report and a companion, “Medicaid Supportive Housing Services Crosswalk,” were commissioned by the Montana Healthcare Foundation (MHCF) and the Montana Department of Public Health and Human Services (DPHHS). During August 2018, DPHHS analysts matched data from individuals entered into the Homeless Management Information System (HMIS) in 2017 with their accompanying 2017 Medicaid claims data to determine the annual costs for each person enrolled in both Medicaid and the HMIS system in 2017. The cost data was stratified into 10 cost groups. About 82% of 4,050 homeless individuals ages 18 to 64 experiencing chronic or short-term homeless whose names are logged in HMIS are already enrolled in Medicaid, represented 3,312 people.

The data was further divided into two groups, one that included 157 individuals experiencing chronic homelessness and the other with 1,708 individuals experiencing non-chronic homelessness. The state data analysts shared deidentified population data with CSH in order to determine if paying for supportive housing services would be more cost-effective than usual care for individuals with the highest 10% of costs.

In the companion report, “Medicaid Supportive Housing Services Crosswalk,” the researchers also analyzed Medicaid reimbursements in local communities, and local health care provider organization knowledge of Medicaid benefits. They found that Montana Medicaid covers many services that are often provided as part of supportive housing interventions. The state currently reimburses for targeted case management for individuals with severe disabling mental illness (SDMI). For individuals living with physical and developmental disabilities, the state uses a variety of waivers to provide services needed to support community living and contribute to better health outcomes. However, these services do not fully cover pre-tenancy and tenancy support services. Additionally, waiver services are not available to individuals with addiction disorder as a primary diagnosis; targeted case management for chemical dependency does not offer the full range of intensive pre-tenancy and tenancy sustaining services necessary in supportive housing.

CSH recommended that the Montana state Medicaid plan explicitly include supportive housing services to align with guidelines of pre-tenancy and tenancy-sustaining services for a 1915i State Plan Amendment as released by the federal Centers for Medicare & Medicaid Services (CMS). DPHHS should examine state program standards that could be more comprehensive in addressing social determinants of health (SDOH) needs of program participants, specifically housing. State agencies and provider organizations will need non-Medicaid funded support to engage persons who are unsheltered and who can be difficult to consistently locate. Such funding will be needed to cover staff travel and transportation time and outreach efforts that do not result in finding the individual. Additionally, CSH recommended that the state continue to work with Tribal Nations to more fully understand how Tribal Nations are funding and operating supportive housing, and to work together to explore opportunities.

Statewide, DPHHS should build capacity for behavioral health and housing service provider networks by promoting training and technical assistance to help supportive housing provider organizations bill Medicaid and to help behavioral health and waiver service provider organizations understand the quality standards in supportive housing and service partnerships unique to supportive housing in rural areas. Community mental health centers should be included in conversations about supportive housing.

Acting on the findings in these two reports, DPHHS applied for and was accepted to participate in a CMS “Innovation Accelerator Program,” which helps states align policies across Medicaid and housing programs to improve outcomes and efficiency. DPHHS has assembled a group of partners that will work together for the duration of this project, including the Department of Commerce, Montana Continuum of Care, and MHCF. Participation in this program provides a direct path to allow DPHHS to design and implement innovations in the supportive services benefit package.

The full text of “Medicaid Supportive Housing Services Crosswalk” was published June 18, 2019, by the Corporation for Supportive Housing. A free copy is available online at https://mthcf.org/resources/supportive-housing-crosswalk/ (accessed July 9, 2019).

The full text of “The Montana Business Case for a Supportive Housing Services Benefit” was published June 18, 2019, by the Corporation for Supportive Housing. A free copy is available online at https://mthcf.org/resources/supportive-housing-benefit-business-case/ (accessed July 9, 2019).

For more information, contact:

  • Robert W. Friant, Managing Director, External Affairs, Marketing & Communications, The Corporation for Supportive Housing, 61 Broadway, Suite 2300, New York, New York 10006; 212-986-2966; ext. 245; Email: robert.friant@csh.org; Website: https://www.csh.org/
  • Job Ebelt, Montana Department of Public Health and Human Services, 111 North Sanders, Room 301, Helena, Montana 59620; 406-444-0936; Email: jebelt@mt.gov; Website: https://mt.gov/
  • Melinda Buchheit, Montana Healthcare Foundation, 777 East Main Street, Suite 206, Bozeman, Montana 59715; 406-451-7060; Email: melinda.buchheit@mthcf.org; Website: https://mthcf.org/

The Virginia Joint Legislative Audit and Review Commission (JLARC) recommends that the state allow more time to effectively deploy its System Transformation Excellence and Performance -Virginia (STEP-VA) mental health initiative, which would push back full implementation from July 2021 to July 2022. The nine-step initiative, which began in 2017, requires Virginia’s 40 local community services boards (CSBs) to implement the following: same day assessments, primary care screening, behavioral health crisis services, outpatient behavioral health, psychiatric rehabilitation, peer/family support services, veteran’s behavioral health, care coordination, and targeted case management. Between 2017 and 2019, all CSBs implemented the first step: same day assessments, and were on schedule to begin step two by July 2019: providing primary care blood pressure and body mass index screening to consumers with serious mental illness (SMI) or serious emotional disturbance (SED). After implementing the primary care screening for consumers with SMI or SED, the CSBs will expand the screenings to all consumers. The JLARC recommended that the Virginia Department of Behavioral Health and Developmental Services (DBHDS) extend the timeline for the remaining seven steps so that DBHDS can complete the requirements, performance measures, and funding allocation plans for each. Additionally, DBHDS should also conduct a pilot of the step two expanded primary care screening at a subset of CSBs before initiating it at all 40 CSBs.

STEP-VA is a long-term initiative designed to improve the community behavioral health system by expanding the services provided by the CSBs. The goals for STEP-VA focus on simplifying access to a uniform set of public mental health services and increasing CSB accountability. All 40 CSBs are required to implement STEP-VA. Currently, Virginia has appropriated a total of $60 million through fiscal-year 2020 to begin implementation, with full implementation expected by July 2021.

This recommendation was made in “Report To The Governor And The General Assembly Of Virginia: Implementation Of STEP-VA, 2019” by the Virginia JLARC. In 2018, the JLARC directed staff to review the initial implementation of the STEP-VA initiative. JLARC staff evaluated implementation through early June, 2019 and assessed CSBs’ overall preparedness to implement the remaining steps by July 2021. For this report, the JLARC staff conducted structured interviews and focus groups with Virginia Department of Behavioral Health and Developmental Services (DBHDS) leadership and staff, CSB leadership, stakeholders, and representatives from other states’ behavioral health systems. The staff also participated in site visits to seven CSBs, conducted a survey of CSB executive directors and chief executive officers, and reviewed state documents and research literature.

In their evaluation of implementation thus far, the researchers found that:

  • Nineteen of the 20 CSBs that currently track assessment data reported assessing at least 70% of individuals on the day they walk in during designated hours.
  • The number of hours and locations available for same-day assessments varied across CSBs, and it is not clear whether the availability of same-day assessments meets community needs.
  • In preparation for step two, in February 2019 DBHDS began providing funds so that CSBs could begin providing primary care screening by July 2019 to check the blood pressure and body mass index of consumers with SMI or SED.
  • CSBs are concerned that the effort needed to expand primary care screenings to all consumers will detract from other, higher priority STEP-VA services, such as expanded outpatient and crisis services.

Going forward in the implementation, the JLARC staff recommended the following regarding the roll-out:

  • DBHDS should work with CSBs to develop metrics that will measure if consumers are able to be assessed on the same day they visit a CSB, and whether same-day access hours are sufficient at each CSB.
  • DBHDS should pilot phase two of primary care screening at a subset of CSBs before initiating it at all 40 CSBs.

The JLARC staff made the following recommendations regarding the role of DBHDS and funding:

  • Require DBHDS to complete the requirements, performance measures, and funding allocation plans for each step before the Department of Accounts releases funding
  • Dedicate a full-time senior staff position to oversee and coordinate STEP-VA implementation
  • Prioritize the implementation of remaining steps based on CSB needs
  • Allow DBHDS to use a portion of future STEP-VA funding to support central oversight and coordination functions at DBHDS

STEP-VA is loosely based on the federal Certified Community Behavioral Health Clinic (CCBHC) model. Virginia was awarded a CCBHC planning grant; however, in October 2016, Virginia opted not to submit a proposal for a demonstration grant due to cost and infrastructure concerns. The STEP-VA model was developed as a sustainable Virginia-specific solution. The CSBs began working on STEP-VA after the 2017 Governor and the General Assembly provided $4.9 million in general fund dollars for an initial group of CSBs to implement same day access. The General Assembly required the remainder of STEP-VA services to be implemented over the next two biennia, with additional funding to be allocated in the coming years. The 2018 Governor and the General Assembly provided $5.9 million for a second group of 22 CSBs to implement same day access in fiscal year 2019. Each CSB will receive $270,000 in ongoing state mental health funds. Nine CSBs had already implemented some form of same day access and received funding on July 1, 2018 to address their implementation costs. By the end of the 2018 calendar year, all but five CSBs had implemented same day access. The remaining CSBs were on-track to implement same day access in early 2019 and did so in March.

PsychU last reported on this topic in “Virginia Community Services Boards Reach STEP-VA Goal Of Same-Day Access,” which published on June 17, 2019. The article is available at https://www.psychu.org/virginia-community-services-boards-reach-step-va-goal-of-same-day-access/.

For more information, contact: Jeff Lunardi, Unit Director, Health and Human Resources, Joint Legislative Audit and Review Commission of Virginia, 919 East Main Street, Suite 2101, Richmond, Virginia 23219; 804-371-4581; Email: jlunardi@jlarc.virginia.gov; Website: http://jlarc.virginia.gov/.

On May 8, 2019, South Carolina submitted a Medicaid waiver to the Centers for Medicare & Medicaid Services (CMS) requesting permission to impose work and community engagement requirements on Medicaid beneficiaries ages 18 to 64. The state seeks to require Medicaid beneficiaries to work, be enrolled in job training, or be in school for an average of 80 hours per month. South Carolina has not expanded Medicaid. According to a South Carolina Department of Health and Human Services (SCDHHS) spokesperson, the agency projects a maximum of 0.59% of the state’s Medicaid population will be impacted during the first year following implementation of the community engagement requirements. If CMS approves the waiver, South Carolina plans to roll out a five-year demonstration as soon as July 2020. CMS is accepting comments on the waiver through July 10, 2018.

SCDHHS intends to issue guidelines that would accept participation in and compliance with medically necessary substance use disorder (SUD) treatments for certain individuals with SUD that would otherwise impair an individual’s ability to participate in employment, education, or other community engagement activities. The provisions of South Carolina’s Community Engagement Section 1115 Demonstration Waiver Application are as follows:

  1. Participation in an adult secondary education program through a public school district or technical college: SCDHHS intends to support certain out-of-pocket costs for adult students not otherwise covered by other state- or federally funded adult education programs, including the cost of general education development (GED) testing.
  2. Full-time participation in a degree- or certificate- seeking program in an accredited institution of higher education, as defined by the South Carolina Commission on Higher Education
  3. Compliance with unemployment insurance (UI) work-search requirements (during the first 16 weeks of UI benefits)
  4. Demonstrated compliance with SNAP community engagement standards for dual Medicaid beneficiaries in either the Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) programs
  5. Employment for no less than 80 hours per month
  6. Community or public service, including verifiable volunteerism with public entities or qualified charitable corporations
  7. Remove financial disincentives for work: This will be done through increasing the income threshold for individuals with Parent Caretaker Relative (PCR) status from 62% of the federal poverty level (FPL) with a 5% income disregard, to 95% FPL with a 5% income disregard, closing what is commonly called the “Parent Caretaker Relative (PCR) gap.” The state will seek waivers to cover pregnant women and support new mothers returning to employment; the waivers will allow the extension of coverage for pregnant women who make up to 194% FPL, with a 5% income disregard, from 60 days postpartum to one-year postpartum; and align transitional medical assistance (TMA) with these new income thresholds by seeking such waivers and amendments as necessary to provide individuals who lose Medicaid coverage due to employment, who are also not eligible for employer-sponsored insurance, with the financial assistance necessary to purchase a qualifying health plan on the federal marketplace administered in South Carolina.

If Medicaid enrollees fail to prove they are exempt from the requirements or are not reporting their work status for more than three months, their Medicaid benefits will be suspended. Populations exempt from the reporting requirement are as follows:

  1. Children enrolled in Medicaid or the Children’s Health Insurance Program (CHIP)
  2. Members of federally recognized tribal organizations
  3. Pregnant women
  4. Disabled individuals, including individuals who have a medical condition that would prevent them from participation in this project
  5. Individuals over the age of 65
  6. Individuals who are the primary caregiver of a child or someone who is disabled
  7. Individuals receiving Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI)
  8. Individuals participating in a Medicaid covered treatment program for alcohol or substance abuse addiction, including opioid addiction;
  9. Individuals receiving treatment for cancer, including those receiving treatment through Medicaid’s Breast and Cervical Cancer Program;
  10. Individuals compliant with, or exempt from, the SNAP or TANF requirements related to employment; and individuals who are determined by SCDHHS to be exempt on a case-specific basis. This includes certain individuals with medically complex conditions that require multidisciplinary specialized care or would otherwise be precluded from employment or community engagement activities due to their health status.

Individuals who are not in one of the above categories and who are enrolled in South Carolina Medicaid as a PCR will be included in this demonstration project. Based upon current program enrollment, Census, and other adjunct data, SCDHHS estimates a mid-range average monthly enrollment estimated increase of 32,300 individuals added into the PCR category; 2,000 pregnant women per month receiving coverage for 10 additional months; and 4,350 individuals transitioning from the current to revised TMA program. PCR individuals will be required to participate in community activities to maintain an active Medicaid enrollment status.

For more information, contact: Communications Office, South Carolina Department of Health and Human Services, Post Office Box 8206, Columbia, South Carolina 29202-8206; 803-898-2580; Email: communications@scdhhs.gov; Website: https://www.scdhhs.gov/

Consumer occupancy of skilled nursing facility (SNF) beds reached a four-quarter high of 83.7% as of the end of March 2019. Over the previous four quarters, SNF occupancy was approximately 82.5% in Q1 2018, 83.0% in Q2 2018, 82.9% in Q3 2018, and 83.5% in Q4 2018. The highest recent occupancy rate was 88.5% in 2014.

These findings were reported in “Skilled Nursing Data Report: Key Occupancy & Revenue Trends, Based on Data from January 2012 Through March 2019” by the National Investment Center for Seniors Housing & Care (NIC). Researchers from NIC collected and analyzed sample population data from 48 states (all but Alaska, Colorado, the District of Columbia, Pennsylvania, and South Carolina), and compared current data with historic data similarly collected. Overall, 26 contributors and 1,402 SNF properties were represented in the data. Historical data is deflated using same-store month-month changes. The goal was to determine current trends in skilled nursing facility occupancy and revenue.

Additional findings include:

  • Skilled mix, or the percentage of those receiving “skilled services” increased 84 basis points, to 26.0%, from the fourth quarter 2018. Skilled services is short-term rehabilitation through Medicare and a health maintenance organization (HMO) divided by total actual patient days.
  • Managed Medicare revenue mix increased to 12.1%, from the fourth quarter of 2018. Managed Medicare revenue mix is the total revenue for each payer source divided by the total revenue.
  • Managed Medicare revenue per patient day (RPPD) decreased about 1.6%, from $439 from the fourth quarter of 2018, to $432 as of March 2019. RPPD is total revenue divided by actual patient days for each payer source.
  • Medicaid patient day mix decreased from 66.4% in the fourth quarter of 2018, to 65.8% as of March 2019. Patient day mix is the actual patient days of each payer source divided by the total actual patient days.

The full text of “Skilled Nursing Data Report: Key Occupancy & Revenue Trends, Based on Data from January 2012 Through March 2019” was published June 10, 2019 by the NIC. A free copy is available online at http://info.nic.org/skilled_data_report_pr (accessed July 9, 2019).

For more information, contact: Bill Kauffman, Senior Principal, National Investment Center for Seniors Housing & Care, 1997 Annapolis Exchange Parkway, Suite 480, Annapolis, Maryland 21401; 410-267-0504; Email: communications@nic.org; Website: https://www.nic.org/

Approximately 72% of executives believe their organizations have the capabilities needed to support increased risk, and plan to take on additional risk in the next one to three years. About 64% of the same executives reported that they would assume additional risk through commercial payer contracting models. Roughly 57% said they would assume risk through Medicare contracting models, and 51% said they would assume risk through Medicare Advantage.

These findings were reported in “Providers Prepared to Increase Risk Model Participation” by Navigant. The report is based on a survey conducted by Navigant and the Healthcare Financial Management Association (HMFA) of 170 hospital and health system senior finance executives. The survey documents the readiness of health care provider organizations to assume increased levels of risk through commercial payer and Medicare contracting as well as the share of responding provider organizations that are partnering on or launching provider-sponsored health plans (PSHPs) as part of their risk-assumption strategy.

Of the provider organizations that were surveyed, the researchers found that 56% were not participating in PSHP plans, while 25% already were part of a PSHP, and 19% plan to launch a PSHP. In addition to assuming risk through commercial and Medicare payment models and participating in PSHP’s, the researchers surveyed provider organizations strategies for fee-for-service (FFS) and value-based revenue and margin growth. Strategies of the respondents included:

  • Engaging physicians to drive clinical standardization through a Hospital Quality and Efficiency Program, a contract between a health system and an accountable-care organization (ACO) or clinically integrated network
  • Focusing on cost reduction in more discrete areas, such as post-acute care, pharmacy care, and management of high-risk health care consumers
  • Emphasizing in-network customer retention by building tight provider network relationships through technological connectivity, a share referral management infrastructure, and common standards for access, quality, and cost

The full text of “Providers Prepared to Increase Risk Model Participation” was published in June 2019 by Navigant and HFMA. A free copy is available online at https://www.navigant.com/insights/healthcare/2019/risk-readiness (accessed July 9, 2019).

PsychU last reported on this topic in “25% Of Health Care Provider Organizations Ready To Take On Risk-Based Contracts,” which published on May 6, 2019. The article is available at https://www.psychu.org/25-of-health-care-provider-organizations-ready-to-take-on-risk-based-contracts/.

For more information, contact:

  • David P. Zito, Healthcare Segment Leader, Navigant, 1200 19th Street Northwest, Suite 700, Washington, District of Columbia 20036; 202-973-2400; Website: https://www.navigant.com/
  • Healthcare Financial Management Association, 3 Westbrook Corporate Center, Suite 600, Westchester, Illinois 60154-5732; 708-531-9600; Fax: 708-531-0032; Email: inquiry@hfma.org; Website: https://www.hfma.org/

The opioid crisis in the U.S. has been well documented over the past several years. Sections of the country have been ravaged by drug overdoses and families are being torn apart by opioid addiction. The healthcare system continues to be strained through a combination of opioid related emergency department visits and other health conditions associated with heroin use such as Endocarditis and Hepatitis C. In 2017, there were 70,237 fatal drug overdoses in the U.S. and 142,557 nonfatal opioid-related hospital visits.¹ The increase in ED visits represents a 30% increase from 2016 to 2017.²

As opioid deaths increased in parts of the country, youth entering the foster care system increased as well. A study by the Office of the Assistant Secretary for Planning and Evaluation found that a 10% increase in opioid deaths was associated with a 4.4% increase in entries into the child welfare system.5 While the impact of the opioid epidemic has caused the issue to come to the forefront of the national and state dialogue, alcohol use disorders continues to have a significant impact on individuals and families, the healthcare system and legal system. Over 15 million Americans suffer with an alcohol use disorder and between 2006-2010, an estimated 88,000 people died annually from alcohol related deaths.6

The Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System, (The Guide) highlighted the ongoing impact of the opioid epidemic and its impact on the national behavioral health landscape. Federal legislation, such as the 21 Century Cures Act, contain provisions specifically targeting the opioid crisis.¹ Additionally, other previous passed federal legislation has provided tools and resources needed to address the issue. Medicaid expansion under the Patient Protection and Affordable Care Act, provides an avenue for funding needed for individuals to access treatment.¹ The flexibility of the 1115 Medicaid waiver has promoted system delivery and payment reform that can be used by states to expand and improve treatment.¹ The Mental Health Parity Act has promoted access to care and has resulted in payers enhancing their networks with a focus on evidence-based medication assisted treatment.¹

One of the primary provisions of the 21st Century Cures Act was the State Targeted Response to the Opioid Crisis grants which provided states with funding to develop and/or expand their local responses to the crisis. The Cures Act initially provided roughly $1 billion to the states that could be used for activities, such as prescription surveillance programs, reducing the availability of opioids through changes in prescribing guidelines and practice, and increasing prevention and treatment efforts.¹ Some of the common ways that states have been utilizing the funding include efforts around prescriber education and workforce development, expanding access to medication assisted treatment, and treatment delivery innovation, such as hub and spoke programs and expanded use of peer support.¹ In March 2019, the Department of Health and Human Services released an additional $487 million to continue these efforts.7

Other recent federal initiatives included $400 million in funding awarded to community health centers, inclusive of federally qualified health centers, in 2018 to increase access and improve the quality of substance use disorder treatment services provided through these centers.¹ CMS, through the Center for Medicare and Medicaid Innovation has created the Maternal Opioid Misuse Model. The model aims to improve the care delivery system for pregnant and postpartum Medicaid beneficiaries with opioid use disorders.8 States had the opportunity to submit a grant application in early May 2019.

Beyond legislative activities, national level advocacy around stigma reduction; the need to expand access to evidence-based, medication assisted treatment and the need to remove barriers to treatment is beginning to arise and shape public and payer policy. Shatterproof, a national non-profit organization, founded by a father who lost his young adult son to an opioid overdose, has brought together a taskforce of treatment and policy experts, providers, public and private payers, and advocates to help improve the access and quality of addictions treatment. They have developed national principles for high quality care, including promoting routine substance use disorder screenings across all medical settings, removing barriers to MAT, such as prior authorization process, promoting access to fully trained and accredited behavioral health professionals and the need for long-term outpatient care and monitoring.¹ Payers are also playing a key role in addressing the crisis. Payers are implementing a number of strategies to address access, quality of care and the rising treatment costs associated with the increased rate of opioid use disorders. The Second Edition of the Guide, which contains survey results from over 1,000 public and private payers, highlighted the focus on access. Across all health plans surveyed, 84% are engaged in activities to expand their MAT network. Additionally, health plans are focusing on social determinants of health which is an important component of comprehensive opiate treatment.¹

By way of example, UnitedHealth Groups Optum Division has developed a nationwide, multipronged approach for addressing access, improving quality and addressing cost. Their strategy includes the development of a specialty MAT network and partnering with providers to expand treatment sites across the country in areas of need, and deploying a bundled payment model that addresses cost and quality while decreasing administrative burden on substance use disorder treatment providers.9

Nationally, BlueCross BlueShield have made successful efforts to decrease the number of prescriptions filled and have decreased the number of their members who have filled at least one opioid prescription in a year based on a five-year study of medical claims.10 Additionally, The BlueCross BlueShield Association is launching Blue Distinction® Centers for Substance Abuse Treatment and Recovery. To receive this designation a provider, hospital or health care facility must demonstrate that they provide quality care, treatment expertise and better overall patient results.11 Blue Distinction® Centers for Substance Abuse Treatment and Recovery must be able to provide MAT as part of an integrated substance use disorder treatment approach. These centers will launch in 2020.

Additional information on the national, state and payer response to the opioid epidemic can be found in the Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System.

About The Guide

The Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide) provides information
and insights into the multi-layered United States behavioral health system. The Guide includes an in-depth view of current statistics, prevailing issues, and emerging trends in order to inform the
discussions, debates and decision-making of policy-makers, payers, providers, advocates and consumers. The Guide addresses current behavioral health care trends topics, including:

  • A look at the national policy that is shaping the U.S. health and human services market
  • A view of the state behavioral health delivery systems that were created by a combination of historical practices, federal and state policy, and market factors over recent years
  • An examination of the practices of 1,265 health plans that manage both physical and behavioral health care for the vast majority of the U.S. population
  • A deep-dive into behavioral health care access and delivery of care from the consumer perspective

Sources

  1. Otsuka America Pharmaceutical, Inc. & Lundbeck, LLC. (2019). 2019 Trends In Behavioral Health: A Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd
    Edition. Rockville, MD: Otsuka America Pharmaceutical, Inc. Retrieved from PsychU.org.
  2. Centers for Disease Control and Prevention. (2018, March 6). Emergency department data show rapid increases in opioid overdoses. U.S. Department of Health and Human Services.
    Retrieved from https://www.cdc.gov
  3. Chang, H. Y., Kharrazi, H., Bodycombe, D., Weiner, J. P., & Alexander, G. C. (2018). Healthcare costs and utilization associated with high-risk prescription opioid use: a retrospective cohort
    study. BMC medicine, 16(1), 69. doi: 10.1186/s12916-018-1058-y
  4. Centers for Medicare & Medicaid Services. (2019, April 26). National health expenditure data: NHE fact sheet 2015. Baltimore, MD: CMS; 2017. Retrieved from https://www.cms.gov
  5. Radel, L., Baldwin, M., Crouse, G., Ghertner, R., & Waters, A. (2018). Substance use, the opioid epidemic, and the child welfare system: Key findings from a mixed methods study. Office of the Assistant Secretary for Planning and Evaluation. Retrieved from https://bettercarenetwork.org
  6. National Institute on Alcohol Abuse and Alcoholism. (2018, August). Alcohol facts and statistics. Retrieved from https://www.niaaa.nih.gov
  7. HHS Press Office. (2019, March 20). HHS releases additional $487 million to states, territories to expand access to effective opioid treatment; 2019 SOR grants will total $1.4 billion. U.S.
    Department of Health & Human Services. Retrieved from https://www.hhs.gov
  8. Centers for Medicare & Medicaid Services. (2018, October 23). CDC fact sheet: Maternal opioid misuse (MOM) model. Department of Health and Human Services. Retrieved from
    https://www.cms.gov
  9. UnitedHealth Group. (n.d.). Addressing the opioid epidemic. Retrieved from https://www.unitedhealthgroup.com
  10. Thomson, T. (2018, July 12). Blue cross and blue shield companies make landmark decision to advance better treatment options for opioid use disorder. Blue Cross Blue Shield Association.
    Retrieved from https://www.bcbs.com
  11. Blue Cross Blue Shield. (n.d.). Blue distinction specialty care. Retrieved from https://www.bcbs.com

On June 14, 2019, the Michigan Department of Health and Human Services (MDHHS) announced that the Medicaid pilots under Section 298 to integrate physical and specialty behavioral health services would be delayed by a year, until October 1, 2020. The pilots had been slated to begin by October 1, 2019, but the announcement said more time is needed to complete design of the financial integration pilot model. In March 2018, MDHHS selected four community mental health services programs for the pilots: Genesee Health System; Saginaw County Community Mental Health Authority; and a joint pilot to be conducted by Muskegon County Community Mental Health (HealthWest) and West Michigan Community Mental Health.

To date, MDHHS said pilot participants have completed the following tasks needed to implement the pilots:

  • Developing a proposed care management workflow
  • Identifying an approach to public policy needs
  • Defining data sharing requirements critical to whole-person care

By October 1, 2019, MDHHS anticipates pilot participants will have reached agreements on risk-management; ownership of the specialty behavioral health provider network; utilization management, claims processing and other managed care responsibilities; and rates and payment structures. After the agreements are in place, MDHHS and pilot participants will proceed with implementation, including seeking approval from the federal Centers for Medicare & Medicaid Services (CMS), establishing new contracts, finalizing technology and reporting changes, establishing new payment flows and potentially creating new legal structures and undergoing accreditation reviews.

Psychu last reported on this topic in “Michigan Medicaid Picks Regional Pilot Organizations For Coordinated Behavioral & Physical Health Services,” which published on March 28, 2018. The article is available at https://www.psychu.org/michigan-medicaid-picks-regional-pilot-organizations-coordinated-behavioral-physical-health-services/.

For more information, contact: Lynn Sutfin, Public Information Officer, Michigan Department of Health and Human Services, Post Office Box 30195, Lansing, Michigan 48909; 517-284-4772; Email: SutfinL1@michigan.gov; Website: https://www.michigan.gov/mdhhs/ and https://www.michigan.gov/mdhhs/0,5885,7-339-71550_2941_76181—,00.html.

So much happened in the past 90 days in the health and human market space. But what really matters? What are the “stop the presses” developments that executive teams need to incorporate in their strategic thinking? The themes were two-fold: One, the push for “whole person” approaches to care and, two, the integration/consolidation of organizations, functions, and financing. Here are five developments that have the potential to unravel the best laid plans of many organizations.

Among the many developments that can reshape strategy are payers increasing focus on social determinants. In the past quarter, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare Advantage plans in 2020 will be able to offer supplemental social service benefits if they diagnose, compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization (see Medicare Advantage To Offer Supplemental Benefits For Social Determinants In 2020). The second was UnitedHealthcare’s announcement that it expects its provider organizations to use the International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) Z-codes, in categories Z55 to Z65, to capture information about the consumer’s reasons for a health care visit that further explain the need for the social support services. The idea is to expand efforts to identify consumers with social service needs (see UnitedHealthcare Expands Initiative To Use Diagnostic Codes To Capture Social Determinants Of Health).

The implications? There will be a new market for “packaged” social services. But these won’t be the social service of the past – they will be “prescribed” packages of support services for specific consumers with a carefully calculated return on investment (ROI). The availability of these new payment streams means that new competitors will enter the market space, forcing traditional social service provider organizations to ramp up their measurement of cost and outcomes.

Long-term questions: Will public social service budgets shrink as these services become “medicalized”? And, will the types of social services available to an individual vary by their health plan members (and whether they are insured)? These are big issues to watch.

There are now 23 states and the District of Columbia with health homes and more states are developing. And almost more importantly, the health home construct is now common in the commercial health insurance market and with accountable care organizations.

At the same time, retail pharmacy, and soon-to-be-insurer, CVS announced their own approach to whole person care in the form of one-stop-shopping HealthHubs. In 1,500 of its current retail locations, CVS plans to dedicate 20% of retail space to health care services like urgent care, telehealth, chronic disease management, and wellness. The HealthHUBs will offer a care concierge professional, seminars, kiosks, and iPads for wellness apps.

The implications? New competition for a number of provider organizations. Obviously, traditional primary care practices face a competitor with a consumer-centric approach and wide range of services. But specialty provider organizations face new competition as well. The model will include chronic care management and Minute Clinics already have telehealth services for specialty consultation. The HealthHub concept—if successful—is perfectly positioned to compete for care coordination, medical home, and health home contracts.

At the same time, the push to value-based forms of reimbursement entered Medicare primary care – with CMS unveiling five new models for value-based primary care reimbursement. CMS primary care payments will likely fall in one of two models.

The first model is called Primary Care First and will utilize a risk adjusted professional population-based payment with a flat primary care reimbursement fee. The second model is a direct contracting model that will pay a capitated, risk adjusted payment for enhanced primary care services. Overall, CMS estimates that 25% or 11 million Medicare FFS enrollees will be served under the new model.

The implications? This is reflective of the overall movement of Medicare away from fee-for-service reimbursement. There will be opportunities for specialty provider organizations to collaborate with primary care practices that, under this model, will be more likely to refer high-needs and complex consumers for specialty care – depending on the performance incentives. But certainly, this change in financing is going to drive the purchase of a host of digital health options by primary care practices who will be substituting tech-enabled interventions for staff time.

Finally, there are two notable mergers among health plans. Wellcare is being acquired by Centene and Anthem is acquiring Beacon Health Options (see Centene To Buy WellCare For $17.3 Billion and Anthem To Acquire Beacon Health Options). These mergers represent the continuation of two trends that have noted before—the consolidation of membership among a small number of health insuring organizations and the dwindling of the use of the horizontal carve-out for care financing and service delivery.

The implications? Centene will continue to be the largest insurer of Medicaid beneficiaries by far and Magellan and New Directions remain the only major national behavioral health carve-out companies (and New Directions is affiliated with the Blues system). The bigger picture is that the standardization of health service delivery will happen within national health insuring systems and not necessarily within geographic regions. While the health insuring organizations do have local plans with local control and local provider networks, we are seeing the advent of national contracts for a wide range of specialty services. This trends poses a market share threat to local provider organizations delivering those specialty services.

Strategy is more important than ever – but that strategy needs to be constantly adjusted with the changing market. What to do? William Arthur Ward quote, ” The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.” It’s all about adjusting the strategy sails, so to speak.

There is a lot of discussion of bundled rates, case rates, and other forms of episodic payments. But it was very enlightening to hear from two executives who have “been there and done that”—the experience of Elizabeth Woike-Ganga, Chief Operating Officer, BestSelf Behavioral Health; and Tony Rajiv Juneja, M.D., Founder/Chief Executive Officer of Manage Addiction Lifeline, Oriah Behavioral Health, was front and center in the session, How To Develop Alternative Payment Models: A Guide To Building Successful Bundled Payment Models, at The 2019 OPEN MINDS Strategy & Innovation Institute session.

Dr. Juneja presented his work at Oriah Behavioral Health, which develops and offers a telehealth platform and optimizes recovery outcomes for people suffering from addiction and mental health issues—Manage Addiction Lifeline. Manage Addiction Lifeline is an opioid addiction app based on the bio-psycho-socio-spiritual model, that is combined with MAT, Individual Therapy (IT), Group Therapy (GT), and a Digital Curriculum (DC) for a comprehensive and evidence-based approach. This 52-week long treatment program is covered by Optum and Oxford (both under United Healthcare Group) and Aetna insurance plans through a bundled rate. The reimbursement is an all-inclusive monthly rate per member enrolled in MAT; costs for enhanced services are included in the monthly rate.

BestSelf Behavioral Health is the largest community-based behavioral health organization serving 20,000 consumers (children, adolescents, and adults) in Western New York state, with an annual budget of $60 million. They are a certified community behavioral health clinic (CCBHC) and in the middle of a two-year pilot program, which provides fully integrated behavioral health care for children, adolescents, and adults under strict criteria, certified by the state. BestSelf CCBHC Clinics provides immediate access, personalized care, a “No Wrong Door” approach, and focuses on evidence-based practices. The CCBHCs are reimbursed through a cost-based prospective payment system (PPS) with a fixed daily rate payment. Under the fixed daily rate, CCBHCs receive the same fixed payment for all services provided to a Medicaid beneficiary on a given day, regardless of the intensity of services provided.

Any type of alternative payment model will present its own unique challenges, but there are some key best practices that can help any provider organization that is moving away from fee-for-service. After listening to Dr. Juneja’s and Ms. Woike-Ganga’s presentations, I have five key take aways for successfully developing and managing alternative payment models:

  1. Understand Your Costs
  2. Focus On Building Accurate Estimates
  3. Build An Optimal Infrastructure For New Payment Models
  4. Scale Slowly & Incrementally
  5. Develop A Plan To Demonstrate Value

Understand Your Costs—Before you can build an accurate financial model, you need to understand your unit costs. Your unit costs should include all direct program costs, direct administrative expenses, and an allocated portion of organizational overhead. This demands accurate data and reporting from your team and a clear definition of the program or service requirements. Without a true understanding of your costs, you will never be able to accurately manage an alternative reimbursement model.

Focus On Building Accurate Estimates—To be successful with an alternative payment model, you need to be able to estimate your volume and predict your until costs for the future. Use your current experience to project service utilization. Build a model based on average utilization, but plot out your utilization patterns to assure you understand the distribution of your high and low utilizers. Once a bundled model in implemented monitor utilization closely, watch for adverse shifts in utilization. Both overestimating and underestimating what you can do and how much it will cost is a major risk. Overestimating runs the risk of takebacks, and underestimating runs the risk of deficits.

Build An Optimal Infrastructure For New Payment Models—Managing bundled rates demands a shift in organizational infrastructure—both in operations and culture. Your team needs technology and data management to track and report on clinical outcomes and costs; new workflow processes will need designed and optimized; staff will need to understand changing expectations and undergo new training; and your organization’s culture needs to shift to a data-driven management model (see Making Your Clinical Team Data Driven).

Scale Slowly & Incrementally—Scaling too quickly and in “leaps and bounds” carries with it unnecessary risk. When negotiating a new contract and building relationships with payers, be careful not to over promise when determining the bundled rate; start slow and take the necessary time to scale correctly and proceed serially with your innovations and advancements. Continuously, plan, roll out, measure, tweak your plan, remeasure, roll out again. To innovate and scale relies on having room for improvement and to make adjustments as feedback and data is received. You may want to modify your processes as you learn from roll out what offers the best return on your investment both in terms of efficacy and financially. Dr. Juneja noted, “If you start with a Maserati, you won’t be able to scale.”

Develop A Plan To Demonstrate Value—The point of alternative payment models is to align cost and quality by delivering on a pre-agreed upon value equation. After you’ve contracted, you need to demonstrate with data how you are delivering on that value equation. A major component of this is to control costs, otherwise payers may shy away from expanding or continuing your arrangement. You’ll need real-time data analysis to address issues with cost and clinical outcomes as they arise, and the ability to share cost and outcomes data with payers as needed.

In the end, bundled rates can allow for innovation and positive treatment outcomes—but only if you have key components covered in your rate. For more, check out these resources in the PsychU Resource Library:

  1. Options For Alternative Payment Models For Behavioral Health
  2. Developing Case Rates? Better Find Your ‘Single Source Of Truth’
  3. Alternate Payment Models – Strategy Implications Of The CMS Roadmap
  4. Preparing For Value-Based Reimbursement-Even Before The Contracts Are Signed
  5. Four Ps For Leading A VBR Evolution (Or Any Change)
  6. Pay For Value-The Glass Half Full, The Glass Half Empty?
  7. VBR Jumping From Hospital-Centric ACOs To Community-Based Players
  8. Crawl, Walk, Run To VBR
  9. The Hospital Perspective On ‘Owning’ Value-Based Reimbursement
  10. Building A Workforce For Value-Based Reimbursement = Advice From Four Executives

Most respondents treated under Medicare bundled payment programs reported positive perceptions of care quality. While respondents participating in the Bundled Payments for Care Improvement (BPCI) initiative were significantly less likely to report favorable feedback on several measures, differences were small in magnitude.

BPCI respondents were 1.90 percentage points less likely to indicate that they were “quite a bit” or “extremely” satisfied with their overall recovery since leaving the hospital than were comparison respondents, at 70.31 for the BPCI group versus 72.21 for the comparison group. However, the BPCI survey respondents reported the same functional status months after their hospitalization as those not in BPCI, indicating that the efficiency incentives in BPCI did not jeopardize functional recovery. More than 95% of both BPCI and comparison survey respondents felt their health needs were manageable after returning home. Nearly 95% of both BPCI and comparison survey respondents agreed that medical staff clearly explained how to take medications, and what follow-up appointments would be needed.

These findings were reported in “Association Of Medicare’s Bundled Payments For Care Improvement Initiative With Patient‐Reported Outcomes” by Matthew J. Trombley, Ph.D.; Sean R. McClellan, Ph.D.; Daver C. Kahvecioglu, Ph.D.; Qian Gu, Ph.D. et al. The researchers analyzed data from a random sample of BPCI beneficiaries, matched with comparison beneficiaries. Date were collected from nine rounds of surveys between 2014 and 2017 which yielded 29,193 BPCI, and 29,913 comparison respondents. All BPCI beneficiaries were treated by hospitals participating in BPCI Model 2. Both groups were similar in characteristics of age, Medicaid eligibility, function, pain, and condition treated. They then estimated risk‐adjusted differences in patient‐reported measures of care and changes in functional status, for beneficiaries treated by BPCI and the comparison hospitals. The goal was to determine whether the BPCI initiative affected patient‐reported measures of quality.

The Centers for Medicare and Medicaid (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative to encourage providers to deliver care more efficiently with equal or better quality. A bundled payment model focuses on outcomes rather than staffing, procedural reimbursement, or prescription reimbursement. Under a bundled payment model, individual episodes are reconciled to the target price and then netted with other episodes. Typical services included in the episode are physicians’ services, inpatient or outpatient hospital services that comprise of the Anchor Stay or Anchor Procedure (respectively), other hospital outpatient services, inpatient hospital readmission services, long term-care hospital (LTCH) services, inpatient rehabilitation facility (IRF) services, skilled nursing facility (SNF) services, home health agency (HHA) services, clinical laboratory services, durable medical equipment (DME), Part B drugs, and hospice services. After adjusting for quality measures, participants will either receive or owe a payment to CMS. A qualifying clinical episode is typically triggered by a claim submitted to Medicare by an Episode Initiator. Four different models exist within the BPCI initiative, each with different rules and incentives. Each BPCI participant can choose to enroll in one Model and any combination of 48 clinical episodes or groups of Medicare Severity Diagnosis Related Group (MS‐DRG).

Because of the slight difference in BPCI responses from consumers, the researchers concluded that better communications and better shared decision-making between consumers and BPCI care teams may result in favorable care experience across several measures. However, similar changes reported in functional status from before to after care episodes for the two groups should reduce concerns about the potential for BPCI incentives to result in harm to consumer health.

The full text of “Association of Medicare’s Bundled Payments For Care Improvement Initiative With Patient‐Reported Outcomes” was published April 30, 2019, by Health Services Research. An abstract is available online at https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13159 (accessed June 24, 2019).

On June 13, 2019, the Ohio Department of Medicaid (ODM) released a request for information (RFI) seeking comments in preparation for its next Medicaid managed care organization (MCO) procurement, which is scheduled for release on January 1, 2020. The RFI seeks comments from consumers, their advocates, and health care professionals and provider organizations. The RFI poses 39 questions in seven broad topic areas to elicit stakeholder comments. Responses to the RFI are due by July 31, 2019.

Ohio Governor Mike DeWine directed ODM to rebid the Medicaid MCO contracts to change the terms related to pharmacy benefit managers. Additional goals are to improve the quality of services and care to those served; use best practices to expand quality services and improve health outcomes; and improve the provider organization experience in managed care. The new contracts are tentatively scheduled to go live in January 2021.

ODM contracts with five MCOs selected in 2012: Buckeye Health Plan, CareSource, Molina Healthcare, Paramount Advantage, and UnitedHealthcare Community Plan. The MCOs are at risk for all medical benefits, behavioral health, and prescription medications. About 90% of Ohio Medicaid beneficiaries are enrolled in a Medicaid MCO. The MCOs also provide additional benefits, such as member services and care management. The reprocurement will not affect the MyCare Ohio program for adults age 18 and older who are eligible for both Medicare and Medicaid. The MyCare Ohio MCOs serve about 120,000 dual eligibles. The MyCare MCOs coordinate physical, behavioral, and long-term care services.

ODM seeks responses in the following topic areas:

  1. Communication and engagement with individuals: How easy is it for individuals to access health care and find a provider, and stay engaged in their health care efforts?
  2. Grievances and appeals: There are times an individual or provider may disagree with a decision made by the individual’s managed care organization; ODM is seeking first-hand experience and ideas regarding the grievance and appeals process.
  3. Provider organization support: What administrative processes or functions make it easier or more difficult to do business in a managed care environment? How might sharing data be improved?
  4. Benefits and delivery system: In what ways can the managed care program improve access to services, and what unique arrangements should ODM consider in place of a one-size-fits-all model of managed care?
  5. Care coordination and case management: As ODM focuses on improving outcomes for individuals with complex health needs, how can MCOs and partners work to ensure appropriate care coordination and case management?
  6. Population health: How can the managed care program improve health outcomes such as infant mortality, adult smoking, and cardiovascular disease?
  7. Performance measurement and management: How should ODM be measuring the performance of the managed care program and the individual managed care plans regarding both processes and outcomes?

The questions directed to provider organization support cover standardization across plans, communications, support, data sharing, workforce development, and payment innovation, as follows:

  1. Standardization across managed care plans: ODM seeks suggestions about how it could promote greater consistency of prior authorization requirements across managed care plans, other functions that should be standardized across managed care plans, the pros and cons of standardizing functions, potential barriers and ideas for addressing them.
  2. Communication about policy updates: Ideas for improving managed care plan communication with network providers about updates and changes to plan policies.
  3. Support for administrative requirements: How could managed care plans could help provider organizations navigate the plans’ administrative requirements, such as submitting clean claims and resolving billing issues.
  4. Data sharing: How could data sharing between the state, managed care plans and providers be improved? What data do provider organizations want access to that they do not have access to today; how would provider organizations use that data? What is the most effective way of providing data to provider organizations? Are there barriers to providing the requested data; how could those barriers be overcome? How could data be shared and used by provider organizations that have limited resources and technology?
  5. Supporting primary care provider organizations: How could managed care plans could support primary care providers in integrating care for individuals enrolled with them. What kind of primary care infrastructure may be needed? What kind of training or coaching may be needed? How could the state/managed care plans incentivize primary care providers to improve access to care? What kind of primary care models should be encouraged by the state/managed care plan?
  6. Workforce development: How could the state/managed care plans support workforce development for different types of professionals and provider organizations, including dentists, pediatric psychiatrists, primary care professionals, in-home caregivers and licensed or unlicensed behavioral health professionals?
  7. Payment innovation: What are some ways the state/managed care plans could prepare and assist providers to move through the continuum of shared accountability models that reward providers for quality and improved health care outcomes? How could the state or managed care plans support and increase the establishment of comprehensive primary care practices and/or accountable care organizations? Are there other payment innovations that the state should consider incorporating into the Medicaid managed care program?

For more information, contact: RFI response, Ohio Department of Medicaid, 50 West Town Street, Suite 400, Columbus, Ohio 43215; Email: MCProcurement@medicaid.ohio.gov; Website: https://medicaid.ohio.gov/FOR-OHIOANS/Managed-Care-Procurement; or Melissa Ayers, Director of Communications, Ohio Department of Medicaid, 50 West Town Street, Suite 400, Columbus, Ohio 43215; 800-324-8680; Email: Melissa.Ayers@medicaid.ohio.gov; Website: https://medicaid.ohio.gov/.  

The Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide) provides information and insights into the multi-layered United States behavioral health system. The Guide includes an in-depth view of current statistics, prevailing issues, and emerging trends in order to inform the discussions, debates and decision-making of policy-makers, payers, providers, advocates and consumers. The Guide addresses current behavioral health care trends topics, including:

    • A look at the national policy that is shaping the U.S. health and human services market
    • A view of the state behavioral health delivery systems that were created by a combination of historical practices, federal and state policy, and market factors over recent years
    • An examination of the practices of 1,265 health plans that manage both physical and behavioral health care for the vast majority of the U.S. population
    • A deep-dive into behavioral health care access and delivery of care from the consumer perspective

The Detroit-Wayne Mental Health Authority (DWMHA) is moving forward with a plan to contract with a Medicaid health maintenance organization (HMO) to integrate behavioral and physical health services for DWMHA members. On May 10, 2019, DWMHA released a request for information (RFI #0000215080) to regional HMOs, with proposals due by June 14, 2019. The goal is to start the integrated care program in the fall of 2019.

The RFI seeks willing Medicaid partner(s) to provide coordinated care of mental and physical services for members of the DWMHA. Currently, the DWMHA operates a prepaid inpatient health plan (PIHP) that manages Medicaid behavioral health services on an annual overall budget of $780 million to provide services for more than 73,000 consumers with serious mental illness (SMI), serious emotional disturbance (SED), intellectual and developmental disabilities (I/DD), and substance use disorder (SUD) in the greater Detroit area. It is the largest regional behavioral health PIHP in the state. The services include hospital-based services, residential services, community-based programs for consumers with SMI/SED, community-based programs for consumers with I/DD, and prevention and treatment services for consumers with SUD.

DWMHA intends to co-design up to two pilot projects. The project(s) will focus on holistic care, which includes behavioral, physical, economic, social, and spiritual well-being of the people being served. DWMHA will work with as many Medicaid health plans (MHPs) as are interested in partnering on an integration model that is based on the DWMHA model of care, core values, and pilot goals. DWMHA is targeting implementation for the fall of 2019.

Approximately 40% of DWMHA behavioral health expenditures are directed to individuals who are not already enrolled in a MHP. This specific population includes a higher percentage of individuals with significant behavioral health needs receiving multiple services. DWMHA is currently analyzing multiple options for the management of specialty behavioral health benefits for this population during the pilot(s).

The MHP(s) and DWMHA will jointly develop tools to augment care management services for shared members/consumers. Development of these tools will be informed by experience with the SMI, SED and I/DD populations as well as experience with the MI Health Link program and national best practices.

  • DWMHA serves a number of SMI and SED patients who are currently unenrolled in an MHP and who could potentially be eligible to enroll in an MHP. This population is projected to be as high as be 7,000 consumers. DWMHA is interested in working with partnered health plans to enroll this population in a MHP.
  • An additional 10,000 consumers served by DWMHA are currently receiving services in the fee for service system. DWMHA is also interested in working with partnered MHP(s) to provide augmented care management services to this population if additional funding is available from the state.

The proposal calls for DWMHA to provide the participating MHPs a network of physical health satellite offices. Each office will provide dental, vision, preventative health care, and other services. Mutual credentialing of providers will also be necessary. DWHMA intends to coordinate and integrate care by developing a medical records exchange system and streamlining referral processes in tandem with making these satellite offices available to MHPs.

DWMHA’s President and Chief Executive Officer Willie Brooks, estimated savings of up to $25 million may come from reducing unnecessary hospital emergency room visits and inpatient and catastrophic care. Currently, DWMHA spends $55 million annually on hospital costs for its 73,000 members. Financing methods for the services provided by the HMO are still in discussion, according to officials.

The DWMHA intends to announce its HMO selection after evaluation and interviews of potential partners in the coming weeks. As of June 16, 2019, the first round of responses from potential partners was received by the DWMHA. The go-live date for managing health care services from DWHMA members is predicated on how quickly the DWHMA comes to an agreement regarding key components of the partnership.

PsychU last reported on this topic in “Detroit Wayne Mental Health Authority To Phase Out Managed Care Network Contracts,” which published on July 13, 2018. The article is available at https://www.psychu.org/detroit-wayne-mental-health-authority-phase-managed-care-network-contracts/.

For more information, contact: Tiffany Devon, Director of Communications, Detroit Wayne Mental Health Authority, 707 West Milwaukee Avenue, Detroit, Michigan 48202; 313-344-9099; Email: tdevon@dwmha.com; Website: https://www.dwmha.com/contact-us/

Following the 2014 Medicaid expansion, the share of psychiatrists who accepted Medicaid declined from 47.9% in 2010-2011 to 35.4% in 2014-2015, as weighted by the National Ambulatory Medical Care Survey’s national weights and adjusted for practice ownership status. There was no similar change among primary care or other specialties.

These findings were reported in “Medicaid Acceptance by Psychiatrists Before and After Medicaid Expansion” by Hefei Wen, Ph.D.; Adam S. Wilk, Ph.D.; Benjamin G. Druss, M.D., MPH; and Janet R. Cummings, Ph.D. The researchers analyzed information from the 2010 to 2015 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of physicians who were not federally employed, were based in offices, and were primarily engaged in direct care of consumers; the research was limited to physicians who reported accepting new consumers for care. The goal was to determine trends in Medicaid acceptance over time. These estimates were weighted by the National Ambulatory Medical Care Survey’s national weights and adjusted for individual-level covariates.

The 11,521 NAMCS respondents who reported seeing new consumers for care included 584 psychiatrists; 4,400 primary care physicians; and 6,537 other specialists. Additional findings include:

  • In expansion states only, the adjusted difference for Medicaid acceptance increased 4.7% for other specialists, decreased 1.9% in primary care physicians, and did not change for psychiatrists.
  • In non-expansion states only, the adjusted difference for Medicaid acceptance increased 7.8% for psychiatrists, decreased 10.2% for other specialists, and did not change for primary care physicians.

The researchers concluded that consumer gains in insurance coverage under Medicaid expansion may not improve access to office-based treatment by psychiatrists. However, due to patterns discovered through different weighting mechanisms, Medicaid expansion did not have a large effect on differences in Medicaid acceptance for psychiatrists. They suggest further studies to determine reasons for the decline in Medicaid acceptance for psychiatrists after Medicaid expansion.

The full text of “Medicaid Acceptance by Psychiatrists Before and After Medicaid Expansion” was published June 5, 2019, by JAMA Psychiatry. An abstract is available online at https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2735109 (accessed June 18, 2019).

PsychU last reported on this topic in “35% Of Psychiatrists & 70% Of All Physicians Accept New Appointments For Medicaid Beneficiaries,” which published on April 15, 2019. The article is available at https://www.psychu.org/35-of-psychiatrists-70-of-all-physicians-accept-new-appointments-for-medicaid-beneficiaries/.

For more information, contact: Hefei Wen, Ph.D., Department of Health Management and Policy, University of Kentucky College of Public Health, 111 Washington Avenue, Lexington, Kentucky 40536; Email: hefei.wen@uky.edu; Website: https://cph.uky.edu/people/hefei-wen

Billing-related administrative costs in the United States health care system are estimated at about 8.3% of the $3.36 trillion total health care spending in 2016. During 2019, billing-related administrative costs are projected to reach $496 billion annually. Excess billing-related administrative costs are estimated at $248 billion annually for 2019.

The billing-related administrative cost estimate includes annual costs for health insurers and provider organizations to submit claims, reconcile claims, and process payments. The 2019 estimate of $496 billion for billing-related administrative costs excludes medical record-keeping; hospital management; initiatives that monitor and improve care quality; and programs to combat fraud and abuse.

Billing-related administrative costs that were categorized as “excess” are caused by inefficiencies. This includes the cost of handling duplicate intake forms, transferring medical records between provider organizations, and ensuring accuracy in insurance bills. The $248 billion estimate of excess costs excludes costs associated with retail sales of medical products, such as sales of prescription drugs and durable medical equipment.

Annual billing-related administrative costs for 2019 incurred by physicians, hospitals, and other provider organizations are estimated at $282 billion. Up to 50% may be excess administrative costs.

Annual billing-related administrative costs for 2019 incurred by private insurers are estimated at $158 billion. Up to 66% may be excess administrative costs. Annual billing-related administrative costs for 2019 incurred by public programs are estimated at $56 billion. For public programs, the share of excess administrative costs is unknown.

These statistics were reported in “Excess Administrative Costs Burden the U.S. Health Care System” by Emily Gee and Topher Spiro for the Center for American Progress. The researchers used recent projections of U.S. health expenditures from the Centers for Medicare and Medicaid Services (CMS), and 2015 and 2016 data from the Organisation for Economic Co-operation and Development to obtain spending information for other countries. They analyzed the National Academy of Medicine’s estimations of billing-related administrative costs (13% of physician care spending; 8.5% of hospital care spending; 10% of spending by other provider types; 12.3% of spending on private insurance; and 3.5% of public program spending, including Medicare and Medicaid). The goal was to provide an overview of administrative expenditures in the U.S. health care system, in the context of proposals to reduce administrative costs and/or implement single-payer health care.

With estimated billing-related administrative costs at 8.3% in 2016, the United States has a higher burden of administrative costs than other developed countries. Those with the next highest percentage of administrative costs are France (5.7%), Austria (4.8%), and Germany (4.2%). In contrast, Norway (0.6%), Finland (0.8%), and both Sweden and Japan (1.6%) have the lowest percentages of administrative costs.

The researchers presented analyses of proposals to reduce administrative costs through a variety of strategies, including implementing a single-payer program. They reported that the estimates of savings varied widely.

The researchers concluded that a large body of evidence shows that the United States has much higher health care administration costs than other countries and may be spending twice what is needed for governance, billing, and insurance. They noted that other nations have high quality health care systems and spend a fraction of what the United States spends. They recommended that a structural overhaul of how the United States finances and prices health care could include key features used in other countries. Simplifying the payment system should be a key focus on future health reform in the United States to make the system work better for taxpayers and for consumers.

The full text of “Excess Administrative Costs Burden the U.S. Health Care System” was published on April 8, 2019, by Center for American Progress. An abstract is available online at https://cdn.americanprogress.org/content/uploads/2019/04/03105330/Admin-Costs-brief.pdf (accessed June 3, 2019).

PsychU last reported on health plan administrative costs in “2018 National Health Expenditure Projected At $3.65 Trillion, Up 4.4%,” which published on April 8, 2019. The article is available at https://www.psychu.org/2018-national-health-expenditure-projected-at-3-65-trillion-up-4-4/.

For more information, contact: Colin Seeberger, Press Contact, Center for American Progress, 1333 H Street Northwest, Floor 10, Washington, District of Columbia 20005; 202-682-1611; Email: cseeberger@americanprogress.org; Website: https://www.americanprogress.org/

The Colorado Department of Human Services (CDHS) awarded contracts to four organizations to operate the state’s existing crisis behavioral health system. On March 26, 2019, CDHS awarded six of its seven regional crisis behavioral health services contracts. The seventh and last contract was awarded on May 7, 2019. The seven regional crisis contractors, called administrative services organizations (ASOs), will provide a network of walk-in crisis centers, crisis stabilization centers and respite and mobile crisis services in their regions.The crisis system aggregate contract value is more than $31 million, which includes the regional contracts and the crisis call line. The contracts go live on July 1, 2019.

The new ASOs for the crisis system and the contract values are as follows:

  • Region 1: Rocky Mountain Health Maintenance dba Rocky Mountain Health Plans, $7,770,860
  • Region 2: Beacon Health Options, $2,655,108
  • Region 3: Signal Behavioral Health Network, $6,060,930.00
  • Region 4: Health Colorado, $2,836,820
  • Region 5: Signal Behavioral Health Network, $3,026,727
  • Region 6: Signal Behavioral Health Network, $3,799,308
  • Region 7: Beacon Health Options, $3,197,726

Another part of the system is the statewide crisis call line. The crisis line contract was awarded to the incumbent Rocky Mountain Crisis Partners, which has operated the state’s crisis line since inception. The crisis line has a budget of $3,068,291 and served 54,826 individuals last year through text, online chat, and call services.

CDHS released the request for proposals (RFP 2019000043) on September 4, 2018, with responses due by November 5, 2018. The unsuccessful bidders were Colorado Crisis Modalities (which applied for Regions 1, 2, 4, 5,6 and 7) and Beacon Health Options (which applied for Region 1). Beacon also applied and was awarded Regions 2 and 7. The incumbents under the previous contracts that started July 1, 2014, were Community Crisis Connection; West Slope Casa, LLC; AspenPointe, Inc.; and Northeast Behavioral Health, LLC. Their contracts ran through June 30, 2015, followed by four one-year renewal options.

The new contracts reflect a change in the number of behavioral health crisis service regions, which are now aligned with the state’s Medicaid regions. The realignment is intended to simplify the process for consumers seeking care, and help the state better analyze and track community health and wellness. The Colorado Crisis System is available to all Coloradans, regardless of insurance or ability to pay. If an consumer has insurance coverage, the regional ASO will bill for covered services. For services not covered by insurance the contracted amount for each region is expected to cover this portion of the care through these contracts.

The RFP and a copy of the winning proposals are available for download at https://www.openminds.com/rfp/colorado-seeks-mobile-crisis-walk-in-crisis-crisis-stabilization-and-crisis-respite-services/.

For more information, contact:

  • Elizabeth Owens, Director, Communications, Colorado Department of Human Services, 1575 Sherman Street, Floor 8, Denver, Colorado 80203-1714; 303-866-7505; Fax: 303-866-5563; Email: elizabeth.owens@state.co.us; Website: https://www.colorado.gov/pacific/cdhs
  • Christopher Miller, Program Assistant, Community Behavioral Health, Colorado Department of Human Services, 3824 West Princeton Circle, Building 15, Denver, Colorado 80236; 303-866-7498; Email: Christopher_miller@state.co.us; Website: https://www.colorado.gov/pacific/cdhs

On April 25, 2019, the Sacramento, California, the City Council announced it will open four low barrier shelters; as a result of these projects, the city will close Railroad Drive shelter, its 200-bed city-run homeless shelter. The Railroad Drive shelter cost $5 million in city and private funds to operate from its opening in December of 2017 to its closing in April of 2019. Since 2017, the city’s unsheltered population has nearly doubled. In December 2018, Mayor Darrell Steinberg presented a plan for developing approximately 800 shelter beds over two years, using City funds as well as state grants and private donations. The City Council members each pledged to find one or more sites within their districts that could be used to shelter 100 homeless people.

In February 2019, the City Council approved $15.7 million for overall sheltering activities and $1 million for rehousing options for women with families and children. On March 25, 2019, the City Council voted unanimously to pursue plans for a new homeless shelter, the Ethan Way Rehousing Shelter, with approximately 100 beds located in the California Exposition complex. If an agreement is reached with Cal Expo, the City would be allocated the use of Lot P, where a pre-fabricated building and low-barrier shelter called “Sprung Shelter” could be placed.  The Ethan Way shelter would serve people experiencing homelessness who already live in the neighborhood and are referred there by the Sacramento Police Department’s IMPACT team or by outreach workers. Ethan Way would have on-site case managers to connect individuals with social and health services and help them move into permanent housing. The total estimated cost of the design, construction, and operation of Ethan Way for a two-year period is estimated at approximately $9.4 million. The county anticipates that State Homeless Emergency Aid Program (HEAP) funds would cover approximately $4.2 million of the shelter’s operations, with the remaining $5.2 million in funds coming from reserve Measure U funds extracted from a temporary city tax used to restore essential city services. The Ethan Way shelter could be operational as soon as six months after the City and Cal Expo reach an agreement. The City will be contracting out for services to run the Ethan Way shelter but did not disclose any information on potential bidders.

The Council voted to use a portion of the remaining $11.6 million of the $25.6 million available for homeless services during the 2019 year to create a 180-bed downtown shelter located in the Capitol Park Hotel. The Capitol Park Hotel Shelter will cost more than $23 million, though the city will be reimbursed $13 million from Mercy Housing when the shelter closes, before Mercy converts it to permanent supportive housing. The shelter is expected to open during the summer of 2019. Operations of the new shelter will be overseen by the Sacramento Housing and Redevelopment Agency (SHRA).

The Council also allocated funds for four “scattered site shelters.” The “scattered site” program will rely on community non-profits to lease homes, which will be in different neighborhoods around the city. These shelters, located in single-family homes, are ideal for special populations including the elderly, members of the LGTQ community, and single women. The scattered site shelters can be created quickly and closed when no longer needed. The City Council also approved plans for a 12-bed shelter for LGBTQ youth, as well as a new “Host Homes” pilot program with the LGBT Community Center, in which host families help house young people experiencing homelessness.

Should more funding become available, the City will prioritize two new potential shelters in this order: South-area Rehousing Shelter, and the Broadway/X Rehousing Shelter. The soonest work could start on either of these potential sites (if they were approved by the City Council) would be more than a year away.

For more information, contact: Office of Media & Communications, City of Sacramento, 300 Richards Boulevard, Floor 3, Sacramento, California 95811; Email: citypublicinformation@cityofsacramento.org;  Website: https://www.cityofsacramento.org/

On April 17, 2019, the Alabama Medicaid Agency issued intent to award notices for the state’s seven regions of the Alabama Coordinated Health Network (ACHN). My Care Alabama was awarded three regions: Northwest, Central, and East. Alabama Care Network was awarded two regions: Midstate and Southeast. North Alabama Community Care was awarded the Northeast region. Gulf Coast Total Care was awarded the Southwest region. If approved by the federal government, the networks are expected to be implemented on October 1, 2019. The aggregate value of the first-year contracts is about $40.9 million; the maximum contract values for the seven regions range from $5.5 million to $6.6 million.

The Alabama Medicaid Agency issued a request for proposals (RFP 2019-ACHN-01) on January 9, 2019, with proposals due by February 25, 2019. Bidders could submit proposals on one or all seven regions in the state but were required to submit a separate proposal for each individual region.

The ACHN is intended to streamline its current roster of care coordination programs through four programs: Family Planning Care Coordination services, Patient 1st State Plan Amendment (SPA) Care Coordination services, Health Home (SPA) functions, and Maternity Care (1915(b) Waiver) functions. Currently care coordination is provided by 12 maternity programs, six health home programs, and services provided by Alabama Department of Public Health staff in 67 counties. The ACHN creates a single care coordination program with seven region-specific managing entities, at one per region. The regional managing entities are called Primary Care Case Management Entities (PCCM-Es). The PCCM-Es will coordinate transportation needs for assigned recipients, as needed. Delivery of medical services is not part of the ACHN; Medicaid will continue to pay provider organizations directly.

The ACHN will serve full-benefit, non-institutionalized children, pregnant women, and aged/blind/disabled beneficiaries in the Patient 1st population, maternity care population, and Plan First (family planning) population. Excluded populations include people dually eligible for Medicare and Medicaid, those in an institutional setting (including prison or jail), those enrolled in the state’s home- and community-based services waiver, children in custody of the Department of Youth Services, and people using hospice services.

Primary care physician (PCP) groups are required to complete an ACHN enrollment agreement with the Alabama Medicaid Agency before July 1, 2019 to avoid any delay in receiving bonus and participation payments. The goal is to incentivize PCPs with additional compensation for developing individualized, comprehensive care plans for Medicaid beneficiaries. Care coordination referrals may be requested by provider organizations, recipients, or community sources. The care coordination services can be provided in a setting of the recipient’s choice, to include provider organization offices, hospitals, ACHN-entity offices, public locations, or in the recipient’s home.

A copy of RFP 2019-ACHN-01 is available for download at https://www.openminds.com/rfp/alabama-seeks-coordinated-health-network-services/. The winning proposals have been requested and will be available at the same page.

PsychU last reported on this topic in “Alabama Medicaid Releases RFP For Regional Care Coordination,” which published on February 3, 2019. The article is available at https://www.psychu.org/alabama-medicaid-releases-rfp-regional-care-coordination/.

For more information about RFP 2019-ACHN-01, contact: Varonica Wagner, Alabama Medicaid Agency, Lurleen B. Wallace Building, 501 Dexter Avenue, Post Office Box 5624 , Montgomery , Alabama 36103-5624; Email: achnrfp@medicaid.alabama.gov; Website: http://www.medicaid.alabama.gov/content/2.0_Newsroom/2.4_Procurement.aspx

For more information the program, contact: Alabama Coordinated Health Network, Alabama Medicaid Agency, 501 Dexter Avenue, Montgomery, Alabama 36104; Email: ACHN@medicaid.alabama.gov; Website: https://www.medicaid.alabama.gov/content/2.0_Newsroom/2.7_Special_Initiatives/2.7.6_ACHN.aspx; or Melanie Cleveland, Communications Director, Alabama Medicaid Agency, 501 Dexter Avenue, Montgomery, Alabama 36104; 334-353-9363; Email: Melanie.cleveland@medicaid.alabama.gov; Website: http://medicaid.alabama.gov. 

On May 13, 2019, attorneys general in five states – California, Connecticut, Massachusetts, Oregon, and Washington – sued the U.S. Department of Health and Human Services (HHS) seeking to overturn an HHS final rule, issued May 6, barring states from making Medicaid payments to third parties on behalf of individual home care direct support professionals (DSPs). The rule applies to voluntary payroll deductions made to pay union dues, as well as deductions to pay for worker benefits obtained through collective bargaining, such as health care coverage.

The reason for the lawsuit is a newly finalized federal rule issued on May 6, 2019, that prohibits states from diverting Medicaid payments away from the DSPs providing services to HCBS participants directing their own services. As a result, states cannot deduct payments for worker benefits obtained through collective bargaining or voluntary union dues from home care workers’ paychecks. The complaint alleges that the rule disrupts well-established collective bargaining relationships authorized for decades by state labor laws. States that fail to comply with the rule may lose their federal Medicaid funding for personal care services.

The lawsuit, California v. Azar, alleges that in California the HHS final rule undermines the state’s In-Home Supportive Services (IHSS) Medicaid program; the other states make similar allegations relative to their consumer-directed Medicaid home- and community-based services (HCBS) programs. In California, more than 500,000 DSPs provide IHSS services; in the other states, several hundred thousand more DSPs provide similar services. In the plaintiff states, the DSPs have the right to collectively bargain for better wages, benefits, and training. The states believe this creates more stable, and higher quality HCBS programs. In California, only DSPs who elect to join the union pay dues to the union. Those who decline to join are not required to pay “fair share” or “agency” fees to cover the costs of collective bargaining.

DSPs who provide consumer-directed home care are employed by the beneficiary (or a guardian). The beneficiary/guardian can direct the beneficiary’s care through the hiring, firing, and day-to-day supervision of the DSPs delivering services. States and/or local authorities are responsible for general conditions related to Medicaid DSP home care employment. Each of the plaintiff states has permitted collective bargaining as a key component of these responsibilities. The states or local authorities negotiate with unions with respect to issues such as determining training requirements, referral programs, and optimizing wage and benefit packages to allow the states and local authorities to recruit and better retain a talented pool of home care workers.

The federal rule rescinded a federal Medicaid regulation confirming the established practice of direct deductions. HHS said the reason was the change is a 47-year-old provision of the Medicaid Act that prohibits assignment of rights to collect payment for Medicaid services to third parties. At that time, HCBS and consumer-directed home care services, such as IHSS, did not exist. Congress enacted that provision to prohibit a fraudulent medical financing scheme unrelated to legal payroll deductions for union dues, health insurance premiums, or other benefits.

After the proposed rule was released on July 10, 2018, California’s Attorney General sent a letter to HHS in opposition. That letter noted that HHS provided no evidence to suggest that Medicaid payments were being inappropriately diverted and that the rule would disrupt established collective bargaining arrangements.

For more information, contact: Press Office, Office of the Attorney General, State of California Department of Justice, Post Office Box 944255, Sacramento, California 94244-2550; 916-210-6276; Email: agpressoffice@doj.ca.gov; Website: https://oag.ca.gov/home.

A review of Medicaid 1115 demonstration waivers and amendments submitted by states between January 2017 and May 2018 found lack of consistency and transparency in the Centers for Medicare & Medicaid Services (CMS) processes. The review was conducted by the Government Accountability Office (GAO), which analyzed 11 CMS approvals of new demonstrations and extensions and 21 amendments submitted by 17 states. CMS conducted inconsistent reviews to determine whether the new applications and renewal requests complied with federal transparency requirements; some applications were deemed complete although they lacked expected changes in enrollment, which is required. CMS was inconsistent in its transparency reviews of state changes to pending applications, even when the changes were major because no criteria exists for determining when a change is major enough to warrant a new transparency review. The transparency review process for waiver amendments does not require states to provide information on expected changes in enrollment and costs, even for amendments to implement work requirements. The rationale for approvals has not been transparent, and it is unclear how public comments inform CMS requirements for monitoring and evaluating waivers.

The 1115 Medicaid waivers allow states to receive federal Medicaid matching funds for experimental, pilot, or demonstration projects that are likely to promote Medicaid objectives. The Patient Protection and Affordable Care Act (PPACA) required the federal Department of Health and Human Services (HHS) and CMS to establish procedures to ensure transparency in approvals of new Medicaid waiver demonstrations and extensions to existing demonstrations. The PPACA did not address waiver amendments, which are subject to long-standing guidance issued in 1994 on public input. HHS issued regulations in 2012 to address transparency in the approval of applications for new demonstrations and extensions.

These findings were reported in “Medicaid Demonstrations: Approvals of Major Changes Need Increased Transparency” by the GAO. The U.S. Senate’s Committee on Finance, and the U.S. House of Representative’s Committee on Energy and Commerce had requested that the GAO examine the public transparency of CMS’s demonstration approvals. The GAO reviewed 11 approvals of new demonstrations and extensions and 21 amendments approved in 17 states to their existing demonstrations. The review focused on transparency policies and procedures. In-depth reviews were performed on four of the 11 approvals and on three of the 21 amendments. Documentation for these seven “in-depth review” subjects were also reviewed to examine CMS’s use of the public input it receives to make demonstration approval decisions and for ongoing monitoring and evaluation.

Transparency requirements for demonstration applications

The 2012 transparency regulations dictate the information states must include in the application and require states to seek public input on their proposals prior to submitting an application to CMS. The regulations present the procedures that CMS will follow upon receiving the application. CMS reviews the submitted application to check for compliance with these regulations, before seeking additional public input through a 30-day comment period at the federal level. The regulations also provide CMS discretion to engage in additional transparency activities on a case-by-case basis. CMS’s regulations also include monitoring and evaluation requirements to ensure that the outcomes of demonstrations are transparent. CMS has developed procedures for assessing states’ applications for new demonstrations and extensions against the transparency requirements established in 2012 by reviewing incoming applications for new demonstrations or extensions against detailed checklists the agency designed to align with transparency requirements in the regulations. CMS completed checklist reviews for each of the 11 applications for new demonstrations or extensions that CMS approved from January 2017 through May 2018.

CMS also developed and implemented procedures for seeking public input at the federal level and making that input publicly available, including sending email notifications to individuals who have registered on the agency’s website when demonstration applications are open for public comment; posting the application on the website where the public can post comments during the 30-day comment period; and maintaining the public comments on the website, which are maintained indefinitely. CMS also offers a record of key decisions and documents for each demonstration on its website. The GAO found weaknesses related to the transparency of major changes made to pending applications, and the transparency of changes to approved spending limits. The GAO found inconsistency in CMS’s review of applications for compliance with transparency requirements, as follows:

  • CMS lacks criteria for determining when a change to a pending application is considered major and warrants an additional state comment period.
  • CMS does not have a policy for reassessing pending applications against transparency requirements when states make changes mid-review.
  • Expected changes in enrollment were not always included in state public notices.
  • Evaluation information was not always included in state applications.

Transparency requirements in approving states’ amendments to existing demonstrations

Applications for amendments to Medicaid section 1115 demonstrations are also subject to requirements for seeking public input. This requirement was outlined in guidance that HHS issued in 1994. The GAO found that CMS applies limited transparency requirements to states’ applications to amend existing demonstrations, despite the fact that states may propose significant changes to demonstrations through amendments, including failure to place limits on what changes can be made through amendments:

  • There is no requirement to hold a state public comment process or provide CMS a summary of public input received.
  • There is no requirement to include expected changes in enrollment and costs.
  • There is no minimum requirements for information to be included in the public notice.
  • Transparency requirements for amendment applications were inconsistently applied to amendment applications across states.

Using public input in making demonstration approval decisions

CMS reviewed state descriptions of issues raised during the state public input process and the state’s response as part of its application review. However, the level of detail in state summaries of their responses to these comments varied considerably. The extent to which CMS used public comments to inform monitoring and evaluation decisions was also not always clear. CMS officials said requirements for evaluations have been evolving as they have gained experience in understanding the public’s concerns. Officials also said they were developing robust evaluation guidance that they plan to use consistently going forward for states implementing work and community engagement requirements. As of January 2019, officials said this guidance was in draft form and under review.

The GAO recommended that, based on the findings in their report, the Administrator of CMS should develop and communicate a policy that defines when changes to a pending section 1115 demonstration application are considered major and should prompt a new review of the application against the transparency requirements applicable to the pending application. They also recommend that the Administrator of CMS should develop and communicate a policy whereby applications for section 1115 demonstration amendments that may have significant impact are subject to transparency requirements comparable to those for new demonstrations and extensions.

PsychU last reported on this topic in “MACPAC Asks HHS To Pause Arkansas Medicaid Work Requirement Disenrollments,” which published on December 24, 2018. The article is available at https://www.psychu.org/macpac-asks-hhs-pause-arkansas-medicaid-work-requirement-disenrollments/.

PsychU also reported on this topic in “From June To November 2018, 17,000 People Lost Arkansas Medicaid Benefits Over Failure To Meet Work Requirements,” which published on February 18, 2019. The article is available at https://www.psychu.org/june-november-2018-17000-people-lost-arkansas-medicaid-benefits-failure-meet-work-requirements/.

For more information, contact:

  • Tom Corry, Director, Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: https://www.cms.gov/.
  • Jacqueline M. Nowicki, Public Affairs, U.S. Government Accountability Office, 10 Causeway Street, Room 575, Boston, Massachusetts, 02222; 617-788-0580; Email: nowickij@gao.gov; Website: http://www.gao.gov/

On June 6, 2019, Anthem Inc., announced plans to acquire behavioral health organization Beacon Health Options from Bain Capital Private Equity and Diamond Castle Holdings. Financial terms of the transaction were not disclosed. The acquisition is expected to close in the fourth quarter of 2019. Via this acquisition, Anthem, a large health benefits company, seeks to expand its focus on behavioral health solutions as part of whole person care.

Specifically, Anthem intends to combine its existing behavioral health business with Beacon’s model and support services to fully scale integrated behavioral and physical health capabilities to customers and consumers nationwide. After the acquisition closes, Beacon will be combined with Anthem’s behavioral health business and they will operate as an integrated team within Anthem’s Diversified Business Group. Russell C. Petrella, Ph.D., Beacon Health Options president and chief executive officer (CEO), as well as other key members of Beacon’s senior team, will join Anthem’s Diversified Business Group to lead the efforts to offer innovative behavioral health solutions and further expand this business.

Beacon Health Options was formed in a 2014 merger between Beacon Health Strategies and ValueOptions. Beacon Health Options became a portfolio company of Bain Capital Private Equity the same year. Beacon currently serves more than 36 million individuals across all 50 states, including nearly 3 million individuals under comprehensive risk-based behavioral programs. Beacon’s CEO Dr. Petrella said, “We are excited to partner with Anthem to serve the behavioral health needs of more than 60 million Americans. Our member-focused, integrated clinical care model helps individuals and their families cope with their physical and behavioral health challenges. Together, we will expand access and enhance the quality of care for our mutual members.”

Anthem serves more than 78 million people, including over 40 million within its family of health plans. Anthem’s President and CEO Gail K. Boudreaux said, “With an extensive track record in behavioral health, Beacon fits well with our strategy to better manage the needs of populations with chronic and complex conditions, and deliver integrated whole health solutions. Together with Beacon, we will enhance our capabilities to serve state partners, health plans and employer groups as they seek to address consumer behavioral health needs.”

PsychU last reported on Beacon Health Options in “Beacon Care Services Launched With Texas Walmart Mental Health Practice,” which published on January 7, 2019. The article is available at https://www.psychu.org/beacon-care-services-launched-texas-walmart-mental-health-practice/.

For more information, contact:

  • Tina Beckwith, Senior Vice President, Marketing & Communications, Beacon Health Options, 200 State Street, Boston, Massachusetts 02109; 860-338-0164; Email: tina.beckwith@beaconhealthoptions.com; Website: https://www.beaconhealthoptions.com/
  • Jill Becher, Media Relations, Anthem Inc., 120 Monument Circle, Indianapolis, Indiana 46204; 414-234-1573; Email: jill.becher@anthem.com; Website: https://www.anthem.com

Greetings from New Orleans, where on the first day of The 2019 OPEN MINDS Strategy & Innovation Institute; we had the opportunity to hear from a lot of great organizations that are implementing new innovative programs such as specialty primary care programs at Woods Services, Intermountain’s social determinants of health, Compass Health’s on-site pharmacy program, and SummitStone’s medication adherence program.

But while we heard from these “‘ahead of the curve” organizations, the big question is how widespread is the adoption of innovations in specialty provider organizations? This question was answered with the release of The 2019 OPEN MINDS National Innovation Survey: 2019 Innovation Adoption Among Specialty Provider Organizations. The survey results were presented today by Monica E. Oss, OPEN MINDS Chief Executive Officer, at the opening of the institute. Some of the key findings include:

  1. Peer support was the top innovation adopted by specialty provider organizations. Fifty-four percent of organizations currently offer peer support. However, as more organizations offer peer support, we may be reaching a saturation point. The use of peer support only increased one percentage point over 2018.
  2. Telehealth/telepsychiatry remains the second most adopted innovation at 50% of organizations. The use of telehealth increased slightly more than peer support from 2018 – five percentage points.
  3. The innovation that saw the biggest increase between 2018 and 2019 was medication adherence technologies and programs. The use of this innovation increased 21 percentage points.

From a strategy perspective, there were a couple developments that caught our attention. The first was the new innovations among providers of intellectual/developmental disabilities (I/DD) and long-term services and supports (LTSS) services. As a group, these provider organizations had the largest increases in telehealth use and medication adherence programs. This market segment also reported an 18% increase in establishing “center of excellence” contracts with payers.

The second was the adoption of innovations by primary care provider organizations. This market segment had a 45% increase in co-location programs providing behavioral health services and an 18% increase in offering medication assisted treatment (MAT) for addiction treatment. Primary care organizations also reported 25%+ increases in offering medical home programs and readmission prevention/hospital diversion programs.

The challenge for health and human service organizations remains the slow implementation of innovations to scale. Specialty provider organization management teams are great at pilot programs but slow to take successful innovations from the pilot stage to scale. The keys to speeding this process are best practice change management processes and making sure there is buy-in at every level of the organization. Second, organizations need to have the data on the performance of innovative in order to respond to problems before it’s too late (see Five Rules For Building An Effective KPI System).

On May 24, 2019, Tennessee Governor Bill Lee signed legislation directing the state’s Division of Finance and Administration (DFA) to request federal approval to transition the Medicaid program to a block grant. The legislation, Tennessee House Bill 1280 of 2019 directs DFA to submit a waiver amendment to the existing TennCare II waiver, or to submit a new waiver to the federal Centers for Medicare & Medicaid Services (CMS) within 180 days after the bill is signed.

Currently, Tennessee’s federal funding for fiscal year 2018 to 2019 totals $7.5 billion. If approved by the federal government, the level of federal funding that would be approved for the Medicaid program is unknown. Nearly 1.4 million people are enrolled in TennCare.

The legislature added an amendment to require that the block grant convert the federal share of all medical assistance funding for Tennessee into an allotment that—according to the legislature—is tailored to meet the needs of the state. The block grant must include the following nine elements:

  1. Factor in, for the base amount, what the legislature said was a “current inaccurate reflection of the state’s labor costs in the state’s Medicare Wage Index and the index’s negative impact on health care delivery in this state.” The bill did not provide additional information about the nature, cause, or degree of the alleged inaccuracy.
  2. Is indexed for population growth.
  3. Is indexed for inflation and other costs.
  4. Excludes from the block grant financing amount any expenses that are not included in the state’s existing 1115 demonstration waiver.
  5. Excludes administrative costs from the block grant financing amount and permits the state to continue to draw federal matching funds for administrative costs
  6. Provides the state with maximum flexibility with regard to existing federal mandates and regulations and with implementing cost controls as determined appropriate by the state, and either exempts the state from the requirements of any new mandates, regulations, or federal court orders during the period of block grant financing or increases the amount of block grant financing to offset any cost increases to the state from such mandates, regulations, or federal court orders.
  7. Provides the state with maximum flexibility regarding pharmacy benefits including fluctuation of prescription drug costs, diabetic testing supplies, and over-the-counter medications.
  8. Provides the state with maximum flexibility to serve other needy populations with distinct financial or healthcare needs.
  9. Remains at the level set according to the block grant without any decrease in the federal share of all medical assistance funding for this state based on deflation or a reduction in population..

For more information, contact:

  • Sarah Tanksley, Deputy Director of Communications and Employee Relations, Division of TennCare, Tennessee Division of Health Care Finance and Administration, 310 Great Circle Road, Nashville, Tennessee 37243; 615-507-6450; Email: sarah.tanksley@tn.gov; Website: https://www.tn.gov/tenncare.html
  • Paul Bailey, Senator, Tennessee General Assembly, 425 5th Avenue North, Suite 736, Cordell Hull Building, Nashville, Tennessee 37243; 615-741-3978; Email: sen.paul.bailey@capitol.tn.gov; Website: http://www.capitol.tn.gov/

On May 13, 2019, Washington State Governor Jay Inslee signed Senate Bill 5526 into law, creating a “public option” health insurance plan for Washington residents. The plan, titled “Cascade Care,” will make Washington the first state in the nation to offer a voluntary public option for health insurance. Under Cascade Care, the Washington State Health Care Authority (HCA) will contract with private health insurers to administer the plans but will control the terms to manage costs. The idea is for the government to create a health insurance program to compete with the private marketplace and to expand coverage and affordability for all Washington residents.

Beginning in January 2021, consumers seeking individual coverage will have the option to buy a state-sponsored plan on the Health Benefit Exchange, Washington State’s online insurance market place. The HCA will contract with private health insurance carriers to offer three levels of plans through the exchange—bronze, silver, and gold. The plans will cap total provider organization and facility reimbursement rates at 160% of Medicare rates for all covered benefits in the statewide aggregate, excluding pharmacy benefits. For services provided by rural hospitals the legislation caps rates at 100% of the Medicare rate. Reimbursement for primary care services provided by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine are capped at 135% of the amount that would have been reimbursed under Medicare for similar services.

Under Cascade Care, the state will not subsidize or help cover the cost of premiums beyond federal subsidies that are already available on the Exchange based on income levels. The legislation directs state officials to devise a plan by November 2020 to subsidize individuals who earn up to 500% of the federal poverty level — roughly $62,500 for an individual and $129,000 for a family of four.

Approximately 200,000 Washington residents, or less than 3% of the population, currently buy individual coverage on Washington’s Exchange. Between 2018 and 2019, enrollment in the individual market dropped by more than 13,000 people, according to data provided by the Exchange. The state’s most recent uninsured rate was 5.5%.  Pam MacEwan, CEO of the Exchange, commented on the decrease in enrollment, saying that the individual insurance market has been buffeted by a series of Trump administration policies, including the end of federal reinsurance and cost sharing payments and the end of penalties for individuals who don’t buy coverage. By offering the Cascade Care plans, Washington officials hope to increase enrollment through the exchange and decrease the uninsured rate.

In addition to increasing enrollment and affordability, a goal of the Cascade Care plan is to offer public option plans in all 39 of Washington’s counties. Currently, 14 counties offer only one individual health insurance plan option on the exchange. In previous years, the state has struggled to find a single carrier to provide coverage in rural areas labelled as “bare counties.” However, participation by health insurers in Cascade Care is voluntary, and there’s no requirement that they offer statewide coverage.

For more information, contact: Amy Blondin, Chief Communications Officer, Washington State Health Care Authority, Post Office Box 45502, Olympia, Washington 98504-5502; 360-725-1915; Email: amy.blondin@hca.wa.gov; Website: http://www.hca.wa.gov/.

One of the big cultural changes happening in health care is moving from “volume” to “value” in reimbursement. The volume of services is still the focus of provider organization management teams when it comes to profitability and sustainability. But, with the increasing use of value-based reimbursement models (VBR), the metrics for sustainability and profitability are shifting. Value-based reimbursement and other alternate payment models increase the “financial return” of achieving other goals—reduced total cost of care, reduce readmission rates, and reduced use of emergency rooms, to name a few.

This is a sea change in financial sustainability models, and it affects every aspect of the organization from the front desk, to clinical programming, to billing. And the effect is particularly pronounced for health systems and organizations with acute care and residential treatment beds—see The Future Has Arrived For VBR. If you’re a manager in an organization with a large amount of revenue (or profitability) tied to beds, the challenge ahead is making the shift from fee-for-service to value-based purchasing landscape-and surviving the transition period.

So, what do executives of these bed-based provider organizations need to do to map a successful trajectory from volume-based payment to VBR? For the answer to that question, we asked some executives with experience in these settings. They had four recommendations: Understand that hospitals play an important “short-term” role; develop a standards-based continuum of services; leverage unique services and expertise; and focus on quality and performance.

Understand that hospitals play an important “short-term” role—The days when hospitals were the undisputed center of the health care delivery experience are over and trying to use this resource as the main lever to meet the demands of value-based care and wellness focused population-based management simply won’t deliver the desired results. OPEN MINDS Senior Associate George Braunstein, noted:

While acute hospitals and residential treatment facilities are still a vital part of the health care continuum, they are no longer the center of gravity. They play an important short-term role and need to design their service system in that manner. If not, they will not only lose money, but will not be very effective at providing overall services and thus find it impossible to meet new standards and reimbursement realities in value-based health care.

Develop a standards-based continuum of services—Populations with complex health needs can’t get those needs met in one place. The solution is to build the provider organization relationships and infrastructure across the whole care continuum so that all those needs can be met with an agreed upon and shared standard of care. Mr. Braunstein, also noted:

Any hospital or residential facility not only needs to find effective community-based partners, they need to work with their partners to develop a standards-based continuum of services. Even if a hospital or residential facility has services available or has contracted partners, their team needs to work in a systematic way to address the service and care coordination needs of the various populations they serve. It is critical to have decision support tools to make these standards uniform across care coordinators in a system of care.

Brandon W. Danz, Director of Government Risk Programs at WellSpan Heath and OPEN MINDS Advisory Board Member, also explained the importance of partnerships across the continuum of care, noting:

Value-based reimbursement requires stronger partnerships across sites of care and across a consumer’s continuum of care – and especially when the consumer has complex medical needs. We are seeing new informal partnerships between hospitals and post-acute providers to institute seamless transitions of care and more importantly, meaningful coordination and communication surrounding patient-centered care. Health systems are recruiting preferred provider organizations who can meet these new population health opportunities. They’re looking for partners who offer solid care management, successfully manage medication adherence, and have in place continual performance improvement strategies to reduce infections and optimize length of stay.

Leverage unique services and expertise—In addition to great care coordination across the health care continuum, specialty services for specialty populations are critical for success in VBR arrangements. There should be a constant lookout for new models, innovations, or education to help maximize the effect these services can have on complex health needs. Mr. Danz explained:

Treatment facilities, skilled nursing facilities, and inpatient rehab facilities are well-positioned to leverage their unique set of services and expertise to succeed in value-based care. They should regularly monitor new models being developed by government and commercial payers. They can start by proactively addressing their organizational culture to be agile and ready to act on an opportunity when it is presented. Governing boards and leadership need to be educated and ready to adapt a value-based mindset. Thinking outside the box is critical here – these organizations must re-imagine their future in new ways. Under value-based models, post-acute facilities are seen as points of admission to divert consumers from hospitals when they can be better served by the unique expertise and set of services offered in the facility. This not only saves money and contributes to value-based success, but it also offers better care at a better location and often, with better outcomes for consumers and their caregivers.

Focus on quality and performance—Above all, the shift from volume to value must be about quality of care and performance of the service delivery system. Simply saving money isn’t good enough if the health outcomes aren’t also improved. When all competitors in a given market have shifted to value-based care and costs have come down across the board, the quality of care will also serve as a powerful market differentiator. Mr. Danz noted:

These types of facilities also need to keep an eye on quality. It is becoming more strongly tied to financial outcomes and is also being reported publicly. In competitive environments, being the second-highest quality provider organization in your region might mean being the second choice of well-informed consumers. It is only a matter of time until app developers commoditize on Medicare’s increased performance transparency data to provide consumers with transparency and choice.

For more on managing the shift from volume to VBR, check out these resources from the PsychU Library:

  1. How Do We Automate Population Health Management?
  2. No Whole Person Care Without Person-Centered Organizations
  3. Using Population Health Tools For Competitive Market Advantage
  4. Population Health Management Strategies – The Hospital Perspective & Beyond
  5. Leadership Evolution Needed For Successful Population Health Management
  6. Behavioral Health Evidence-Based Practices As Population Health Management Tools
  7. Improving Population Health Management With Public Health Approaches

As of March 2019, all 39 of Virginia’s local Community Services Boards (CSBs) and the Richmond Behavioral Health Authority (RBHA), which provide access to public mental health services had implemented same day access, a provision of the state’s larger System Transformation Excellence and Performance (STEP-VA). The Virginia Department Of Behavioral Health and Developmental Services (DBHDS) developed STEP-VA to provide easier access to public mental health services; ensure a uniform set of services across all CSBs, and ensure accountability across CSBs. STEP-VA requires CSBs to implement same day access, primary care screening, behavioral health crisis services, outpatient behavioral health, psychiatric rehabilitation, peer/family support services, Veteran’s behavioral health, care coordination, and targeted case management.

For same day access, the CSBs provide a clinical assessment that same day to any individual who comes to the CSB during open access hours. If the assessment determines that the person needs services, the first appointment will be offered within 10 days. The goal is to improve consumer satisfaction and engagement, as well as avoiding “no shows” in the assessment process. Before implementing same day access, people needing an assessment potentially waited weeks for their first clinical appointment, and some CSBs reported 40% no-show rate.

Now that all CSBs have implemented same day access, they will focus on implementing the next STEP-VA provisions: primary care screening and monitoring at all CSBs, phasing in a statewide expansion of outpatient services, and planning for more comprehensive crisis services at all CSBs.

STEP-VA is loosely based on the federal Certified Community Behavioral Health Clinic (CCBHC) model. Virginia was awarded a CCBHC planning grant, but in October 2016 opted not to submit a proposal for a demonstration grant due to cost and infrastructure concerns. The STEP-VA model was developed as a sustainable Virginia-specific solution. The CSBs began working on STEP-VA after the 2017 Governor and the General Assembly provided $4.9 million in general fund dollars for an initial group of CSBs to implement SDA. The General Assembly required the remainder of STEP-VA services to be implemented over the next two biennia, with additional funding to be allocated in the coming years. The 2018 Governor and the General Assembly provided $5.9 million for the second group of 22 CSBs to implement same day access in fiscal year 2019. Each CSB will receive $270,000 in ongoing state mental health funds. Eight CSBs had already implemented some form of same day access and received funding on July 1, 2018, to address their implementation costs. By the end of calendar year 2018, all but five CSBs had implemented same day access. The remaining CSBs were on-track to implement same day access in early 2019 and did so in March.

CSB progress on same day access was reported in March 2019 by the Virginia Association of Community Service Boards, Inc., a trade association for the CSBs. Additional information about same day access and STEP-VA was reported by the Virginia Department Of Behavioral Health and Developmental Services (DBHDS) in a December 2018 year-end report to the legislature, and was also mentioned in June 2018 in the CSB contract requirements for fiscal years 2019 and 2020. During fiscal year 2018, CSBs reported receiving more than $1.3 billion from all sources to provide community-based services for 218,894 individuals

For the fiscal year 2019 and 2020 CSB contracts, DBHDS implemented new reporting requirements that are focused on the continuity of care and utilization, as follows:

  1. Continuity of care for local psychiatric inpatient discharges: The population includes individuals for whom the CSB purchased or managed local inpatient psychiatric services from a private psychiatric hospital or psychiatric unit in a public or private hospital who keep a face-to-face (non-emergency) mental health outpatient service appointment within seven calendar days after discharge. The benchmark is 70%.
  2. Continuity of care for state hospital discharges: The population includes individuals for whom the CSB is the identified case management CSB and who keep a face-to-face (non-emergency) mental health outpatient service appointment within seven calendar days after discharge from a state hospital. The benchmark is 80%.
  3. Residential crisis stabilization unit utilization (RCSU): The measure focuses on the percent of all available RCSU bed days for adults and children utilized annually. The target annual utilization rate is 75%. This measure applies to CBS that operate an RCSU.
  4. Regional discharge assistance program (RDAP) service provision: The measure focuses on the share of total annual state RDAP fund allocations to a region obligated and expended by the end of the fiscal year. The benchmark: CSBs in a region shall obligate at least 95% and expend at least 90% of the total annual ongoing state RDAP fund allocations on a regional basis by the end of the fiscal year. The benchmark does not include one-time state RDAP allocations provided to support ongoing DAP plans for multiple years.
  5. Local inpatient purchase of services (LIPOS) provision: The measure focuses on the share of the total annual regional state mental health LIPOS fund allocations to a region expended by the end of the fiscal year. The benchmark: CSBs in a region shall expend at least 85% of the total annual regional state mental health LIPOS fund allocations by the end of the fiscal year.
  6. Program of assertive community treatment (PACT) caseload: The measure applies to the average number of individuals receiving services from the PACT team during the preceding quarter. The benchmark calls for CSBs that operate PACT teams to serve at least 75% of the number of individuals who could be served by the available staff providing services to individuals at the ratio of 10 individuals per clinical staff on average.
  7. Frequency of developmental enhanced case management (ECM) services: The percentage of individuals who receive Developmental Disability Waiver services who meet the criteria for receiving ECM who receive at least one face-to-face case management service monthly, with no more than 40 days between visits, and who receive at least one face-to-face case management service visit every other month at their residence. The benchmark: The CSB shall provide the face-to-face visits on time to at least 90% of individuals receiving DD Wavier services who meet the criteria for ECM.

The requirements were outlined in “Virginia Department Of Behavioral Health & Developmental Services Administrative Requirements For Community Service Boards For Fiscal Years 2019 & 2020.” The CSB Administrative Requirements include or incorporate by reference ongoing statutory, regulatory, policy, and other requirements that are not expected to change frequently. Reporting requirements are included for financial management; procurement; reimbursement; human resource management; information technology; planning; forensic services; interagency relationships, and access to services for those who are deaf, hard of hearing, late deafened, or deaf-blind. The document also outlines treatment block grant requirements for federal substance abuse prevention and treatment.

The VACSB notice, “All CSBs Have Implemented the Same Day Access Model,” is posted at https://vacsb.org/wp-content/uploads/2019/03/Same-Day-Access-at-CSBs-March-2019-.pdf (accessed May 14, 2019).

PsychU last reported on this topic in “Virginia Opts To Avoid CCBHC Demonstration,” which published on December 14, 2016. The article is available at https://www.psychu.org/virginia-opts-avoid-ccbhc-demonstration/.

For more information, contact:

  • Maria Reppas, Freedom of Information Act and Media Relations, Virginia Department of Behavioral Health and Developmental Services, Post Office Box 1797, Richmond, Virginia 23218-1797; 804-786-3921; Email: maria.reppas@dbhds.virginia.gov; Website: http://www.dbhds.virginia.gov/developmental-services/step-va
  • Hilary Piland, Public Policy Manager, Virginia Association of Community Services Boards, 10128 West Broad Street, Suite B, Glen Allen, Virginia 23060; 804-330-3141; Fax: 804-330-3611; Email: hpiland@vacsb.org; Website: https://vacsb.org/

Is your organization ready for a contract with down-side financial risk? Perhaps a bundled rate? A care coordination contract paid on a per-member per month basis? A six-month case rate for residential services?

Only 25% of executives answered “yes” (sort of) to that question in recent survey led by the Jefferson College of Population Health and conducted by Numerof & Associates (see 25% Of Health Care Provider Organizations Ready To Take On Risk-Based Contracts). Only 4% are “completely” ready, and only 21% are “very” ready. What we also found interesting was that 64% claim to be “somewhat” or “moderately” ready—and that could mean they aren’t really ready at all.

The same survey of physician group executives or vice presidents, as well as individuals working in U.S. provider organizations including health care systems, hospitals, and academic medical centers found that about three-quarters of the organizations have at least one payer agreement that includes upside gain and/or downside risk—but less than 20% of revenue is at-risk. The median amount of revenue at-risk was 10% and the median amount of revenue in capitated contracts was 5%. For 31%, the risk-based agreement is one-sided and has no downside risk.

This squares with the results of OPEN MINDS recent national survey—about 58% of specialty provider organizations are getting some revenue from value-based reimbursement agreements, and 9.3% have 20% or more of their revenue coming from VBR.

And The Centers for Medicare and Medicaid Services (CMS) push for ACOs to accept downside risk is going to move the field (see The ACO ‘Savings Confusion’. In addition, health plans are also starting pilot programs with value-based reimbursement (VBR) arrangements that include downside risk (see Health Plan Contracting Opportunities – More Consistency Emerging).

The “million-dollar question”? What are the most important organizational competencies needed to accept downside financial risk? We reached out for perspectives from the field and came up with a short list:

  1. An integrated tech platform with clinical data, interoperability, performance management analytics, and care coordination functionality
  2. Real-time performance data for real-time decision making
  3. An understanding of service delivery cost variables and the risk-based contracting process
  4. An organizational culture focused on performance metrics and performance management

An integrated tech platform with clinical data, interoperability, performance management analytics, and care coordination functionality—One of the most common competencies needed to work effectively with a VBR contract is sufficient data management skills to address the financial risk. This starts with adopting an integrated tech platform and investments in tech infrastructure and data analytics so that you can integrate data from multiple sources, meaningfully analyze data for business intelligence, and inform stakeholders from front-line, to clinicians, to management, to payers, to health plans. OPEN MINDS Senior Associate George Braunstein noted:

In my experience with managed care as well as service delivery it would be unusual for any organization to enter into a risk-based contract without those basic tools. This does not mean that they always manage to effective outcomes, but they can ensure that they can monitor performance and manage the risk sufficiently to have a positive bottom line.

OPEN MINDS Senior Associate Ken Carr also noted how poorly many organizations do this:

Based on our analysis of VBR readiness assessment results so far, the lowest scoring competency has been technology infrastructure. I think that this is one of the most important competencies for VBR-implementing the right technology in the most effective manner is the foundation for using data to drive quality outcomes and operating performance.

Real-time performance data for real-time decision making—Even if your organization has the right tech platform, it doesn’t mean you know how to use the data for decisionmaking. OPEN MINDS Senior Associate John Talbot explained:

You must have the ability to track VBR performance measures in as close to real time as possible. And then you need a team that can use that information to act quickly. This involves timely root cause analysis and being willing to change processes as needed.

An understanding of service delivery cost variables and the risk-based contracting process—One element that is often overlooked in preparing organizations is understanding the cost of your current services and the drivers that would increase or decrease those costs. Success in a VBR arrangement relies on developing and maintaining contractual partnerships with payers and health plans and that can’t happen in a mutually beneficial way unless you know how to come to the table and can discuss your costs and the cost assumptions. OPEN MINDS Senior Associate Deb Adler noted:

The most common VBR competency needed is understanding your current unit costs so as you enter into alternative payment arrangements, you must know your current costs to confirm the financial modeling matches up to your business practices.

An organizational culture focused on performance metrics and performance management—Another important competency needed is an organizational culture that values the use of timely data and responds with effective improvements in performance when needed. This cultural competency is usually built upon the use of evidence-based practices, open communication among staff at all levels, and aligning the measures of performance with great consumer care. This culture is essential for long-term sustainability because the relationship between health plans and provider organizations is shifting from vendor to partner, from volume to value. This means, to quote OPEN MINDS Senior Associate Peggy DeCarlis, that the key is “the ability for health plans and provider organizations to create authentic, transparent, mutually beneficial relationships.”

For more, check out these resources in the PsychU Resource Library:

  1. Preparing For Value-Based Reimbursement-Even Before The Contracts Are Signed
  2. Four Ps For Leading A VBR Evolution (Or Any Change)
  3. Pay For Value-The Glass Half Full, The Glass Half Empty?
  4. The Future Has Arrived For VBR
  5. VBR Jumping From Hospital-Centric ACOs To Community-Based Players
  6. Crawl, Walk, Run To VBR
  7. Building A Workforce For Value-Based Reimbursement = Advice From Four Executives

There has been lots of activity by health plans around the social determinants of health—and arranging and/or paying for social services. The question is whether this a passing interest by health plan managers or will this become a permanent shift in health plans service array which will provide a sustainable funding stream for provider organizations.

What has been happening? Eighty percent of health plans moving to make social support part of their service array. The Health Care Service Corporation (HCSC) and the Blue Cross Blue Shield (BCBS) Institute launched foodQ, a six-month food delivery pilot program (see Blue Cross Launches Food Delivery Program To Address Social Determinants), and the Humana Foundation Dedicating $7 Million To Address Social Determinants Of Health. The American Medical Association (AMA) and UnitedHealthcare (UHC) announced a collaboration to support the creation of 23 new ICD-10 codes related to social determinants of health (see AMA & UnitedHealthcare Partner To Propose New ICD-10 Codes To Identify & Address Social Determinants Of Health) and Anthem is making a push to whole person care, as well as person-centered care (see No Whole Person Care Without Person-Centered Organizations).

There are several initiatives coming out of the Kaiser system. Kaiser Permanente last year announced they are investing $200 million in housing projects with the goal of supporting more housing projects in the future and recently announced a $5.2 million investment in a 41-unit affordable housing complex in East Oakland, California (see Kaiser Permanente Invests In Affordable Housing Complex In Oakland, California For $5.2 Million As Part Of Initiative To Improve Community Health By Addressing Housing Insecurity). And the organization just unveiled plans for a partnership with social coordination platform Unite Us as part of their comprehensive health network-Thrive Local. The goal of this new network is “to connect health care and social services providers to address the pressing social needs including housing, food, safety, utilities and more for millions of people across the United States”. The goal is to begin the roll out this summer and expand to Kaiser Permanente’s 12.3 million members and the 68 million people in the communities Kaiser Permanente serves, within three years. The network will track community partner referrals and service outcomes to measure if consumer needs are being met.

The big question—will this be “referrals only” to already overburdened social service programs or will the health plans pay health and human service provider organizations for selected types of social services? And, if health plans are to pay for “non-medical” social support services, this assumes they can get past the immediate hurdle—that the U.S. does not consider certain social services as part health care expenses. The recent changes to the Medicare Advantage plan rule (see The Thinning Line Between Health Care & Social Services) indicate that there may be new funding available for under-funded social services.

A concern is that the health plan interest in social determinants of health has been driven by a decade of the provisions of the Patient Protection & Affordable Care Act (PPACA). No preexisting conditions clauses, behavioral health parity, no annual and lifetime limits, and nearly universal health care coverage has changed the risk management practices of health plans from cost shifting to other service systems to managing the long-term health and well being of enrolled consumers. This could all change if the PPACA is overturned.

The long-term role of social service initiatives in health plans has yet to be determined. OPEN MINDS Senior Associate Sharon Hicks is cautiously optimistic about the potential—but raises the issue of the decades-long systematic underfunding of social services. She said:

If these recent notices about social determinants of health is signaling a permanent change in the way that we think about taking care of acute and chronic illness, then the money that flows into the supportive services, which are important to the success of the medical care received, will serve to increase the capacity for service delivery.

If, however, the medical/insurance community continues to question the value of the supportive services and refuses to pay a fair value for the delivery of the services, then we are likely to experience a tremendous shortage of availability of these types of services. The market for the services has been inappropriately deflated by the current models of compensation for staff. If that doesn’t change, then the addition of these SDH-focused services will likely fail to realize significant improvements in outcomes for this country.

Deb Adler, OPEN MINDS Senior Associate, links the future of these initiatives to the ability to demonstrate return-on-investment (ROI)—a topic we’ve covered before. She noted:

I do think payers will go beyond a referral only model, but I suspect it may take some time to transform payer thinking. I suspect the Medicaid managed care programs or divisions within large payers are already leading the pack. It’s wise guidance to demonstrate value to payers as there are social service disruptors out there who may be more nimble, effective (read: less caught up in the “way things have always been done”), and willing to compete with traditional social service providers for the opportunity to provide these services as part of their business model and social mission.

I wouldn’t underestimate the time it will take to prove a return-in-investment and the challenges. Social service needs are complex and not binary (it’s not like you have unstable housing and then “flip a switch” and have stable housing). And statistically there can be a high mortality or “drop-out rate” of the population that is the target focus, which makes the analysis that much more difficult.

A recent payer was hesitant to enter into a shared savings arrangement tied to implementing interventions tied to SDH because they felt it would be difficult to determine if the improvement was a “regression to the mean” or actual improvement. A charitable backer of the program wanted to have a simple “start” and “stop” point for the program to more easily measure impact when the reality is it was unrealistic to use the same “point in time” for individuals targeted to move from a homeless situation to stable housing. Statistically this all can be managed but it illustrates that barriers remain in moving to payment for social service interventions.

For those social support services that health plans may pay for, provider organization business development teams need the same type of approach used for any payer contract development. The key-get your proof of return-on-investment (ROI) for your social service supporting services ready (see Social Services ROI Essential To Social Determinants Wave). Any provider organization management team out there that thinks their “social services-infused approaches” to health care will become a long-term market differentiator need to get their “proof” ready now. Without it, the long-term programmatic approaches adopted by payers and health plans will use someone else. As stated before-this is a big opportunity for someone (see A Big Opportunity For Someone).

For more information to get your team thinking about new programming integrating social services, check out these resources from the PsychU Resource Library:

  1. Addressing Social Determinants-The Measurement Challenge
  2. Social Determinants Today, Social Determinants Tomorrow
  3. Addressing The Social Determinants Of Health With Income Assistance
  4. Medicare’s Path To Incorporating Social Determinants Into Value-Based Payment
  5. Screening Humana Medicare Advantage Members For Social Determinants Of Health Reduced ‘Unhealthy Days’ By 2.7%

California-based provider organizations sharing financial risk through a capitated payment model had better health outcomes and performance on quality measures than provider organizations reimbursed using a fee-for-service (FFS) model. In addition, average consumer out-of-pocket (OOP) costs were 60% lower for consumers under the care of a risk-sharing provider organization, at $268 OOP annually, compared to $672 OOP per year for those under the care of a FFS provider organization.

These findings were reported in “Health Care Cost & Quality Atlas” by the Integrated Healthcare Association (IHA). The researchers analyzed data from seven California health plans that cover 7.2 million lives via health maintenance organization (HMO), preferred provider organization (PPO), and accountable care organization (ACO) products, both fully insured and self-insured. The data set represents about 55% of the statewide commercial enrollment of 13.1 million, excluding Kaiser Permanente. The researchers excluded Kaiser Permanente data from the analysis, because its more than 6 million commercial lives would skew the results. The prevalence of provider organizations participating in risk-sharing varies from 24% in Northern California, 18% in Central California, and 45% in Southern California. The analysis compared three risk-sharing arrangements:

  • Full risk, which was defined as capitation for both professional and facility costs
  • Professional-risk only, which was defined as capitation for non-facility clinical professional and ancillary services such as outpatient lab tests
  • No risk, which was defined as FFS

Quality was defined as clinical quality scores based on a composite of eight measures, and on preventive screening rates. Provider organizations participating in a risk-sharing arrangement had higher scores than those in FFS. Quality scores for provider organizations in a full-risk arrangement had an average composite quality score of 67.1%. Provider organizations with professional risk only had an average quality score of 65.6%. Provider organizations paid FFS had an average quality score of 57.9%. Preventive screening rates were 11 percentage points higher for full-risk provider organizations compared to FFS provider organizations.

The total cost of care was up to 3.5% lower for risk-sharing provider organizations. The total cost of care for members under the care of a FFS provider organization averaged $4,589; the average cost was $4,428 for members under the care of a full-risk provider organization. The total cost of care averaged $4,501 for members under the care of a provider organization sharing professional services risk.

Pharmacy costs were up to 13% lower for risk-sharing provider organizations. Pharmacy costs per member per year (PMPY) averaged $970 for FFS provider organizations and averaged $840 PMPY for those under the care of a full-risk provider organization. Pharmacy PMPY averaged $882 for members under the care of a provider organization sharing professional services risk. The researchers noted that clinical risk was very similar across the three risk sharing levels (within 1% to 2% of the others) and did not account for the differences.

In each of the three geographic regions (Northern, Central and Southern), provider organizations participating in risk arrangements had higher clinical quality scores compared to FFS-only provider organizations. The researchers noted similar associations between risk sharing, quality scores, and cost of care in the 19 Covered California regions. They concluded that risk sharing is associated with higher value, defined as better clinical quality at lower cost. They proposed that the provider organizations participating in risk arrangements may be using the capitated payment to invest in care management programs and other infrastructure to support population health and quality improvement.

The full text of “Health Care Cost & Quality Atlas” was published April 11, 2019 by the Integrated Healthcare Association. A copy is available online at https://atlas.iha.org/story/risk (accessed May 3, 2019).

For more information, contact: Akhila Nanduri, Media Contact, Integrated Healthcare Association, 500 12th Street, Suite 310, Oakland,California 94607; 510-585-7422; Fax: 510-444-5842; Email: akhila.nanduri@ogilvy.com; Website: https://www.iha.org/

On April 9, 2019, Cuyahoga County, Ohio approved a $42.3 million contract with The MetroHealth System (MetroHealth) to provide correctional health care services for the Cuyahoga County Jail system. The contract began May 9, 2019 and runs through May 8, 2022. MetroHealth previously provided physicians and advanced practice providers for the County Jail system, and the County provided nursing staff.

Under the agreement, Cuyahoga County will pay MetroHealth up to $12.75 million annually for all staffing, plus other expenses for medical supplies, pharmaceuticals, insurance, administrative duties, and accreditation. Medical staffing will be based on an average of 2,000 inmates per day at the Cuyahoga County Corrections Center (CCCC). If the average daily population increases, MetroHealth and the County would work together to adjust staffing levels.

The contract specifies that MetroHealth must fully staff operations at the county’s three jails by October 31, 2019. The three jails include the downtown Justice Center, Bedford Heights City Jail, and Euclid City Jail. However, MetroHealth agreed to fully staff administrative positions by June 30, 2019. Additional specifics in the contract include:

  1. The corrections officers providing security for medical staff will receive specialized health care training and will be dedicated to the medical unit.
  2. The county is required to work with MetroHealth toward accreditation from the National Commission on Correctional Health Care. Health care in the jail must meet the national organization’s standards by January 2020.
  3. The county is not able to select or remove any medical staff member and has no control over clinical operations. The county is required to promptly carry out any medical directives issued by MetroHealth’s jail medical director, as long as those directives do not impact the safety and security of staff and inmates.
  4. The county is required to staff the jail with an adequate number of corrections officers, and the county is required track how often inmates are locked in their cells.
  5. Legally required medical intake screenings are required to occur at the sally port, which is the first place inmates go when they are brought into the jail.
  6. At additional cost, MetroHealth will provide a dietitian to plan healthy and appropriate meals.
  7. MetroHealth will provide input on the county’s choice for a new jail administrator.
  8. MetroHealth will provide staff to administer a medically assisted treatment (MAT) program for those with addiction issues.
  9. Within 30 days of contract approval, the county will work with MetroHealth on a new system to process health-related requests from inmates.
  10. The county will be required to submit jail policies that impact inmates’ health and safety to MetroHealth for review and feedback.
  11. The county will be required to collaborate with MetroHealth in a variety of ways, including attending a daily safety briefing to resolve safety concern; participating in a monthly leadership meeting held to address any systems issues with the medical unit; and conduct a detailed review in the case of an inmate death, serious injury, or an injury to medical staff.
  12. The county is required to provide inmates with adequate hygiene supplies.
  13. Medical staff are required to have proper licenses.

The contract comes following a November 2018 report by the U.S. Marshals Service that summarized “inhumane” conditions at the jails. The conditions described included a lack of adequate medical and mental-health care. Many provisions in the MetroHealth contract correspond to problems identified in 2018 by the marshals, common pleas judges, and jail medical officials.

In December 2018, Cuyahoga County and MetroHealth were named as defendants in a class-action lawsuit resulting from the conditions at the CCCC. The civil rights lawsuit claims that conditions at the facility violate the First, Fourth, Fifth, Sixth, Eighth, and Fourteenth Amendments to the U.S. Constitution. The lawsuit, filed in the U.S. District Court Northern District of Ohio, seeks an independent monitor to oversee changes at the jail, and calls for an immediate fix to the crowding of inmates and understaffing of corrections officers. Specific allegations in the lawsuit that may be alleviated through the updated contract with MetroHealth include poor hygienic conditions, and “regular denial” of inmate medical and mental health care.

PsychU last reported on prison health care in “Milwaukee County Contracts With Wellpath For Correctional Health Care, Develops Plan To Self-Operate By 2021,” which published on May 13, 2019. The article is available at https://www.psychu.org/milwaukee-county-contracts-with-wellpath-for-correctional-health-care-develops-plan-to-self-operate-by-2021/.

For more information, contact:

  • Tina Shaerban-Arundel, Manager, Public & Media Relations, MetroHealth System, 2500 MetroHealth Drive, Cleveland, Ohio 44109; 440-592-1334; Email: tarundel@metrohealth.org; Website: https://www.metrohealth.org/
  • Rich Luchette, Communications, Information Office, Cuyahoga County, 2079 East 9th Street, Cleveland, Ohio 44115; 216-443-7000; Email: questions@cuyahogacounty.us; Website: https://cuyahogacounty.us/

For more information regarding the lawsuit, contact:

  • Terry H. Gilbert, Partner and Attorney, Friedman & Gilbert, 55 Public Square, Suite 1055, Cleveland, Ohio 44113-1901; 216-241-1430; Fax: 216-621-0427; Email: tgilbert@f-glaw.com
  • Caroline H. Gentry, Attorney, Porter Wright Morris & Arthur, LLP, 1 South Main Street, #1600, Dayton, Ohio 45402; 937-449-6748; Fax: 937-449-6820; Email: cgentry@porterwright.com

James Hardiman, Attorney, National Association for the Advancement of Colored People – Cleveland Branch, 12200 Fairhill Road, Suite 401, Cleveland, Ohio 44120; 216-256-6544; Email: attyjhard@aol.com

The Arizona Health Care Cost Containment System (AHCCCS) is planning to allow one Arizona Complete Care (ACC) plan for the general Medicaid population in each geographic service area (GSA) to expand their service lines to include certain specialty services currently provided by the Regional Behavioral Health Authorities (RBHAs). The expansion would take place no earlier than October 1, 2020. To select the ACCs to provide RBHA services, during August 2020, AHCCCS anticipates releasing a request for proposals (RFP) to the current ACC plans/ vendors. AHCCCS intends to expand the provision of services for at least one ACC plan in each GSA, in lieu of a public RFP for the solicitation of unique RBHA services. Awards would be announced by October or November 2020. The plans would launch the new service implementation by October 2021.

As of January 1, 2019, AHCCCS provided coverage to approximately 1.9 million members. The ACC managed care organizations (MCOs) are: Banner – University Family Care Plan; Care1st Health Plan Arizona; Health Choice Arizona (Steward Health Choice Arizona); Health Net Access (a Centene subsidiary); Magellan Complete Care of Arizona; Mercy Care; and UnitedHealthcare Community Plan. The ACC MCOs serve about 1.6 million members.

The RBHAs provide integrated Medicaid physical and behavioral health (including specialty services) and non-Medicaid services for members determined to have serious mental illness (SMI). The RBHA contractors are Arizona Complete Health (South GSA – 13,352 members), Mercy Care (Central GSA – 21,597 members), and Steward Health Choice Arizona (North GSA – 5,725 members). Each also has an ACC contract to provide integrated care for the general population in the same region.

In addition to providing integrated care for individuals with SMI, the RBHAs provide behavioral health services for foster children enrolled in the Department of Child Safety/Comprehensive Medical and Dental Program and provide behavioral health services for members enrolled with the Department of Economic Security/Division of Developmental Disabilities (DES/DDD). The RBHAs also provide crisis services, grant funded, and state-only funded services. The crisis services include telephone, community-based mobile, and facility-based stabilization (including observation not to exceed 24 hours).

In preparation for this transfer of services from the RBHAs to the ACCs, AHCCCS released a request for information (RFI) on February 12, 2019. Responses were due by March 14, 2019. The RFI explained the background, provided a rough timeline for the initiative, and sought feedback on specific questions, as follows

  1. Should AHCCCS allow choice of plan by allowing more than one ACC plan to address unique RBHA services for Central and Pima?
  2. Individuals with an SMI who have not received behavioral health services in two years are allowed to decertify as SMI to receive services through another ACC Plan. Should this remain?
  3. Should there be a single statewide vendor for crisis services? Single regional vendor?
  4. Should there be a single statewide telephone number for crisis services?
  5. Other thoughts to improve the first 24 hours of crisis service delivery?
  6. What feedback do you have on AHCCCS coordinating crisis services with the 22 Tribes across Arizona?
  7. Payment for court-ordered evaluations (COE): Currently each RBHA pays for some or all COE services within one county of their service area. COE costs are shared by the county, AHCCCS, and the plans. As of October 1, 2021, how should COE payment per county be delegated?
  8. AHCCCS, RBHAs and ACC Plans are required to have an Office of Individual and Family Affairs (OIFA) administrator and unit including a member liaison for adults and children. Any thoughts?
  9. SMI-specific responsibilities: What should AHCCCS consider to maintain focus on the needs of individuals with an SMI as the responsibilities are blended within one plan?

PsychU last reported on this topic in “Arizona Awards Integrated Health Plan Contracts To UnitedHealthcare & Mercy Care,” which published on March 30, 2018. The article is available at https://www.psychu.org/arizona-medicaid-awards-ahcccs-complete-care-contracts-seven-mcos/.

For more information, contact: Heidi Capriotti, Public Information Officer, Arizona Health Care Cost Containment System, 801 East Jefferson Street, Phoenix, Arizona 85034; Email: Heidi.Capriotti@azahcccs.gov; Website: https://www.azahcccs.gov.

On May 1, 2019, Capital BlueCross and WellSpan Health announced a strategic partnership to coordinate financing and delivery of health care, with a focus on population health management. The two organizations have agreed to enter into a long-term agreement to be finalized in the coming months, a partnership that will leverage WellSpan’s system-wide electronic health record and Capital BlueCross’ data systems.

According to Melissa Fox, public relations representative for Capital BlueCross, “This agreement is different than other agreements in the service area. This is a partnership that will benefit Capital BlueCross members who use WellSpan doctors and hospitals. This is not a partial or full ownership model, nor will either company have seats on the board of the other. The companies have a like-minded vision for using data, innovation and products that drive down the cost of care and increase the overall health of individuals.”

The two companies anticipate that the partnership will result in a variety of new product offerings and tools. The partnership will also give WellSpan Health enhanced access to a data and analytics toolset for population health management through Genia, LLC, a Capital BlueCross subsidiary. Discussions are in progress; the early targets are as follows:

  1. New product offerings and care coordination programs for employers.
  2. Expanded Medicare offerings in Adams, Franklin, northern Lancaster, Lebanon, and York counties.
  3. Innovative digital health strategies.
  4. Navigation tools to help consumers find the most appropriate medical or pharmacy care for their needs.
  5. Payment arrangements that are focused on improved quality and outcomes.
  6. Ways to better use data and analytics to improve patient experience.

WellSpan President and Chief Executive Officer (CEO) Roxanna L. Gapstur, Ph.D., R.N. said, “As we look for a multitude of ways to enhance the value of the care we deliver, we see great benefit in working more closely with organizations that provide health care coverage to the patients we serve, especially those that share WellSpan’s commitment to transforming the care experience. We look forward to working closely with the Capital BlueCross family of companies to improve the health of the people we mutually serve.” Gary D. St. Hilaire, president and CEO of Capital BlueCross said, “Capital BlueCross and WellSpan Health have a shared history of offering consumers access to high quality care. This partnership enables us to create even more innovative and affordable solutions for our members and our community.”

For more information, contact:

  • Melissa Fox, Supervisor, Public Relations and Social Media, Capital BlueCross, 2500 Elmerton Avenue, Harrisburg, Pennsylvania 17177; 717-541-6843; Email: melissa.fox@capbluecross.com; Website: https://www.capbluecross.com/
  • Brett Marcy, Senior Director, Public Relations & Communications, WellSpan Health, 912 South George Street, York, Pennsylvania 17403; 717-851-5122; Email: bmarcy@wellspan.org; Website: https://www.wellspan.org/

On April 10, 2019, UnitedHealthcare (UHC) announced plans to launch the UnitedHealthcare Care Bundles program for its Medicare Advantage contracted provider organizations. The program provides tools and support to help participating provider organizations manage bundled payments for 10 procedures for UHC Medicare Advantage members. These tools can also be used by those provider organizations serving Medicare fee-for-service (FFS) beneficiaries in the Centers Medicare & Medicaid Services (CMS) Bundled Payment for Care Improvement Advanced (BPCI-A) bundled payment program. The program will begin on January 1, 2020.

The Care Bundles program is a retrospective shared risk model. The program is intended for UHC contracted network provider organizations that participate in both original fee-for-service Medicare and in UHC Medicare Advantage plans. The 2020 UHC Medicare Advantage Care Bundles program will include the following 10 procedures:

  • Four cardiac bundles: inpatient cardiac valve, inpatient coronary bypass, and inpatient and outpatient percutaneous coronary intervention.
  • An inpatient spinal fusion (non-cervical) bundle.
  • Five orthopedic bundles: inpatient hip (double) joint replacement, inpatient knee (double) joint replacement, inpatient and outpatient knee (single) joint replacement, and inpatient hip (single) replacement.

For both the UHC Care Bundles program —and for the CMS BPCI-A program, a target price is established based on historical claims data for each episode of care. The historical claims costs are based on all acute and post-acute services associated with the bundle. The participating provider organizations will be eligible for shared savings (up to a gain-share limit) if their performance is below the target price and meets quality metrics. A repayment up to a stop-loss limit is required if the target price is exceeded.

The duration of the bundle is the same across all bundle types. For an inpatient bundle, the duration includes a trigger period (lasts from admission to discharge), plus the 90 days following discharge. For an outpatient bundle, the duration includes the trigger period plus 90 days following completion of the outpatient procedure. The trigger period includes physician services, and inpatient or outpatient hospital services. The post-trigger period includes other outpatient services, inpatient hospital readmission services, long term care hospital (LTCH) services, inpatient rehabilitation facility (IRF) services, skilled nursing facility (SNF) services, home health agency (HHA) services, clinical laboratory services, durable medical equipment (DME), Part B drugs and hospice services.

The provider organizations that participate in Care Bundles will receive assistance with the following from UHC:

  • Care management for consumers from pre-operative education through post-acute care, to include consumer identification and risk stratification, care plan creation and end-to-end management and tracking medication review, a post-acute care network by market, site of care optimization, and length-of-stay care management.
  • Technology to improve pre and post-operative interactions with consumers by connecting them with their care teams through an automated, personalized digital experience. The technology includes: a consumer mobile app, a provider organization web and mobile application, secure messaging, care plan design, and dashboard reports.
  • Data and analytics to help provider organizations better understand risk and to know how the care bundles are performing. The tools include real-time clinical and claims-based bundle analytics; predictive modeling and selection bundles prior to program launch; claims data intake, processing, analytics, and distribution; a portal for provider organization partners; and financial reconciliation and provider organization performance.
  • Financial administration to support financial performance reporting, risk delegation services and reconciliation services. The services include comprehensive tracking and reporting of shared savings; provider funds distribution; and payment of full savings earned within 30 days after UHC receives it from CMS.
  • Business administration to help participating provider organizations transition to value-based care. The services include bundled payment operations oversight, all recruitment of new provider organizations, development of strategic operating models, and performance improvement and strategy consulting with provider partners

Currently, more than 110,000 physicians and 1,100 hospitals participate in UHC value-based care programs. More than 15 million UHC members access care from physicians in value-based arrangements, including more than three million UHC Medicare Advantage members. By the end of 2020, UHC expects to have $75 billion in provider organization reimbursements tied to value-based arrangements annually.

For more information, contact: Jeff Meyerhofer, President, Bundled Payment Solutions, Medicare & Retirement, UnitedHealthcare, 9800 Healthcare Lane, Minnetonka, Minnesota 55436; Email: carebundles@uhc.com; Website: https://uhgcarebundles.com/; or Steven Shivinsky, Vice President of Corporate Communications, UnitedHealthcare, 9800 Healthcare Lane, Minnetonka, Minnesota 55436; 763-361-2882; Email: stephen.shivinsky@uhc.com; Website: https://www.uhc.com/; or Taylor Joseph, Media Contact, Medicare and Retirement, UnitedHealthcare, 12501 Whitewater Drive, Hopkins, Minnesota 55343; 952-931-5430; Email: taylor.joseph@uhc.com; Website: https://www.uhc.com/.

In March the California Department of Health Care Services (DHCS) released draft value-based payment (VBP) performance measures for the state’s Medicaid managed care program (in California, the Medicaid program is called Medi-Cal—for more on the California Medicaid system, see California Mental Health System Guidebook. The measures are grouped into four domains: behavioral health integration; chronic disease management; prenatal/post-partum care; and early childhood preventive care. Each domain has five performance measures. These measures will be tied to risk-based incentive payments and are aimed at improving care for certain high-cost or high-need populations (see California Releases Proposed Medi-Cal Value-Based Payment Program Measures).

What is interesting about the draft VBP measures is that DHCS focused the measures on screening, prevention, and integration of physical health care and behavioral health. Many states and national measures have incentivized screening for depression or substance abuse in primary care settings, but these measures go one step farther. The measures include an additional incentive payment to provider organizations per visit for services delivered in an environment that has co-located primary care with behavioral health care.

Why do these measures matter if you’re not serving consumers in the state of California? Just keep in mind the adage: “As California goes, so goes the nation.” California is the most populous state in the country and has the largest Medicaid population of any state by far, at about 10.5 million total enrollees—or about 16% of the total Medicaid population. While they are not alone in requiring their Medicaid health plans to utilize value-based reimbursement (VBR) models, with such a huge portion of the Medicaid population they are often a bellwether for innovation in Medicaid and the results of their program changes can provide a significant data set for other states to analyze when making their own program modifications.

What do these measures tell us? First, primary care-led integration will continue to be a priority for payers and health plans. In California and elsewhere, performance measures related to behavioral health tend to be aimed at primary care—not behavioral health care provider organizations. Measures like screening for depression or alcohol use are about improving behavioral health, but they are intended for the primary care setting. With California adding additional incentives for services to be delivered in an integrated care setting, we will see health plans give priority in referrals to co-located programs. If so, this presents an incentive for provider organizations to form new partnerships with primary care practices and health systems. In a co-located system of care, behavioral health screening measures are easier to meet. The right changes in workflow ensure that consumers who may screen positive can see the right clinical professionals on site as needed.

Second, integration measures, particularly screening measures, are a new opportunity to use technology tools to streamline processes. Online or tech-based screening systems are a convenient and efficient way to ensure that every consumer has their screening either before they come into the office for their visit utilizing on online tool or in office while waiting for their appointment using a tablet device or kiosk. Studies have shown that online screenings can be just as effective as in-person screening (see Computer-Based Suicide Risk-Assessment Tool As Accurate As In-Person Psychiatric Assessment), and with screening being such a huge part of VBR performance measures, we can expect the use of these tools to grow.

California was accepting comments on their draft performance measures through the end of March, with the final measures expected this year. We’ll continue to monitor the effectiveness of California’s new performance measures and how other states are utilizing VBR to prioritize integration.

The Illinois legislature is considering three bills to change the practices of managed care organizations (MCOs) operating under HealthChoice Illinois, the state’s Medicaid managed care program. The proposed legislation comes in response to news that during the first three months of the statewide HealthChoice Illinois implementation, January 2018 through March 2018, the MCOs denied 10.6% of Medicaid hospital claims.

The bills were introduced on February 15, 2019, to change MCO business practices and performance as a result of the denial rate. The bills address MCO rates, appeals processes, and timely payment. The MCO rates, and timely payment bills specifically concern medically necessary treatment that was provided without obtaining prior approval. The appeals process bill guarantees a third-party review of denials.

The denial rate was reported in “Illinois Medicaid MCO Hospital Denial Claims Report,” by the Illinois Department of Healthcare and Family Services (HFS) in November 2018. HFS analyzed the MCO claims processing and payment performance regarding hospital claims under the redesigned mandatory managed care program. HealthChoice Illinois expanded Medicaid managed care from just 30 counties to all 102 counties in the state. As of the end of fiscal year 2018, HealthChoice Illinois covered about two million people and cost the state about $10.7 billion during fiscal year 2018.

The 10.6% denial rate represented more than $630 million in denied revenue for the hospitals. About 43.6% of these were benefit denials; about 21.7% were denials for missing information; and about 17% were denials for not meeting the MCO’s authorization policy on provider network status, service limits, medical necessity, non‐emergency services, or missing/invalid authorization form/record.

As of May 1, 2019, all three proposed state senate bills were still in committee. The three bills currently in front of the state senate include:

Senate Bill 1697: The bill assures fair Medicaid managed care rates. The bill was first read in the Senate and filed on February 15, 2019. Specifically, the bill:

  • Requires MCOs to ensure that contracted provider organizations shall be paid for any medically necessary service rendered to any of the MCO’s enrollees, regardless of inclusion on the MCO’s published and publicly available roster of available provider organizations.
  • Requires that all contracted provider organizations are contained on an updated roster within seven days of entering into a contract with the MCO and that such roster be readily accessible by all medical assistance enrollees for purposes of selecting an approved health care provider.
  • Requires HFS to develop a single standard list of all additional clinical information that shall be considered essential information and may be requested from a hospital to adjudicate a claim.
  • Provides that a provider organization shall not be required to submit additional information, justifying medical necessity, for a service which has previously received a service authorization by the MCO or its agent.
  • Contains provisions concerning a timely payment interest penalty; an expedited payment schedule; a single list of standard codes to identify the reason for nonpayment on a claim; payments under the HFS fee-for-service system; a 90-day correction period for provider organizations to correct errors or omissions in a payment claim; service authorization requests; discharge notification and facility placement; and other matters.

Senate Bill 1703: The bill assures a fair appeal process for denied Medicaid claims. The bill was first read in the Senate and filed on February 15, 2019. Specifically, the bill:

  • Provides that a provider organization that has exhausted the MCO written internal appeals process shall be entitled to an external independent third-party review of the MCO’s final decision that denies, in whole or in part, a health care service to an enrollee or a claim for reimbursement to a provider organization for a health care service rendered to an enrollee of the Medicaid managed care organization.
  • Requires a MCO’s final decision letter to a provider organization to include: a statement that the provider organization’s internal appeal rights within the MCO have been exhausted; a statement that the provider organization is entitled to an external independent third-party review; the time period granted to request an external independent third-party review; and the mailing address to initiate an external independent third-party review.
  • Provides that a party shall be entitled to appeal a final decision of the external independent third-party review within 30 days after the date upon which the appealing party receives the external independent third-party review.
  • Provides that a final decision by the Director of HFS shall be final and reviewable under the Administrative Review Law. Contains provisions concerning fees to help defray the cost of the administrative hearings; the specific claims of services that are appealable; and the HFS rulemaking authority.

Senate Bill 1807: The bill assures timely payment by MCOs for any medically necessary service provided to health care consumers. The bill was first read in the Senate and filed on February 15, 2019. Specifically, the bill:

  • Requires HFS to require MCOs to ensure that any provider organization under contract with an MCO on the date of service shall be paid for any medically necessary service rendered to any of the MCO’s enrollees, regardless of inclusion on the MCO’s published and publicly available roster of available providers; that all contracted provider organizations are listed on an updated roster within seven days of entering into a contract with the MCO; and that the roster is readily accessible by all medical assistance enrollees for purposes of selecting an approved health care provider organization.
  • Requires HFS to require MCOs to expedite payments to provider organizations based on specified criteria (rather than providing that HFS may establish a process for MCOs to expedite payments to providers based on criteria established by HFS)
  • Contains provisions concerning discharge notifications and facility placements and other matters.

PsychU last reported on this topic in:

For more information, contact: John Hoffman, Director of Communications, Illinois Department of Healthcare and Family Services, 401 South Clinton Street, Chicago, Illinois 60607; Email: John.K.Hoffman@illinois.gov.

On March 18, 2019, the North Carolina Department of Health and Human Services released final policy guidance on eligibility and enrollment for the upcoming Medicaid Behavioral Health Intellectual/Developmental Disability (BH/IDD) Tailored Plans. Nine consumer populations will automatically included in the BH/IDD Tailored Plans. The Tailored Plans will be designed to meet the needs of beneficiaries with complex care needs due to I/DD or with higher intensity behavioral health needs due to serious mental illness (SMI), severe substance use disorder (SUD), or a traumatic brain injury (TBI).

This final guidance outlines the eligibility criteria for Tailored Plans and describes how people will enroll in these plans, how transitions between Standard Plans and Tailored Plans will work, and what benefits will be covered in Tailored Plans. The guidance was issued as part of the Department’s transition to integrated managed care. The Standard Plans are for the general Medicaid population, with exceptions for those also enrolled in Medicare and other special populations excluded or delayed by legislation.

The following Medicaid and Health Choice beneficiaries will automatically be included in the BH/IDD Tailored Plan, based on available data:

  1. Enrollees in the Innovations waiver and those on the waiting list as well as any beneficiaries with a qualifying I/DD diagnosis code
  2. Enrollees in the TBI Waiver and those on the waiting list
  3. Transition to Community Living Initiative (TCLI)-qualified beneficiaries; any beneficiary who has used a Medicaid service that will only be available through a Behavioral Health I/DD Tailored Plan; and any individuals who has used a behavioral health, I/DD, or TBI service funded with state, local, federal or other non-Medicaid funds
  4. Children with complex needs (as that term is defined in the 2016 settlement agreement between the NC DHHS and Disability Rights of North Carolina)
  5. Any beneficiary who has a qualifying SMI or serious emotional disturbance (SED) diagnosis code or qualifying
    SUD diagnosis code who used a Medicaid-covered enhanced behavioral health service during the look-back period
  6. Beneficiaries who have had two or more psychiatric hospitalizations or readmissions within 18 months, or two or more visits to the emergency department for a psychiatric problem within 18 months, or two or more episodes using behavioral health crisis services within 18 months
  7. Beneficiaries who have had an admission to a state psychiatric hospital or alcohol and drug abuse treatment center (ADATC), including, but not limited to, individuals who have had one or more involuntary treatment episode in a state-owned facility

The guidance was outlined in the “North Carolina Behavioral Health & Intellectual/Developmental Disability Tailored Plan Eligibility & Enrollment.” DHHS said this guidance document is the first in a series that will be released over the next year as part of the Department’s commitment to transparency throughout the Tailored Plan design and implementation process. On November 2019, most North Carolina Medicaid beneficiaries, in two of six regions, will begin to transition to managed care, enrolling in Standard Plans designed to meet the needs of most people in the Medicaid program. The remaining four regions will begin the transition to managed care in February 2020. When BH/IDD Tailored Plans launch in 2021, beneficiaries who meet the eligibility criteria will be automatically enrolled in the BH/IDD Tailored Plan in their region, unless they actively select a Standard Plan.

DHHS is reviewing encounter, claims, and other data to identify beneficiaries eligible for the BH/IDD Tailored Plans. DHHS does not intend to cap enrollment in the BH/IDD Tailored Plans. However, enrollment caps will remain for the Innovations and TBI waivers. Based on its review of past data, DHHS estimates that about 25,000 to 35,000 dual eligible beneficiaries and 80,000 to 100,000 Medicaid-only beneficiaries will meet the eligibility criteria for enrollment in a BH/IDD Tailored Plan. DHHS intends to regularly review encounter, claims and other relevant and available data to identify beneficiaries enrolled in Standard Plans and new Medicaid beneficiaries who meet BH/IDD Tailored Plan eligibility criteria. For beneficiaries who are not identified as meeting the eligibility criteria through the data review process, there will be a process for requesting eligibility.

In early summer 2019, DHHS will notify individuals eligible for Tailored Plan enrollment in the first two regions of their status; the other four regions will be notified in fall 2019. They will not be eligible to enroll in a Standard Plan unless they are on Innovations or TBI waiver. Until the Tailored Plan enrollment begins in July 2021, they will remain in their current delivery system, receiving behavioral health services through the Local Management Entity/managed care organizations (LME/MCOs) and other Medicaid services through the current fee-for-service structure.

An individual who qualifies for Medicaid and who believes they meet the eligibility and wishes to be in the BH/IDD Tailored Plan can make that request with the help of their provider organization. DHHS will address transitions of care from the Standard Plan to the BH/IDD Tailored Plan on the following schedule:

  • Auto enrollments will be processed on a monthly, or more frequent basis based on available data
  • Standard BH/IDD Tailored Plan enrollment requests made to the Enrollment Broker will be approved or denied within five to seven calendar days
  • Expedited transfers for urgent medical needs will be reviewed and approved or denied within 24 to 48 hours from when the beneficiary makes the request to the Enrollment Broker

At the time of the BH/IDD Tailored Plan launch, beneficiaries participating in the Innovations and TBI waiver must enroll in the BH/IDD Tailored Plan to receive services under the waiver. Medicaid beneficiaries who are eligible for the Innovations waiver but are waiting for a slot will be able to enroll under the Standard Plan while on the waiting list without losing their place on the list.

However, other beneficiaries eligible for a BH/IDD Tailored Plan who choose to enroll in a Standard Plan will not have access to benefits offered through LME-MCOs that are not part of the Standard Plan benefit package. Accordingly, an Innovations or TBI Waiver beneficiary must disenroll from their waiver program to transition to a Standard Plan.

Foster children up to age 21 and those who were formerly foster children up to age 26, or receiving Title IV-E Adoption Assistance will have a choice in 2021. They will stay in the current delivery system until 2021, at which point they can choose between a Specialized Foster Care Plan—if available, the Standard Plan, or the BH/IDD Tailored Plan.

Long-stay nursing home residents (90 days or longer) are excluded from managed care. Nursing home residents with shorter stays who are eligible for the BH/IDD Tailored Plan when it begins could be included. However, dual eligibles will not be included in managed care until 2023.

The following populations are excluded from Medicaid managed care. They will remain in fee-for-service.

  • Beneficiaries with limited Medicaid benefits, such as those enrolled in the Health Insurance Premium Payment program or the family planning program; beneficiaries eligible for emergency services only; and partial dual eligibles.
  • Medically needy beneficiaries who are subject to a deductible or spend-down.
  • People enrolled in the Community Alternatives Program for Children (CAP/C) and Community Alternatives Program for Disabled Adults (CAP/DA) waiver.

PsychU last reported on this topic in the following articles:

For more information, contact: Division of Health Benefits, Department of Health and Human Services, 1950 Mail Service Center, Raleigh, North Carolina 27699-1950; 888-245-0179; Email: Medicaid.Transformation@dhhs.nc.gov.

On April 24, 2019, the Centers for Medicare & Medicaid Services (CMS) urged governors and state Medicaid directors to implement financing and service delivery models to integrate care for people dually eligible for Medicare and Medicaid. In addition to inviting states to launch or continue capitated financial alignment initiative (FAI) demonstration projects, or managed fee-for-service model for high-risk beneficiaries, CMS invited state-developed proposals.

As of December 2018, more than 12 million individuals nationwide were enrolled in both Medicare and Medicaid – and 561,295 were enrolled in fully-integrated dual eligible Medicare Advantage Special Needs Plans (FIDE SNPs) or in capitated FAI demonstration program Medicare-Medicaid Plans (MMPs). The FIDE SNPs and capitated FAI program MMPs operate in 16 states. However, in 2017, only about 29% of eligible individuals enrolled in MMPs.

The capitated FAI demonstration models: CMS is offering the nine states already participating in this model a potential multi-year extension and is interested in partnering with new states. The nine participating states are: California, Illinois, Massachusetts, Michigan, New York (two programs), Ohio, Rhode Island, South Carolina, and Texas. This model involves a three-way contract between the state, CMS, and MMP. As of June 2016, 364,334 dual eligibles were enrolled in an integrated MMP. This represented about 3% of the total 9.9 million full dual eligible population in 2016.

The managed fee-for-service demonstration models: CMS proposes working with additional states to test the model on a similar cohort of individuals to Washington State’s demonstration group. The Washington demonstration provides a high-intensity intervention for high-risk beneficiaries. In the demonstration project, health homes act as the central point to integrate primary and acute care, behavioral health, and long-term care services for beneficiaries with the highest risks. The program was implemented in 14 counties in July 2013, 23 additional counties were added in October 2013, and the remaining two counties (King and Snohomish) joined in April 2017.

State-specific demonstration models: Additionally, states can submit concept papers or proposals, or to reach out to the CMS Medicare-Medicaid Coordination Office (MMCO) with their ideas for state-specific initiatives. In the letter, CMS said it is open to a wide range of initiatives. CMS also noted that there are a number of opportunities available to states that do not require demonstration authority or waivers to better serve dually eligible individuals. On December 19th, 2018, CMS released a State Medicaid Director Letter outlining 10 such opportunities, including integrating care through dual eligible special needs plans (D-SNPs), using Medicare data to inform care coordination and program integrity initiatives, and reducing administrative burden for dually eligible individuals and the provider organizations who serve them.

The 2017 MMP enrollment rate was reported in “The Complex Art Of Making It Simple: Factors Affecting Enrollment In Integrated Care Demonstrations For Dually Eligible Beneficiaries,” by Debra J. Lipson, Erin Weir Lakhmani, Alena Tourtellotte, and Danielle Chelminsky, of Mathematica Policy Research. The goal was to examine program elements, state policies, and MMP characteristics, and strategies to identify factors associated with enrollment. The researchers interviewed state Medicaid officials in the 10 states and representatives from 15 MMPs.

The topic was further discussed in “Care Coordination in Integrated Care Programs Serving Dually Eligible Beneficiaries – Health Plan Standards, Challenges and Evolving Approaches” by Sarah Barth, Sharon Silow-Carroll, Esther Reagan, Mary Russell, and Taylor Simmons of Health Management Associates. The researchers examined care coordination requirements for several types of integrated care models for duals. The models included managed long-term services and supports programs that require integration with Medicare Advantage dual eligible special needs plans, fully integrated dual eligible special needs plans, and the FAI. The researchers found that few states have prescriptive contract standards regarding care coordination, and that most states provide plans with a great deal of flexibility. Stakeholders noted that it could be difficult to engage primary care provider organizations in care coordination, but opportunities existed for plans to more effectively partner with consumer advocates and organizations providing home and community-based services (HCBS) to improve care coordination for duals.

A link to the full text of “The Complex Art Of Making It Simple: Factors Affecting Enrollment In Integrated Care Demonstrations For Dually Eligible Beneficiaries” may be found at the MACPAC website at https://www.macpac.gov/publication/the-complex-art-of-making-it-simple-factors-affecting-enrollment-in-integrated-care-demonstrations-for-dually-eligible-beneficiaries/.

A link to the full text of “Care Coordination In Integrated Care Programs Serving Dually Eligible Beneficiaries – Health Plan Standards, Challenges And Evolving Approaches” may be found at the MACPAC website at https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf.

PsychU last reported on this topic in the following articles:

For more information, contact:

  • Tom Corry, Director, Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov.
  • Kathryn Ceja, Medicaid and CHIP Payment and Access Commission, 1800 M Street NW, Suite 650 South, Washington, District of Columbia 20036; 202-350-2000; Fax: 202-273-2452; Email: Ceja@macpac.gov.

The San Diego County Health and Human Services Agency (HHSA) is planning a pay-for-results project that provides housing and community development services to help low-income families become financially self-sufficient. HHSA seeks to apply for funding through the federal Social Impact Partnerships to Pay for Results Act (SIPPRA) demonstration project.

The county’s project is an existing program serves the communities in the North County and supports low income families with housing and offers trainings/solutions to help the participants become financially self-sufficient. The documents announcing the plans to apply for the SIPPRA funds provided no information about how the program is currently funded or what might change if it is selected for SIPPRA.

Many of the project participants have history of addiction and have completed addiction treatment programs. Most of the participants also have children and/or are in process of reuniting with their children as they enter a stable housing environment and working towards financial stability. All the participants enter the program at the extremely low-income category.

As part of its preparations, on April 17, 2019, HHSA issued a request for proposals (RFP 9498) seeking a contractor to help the county apply for SIPPRA funding and then evaluate the project outcomes. Responses were due by April 26, 2019. HHSA described the project in an addendum responding to questions. The contract term is anticipated to be an initial (base) period from the May 22, 2019 through November 30, 2019 with seven one-year options.

The evaluation will focus on program outcome measures to determine whether the intervention group outcomes are better than those of a comparison group. If the intervention group outcomes are better, the evaluation will calculate the amount of federal savings. Value to the federal government will be estimated from the public sector savings (decrease in federal outlays) and federal tax receipts (potential increase in revenue) that are the result of the intervention.

SIPPRA was signed into law on February 9, 2018. It is intended to improve the effectiveness of certain social services. The federal government will pay for a project only if predetermined project outcomes have been met and validated by an independent evaluator, a system called a “pay for results partnership.” Congress appropriated $100 million for the SIPPRA program to implement “Social Impact Partnership Demonstration Projects” and feasibility studies to prepare for those projects. The SIPPRA program is largely administered by the Department of the Treasury (Treasury). Only state and local governments are eligible to apply for SIPPRA funding.

The purpose of SIPPRA is to facilitate creation of public-private partnerships that bundle philanthropic or other private resources with existing public spending to scale up effective social interventions already being implemented, with the goal of establishing the use of social impact partnerships to address pressing national social service problems. SIPPRA also seeks to redirect funds away from programs that, based on objectives data, are ineffective, and into programs that achieve demonstrable, measurable results; ensure federal funds are used effectively on social services to produce positive outcomes for both service recipients and taxpayers.

Treasury released the SIPPRA Notice Of Funding Availability on February 21, 2019. Applications are due by May 22, 2019. The funding will be awarded in November 2019. The first SIPPRA demonstration period will begin on December 1, 2019 and run through November 30, 2020. There will be six additional option years, plus an additional six months of funding. Treasury anticipates making between five and 15 awards under this first Notice of Funding Availability. However, the number of project awards will depend on the quality and viability of the project applications and the amount of funds requested by individual applicants. The project outcomes can vary from a single outcome with one federal payment to be made at the end of the project to multiple outcomes and milestone payments. Each outcome and related payment will be evaluated independently.

For more information, contact:

  • Sarah Sweeney, Communications Officer, Health and Human Services Agency, San Diego County, 5560 Overland Avenue, Suite 270, San Diego, California 92123; 619-685-2522; Email: Sarah.Sweeney@sdcounty.ca.gov.
  • David Dominguez, Procurement Contracting Officer, San Diego County Department of Purchasing and Contracting, 5560 Overland Avenue, Suite 270, San Diego , California 92123-1204; 858-505-6367; Fax: 858-715-6452; Email: David.Dominguez@sdcounty.ca.gov

The New Jersey Department of Human Services (DHS) will provide coverage for a new Medicaid office-based addiction treatment (OBAT) benefit starting July 1, 2019. OBAT is limited to primary care offices, and is part of a larger initiative, called MATrx, to increase access to medication-assisted treatment (MAT) for addiction disorder.

MATrx consists of three tiers of treatment to be provided by primary care provider organizations, federally qualified health centers (FQHCs), and clinic-based Opioid Treatment Providers (OTPs) and Centers of Excellence (COEs). These settings will serve as a resource for treatment, training, and mentoring. All three tiers will work together to promote evidence-based and integrated care, as follows:

  • The COEs, to be created at Rutgers New Jersey Medical School and Cooper Medical School of Rowan University, will provide training, consultation, and peer services in addition to primary care for complex cases.
  • Premier provider organizations, such as OTPs, FQHCs, and Certified Community Behavioral Health Clinics (CCBHCs), and independent substance abuse licensed independent clinics that have the ability to provide integrated physical health and counseling services in addition to MAT services. Currently they receive a bundled rate. Under OBAT, they will receive an enhanced primary care rate to provide intake and assessment, and will be able to bill for navigator services.
  • OBAT primary care provider organizations will provide initiation, stabilization, and maintenance treatment. The services must be provided by physicians and non-physician clinical professionals whose scope of practice and benefit category include the services described by the applicable CPT code. The primary care professionals must be able to prescribe specific MAT medications.

OBAT is for any chemical dependency. The covered benefit includes MAT with FDA-approved medications, care coordination provided by navigators, plus peer services to be provided by the COEs. The OBAT program consists of three phases of addiction disorder treatment: initiation, stabilization, and maintenance. As part of this initiative, the state Medicaid program will remove prior authorization requirements for MAT. Additional details are as follows:

  • Care coordination is a required component for individuals receiving MAT. The navigators will work with the individuals receiving OBAT to establish a comprehensive, individualized treatment plan that addresses the non-medical factors that have an impact on addiction disorder treatment and recovery, such as housing, transportation, or employment. This includes connecting the individuals with social service organizations, recovery supports, family education, and referrals to alternate levels of care as needed. The navigator will work together with the primary care professional who is managing the clinical aspects of care, to ensure that all of the individual’s treatment needs are being addressed and to ensure integrated care.
  • Peer services will be covered starting July 1, 2019. Peers are individuals who had an experience with addiction disorder and are now certified to provide support and assistance to individuals with addiction disorder seeking help transitioning from treatment to recovery.

OBAT services may be billed by CCBHCs OTPs, FQHCs, the COEs, or physician and non-physician clinical professionals. Primary care OBAT practices will receive an enhanced office rate and new reimbursement for navigator services billed by the practice. The enhanced office rate will apply to primary care intake and assessments for individuals with opioid use disorder or other chemical dependency. The OBAT practices will initiate and manage MAT, provide navigator support services, and provide access to peer services, which were not previously reimbursable. Fully integrated OBAT primary care provider organizations will be able to offer and be reimbursed for peer services, which will be newly reimbursable under the OBAT program after July 1

To launch OBAT, DHS submitted a state plan amendment (SPA) in December 2018. The OBAT program received about $14.5 million in funding from the Governor’s budget initiative, plus the services will be eligible for federal matching funds. DHS discussed early details of the new MATrx model in focused presentation, “MATrx Model” and in a larger presentation “New Jersey DHS Listening Session: Strengthening Medicaid: Alignment & Redesign Through Integration.”

For more information, contact: Tom Hester, Director of Communications, New Jersey Department of Human Services, Post Office Box 700, Trenton, New Jersey 08625-0726; 609-292-3717; Email: Tom.Hester@dhs.state.nj.us.

All but four states —Georgia, Indiana, Mississippi, and West Virginia—are using value-based care (VBC) and alternative payment models. The remaining 46 states, the District of Columbia, and Puerto Rico are implementing some sort of value-based model. About 50% of those programs are multi-payer in scope.

These findings were presented in “Value-Based Care in America: State-by-State,” by Change Healthcare. Researchers with Change Healthcare analyzed publicly available information, compiled in 2017 and updated in 2019, with a focus on statewide VBC and payment programs for the 50 states, the District of Columbia, and Puerto Rico.

The analysis focused on publicly acknowledged and promoted initiatives, including: Comprehensive Primary Care Plus (CPC+), State Innovation Models Initiative (SIM) Grants, accountable care organizations (ACOs) or ACO-like entities, and episodes of care programs. The goal was to determine how VBC is being delivered across the U.S., and to provide a state-by-state update of subsequent VBC progress made in the past 18 months.

State participation in the various models was as follows:

  • 18 states are approved for Comprehensive Primary Care Plus (CPC+): Arkansas, Colorado, Hawaii, Kansas, Kentucky, Louisiana, Missouri, Montana, Nebraska, New Jersey, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, and Tennessee.
  • 38 states are pursuing State Innovation Models Initiative (SIM) Grants: Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Idaho, Illinois, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.
  • 22 states have adopted, or are considering the adoption of, ACOs or ACO-like entities to help manage costs and deliver better care: Alaska, Colorado, Delaware, Illinois, Iowa, Louisiana, Maine, Massachusetts, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New York, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Vermont, and Washington.
  • 16 states have implemented episodes of care programs: Arkansas, Colorado, Connecticut, Illinois, Iowa, Maine, Minnesota, Nevada, New York, Ohio, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Vermont, and Washington.

Key findings about the adoption rate were as follows:

  • At least 34 states are two years or more into implementation, and eight states are in the early development of a new model.
  • Three states—New York, Pennsylvania, and Vermont—are considered “standout states” which have a broad scope in their breadth of initiatives, embrace of payment models that involve shared risk, and are willing to test innovative strategies in VBC models.
  • Six states—Arkansas, Colorado, Maryland, Minnesota, Oregon, and Vermont—have well-developed VBC strategies that have been in place four years or more.

The full text of “Value-Based Care in America: State-by-State” was published April 16, 2019, by Change Healthcare. A copy can be requested online at https://inspire.changehealthcare.com/stateVBRstudy (accessed April 29, 2019).

PsychU last reported on this topic in:

For more information, contact: Kerry Kelly, Vice President of External Communications, Change Healthcare, 3055 Lebanon Pike, Suite 1000, Nashville, Tennessee 37214; 339-236-2756; Email: kerry.kelly@changehealthcare.com or Angela Evatt, State Health Policy Strategy, Change Healthcare; Email: angela.evatt@changehealthcare.com.

On April 4, 2019, the Florida Agency for Health Care Administration (AHCA) announced plans to launch a Medicaid Behavioral Health and Supportive Housing Assistance Pilot during the summer of 2019. The pilot will take place in Region 5 (Pasco and Pinellas counties) and Region 7 (Brevard, Orange, Osceola, and Seminole counties). Enrollment would be limited to homeless beneficiaries age 21 and older with addiction disorder, serious mental illness (SMI), or co-occurring addiction disorder and SMI. The pilot will provide participants with access to pre-tenancy and tenancy maintenance services, plus mobile crisis centers and peer support. The pilot will not pay for room and board, rent, or mortgage; although it could cover housing-related activities such as one-time moving expenses, or home furnishings such as bedding or lighting.

On March 26, 2019, the Centers for Medicare & Medicaid Services (CMS) approved AHCA’s Medicaid 1115 waiver request for the pilot. AHCA will implement an enhanced capitation rate for participating Medicaid health plans. The waiver is effective through June 30, 2022. The Florida Legislature appropriated $10 million annually for the pilot services. The pilot sets an annual enrollment limit of 42,500 member months for each demonstration year.

Services to be provided through the pilot include the following:

  • Transitional housing services: This includes a variety of services that support an individual to prepare for and transition into housing. Services could include: conducting a tenant screening and housing assessment that identifies preferences and barriers related to successful tenancy developing an individualized housing support plan based upon the housing assessment that addresses identified barriers, assisting with the housing application process, and developing a housing support crisis plan that includes prevention and early intervention services when housing is jeopardized.
  • Individual housing and tenancy sustaining services: This includes services that help the participant be a successful tenant in a housing arrangement and able to sustain tenancy. Services could include: education and training on the roles, rights and responsibilities of the tenant and landlord; coaching on developing and maintaining key relationships with landlord/property managers; assistance in resolving disputes with landlords and/or neighbors to reduce risk of eviction; advocacy and linkage with community resources to prevent eviction; and coordinating with tenant to review, update, and modify their housing support and crisis plans.
  • Mobile crisis management: This includes intensive on-site intervention to recipients experiencing a behavioral health crisis provided by a team of behavioral health professionals who are available 24/7/365. These services will be available for eligible enrollees regardless of residence, except for individuals who are residing in an institution of mental disease (IMD) or who are inmates in a correctional institution.
  • Self-help/peer support: This includes person centered service promoting skills for coping with and managing symptoms while utilizing natural resources and the preservation and enhancement of community living skills with the assistance of a certified peer support specialist. These are mental health substance abuse recovery peer specialists and recovery support specialists; both are required to complete a 40-hour curriculum that covers four content learning areas identified by the state: mentoring, advocacy, recovery support, and professional responsibility.

AHCA has not released any details about reimbursement rates or how the Medicaid managed care organizations (MCOs) will select provider organizations for the pilot. MCOs participating in the pilot must be either a Managed Medical Assistance (MMA) standard plan or an MMA specialty plan serving individuals diagnosed with an SMI, addiction, or co-occurring SMI and addiction, and who are homeless or at-risk of homelessness due to their disability. The MCOs must also meet all the following requirements:

  • Provide services in Regions 5 and/or 7
  • Include in-network addiction treatment provider organizations that furnish services in accordance with Chapters 394 and 397 of Florida Statues Substance Abuse Services
  • Have the capability to provide supportive housing assistance services as specified in the waiver’s Special Terms and Conditions (STC) through housing provider organizations and must have relationships with local housing coalitions.

AHCA must develop performance measures within 90 days (early July 2019) following CMS approval of this waiver amendment. The performance measures must address the following:

  1. Service plans must address participants’ assessed needs. They must be updated annually. The person’s choices of services and provider organizations must be documented.
  2. Evaluation requirements must be appropriate to determine need for determining transitional housing services and tenancy support services.
  3. Provider organizations must meet qualifications specified in the STC.
  4. AHCA will retain authority and responsibility for program operations and oversight by MCOs as required in the MCO contract. AHCA will maintain financial accountability through payment of claims by MCOs for services that are authorized and furnished to participants by qualified provider organizations.
  5. AHCA will identify, address, and seek to prevent incidents of abuse, neglect, and exploitation.

During the demonstration period, the state must conduct an evaluation to accomplish the following: assess if the pilot program can be transitioned to 1915(c) and 1915(i) Medicaid waivers, and submit a plan to CMS by July 1, 2021 for transitioning the pilot to 1915(c) and 1915(i) authority. The evaluation design must be submitted by early August 2019 (120 days from April 4).

PsychU last reported on this topic in “CMS Approves Florida Plan Adding Community Behavioral Health To The Low-Income Safety Net Pool,” which published on January 21, 2019.

For more information, contact: Mallory McManus, Communications Director, Florida Agency for Health Care Administration, 2727 Mahan Drive, Tallahassee, Florida 32308; 850-412-3623; Email: AHCACommunications@ahca.myflorida.com.

“Backward integration.” This is a business strategy concept – “when a company expands its role to fulfill tasks completed by organizations in its supply chain.”

In health care, we’re seeing backward integration by health plans, particularly into primary care. Most recently, Blue Cross and Blue Shield of Texas announced a partnership with Sanitas USA to open 10 advanced primary care medical centers in Dallas and Houston. These locations will offer weekday and weekend hours, some will be open 365 days per year, and all will provide primary care, urgent care, lab and diagnostic imaging services, care coordination, and wellness and disease management programs.

In this same vein, the Aetna/CVS merger has the attention of health care analysts. After acquiring Aetna, CVS has “vowed to change the way U.S. health care is delivered,” including plans to decrease consumer’s need for hospital services by focusing on wellness and preventative care. In February, CVS Health introduced three redesigned health-focused HealthHub® stores in the Houston market. The new stores offer a broader range of health care services, new product categories, digital tools and on-demand health kiosks, and personalized care. And in January, CVS Health Foundation and the Aetna Foundation announced a $100 million commitment to support community health initiatives over the next five years through the company’s “Building Healthier Communities” initiative (see CVS Health Invests $100 Million Over 5 Years In Community Health Initiatives).

Humana, Inc. and Walgreens announced a partnership in the Kansas City, Missouri area to open in-store primary care health clinics at two Walgreens pharmacy locations. Humana representatives will be available in these stores to assist Humana Medicare members, and other customers, with information and assistance in accessing a range of health-related services. Humana and Walgreens indicated that they are considering expanding this collaboration into other markets (see Humana Partners With Walgreens To Provide ‘Senior-Focused’ Primary Care In Missouri). Humana also entered into a partnership with telehealth provider organization Doctor on Demand to create a new health plan centered on virtual primary care and charging between $150 and $200 a month, with no copayments for video visits. And earlier, Humana has purchased Kindred, the long-term care provider organization, operating home health, hospice and community care businesses, long-term acute care hospitals, and inpatient rehabilitation facilities.

And, as we’ve written about before, United Healthcare and Kaiser Permanente are now among the largest employers of primary care physicians in the U.S

It is obvious that these developments are going to “remake” the primary care market landscape. Referral patterns, reimbursement, economies of scale, and more will be reinvented by large chains of primary care clinics tied to health plans. If you are with an organization providing primary care services—whether a private practice model, a federally-qualified health center (FQHC), or some affiliated health clinic—your strategies for sustainability are being rewritten by these large and looming outside forces. But, if you are an executive of an organization, you may assume that primary care backward integration has little to do with your strategy. This may be a dangerous assumption, from a strategy perspective.

It is possible that this emerging primary care infrastructure will become the hub for consumer care management, reshaping specialty services along the way. Newly available technologies will enable these new primary care clinics to become purveyors of a range of specialty services—case management, mental health counseling, addiction treatment aftercare, applied behavioral analysis (ABA) services, women’s health services, administration of infusion therapies, and much more.

The counter argument is that primary care professionals don’t do a great job with specialty care—in terms of expertise, treatment planning, and more. There is ample evidence supporting that view. But the countervailing force is that tech-enabled specialty care platforms, rising telehealth reimbursements, and consumer convenience will drive consumers to primary care centers for some specialty care. Backward integration may continue at the primary care center level—adding specialty care staff as demand grows. This evolution will the change the role of specialist provider organizations in the health and human service system—with options for “complete care” models for special populations (like the emerging vertical carve-out plans) or for special niches in acute/urgent specialty care.

Oss, M.E. (2018)., Using ‘best practice’ models to reinvent health & human service organizations for a value-based world. [Presentation Slides]. Gettysburg, PA: OPEN MINDS. Retrieved from https://www.openminds.com/wp-content/uploads/081618ClosingKeynote.pdf

We’ll continue to track the clinical care delivery trends of payers, health plans, and accountable care organizations (ACO). For some of our recent coverage, check out:

  1. Centene To Acquire Community Medical Group To Expand Its Provider Assets
  2. Centene To Acquire MHM Services, Expanding Correctional Health Care Reach
  3. OptumRx Acquires Genoa Healthcare

And for more on strategy in a disruptive market, check out these resources in the PsychU Resource Library:

  1. No System Too Big? No Niche Too Small? Strategy Challenges Ahead
  2. If 1 In 8 Community-Based Organizations Are Insolvent, The Answer Is?
  3. David Versus Goliath?
  4. Value-Based Reimbursement—The Numbers Are In

Rural health care—or at least the closure of hospitals in rural areas—has gotten a lot of attention. Rural hospital closures more than doubled between 2013 through 2017, from 31 to 64 closures (see 64 Rural Hospitals Close In Past Five Years). Delivering health care services to isolated populations across broad geographies has always been a logistical challenge. And, getting a critical mass of consumers and driving distances to do home-based care is a financial challenge—with the traditional fee-for-service (FFS) reimbursement model at the heart of financial sustainability problems. Largely as a result of the reliance of rural hospitals on FFS admissions, many of them (41% by some counts) have negative operating profit margins.

The net effect of these longstanding consumer access and financial challenges is apparent in the health care statistics. Rural populations (roughly 46 million people) lead the country in five leading causes of death including heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke.

One possible solution is the use of telehealth, which surprisingly, rural populations have not embraced as thoroughly as they should. According to the United States Department of Agriculture, while 11% of urban residents used telehealth for health maintenance activities—such as “make appointments, examine and maintain medical records and accounts, pay medical bills, communicate with their health providers, and have direct online interaction with medical staff”—only 7% of rural consumers used telehealth for health maintenance. Those percentages drop to 2.5% of urban consumers and 1.3% of rural consumers who use health monitoring tools, or “medical devices ranging from simple self-actuated or automated medical alert devices.”

It is critical to increase the use of tech-enabled services but that won’t bring financial sustainability for rural hospitals. But a new reimbursement model on the horizon holds potential for stabilizing the finances of rural care delivery. In 2017, the Centers for Medicare & Medicaid Services (CMS) and the Commonwealth of Pennsylvania announced the formation of the Pennsylvania Rural Health Model that will allow rural hospitals to transition from a FFS reimbursement system based on volume to a multi-payer global budget payment method (see Pennsylvania Rural Hospital Financing Model Announced In CMS/State Collaboration).

The financial underpinnings of the Pennsylvania model? A global budget—a fixed amount set in advance and funded by participating payers. The global budget in this model is a fixed annual prospective payment that is calculated based on historic net patient revenue data (either the average of the past three years or the most recent year, whichever is highest) and paid to the hospitals on a monthly basis. The global budget is adjusted annually for transformation-related changes in service utilization. The model is simple in its construct:

  1. Each performance year of the model, Pennsylvania will prospectively set the all-payer global budget for each participating rural hospital, based primarily on hospitals’ historical net revenue for inpatient and outpatient hospital-based services from all participating payers.
  2. Each payer will then pay the participating rural hospitals for all inpatient and outpatient hospital-based services based on the payer’s respective portion of this global budget.
  3. In the first two years, participating hospitals will retain 100% of the realized savings. In the third year, participating hospitals will retain 75% of the savings. In the fourth and fifth years, the payers and hospitals are expected to share an equal portion of the savings.

The global payment also hinges on whether the hospitals meet performance expectations. Specific performance targets haven’t been announced yet, but will be centered on “increasing access to primary and specialty care; reducing rural health disparities through improved chronic disease management; and decreasing deaths from substance use”.

What is most important about this model is that it allows rural hospitals and health systems to participate in value-based reimbursement, with a model that doesn’t jeopardize financial stability. And, the model allows flexibility and promotes innovation in programming. An example of this in practice is the Geisinger Jersey Shore (Pa.) Hospital, which has used this model to hire a health coach and an emergency department care manager, and is currently developing telehealth access to pulmonologists and cardiologists for its consumers.

We’ll be covering the challenges and successes of this model over time, which could be a reimbursement approach that could be applied to other geographies or consumer groups where the “fit” of traditional value-based reimbursement models don’t work well. For an update on rural health issues, check out our recent coverage:

  1. Texas Blues & Texas A&M University To Test Drones & Self-Driving Cars For Rural Health Delivery
  2. About 5% Of Medicare Psychiatrists Provide Telemental Health Services
  3. Top Recruiting Targets Of Rural Behavioral Health Provider Organizations – Occupational Therapists, Pharmacists & Nurse Practitioners
  4. Indian Health Service Announces New Policy To Expand MAT For Opioid Treatment In Remote Locations

On March 22, 2019, the Centers for Medicare & Medicaid Services (CMS) clarified that Medicaid home- and community-based services (HCBS) settings assumed to be “presumptively institutional” will be subject to heightened scrutiny. Presumptively institutional settings are those that have the qualities of an institution and/or isolate beneficiaries receiving HCBS. Medicaid will not cover HCBS provided in institutional settings. The goal of heightened scrutiny is to determine if the setting overcomes the presumption that it is an institution, or if remediation is needed. CMS defines HCBS settings that have the qualities of an institutions as: settings that are located in a building that is a publicly- or privately-operated facility that provides inpatient or residential institutional-treatment; settings that are located on the grounds of, or adjacent to, a public institution; any other settings that have the effect of isolating individuals receiving Medicaid HCBS.

By March 17, 2019, states were required to ensure that all Medicaid HCBS waiver services are provided in integrated community-based residential and non-residential settings. For settings that the state has deemed to be isolating, the provider organizations must implement remediation by July 1, 2020. For some settings, an extended transition period is available; for those settings, states must ensure provider organization compliance by March 17, 2022.

If a state determines that a presumptively institutional setting meets the HCBS community-setting requirement, CMS will use a list of such settings provided by the state to compile a random sample of settings to review. CMS will review all information presented by the state and other parties on settings selected for the review sample and will either: approve the state’s assertion that the setting overcomes the presumption that the setting is an institution; or provide the state feedback on missing information. The state will use CMS feedback to remediate settings that have the qualities of an institution.

The clarification about how CMS will impose heightened scrutiny on presumptively institutional settings was issued on March 22, 2019, in a State Medicaid Director (SMD_#19-001). The letter clarifies CMS responses to frequently asked questions regarding guidance issued in 2014 on HCBS settings, specifically regarding which settings are identified as having the qualities of an institution. The guidance in SMD_#19-001 replaces or supplements the 2014 guidance. However, any content not specifically referenced in the 2019 guidance as being replaced remains in effect. The following provisions replace or supplement the guidance issued in December 2014:

  1. CMS will determine whether a setting may have the effect of isolating individuals receiving Medicaid HCBS from the broader community on account of various factors. These factors include the design or model of service provision in the setting; the opportunities for interaction in and with the broader community; restrictions of beneficiary choice to receive services or to engage in activities outside of the setting; and location of the setting in relation to the broader community
  2. CMS does not automatically presume settings located in rural areas to have qualities of an institution, and more specifically, does not consider these locations as automatically isolating to HCBS beneficiaries.
  3. The state may notify the individuals living in a non-residential setting determined to overcome an institutional presumption of isolation, and if permitted by applicable law, may also notify family members, and guardians of the following: that the state has determined that the settings overcomes the institutional presumption of being isolating, the state’s justification for that determination, and how these individuals may offer comments in response.
  4. During periods of public comment, states should provide strategies to identify settings falling into the three categories of settings presumed to have qualities of an institution and the approaches to be used for flagged settings. Once these settings have been flagged, the state should organize the settings into a numbered list which is divided into categories of settings that the state believes overcome the presumption that the settings are institutions. A list of settings that the state does not believe can overcome the “institutional setting” presumption by the end of the transition period should also be included.
  5. CMS has implemented the following review strategy for state requests for heightened scrutiny of settings that the state believes overcome the presumption of having the qualities of institutional settings: The numbered list of settings identified for each category of presumptively institutional setting will be made available to CMS. CMS will use the list provided by a state to compile a random sample of settings to review. CMS will review all information presented by the state and other parties on settings selected for the review sample and will either: approve the state’s assertion that the setting overcomes the presumption that the setting is an institution; or provide the state feedback on missing information. The state will use CMS feedback to remediate settings that have the qualities of an institution. CMS will then make final heightened scrutiny review determinations of each setting.
  6. Individual, privately-owned homes are presumed to be in compliance with the regulatory criteria of a home and community-based setting. States are not responsible for confirming this presumption for purposes of ensuring compliance with the regulation. States should, however, include private residences as part of their overall quality assurance framework when implementing monitoring processes for ongoing compliance with the federal HCBS requirements.

Provisions pertaining to all presumptively institutional settings are as follows:

  1. When submitting to CMS for a heightened scrutiny review of a setting selected for the review sample, states should provide evidence of how they determined that the setting overcomes the presumption that it has the qualities of an institution. Information should focus on the qualities of the setting and how the setting is integrated in and supports access of individuals receiving HCBS into the broader community via the organization’s policies and practices as well as in ow the setting supports individuals consistent with their person-centered plans.
  2. CMS intends to utilize different mechanisms to ensure that settings presumed to be institutional are compliant with regulatory home and community-based setting criteria by the end of the transitional period. A key component of a state’s Statewide Transition Plan is a description of the process the state will use to ensure identified remediation is completed for all settings presumed to have qualities of an institution. The description of this process should also include an articulation of the steps and associated timelines for bringing provider information into compliance with the regulatory criteria.
  3. States are responsible for ensuring compliance with HCBS criteria for those settings in which Medicaid beneficiaries receive HCBS. If Medicaid is only funding non-residential HCBS for an individual, then the state is not responsible for ensuring compliance with the settings criteria for the setting in which that individual receives.

To remediate settings that have been identified as isolating, CMS offered states and provider organizations a list of promising practices. States are advised to seek technical assistance to transform the long-term services and supports systems to fully implement person-centered thinking, planning and practices. CMS also suggested increasing engagement with the broader community by implementing a broad range of services and supports to facilitate access to the community; states should expand strategies that increase beneficiary access to transportation.

Further, the guidance noted that the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule restricts covered entities, such as state Medicaid agencies and providers that meet the definition of covered entities, from publicly disclosing protected health information (PHI) without authorization of the individual, unless disclosure is expressly permitted under the Rule. Examples of PHI include an HCBS beneficiary’s name and health condition. The state should not include any personally identifiable information of beneficiaries in the submission of the Statewide Transition Plan or in any notification or information disseminated to the public.

PsychU last reported on this topic in “CMS Approves First Three State Plans For New HCBS Person-Centered Settings – Kentucky, Ohio & Tennessee,” which published on July 20, 2016.

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov.

It was five years ago that Monica E. Oss wrote about the “totally accountable care organization” or “TACO” described in a Health Affairs blog. Health Affairs wrote:

Within state-run Medicaid programs, [there are now] ACOs tailored to the care needs of Medicaid’s beneficiaries, many of whom have multiple chronic health and social challenges … [TACOs] offer the potential to push accountability for Medicaid populations, including those with complex needs, to a new level … beyond just medical care (for example, mental health, substance abuse treatment and other social supports).

Roll forward five years, and there are approximately 1,000 ACOs covering 32.7 million consumers under 1,477 different contracts. But, the potential for using the ACO model to serve consumers with chronic conditions and complex support needs is still a work in progress; that according to a recent report from HealthAffairs—”An Initial Assessment Of Initiatives To Improve Care For High-Need, High-Cost Individuals In Accountable Care Organizations”, that stated:

ACOs are keenly aware of the need to focus targeted interventions and care management on HNHC [High-Need, High-Cost] individuals, and most have implemented strategies to do so … and consider it an area of high priority … While some ACOs reported they have effective approaches, most survey respondents are in the early stages of program development. In most cases, their interventions have not been rigorously evaluated for effectiveness or scalability across settings.

What are the challenges for ACOs to address the needs of this population? The recent survey identified six factors:

ACOs can identify HNHCs, but need better methods—ACOs rely on several claims-based and clinical-data-based methods for identifying these high-cost consumers, as well as referrals from clinical professionals and staff identification. While adequate in the short-term, many ACOs “expressed frustration with the capabilities of existing tools” and need better, more efficient, more accurate methods.

ACOs don’t rely on one initiative, so bring options—The top five service approaches ACOs rely on are traditional care management, nurse care coordinators embedded in physician offices, patient-centered medical homes, centrally-located nurse care coordinators, and post-acute/skilled nursing programs. The biggest hurdles to achieving this were limited consumer engagement, limited access to data, and difficulty scaling successful programs.

ACOs need help with social determinants of health (SDH)—While most ACOs take SDH into account when assessing the needs of consumers, few can identify HNHC consumers in need of services by identifying SDH indictors. The needed competencies are the ability to collect and/or identify SDH data, make referrals based on this data, and work with consumers to identify social service gaps.

ACOs need more community-health workers—While most ACOs have a long history of using registered nurses, social workers, and physicians, the biggest trend was the increased need for non-clinical staff, including community health workers. These positions are needed to visit consumers in the home and provide non-clinical assessments and services, including “collecting information about social determinants of health, helping individuals make medical appointments, securing transportation, helping individuals enroll in social services, addressing social isolation, or even setting up home-monitoring devices.”

ACOs need provider organizations that can operate in shared savings arrangements—Shared savings payments are a principal source of program funding for ACOs, and most use this funding mechanism for HNHC consumer populations. Because of the financial uncertainty of these contracts, ACOs are highly selective about which programs to fund. In addition, most funding of any kind is fee-for-service (FFS), which limits the amount of care coordination that is available.

ACOs need help measuring program “impact”—Even though measuring inpatient admissions, emergency department visits, re-admissions, or skilled nursing facility stays is important to most ACOs, few can identify which services have the greatest effect on spending or service use. The result is the inability to accurately gauge return-on-investment (ROI).

These six challenges are areas where analytics experts and entrepreneurial provider organization management teams can help in expanding ACO ability to successfully serve complex consumers. The first challenge—better methods for identifying HNHC consumers—is one that can be best addressed by models using big data and augmented intelligence (see Yes, There Are Organizations Using Augmented Intelligence).

The other five factors are the opening that entrepreneurial managers of clinical organizations have been waiting for—a range of programs options with demonstrated cost savings that are focused on community health and social determinants, paid on shared savings basis. Our team has written before about addressing “pain points” of payers (see Pain Points Matter) and demonstrating the ROI of new programs (see Social Services ROI Essential To Social Determinants Wave and Five Keys To ‘Partnering’ With Health Plans On Social Determinants). And there are a group of specialty provider organizations who are ready for value-based reimbursement (VBR) arrangements—data shows that 69% of those provider organizations are already getting more than 58% of their revenue from VBR contracts (see Adapting Revenue Cycle Management For A VBR-Driven World).

For more on the ACOs, check out these resources from the PsychU Resource Library:

  1. How To Build Successful ACO Health Plan Partnerships
  2. Building The ‘Next Generation’ Behavioral & Social Service ACO
  3. New ACO Developments, Same Challenges
  4. 62% Of ACOs Launched In 2012 Implemented Behavioral Health Initiatives
  5. 61% Of ACO Contracts Only Include Upside Financial Risk
  6. Most ACOs Not Ready For Two-Sided Risk Model
  7. Half Of ACOs Consider Exiting MSSP Over New Downside Risk Rules

On April 2, 2019, the American Medical Association (AMA) and UnitedHealthcare (UHC) announced a collaboration to support creation of 23 new ICD-10 codes related to social determinants of health (SoDH). The codes would be used to trigger referrals to social and government services so that health care professionals can help connect consumers to local and national resources in their communities.

The ICD-10-CM is a system used by physicians and other health care provider organizations to classify and code all diagnoses, symptoms and procedures recorded in conjunction with health care in the United States. However, many ICD Diagnosis Codes are used for the purposes of reimbursement. Previously, UnitedHealthcare had used, and recommended using, Z codes Z55 through Z65 to address social determinants of health. However, the two organizations are supporting the creation of 23 new ICD-10 codes related to social determinants which combine traditional medical data with self-reported social determinants of health data. Social factors that the new codes would capture include:

  • Access to nutritious food
  • Adequate and safe housing
  • Available transportation
  • Financial ability to pay for medications
  • Financial ability to pay for utilities
  • Caregiver needs

The new codes have not yet been released.

The 2019 edition of the ICD-10-CM Official Guidelines for Coding and Reporting were released by the National Center for Health Statistics (NCHS) on July 26, 2018. The ICD-10-CM Official Guidelines for Coding and Reporting identify which codes can be assigned as principal or first-listed diagnosis only, secondary diagnosis only, or principal/first-listed or secondary (depending on the circumstances). In a key update, the 2019 edition allows codes from categories Z55 through Z65 to be reported based on information documented by any clinical professionals (not only the physicians) involved with the consumer’s care.

The ICD-10 is copyrighted by the World Health Organization (WHO) External, which owns and publishes the classification. WHO has authorized the development of an adaptation of ICD-10 for use in the United States for U.S. government purposes. On October 1, 2015, the Centers for Medicare & Medicaid Services (CMS) began using ICD-10-CM to replace ICD-9-CM, volumes 1 and 2. The transition to ICD-10 meant that physicians would be able to use much more specific diagnosis and symptom codes to document health care encounters. The ICD-10 code set added information relevant to ambulatory and managed care encounters; expanded injury codes; and use of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition.

The joint AMA and UCH effort is made possible through the AMA’s Integrated Health Model Initiative™ [IHMI], a collaborative effort across health care and technology stakeholders that seeks to improve health outcomes by empowering physicians with the clinically valid health care data needed to make informed clinical decisions. Its work focuses on market-driven needs in health care data interoperability through the development of common data portability standards that enhance information sharing and work to improve consumer outcomes.

PsychU last reported on this topic in “UnitedHealthcare Expands Initiative To Use Diagnostic Codes To Capture Social Determinants Of Health” which published April 1, 2019.

For more information, contact: Steve Shivinsky, Vice President of Corporate Communications, UnitedHealthcare, 9800 Healthcare Lane, Minnetonka, Minnesota 55436; 763-361-2882; Email: stephen.shivinsky@uhc.com or Robert J. Mills, Media Relations Coordinator, American Medical Association, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885; 312-464-5970; Email: robert.mills@ama-assn.org.

On April 5, 2019, the Centers for Medicare & Medicaid Services (CMS) finalized policies intended to allow Medicare Advantage plans to include expanded telehealth benefits starting in plan year 2020. Beneficiaries living in urban or rural areas will be able to receive telehealth services at home, as well as at a health care facility. The new policies will allow Medicare Advantage plans to offer telehealth services as a standard benefit, rather than only a supplemental benefit accessible at a health care facility. Additionally, Medicare Advantage plans will be able to offer supplemental benefits that are not covered under original Medicare via remote access technologies and/or telemonitoring for services that do not meet the requirements for coverage under original Medicare or the requirements for Medicare Advantage additional telehealth benefits.

The changes are due to the Bipartisan Budget Act of 2018 (BBA).  Before the BBA changes went into effect, telehealth services for fee-for-service (FFS) Medicare beneficiaries were available only to those living in rural areas. The services are available only at designated facility sites, and are limited to a set of specific services covered under Medicare Part B that have been identified as clinically appropriate to furnish through electronic information and telecommunications technology. Medicare Advantage plans have historically been able to offer more telehealth services than were available through FFS Medicare, but only as part of the plan’s supplemental benefits.

For 2019, the BBA changes allowed FFS Medicare to pay for “virtual check-ins” for all FFS beneficiaries regardless of their location. Medicare Advantage plans will now be permitted to offer – as part of the basic benefit package –additional telehealth benefits beyond what is currently allowable under the original Medicare telehealth benefit. CMS anticipates that the finalized new policies will encourage Medicare Advantage plans to offer additional telehealth benefits outside of supplemental benefits. However, members must have the option whether to receive such service through an in-person visit or, if offered by the Medicare Advantage plan, through electronic exchange.

The final rule was published in “Medicare & Medicaid Programs: Policy & Technical Changes To The Medicare Advantage, Medicare Prescription Drug Benefit, Etc.” on April 16, 2019. The rule updates the Medicare Advantage (Part C) and Medicare Prescription Drug Benefit (Part D) programs. CMS is implementing two other BBA sections, as follows

  • BBA Section 50311 requires increased integration of Medicare and Medicaid benefits and appeals and grievance processes for Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs)
  • BBA Section 50354 requires the CMS Secretary to establish a process to allow Part D plan sponsors to request standard extracts of Medicare Parts A and B claims data regarding their enrollees

The final rule provisions for D-SNPs create a single appeals process for beneficiary complaints. The new appeals process will used across Medicare and Medicaid. The goal is to simplify how D-SNP enrollees navigate the health care system. D-SNPs will be required to more seamlessly integrate Medicare and Medicaid benefits across the two programs, such as notifying the state Medicaid agency (or its designee) of hospital and skilled nursing facility admissions for certain high-risk beneficiaries, to promote coordination of care for these patients.

CMS finalized an update to the methodology for calculating Medicare Advantage and Part D Star Ratings. The goal is to give consumers more information on plan quality to help them identify high-value plans. The new Star Ratings methodology is intended to improve the stability and predictability for plans, and CMS will adjust how the ratings are set in the event of extreme and uncontrollable events such as hurricanes.

PsychU last reported on the Medicare Advantage call letter in “Medicare Advantage To Offer Supplemental Benefits For Social Determinants In 2020,” which published on May 6, 2019.

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov.

In December of last year, the Centers for Medicare and Medicaid Services (CMS) released guidance to state Medicaid programs on how to better serve consumers who are dually eligible for Medicare and Medicaid. The guidance recommended that states leverage managed care models to better ingrate care for dual eligible populations, including existing dual eligible special needs plans (D-SNPs) and Programs of All-Inclusive Care for the Elderly (PACE). The guidance also referenced new opportunities for states to improve data exchange and streamline the enrollment.

But the general direction of these recommendations seems to run counter to the market numbers. One example is PACE, a program that has been part of Medicare in some form since the 1990’s. Though PACE programs have been able to show some positive results, in 2019, there were about 49,000 consumers enrolled in PACE programs in 31 states—that’s just 0.04% of the 12 million consumers who are dual eligibles. PACE programs in many states only have a few hundred enrollees.

Another example: enrollment in the much-touted dual eligible demonstration projects are not growing. Started in 2012, 13 states tested integrated financing models for their dual eligible populations through a waiver program. Though several states extended their original demonstration programs and shown some positive outcomes, only three states have been extended their projects through 2020—Massachusetts, Minnesota, and Washington. The other states have opted to end their programs, and there is little comprehensive data about the return on investment for these models (see Dual Eligible Demonstrations: Where Are We 4 Years Later?).

Why does this matter? The dual eligible population is one of the most expensive populations to serve. The dual eligible population represent 20% of all Medicare enrollees and accounted for 34% of all Medicare spending. In Medicaid, the dual eligible population represented 15% of all Medicaid enrollees and 32% of all Medicaid.

It appears that the path forward for provider organizations serving the dual eligible population will continue to involve navigating separate health plans for the same consumer, with separate health plans for Medicare and for Medicaid long-term services and supports. For provider organization administrative and clinical team members, this was simpler when both Medicare and Medicaid were fee-for-service plans. But we now have an increasing number of consumers in Medicare managed and of the 21 states with Medicaid managed long-term services and supports (MLTSS), 19 have included dual eligibles in their population.

If your organization serves dual eligible consumers—whether you are with a provider organization, a care coordination entity, a health plan, or a government agency—there will likely be more administrative complexity for more consumers. There are three administrative competencies that will become more critical as we see fewer dual eligible consumers in a single integrated health plan and more of the services for these consumers in separate managed care plans. First, there is the ability to “braid” services at the consumer level—making services paid by different health plans a seamless consumer experience. Second, there is the ability to participate in multiple approval processes for the same consumer—from prior authorizations, to care coordination, to coordination of benefits and more. Finally, organizations with health information exchange capabilities with the multiple organizations financing or delivery services for dual eligible consumers have a distinct advantage—clinically, financially, and in consumer experience.

On April 1, 2019, Milwaukee County, Wisconsin, launched a two-year contract with Wellpath, LLC, valued at $39 million, to provide medical, dental, and mental health services to all inmates residing in the Milwaukee County Jail and House of Correction. By 2021 when the contract ends, the county intends to transition to a self-operated model of inmate medical care. Previously, the county contracted with Armor Correctional Health Services to provide correctional medical services; that contract ended March 31, 2019.

The county issued a request for proposals (RFP 98180020) on July 20, 2018, to rebid the contract. Initially, responses were due by September 7, 2018, but the deadline was extended to account for increased complexity in responses. The county ultimately received five responses, which included a bid from the incumbent. The county has not named the other unsuccessful bidders. On December 19, 2018, based upon the scoring and recommendation of the RFP evaluation committee, the County issued notice of intent to award the contract to the winning respondent, Wellpath.

On February 1, 2019, the Finance and Audit Committee of the Milwaukee County Board of Supervisors rejected options for a five-year contract and a one-year agreement with a new vendor, and instead approved a two-year, $39 million contract with Wellpath, LLC. The Committee also recommended approval of a $373,000 contract with National Commission on Correctional Health Care Resources, Inc. (NRI), an independent, third-party medical monitor, to provide oversight of the provision of care through Wellpath. The NRI contract went into effect on April 1, 2019, and runs through March 30, 2020; the initial term is followed by four one-year renewal options.

Before the county contracted with Armor Correctional Health Services, county employees had provided inmate medical care. On May 21, 2013, a court ordered the county to enter into a contract with Armor Correctional Health Services to provide medical care to people housed in the Milwaukee County Jail and House of Correction. The contract was slated to run through December 31, 2018. However, in November 2016, the county’s Chairman of the Board of Supervisors requested an audit of Armor, which found that over 22 months, Armor never achieved the minimum staffing levels required by the contract. The audit was publicly released in the fall of 2018.

At a meeting on December 6, 2018, the Milwaukee County Board of Supervisors voted to explore using county employees to provide jail medical services. The resolution had been introduced by the Board of Supervisors’ Committee on Finance and Audit to request a report on the feasibility of Milwaukee County directly providing inmate medical health services. The goal is to give the county greater accountability and transparency over the care provided, and ensure that the care is high quality. On February 7, 2019, the Board of Supervisors created the Correctional Health Care Self-Operation (CHCSO) Project. At the March 7, 2019, meeting of the county’s Committee on Judiciary, Safety, and General Services, the Director of the county Department of Administrative Services provided its initial decision paper on self-operation. The paper outlines the working definition of self-operation and potential governance model alternatives.

PsychU last reported on this topic in “Audit Finds Persistent Health Staffing Issues In Milwaukee Corrections Contracts,” which published on October 29, 2018.

For more information, contact:

  • Theodore Lipscomb, Sr., Chairman, Milwaukee County Board of Supervisors, 901 North 9th Street, Courthouse, Room 201, Milwaukee, Wisconsin 53233; 414-278-4282; Email: theodore.lipscomb@milwaukeecountywi.gov.
  • Judy Q. Lilley, Vice President, Communications & Public Affairs, Wellpath, LLC, 1283 Murfreesboro Road, Suite 500, Nashville, Tennessee 37217; 615-324-5766; Email: JQLilley@Wellpath.us.

To increase the adoption of value-based reimbursement (VBR) models, the Centers for Medicare and Medicaid (CMS) Administrator Seema Verma announced extensive proposed changes to the federal Stark Law. What is the Stark Law? It is a series of federal laws that regulate the financial relationships between health care professionals and provider organizations, with the goal of prohibiting relationships that may influence clinical decision-making based on financial incentives.

The first piece of legislation was enacted in 1989, when reimbursement was primarily on a fee-for-service (FFS) basis. Since that time, while the legislation has grown in scope, it has not been adapted in any way for new reimbursement models—including VBR. Under VBR models, incentive payments are made for meeting cost and quality targets. But these arrangements could violate rules of the Stark Law. How? Under the provisions of Stark, physicians delivering care to Medicare or Medicaid beneficiaries are specifically prohibited from referring to an entity performing health services if that physician, or his/her immediate family member, has any financial relationship with that entity. This could mean that several fundamentals of VBR are potential violations of Stark.

Due to the evolution of the Stark Law over time and the changes to health care from not only reimbursement model changes but also technological innovation, there is ample opportunity for violations. For example, incentive payments to providers based on cost and quality targets may violate the Stark Law if a physician is compensated for meeting targets that are in any way related to volume or value of referrals. Second, shared savings payments to provider organizations based on actual cost savings may be problematic if the way to achieve savings is by reducing medical necessity criteria or substituting a health care product based on cost savings alone. Third, another area under consideration for reform is when infrastructure payments of in-kind assistance occur between a provider organization and a physician. For example, this may include a hospital supplying a physician with televideo equipment for that physician to provide services via televideo that results in a referral to the hospital for health care services, i.e. admission.

Specifically, Ms. Verma has indicated that the current ban on paying physicians for value or volume of referrals will be addressed. CMS had requested and received public comments in 2018. Additionally, she noted that the new regulations will standardize the definition of payments that are commercially reasonable and represent fair market value. These two areas of Stark have hindered the development of more robust care coordination within provider organizations. Ms. Verma has also indicated that documentation issues, electronic health requirements, and cyber security will be addressed in the new regulations.

Health care provider organization executives have struggled with seeking legal safety in a mixture of waivers that have been written by CMS to address some of the conflicts of Stark and VBR. The Medicare Shared Savings Program and bundled payment models have the most broadly written waivers with wide applicability to avoid violation of Stark. For health care executives, it is a challenge to navigate compliance with Stark, monitoring which provisions have waivers and which do not, and while making a VBR contract financially viable. Add into this mix the emerging recognition of social determinants of health, and opportunities to offer remedies such as housing, nutrition, and transportation assistance, and it becomes nearly impossible to create a system built on collaboration that is without violations.

As we look forward to a wide range of alternative payment models—models that include more than physicians and hospitals and beyond those currently covered by waivers—clear rules around the Stark Law will be welcomed by health and human service executives. And I think this regulatory relief will speed up adoption of VBR models by the largest of health plans and provider systems. According to a speech given by Ms. Verma in March, CMS is planning to issue updated regulations this. We’ll cover the changes to the rules, and their implications, when they are released.

Approximately 50% of surveyed Medicare accountable care organizations (ACOs) say they are moderately likely, or very likely, to exit an existing Medicare and Medicare Shared Savings Program (MSSP) if they are required to take on downside risk.  Starting July 1, 2019, the Centers for Medicare & Medicaid Services (CMS) will launch the new “Pathways to Success” rule that limit how long ACOs can participate in the program without downside risk.

Under the new “Pathways to Success” rules, ACOs will be able to participate in the program without downside risk for only two years. Physician-led ACOs considered “low revenue” ACOs and some rural ACOs will be permitted to remain in a model without downside risk for three years. Previously, ACOs could remain in an upside-only model for six years. CMS predicted that the Pathways model would significantly reduce the number of years ACOs can participate in the ACO program with upside-only risk. CMS expected this change would result in fewer total ACOs participating in the program, but that a higher number of ACOs that accept downside risk.

The survey findings were presented in “The 2018 ACO Survey: Unique Paths to Success,” by Kerstin Edwards, Robert Richards, and David Muhlestein for Leavitt Partners. Leavitt Partners, and the National Association of ACOs (NAACOS), collaborated to conduct the 2nd Annual ACO Survey. Responses were submitted by 203 ACOS, representing about 20% of all 1,016 ACOs in the United States. The survey covered topics related to contracting, risk, organizational structure, program initiatives, challenges, and priorities and was sent to all known ACOs. The goal was to better understand current trends and predict future developments of ACOs in order to help ACOs adapt to changes in the industry and proliferate new ideas and best practices.

Additional findings include:

  • About 52% of ACOs reported that they are currently considering or planning to enter into a shared savings with downside risk or capitated contract.
  • About 12% of ACOs reported that they are not considering a shared savings contract with downside risk
  • Integrated/hospital-led ACOs were much more likely (69%) than physician-led ACOs (36%) to say they were at least moderately likely to exit the program if required to take on downside risk.
  • More experienced ACOs and ACOs that have taken on downside risk have adopted medication management initiatives at a higher rate than less experienced ACOs. These include requesting that health care professionals minimize the frequency of medication administration (39% for those with downside risk, versus 20% for those with upside risk only), and requesting that health care professionals minimize medication dosages (36% for those with downside risk, versus 11% for those with upside risk only).

The full text of “The 2018 ACO Survey: Unique Paths to Success” was published on March 28, 2019, by Leavitt Partners. A copy can be requested online at https://leavittpartners.com/whitepaper/2018-aco-survey-unique-paths-to-success/ (accessed April 15, 2019).

PsychU last reported on this topic in the following articles:

For more information, contact: Robert Richards, Senior Data Analyst, Leavitt Partners, 299 South Main Street, Suite 2300, Salt Lake City, Utah 84111-2278; Email: robert.richards@leavittpartners.com or Kerstin Edwards, Research Manager, Leavitt Partners, 299 South Main Street, Suite 2300, Salt Lake City, Utah 84111-2278; Email: kerstin.edwards@leavittpartners.com.

A quarter of more than 500 health care executives responding to a survey said their organizations are either completely (4%) or very (21%) prepared for risk-based population management contracts. The majority (64%) said their organizations were somewhat (26%) or moderately (38%) prepared. About 1% said their organizations were not at all prepared, 4% said their organizations were very unprepared, and 6% said their organizations were somewhat unprepared.

About three-quarters of the organizations have at least one payer agreement that includes upside gain and/or downside risk. However, for 66% of the organizations in a risk-based agreement, less than 20% of revenue is at-risk. The median amount of revenue at-risk was 10%; the median amount of revenue in capitated contracts was 5%. For 31%, the risk-based agreement is one-sided and has no downside risk.

These findings were reported in “State of Population Health, Fourth Annual Numerof Survey Report” by Numerof & Associates, Inc., in collaboration with David Nash, Dean of the Jefferson College of Population Health. The researchers conducted an online survey with more than 500 health care executives, and with a subset, conducted open-ended interviews. The target audience was defined as physician group executives or vice presidents, as well as individuals working in U.S. provider organizations including health care systems, hospitals, and academic medical centers. The researchers analyzed the respondents’ global perspectives about population health, their reported progress on implementing supporting management processes, and their reported assumptions about risk-based contracts. The key findings were as follows:

  1. About 23% said the threat of financial losses was a primary barrier to pursuing at-risk population health contracts. About 14% said difficulties changing the organization’s culture was a key difficulty. Another 14% said their key barrier was issues with their internal information technology, tracking, and management systems. About 11% cited uncertainty about when to make the transition from their current model. About 10% said they had difficulty modeling the cost of care across the continuum.
  2. Less than half of the respondents said their organizations routinely used a process to identify physician-level outliers in cost and quality, most lacked a process to address such variation. Less than 40% said their organization linked clinical professional compensation to cost and quality performance.
  3. Large hospital and/or health systems were more likely than smaller institutions to report having at least one risk-based contract. Risk based contracts were reported by 90% of large institutions (850+ beds), 76% of mid-sized institutions 9300 to 849 beds), and 71% of smaller institutions (less than 300 beds). Among the institutions with risk-based contracts, smaller hospitals tended to have more revenue at risk than medium or large hospitals.
  4. Most respondents,