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Data & Decision Support For Suicide Assessment

Suicide rates have increased by 33% between 1993 and 2017. It is the tenth leading cause of death in the United States, and the second leading cause of death among Americans aged 15 and 34. For every person who takes their own life, there are 30 suicide attempts (see American Foundation for Suicide Prevention).

These are stark statistics that paint a complicated picture of a fragmented system. During The 2019 OPEN MINDS Strategy & Innovation Institute, Carol Clayton, Ph.D., Translational Neuroscientist and Christopher Reist, M.D., MBA, Chief Population Health Strategy for Relias discussed the key issues driving some of these statistics and offered some potential solutions in the session, Beyond Suicide Risk Assessment: Adopting A Comprehensive Solution To Rising Suicide Rates.

It is known that there are risk factors commonly associated with suicide—and screening tools that can help provider organizations and clinical professionals prevent suicide. One huge challenge with assessment tools is that assessment protocols are not standard across organizations and not practiced consistently across providers. The session reviewed two models for identifying those consumers using data to predict risk instead of relying only on assessments—the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), and the Mental Health Research Network (MHRN) Suicide Risk Calculator Project. Common to both programs are components that ensure a review of treatment and an intervention if indicated for those individuals most at risk, and studies are under way to determine if these approaches reduce suicide attempts or deaths.

In 2017, the Department of Veterans Affairs’ (VA) launched (REACH VET)—the model analyzes data from veterans’ health records to identify individuals with an elevated risk for suicide, hospitalization, or illness (see VA REACH VET Initiative Helps Save Veterans Lives: Program Signals When More Help Is Needed for At-risk Veterans). Over 100 variables have been identified, including demographics, prior suicide attempts, diagnoses, VHA utilization, medications, and interactions.

In 2018, the Mental Health Research Network and Kaiser Permanente conducted the Mental Health Research Network (MHRN) Suicide Risk Calculator Project, which combined data from electronic health records (EHR) with results from standardized depression questionnaires to predict suicide risk in the 90 days following either a mental health care visit, or a primary care outpatient visit (see Suicide Prevention: Research Network Finds New Way To Predict Risk). The study was conducted in seven health systems (HealthPartners, Henry Ford, KP Colorado, KP Hawaii, KP Northwest, KP Southern California, KP Washington) using information from eight million members, and identified 150 predictors. These predictors included demographics, mental health and substance use diagnoses, mental health inpatient and emergency department utilization, psychiatric medication dispensing, co-occurring medical conditions, and PHQ8 and item 9 scores.

But while we have the information needed to identify those consumers most at risk for suicide and effective screening tools, those assessments don’t happen routinely. This is proven by the statistics that within one month of a suicide attempt, 63% of individuals had a health care visit of any type and 44% of individuals had a mental health visit.

The reasons for this gap between science and practice are many. There is an absence of standardized assessment protocols across provider organizations. Non-mental health clinical professionals are concerned about their ability to find treatment services for consumers who are at risk. There is also a general lack of awareness and acknowledgement of “critical assessment windows,” which are the time periods when consumers are the most at-risk of suicide ideation. These time windows include the week after a visit to the emergency department for substance abuse, the week after discharge from psychiatric hospitalization, and the first weeks after starting an antidepressant. These are crucial time periods but there is no standardization of screening practice—which results in missing the opportunity to intervene.

For health and human service executives, there is a lot to take in when assessing suicide assessment capabilities. Do you have a screening protocol in place? Do you have data analytics tools to recognize risk factors and build a population health management strategy? Do you understand how to build, find, and/or adopt evidence-based practices for treating consumers with suicide ideation? Answering these strategic questions is essential to building a comprehensive suicide prevention program within your organization and across the market.

For more on bringing standardized decision support models to your organization, check out these resources in the PsychU Resource Library:

  1. The ‘Best Practice’ Challenge
  2. Your Organization Is Ready For VBR When.
  1. Challenges In Changing To A Culture Of Value (Or Making Any Culture Change)
  2. Building A Workforce For Value-Based Reimbursement = Advice From Four Executives
  3. ‘Virtual Psychiatrist’ Telemedicine Decision Support System Effective In Diagnosing Mental Disorders
  1. Preparing For Your ‘Augmented’ Workforce

And for more on leveraging your data, join OPEN MINDS Senior Associate Deb Adler on August 12 for her seminar, How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating, & Contracting With Health Plans.

If you or someone you know are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741.

In 2018, 95% of prescriptions in the United States were handled by six prescription benefit management (PBM) organizations: CVS Health (including Caremark and Aetna), Express Scripts, OptumRx (including UnitedHealth), Humana Pharmacy Solutions, Medimpact Healthcare Systems, and prime Therapeutics. Three of these – CVS Health, Express Scripts, and OptumRx – handled 76% of all U.S. prescriptions. This concentration helps plan sponsors and payers to maximize negotiations by combining their prescription volumes within a small number of PBMs. The concentration also maximizes profits to these PBMs.

These findings were reported in “2019 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers” by Adam J. Fein, Ph.D. Chief Executive Officer of Drug Channels Institute. Researchers from Drug Channels Institute completed a comprehensive analysis of U.S. pharmacies, benefit managers, and prescription revenues though both internal data and a number of publicly available external reports and data sources. The goal was to create a comprehensive report of the PBM Market.

Through their analysis, the researchers identified four trends in the industry that dictate, and will dictate in the future, how PBMs make money. These trends include:

  1. Vertical integration of PBMs into companies that offer health insurance, as well as operation of specialty pharmacies. This integration is partly motivated by the continued growth in specialty drugs which treat a small number of consumers, but account for a large share of payers’ drug spending. For example, the CVS/Aetna partnership, and the Express Scripts/Cigna/Accredo pharmacy partnership. This integration will encourage insurers and PBMs to compete more aggressively on their bundled services.
  2. PBMs will continue to reduce reliance on rebate profits. The largest PBMs have announced approaches that adapt compensation into a system that features low (or no) rebates.
  3. PBMs will depend more on profits from specialty drug dispensation. A large percentage of PBMs and insurers operate the largest pharmacies that provide mail service and specialty handling. These profits results from a difference between the reimbursement to the pharmacy, and the pharmacy’s net acquisition cost for product purchase. Absorption of these costs internally allows PBAs to operate the pharmacies from within. PBMs now earn more than 50% of their profits through dispensing activities and look to increase these profits in the future.
  4. PBMs’ ability to capture network spreads will lessen due to payer and government pressure. Payments for drugs go through the PBM from plan sponsors to pharmacies that dispense the prescriptions. The difference between what goes in and what goes out is the spread. Spread pricing occurs when a company marks up the difference between the amount they reimburse pharmacies for a drug, and the amount they charge consumers. This practice is controversial in Managed Medicaid programs, which are run by PBMs and account for most Medicaid prescriptions and spending.

The full text of “2019 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers” was published in March 2019, by Drug Channels Institute. A copy can be purchased online at https://drugchannelsinstitute.com/products/industry_report/pharmacy/ (accessed June 18, 2019).

PsychU last reported on this topic in “CVS Health Completes Aetna Acquisition,” which published on January 7, 2019. The article is available at https://www.psychu.org/cvs-health-completes-aetna-acquisition/.

For more information, contact: Adam J. Fein, Ph.D., Chief Executive Officer, Drug Channels Institute, 1515 Market Street, Suite 960, Philadelphia, Pennsylvania 19102; 215-523-5700; Fax: 215-523-5758 Email: afein@drugchannels.net; Website: https://www.drugchannels.net/

On April 29, 2019, the National Association of Addiction Treatment Providers (NAATP) announced the release of a foundational set of resources to raise the standards for addiction treatment. The 3 documents form the foundation of NAATP’s Quality Assurance Initiative. The resources include:

  • The Addiction Treatment Provider Quality Assurance Guidebook
  • The NAATP Addiction Treatment Outcomes Measurement Toolkit
  • The NAATP Code of Ethics Version 2.5

The NAATP Quality Assurance Initiative (QAI) was created in 2018 to establish standards for addiction treatment service delivery.

The Addiction Treatment Provider Quality Assurance Guidebook

The guidebook was created to set a strong standard for treatment service delivery. It identifies the core competencies of addiction treatment service through various categories of operations. Within these categories are 32 specific guidelines, each accompanied by an explanatory commentary from an industry expert, followed by a list of resources referenced to develop the guideline. Overall, the focus is that provider organizations should operate programs, and maintain and use their facilities in a way consistent with zoning and intended use of the property, to enhance the therapeutic environment, convey a safe and professional setting, and integrate within the surrounding community. The guideline address the following operational areas:

  1. Admissions and consumer screening: The purpose of this section is to provide guidelines for admissions and patient screenings at addiction treatment facilities. Provider organizations should follow a written admissions process that governs admission criteria, decision making, and intake procedure at the facility. The process should provide information on the anticipated length, intensity, and cost of treatment, as well as what services are provided at the facility. Standardized screenings should be conducted before admission, at intake, and throughout treatment to determine if the facility is equipped to treat the consumer, assess the consumer’s needs, inform treatment planning, and measure progress throughout treatment.
  2. Employment, training, and credentialing: The purpose of this section is to provide guidelines that assist treatment provider organizations in developing and enhancing systems for employment, staff training, and credentialing. All personnel should receive training on their roles, responsibilities, and organizational expectations. Provider organizations should employ professional, credentialed/licensed staff. Salaries and benefits should be competitive enough to recruit and retain competent staff. In the event that a provider organization hires a former consumer, the organization should have a written policy that protects the consumer from exploitation, and ensures that the facility and treatment staff are not placed in a position of dual relationships with former consumers.
  3. Billing: The purpose of this section is to provide guidelines that assist provider organizations in developing policies, procedures, and best practices for billing, receiving, and collections from consumers. Provider organizations should have a methodology for calculating the cost of services, and use this cost in contracting and forecasting. The rates should reflect “reasonable” profit margins consistent with other health care sectors. Provider organizations should consider usual and customary rates when developing billing policies, and be prepared to justify billing amounts that significantly differ from usual and customary. Provider organizations should develop and adhere to a written policy regarding balance billing that complies with state law, network contracts, and insurance policy documents. Written policies should be developed for the use of and billing for toxicology provided at the facility; the type and frequency should be decided based on disease severity, best practices, and clinical need, and billing should be related to the actual cost of the service. Provider organizations should collect all deductibles and copayments in alignment with the consumer’s health insurance policy; routinely waiving the consumer’s financial responsibility is prohibited. Financial hardship waivers must be based on written objective criteria.
  4. Discharge and continuing care: The purpose of this section is to provide guidelines on effective utilization of the continuum of care and best practices for discharge planning. Addiction treatment provider organizations should offer treatment along a continuum of care that recognizes addiction as a chronic illness requiring ongoing bio-psycho-social treatment. Provider organizations offering only specific levels of care should have resources to help consumers access the full continuum. Discharge planning should focus on supporting consumers and their goals through the continuum of care and community reintegration. Provider organizations should develop policies and procedures for atypical discharges to prevent consumers from being discharged to the street.
  5. Outcomes measures: The purpose of this section is to provide guidelines for the implementation of validated outcomes measurement at addiction treatment facilities. Provider organizations should collect, analyze, and publish consumer outcomes to inform program development, enhance service quality, and inform the public.
  6. Community engagement, public relations, and public policy: The purpose of this section to provide guidelines for effective community engagement, public relations activities, and public policy advocacy. Addiction treatment provider organizations should integrate into and engage with the communities in which they serve and operate; this includes establishing collaborative collegial relationships with other addiction treatment provider organizations and other medical professionals. The public relations strategy should focus on communicating the provider’s mission, values, and treatment philosophy; promoting a positive relationship with the community. Public policy conditions should be guided by organizational vision, values, and treatment philosophy, but should frame addiction disorder as a chronic health condition best treated in an integrated and comprehensive continuum of care that addresses the bio-psycho-social-spiritual needs of the individual, uses best practices, and integrates within the larger health care field.
  7. Marketing, advertising, and visibility: The purpose of this section is to provide effective guidelines for the development and implementation of ethical and transparent marketing, branding, and advertising practices. Marketing practices should promote transparency, foster trust, support consumer confidence, and focus on the best interest of the consumer. To promote transparency and brand integrity, marketing materials should clearly identify the actual corporate identity of the program being promoted, and accurately reflect the provider organization’s clinical competence, location, amenities, staff, and staff credentials; the materials should not infringe on the recognition or integrity of a third brand. The provider organization should not provide or receive payment—financial or otherwise—for referrals made to or by the provider organization. Third parties can be used for some marketing activities, but that third-party must adhere to all other provisions of the NAATP Code of Ethics, and Marketing, Advertising, and Visibility standards of the NAATP Quality Assurance Guidebook.
  8. Ethics: The purpose of this section is to provide rationale for and guidance in implementation of professional ethics. Addiction treatment provider organizations should, and NAATP members must, adopt and adhere to the NAATP Code of Ethics.

The Addiction Treatment Outcomes Measurement Toolkit

The Outcomes Measurement offers a nationwide standard for provider organizations to collect data through common outcome measures. The Toolkit is a set of comprehensive protocols, checklists, surveys, and best practices for use at addiction treatment facilities. The toolkit was developed following an Outcomes Pilot Program study by NAATP and conducted by the OMNI Institute. They conducted a three-year study at eight facilities across the United States to test the data collection method and produce a standardized, uniform, and replicable methodology for outcomes tracking. NAATP members interested in more information and implementing the Toolkit should contact NAATP at outcomes@naatp.org or the OMNI Institute at omni@omni.org with the subject line “Outcomes Toolkit Implementation.”

The Code of Ethics Version 2.5

Updated in February 2019, the NAATP Code of Ethics is guidance for the adherence to the highest levels of professionalism and ethical conduct through the entire continuum and spectrum of clinical and business services. The code of ethics outlines those standards to which all NAATP members must follow. The standards cover issues related to treatment, management, facilities, and marketing.

The National Association of Addiction Treatment Providers (NAATP) is a non-profit professional membership association comprised of addiction treatment providers and entities that support addiction treatment. Founded in 1978, the mission of NAATP is to provide leadership, advocacy, training, and member support services to ensure the availability and highest quality of addiction treatment.

The OMNI Institute conducts social science research, evaluation, and capacity building with non-profits, foundations, and government agencies focused on addressing society’s most pressing social challenges. For over 20 years, OMNI has partnered with stakeholders and providers across the spectrum of substance use prevention, treatment, and recovery to conduct research and support implementation of best practices.

The full text of “The Addiction Treatment Provider Quality Assurance Guidebook” was published April 8, 2019 by the NAATP. A copy is available online at https://www.naatp.org/sites/naatp.org/files/NAATP%20QA%20Guidebook%20Beta.pdf (accessed June 18, 2019).

The full text of “NAATP Addiction Treatment Outcomes Measurement Toolkit” was published March 11, 2019 by the NAATP. A copy is available online at https://www.naatp.org/sites/naatp.org/files/NAATP_Newsletter_Outcomes_FINAL.pdf (accessed June 18, 2019).

The full text of “NAATP Code of Ethics” was published in February 2019 by the NAATP. A copy is available online at https://www.naatp.org/resources/ethics/code-ethics (accessed June 18, 2019).

For more information, contact: Marvin Ventrell, J.D., Executive Director, National Association of Addiction Treatment Providers, 1120 Lincoln Street, The Chancery Building, Suite 1104, Denver, Colorado 80203; 888-574-1008; Email: mventrell@naatp.org; Website: https://www.naatp.org/; Kayla Huett, Program Coordinator, National Association of Addiction Treatment Providers, 1120 Lincoln Street, The Chancery Building, Suite 1104, Denver, Colorado 80203; 888-574-1008; Email: khuett@naatp.org; Website: https://www.naatp.org/

A couple of months ago, we wrote about the lack of measurement-based care or the use of decision support tools and data to inform how consumers receive care. Measurement-based care is defined as the collection of quantifiable data using validated scales and then incorporating that data into the treatment planning process creating a feedback loop. Currently only 7% of psychiatrists use measurement-based psychiatric scales when consumer treatment planning (see Why So Little Measurement-Based Mental Health Care?), and only 11.1% of psychologists routinely administer symptom rating scales.

Where does measurement-based care “fit” in the move toward metrics-based performance management and value-based reimbursement (VBR)? Measurement-based care facilitates standardization of service delivery. And, going a step further, measurement-based care allows clinical managers to identify the most effective service models. By measuring care outcomes, managers of provider organizations can see what is and isn’t working, and adjust accordingly in real time these are essential skills in value-based reimbursement environments.

What does measurement-based care look like in practice? An example was given at The 2019 OPEN MINDS Strategy & Innovation Institute during the session, Grafton’s Journey Into Measurable Patient Success, presented by Scott Zeiter, Executive Vice President/Chief Operating Officer, and Jeremy Ulderich, Director of Educational Consulting at Grafton Integrated Health Network. In the Welligent-sponsored session, Mr. Zeiter and Mr. Ulderich talked about Grafton’s development of measurement-based care and what they learned from that experience.

Grafton’s strategy for investing in measurement-based care began with questions—what do payers want from services for children with complex, co-morbid intellectual/developmental disability (I/DD) and behavioral health conditions? And, how could the Grafton team deliver on that? Answering the first question started with market research on what payers and health plans are looking for. Mr. Zeiter explained that their research found that payers are looking for efficiency, empiricism, evidence of change, and expedited responses to lack of change.

The answer to the second question was to build a measurement-based care system that provided payers with these answers. To build the system, the Grafton team started with a goal mastery model that they had already developed. The model creates quantifiable goals for individuals and then tracked those goals to determine whether they are met. While this existing system identified the “what” of the desired outcomes, it did not recommend an appropriate clinical pathway, or provide decision support. Adding that functionality was key to having a working measurement-based care system.

How Grafton’s Model For Measurement Based Care Works

To implement their model for children with complex behavioral conditions, Grafton’s clinical professionals first select from nine broad categories of actions that result in the children they serve needing supportive services. These categories include physical aggression, self-injurious behavior, elopement, lack of safety awareness, disruption, property destruction, sexual acting out, threats of harm, and psychological impairment (Grafton identified these categories as team). These categories form the basis of Grafton’s analysis. For example, they may find that children with physical aggression and elope have better outcomes when they receive motivational interviewing compared to cognitive behavioral therapy (CBT). Any of the variables in the EHR, from demographics to diagnosis to treatment approach can be compared to seek correlations.

In step two, the clinical professional develops a goal to address each problem area. This is a structured process that must include data points such as how long the goal will take to complete, the current rate of behavior occurrence (baseline), and the target rate. In step three, the clinical professional chooses from a list of empirically-based practices This is a structured process that must include data points such as: how long the goal will take to complete,the current rate of behavior occurrence (baseline), and the target rate, such as antecedent-based interventions, reinforcement, and prompting that will be used to meet the goal. Finally, in step four, the clinical professional selects from a list of “intervention objectives” nested under each empirically-based practice. These intervention objectives are the individualized for each client.

Step five is focused on behavior tracking. The direct support professionals working with the children enter the behaviors into the EHR as the behaviors occur (or shortly thereafter). The frequency of the behavior is then updated in real-time on the graphs that Grafton uses to track changes in behavior. If the behaviors are more than three points off the planned trajectory than staff know that it may be time to intervene to meet the goals. In the future, Grafton is partnering with Welligent to set up alerts for when goals go off track.

The Grafton measurement-based care system is in its initial implementation. Over time, Grafton will be able to use and analysis this data to inform appropriate clinical pathways and decision support. Mr. Zeiter and Mr. Ulderich explained that this obviously isn’t an academically rigorous study, it does tell them what works in the “real world” and will be used to refine their service approaches over time.

Advice To Executives Embarking On The Measurement-Based Care Journey

Mr. Zeiter and Mr. Ulderich had much to share about their evidence-based care journey. Their advice to other executives – know when to compromise, be constantly vigilant about model fidelity, and ensure a consumer-driven care plan.

First, know when to compromise and when to hold your ground. Mr. Zeiter explained that the new system was specifically designed to be user friendly and as simple as possible. As part of this, Grafton leadership decided not to develop a user manual for the new EHR system. However, staff were uncomfortable with this and in the end, they compromised to come up with a series of videos that explain the system. One area where Grafton leadership chose not to compromise was when staff wanted to implement a complicated paper system to enter behaviors in the EHR. For the new system to work and be updated in (near) real-time, data needed to be entered directly into the EHR.

Second, ensuring the fidelity of the model takes vigilance. Initially, Mr. Zeiter was afraid that staff would not accurately track behaviors in the EHR and then the model wouldn’t work due to a lack of data. What they found was that ease of the system means that sometimes staff are over-tracking behaviors, or two staff members will enter the same behavior. Grafton is working to ensure that behaviors are accurately tracked in the system. Additionally, just because a clinical professional chooses a specific intervention for a child, it is difficult to ensure that a child is getting that intervention.

Third, using a measurement-based model means that organizations must be extra careful that they are offering a consumer-driven care plan. With the ability to choose from drop downs and a set number of options, there is the possibility that plans may not be individualized enough for payers. Mr. Zeiter explained that in order to maintain a consumer-driven organization, Grafton must ensure that this is an important part of their culture and that care plans are carefully monitored.

Implementing a measurement-based care model is a heavy lift, but for organizations who have the culture and the will, it is possible. Crucial to developing this model is the use of a technology platform that is easy for staff to use and can capture the needed data and show progress in near real-time.

The North Carolina state auditor says that for the past seven years the state has not provided adequate oversight of the seven local management entity-managed care organizations (LME-MCOs) that manage Medicaid behavioral health, addiction treatment, and disability support benefits. The auditor said the North Carolina Department of Health and Human Services (DHHS) failed to obtain reports needed to ensure that services were provided, costs were reasonable, or that performance standards were met. DHHS did not document how it conducted evaluations, the results of the evaluations, or the feedback provided to the LME-MCOs as a result of the evaluations. In case of noted deficiencies, DHHS did not compel the use of corrective action plans (CAPs) or assess penalties. Further, DHHS did not monitor or follow-up on CAPs identified by the DHHS external quality review (EQR) contractor during annual reviews.

The findings were reported in “North Carolina Department Of Health & Human Services, Division Of Health Benefits, Medicaid LME-MCO Contract Monitoring Performance Audit” by the North Carolina Office of the State Auditor. The purpose was to identify DHHS weaknesses in monitoring the LME-MCOs so that DHHS can make changes to better monitor the performance of integrated Medicaid managed care organization (MCO) plans, which are slated to go live in November 2019. The Medicaid managed care plans will be responsible for integrated physical health and pharmacy services, plus behavioral health care services. Following a competitive procurement, in February 2019 DHHS awarded $6 billion in contracts to five managed care entities. After the integrated Medicaid managed care plans go live they will serve most of the state’s 2.1 million Medicaid beneficiaries.

Based on the audit findings, the auditor expressed concern about DHHS’s ability to oversee the integrated Medicaid managed care organizations. The report did not address whether the lack of monitoring led to excess costs. Currently DHHS oversees $3.2 billion in funds managed by the LME-MCOs. The integrated plans at full enrollment will manage nearly $13.9 billion. The auditor recommended that DHHS develop a formal, centralized tracking mechanism to ensure the timely receipt and retention of all LME-MCO reports and data, create formal policies and procedures for evaluating MCOs, and assess penalties and compel the use of CAPs to hold LME-MCOs accountable for their performance. DHHS should monitor and follow-up on CAPs initiated through the EQR process prior to the next annual EQR review.

DHHS has reviewed the audit and is addressing the issues raised in several ways. It has created a new process for Medicaid managed care oversight that will also be implemented for the LME-MCOs. Additional staffing has been added, including an Assistant Secretary for Transformation and a Chief Operating Officer (with health plan oversight experience) and other staff with managed care and health plan experience. Additionally, DHHS has a contract management plan that involves both contract specialists and subject matter expertise, as well as a contract management system that will document the incoming requirements and the internal responses and external communications. DHHS is currently conducting detailed readiness reviews to ensure that DHHS and the health plans are prepared to launch in November 2019.

For more information, contact:

  • Brad Young, Press Contact, North Carolina Office of the State Auditor, 20601 Mail Service Center, Raleigh, North Carolina 27699-0600; 919-807-5700; Email: Brad_Young@ncauditor.net; Website: https://www.ncauditor.net/pub42/Default.aspx
  • Mandy Cohen, Secretary, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina 27699-2001; 919-855-4840; Email: news@dhhs.nc.gov; Website: https://www.ncdhhs.gov/

Editor’s note: this article was updated on June 24, 2019, to incorporate the state’s description of how it is responding to the audit.

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/

With all the discussion about “consumerism” in health and human services, there are many terms—old and new—floating around. We’ve covered the current thinking about customer service and consumer experience (see Consumers Know What They Need. Do We?, and Considering Cash—& Consumerism—In Service Line Planning). But the discussion of new service models for consumers with disabilities has added self-direction, self-determination, and self-advocacy to this lexicon.

There is a lot of reference to the importance of health plans and provider organizations to incorporate these concepts in their service delivery models. But, it is important to get clarity on exactly what these terms mean from an operational and performance perspective. How are they the same or are they different? What are the “best practice” in service models incorporating these principles? And how to you measure success?

These were the issues tackled by Dan Ohler, Vice President, State Government Programs, Optum Behavioral Health and Molly Murphy, President, Applied Self-Direction discussed this at The 2019 OPEN MINDS Strategy & Innovation Institute during their session, Self-Determination In The I/DD Market: Keys To Incorporating Consumer-Directed Care Into Your Services. From their perspective, each of these terms takes on a slightly different flavor and has different nuances.

Self-determination is the idea that individuals can control their life and make decisions about where they live, how they access supports, their goals, etc. There are four overarching principles to self-determination—freedom to plan their own lives, authority to control their resources, support to build a life in the community, and responsibility to be a valued member of the community.

Mr. Ohler explained that health plans are looking for organizations that can incorporate these principles into their service delivery model because these principles result in higher consumer satisfaction. He said that in order to incorporate self-determination, provider organization management teams need to take a hard look at their culture and how they deliver services. For case managers, the shift to self-determination can be difficult. It is a change from managing people to helping people managing themselves. To be successful with self-determination, management teams must embed the principles of self-determination into their policies, communications, and community outreach materials.

Self-direction is a more specific form of self-determination where individuals (or a designated person) are given the ability to design and direct their support services. There are two types of self-direction—budget authority and employer authority. Under employer authority, participants can recruit, supervise, and manage their support professionals. Under budget authority, individuals manage their support budget and make decisions about the goods and services to purchase.

Ms. Murphy talked about the trends in the adoption of self-direction. Over the past ten years or so, self-direction has gone from boutique pilot programs to statewide programs serving a wider population. Her organization’s research found that, in 2016 there were over 250 self-direction programs serving approximately one million self-direction recipients—a 30% increase over three years. Additionally, in 21 states, the adoption of managed long-term services and supports resulted in an increase in the use of self-direction.

Finally, there is self-advocacy, which is the ability to speak up about your feelings and ask for what you need. Self-advocacy is a critical component of both self-direction and self-determination. Without self-advocacy, true self-determination and self-direction cannot occur. Mr. Ohler spoke to the importance of creating an organizational culture that encourages and welcomes self-advocacy. He also noted that it’s important not to confuse “self-advocacy” with “family-advocacy.” While families can play an important role in an individual’s life, ultimately the wants and needs of the consumer are the most critical.

Over time these principles for changing the role of consumers in the service system are going to become increasingly important to the success of health and human service organizations. Both Ms. Murphy and Mr. Ohler noted that managed care program managers see self-determination and self-direction as important components of their new service offerings. Managers and service professionals need to allow individuals to make their own choices, even if this involves more risk and overcoming the instinct is to “save” them from failing.

Depression, alcohol dependency, risk of suicide, childhood trauma — clinical professionals and provider organizations employ a variety of assessment tools and standardized questions to screen consumers for the drivers of poor health care. These screening tools help to identify issues, standardize treatment planning, and uncover issues that influence a consumer’s whole health. One area where we’ve recently seen a greater interest in screening tools and assessments is social determinants of health (SDH).

As health plans and provider organizations are increasingly focused on value and consumer outcomes, the interest in addressing social determinants has increased. But there is a long path between identifying the correlation between social determinants and health care costs and developing social service interventions with a clear return-on-investment (ROI) for payers and health plans. This is especially difficult because the field hasn’t traditionally had great mechanisms for identifying SDH. And while screening for social needs is not yet standard in clinical practice, the ability to effectively screen for SDH continues to evolve.

In 2017, in an attempt to create a more standardized screening process, researchers with the Centers for Medicare & Medicaid Services (CMS) developed a 10-item screening tool to identify health-related social needs. The tool focuses on five domains that can be addressed through community-based services: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety. The tool was developed in coordination with the Accountable Health Communities model, a five-year program that will test delivery approaches for linking clinical and community services. The 32 organizations selected for participation in the program are utilizing the screening tool as a standardized resource (see CMS Develops 10-Item Screening Tool Focused On Social Determinants and CMS Accountable Health Communities Model Selects 32 Participants To Serve As Local Test ‘Hubs’).

Earlier this month, Boston Medical Center (BMC) announced it had implemented a SDH screener for primary care consumers in order to better identify and address their unmet social needs—the BMC THRIVE Screening and Referral Program; it is based on the BMC electronic health record (see Boston Medical Center Develops EHR Tool To Screen For Social Needs). Consumers complete the screener before an appointment, answering questions on housing, food insecurity, transportation, and employment, and the screener autogenerates ICD-10 codes that are added to the consumer’s medical record. Of those with a social need, the most prevalent concerns were employment (12%), food insecurity (11%), and problems affording medications (11%).

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) from the National Association of Community Health Centers (NACHC) continues to be a popular tool utilized by health care provider organization. PRAPARE’s evaluation tool asks social health questions in areas ranging from demographic data and housing status to social-emotional health and physical security (see About the PREPARE Assessment Tool). They also provide an implementation and action toolkit that is being used by providers nation-wide to gather data that will allow them to assess their patients’ social needs, so they can take measures to address them. And many other organizations are developing their own screening and assessment processes (see How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care).

Already, 80% of payers use some method to identify SDH (see Payers Approaches To Addressing Social Determinants Vary), which means that even if you aren’t contracting with health plans right now that are focused on assessing consumer’s social support, the chances of that requirement in the future are all but guaranteed. As health plans put a greater emphasis on social determinants of health in value-based arrangements, provider organizations will need to find new ways to address consumer’s social support needs. But before those needs can be addressed, organizations will need a standardized tool to assess what those needs are. There are already many existing screening tools to explore, the key will be building an infrastructure (including staff training, shifting workflows to make screening a standard practice, incorporating assessment tools into electronic health records, etc.) that can support a standardized approach to screening for social support needs.

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%

 

The Centers for Medicare & Medicaid Services (CMS) has finalized a rule to maintain its existing 2006 policies on prior authorization and step therapy for Part D protected medication classes. The Part D protected classes include antidepressants, antipsychotics, anticonvulsants, immunosuppressants for treatment of transplant rejection, antiretrovirals, and antineoplastics. Effective January 1, 2020, Medicare Part D plans can establish prior authorization and step therapy for only members initiating treatment with five of the six protected classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants, and antineoplastics. Prior authorization and step-therapy will not be permitted for Part D members initiating treatment with antiretrovirals.

In the proposed rule, CMS presented three exceptions to the protected class policy. These exceptions would:

  • Implement broader use of prior authorization and step therapy for protected class Part D drugs, including to determine use for protected class indications
  • Exclude a protected class Part D drug from a formulary if the drug represents only a new formulation of an existing single-source drug or biological product, regardless of whether the older formulation remains on the market
  • Exclude a protected class Part D drug from a formulary if the price of the drug increased beyond a certain threshold over a specified lookback period.

In the final rule, “Modernizing Part D & Medicare Advantage To Lower Drug Prices & Reduce Out-of-Pocket Expenses,” CMS finalized the first provision of the three exceptions, with modifications. This final rule does not place additional limits on beneficiary access to medications. The exception will permit prior authorization and step therapy only for enrollees initiating therapy, and will apply to all Part D protected classes, except antiretroviral medications, for non-protected class indications only. As is required for all other Part D drug categories or classes, these formulary design and utilization management edits will be subject to CMS review and approval as part of the annual formulary review and approval process, which includes reviews of prior authorization and step therapy edits that restrict access, step therapy criteria, prior authorization outliers, and prior authorization criteria.

Estimated savings to enrollees due to reduced out-of-pocket costs for this step therapy are between $5 and $8 million for the 2020 to 2029 timeframe, resulting in an aggregate savings of $62 million over 10 years. The Medicare Trust Fund savings are between $145 and $240 million annually for the 2020 to 2029 timeframe, resulting in an aggregate savings over 10 years of $1.9 billion. There is a $1-to-$1.3 million cost to the government and its contractors for the 2020 to 2029 timeframe, due to a projected increased in appeals, resulting in an aggregate cost of $11.2 million cost over 10 years.

Under the rule, Part D plans will also be required to build a tool to provide drug pricing data. The tool must be operational by January 1, 2021. This tool should be able to integrate into electronic health records or electronic prescribing. Plan sponsors must also update their explanation of benefits for members to include pricing information and offer potential alternatives for expensive therapies.

PsychU last reported on this topic in “CMS Approves Prior Authorization & Step Therapy For Part B Drugs Under Medicare Advantage,” which published on October 29, 2018. The article is available at https://www.psychu.org/cms-approves-prior-authorization-step-therapy-part-b-drugs-medicare-advantage/.

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/medicare-advantage-and-part-d-drug-pricing-final-rule-cms-4180-f

Editor’s note: This article was revised on June 17, 2019, to clarify that the final rule codified existing Medicare Part D policies on prior authorization and step therapy for the six protected drug classes. In the proposed rule, CMS had presented three changes. 

Many specialty provider organizations are facing formidable strategic challenges as the result of the growing payer preferences for integration. Health plans are looking for best practice models that take a whole person approach to care delivery—integrating primary care, pharmacy, behavioral health, social services, and long-term services and supports. This leaves specialty provider organizations with strategic questions: Will hospital systems, primary care providers, or retail clinics become the new competition for the delivery of specialty services to complex consumers? Should we pursue some form of partnership with these types of organizations to deliver integrated care? Or should we develop our own primary care services to provide the full care continuum to our complex consumer populations?

There are many ways to leverage payer preference for integrated care to find a competitive advantage in this shifting market—co-location between primary care clinic and behavioral health care provider organization, health homes and specialty medical homes, embedding behavioral health clinical professionals in a primary care office, comprehensive integrated care delivery, and more. Last week at The 2019 OPEN MINDS Strategy & Innovation Institute, we learned about two different models for delivering integrated care to the complex consumer populations in the session, Building A Specialty Primary Care Program: New Models For Consumers With Complex Conditions, featuring Stephanie M. Murtaugh, Director of Clinical Services, Pittsburgh Mercy; and Tine Hansen-Turton, President & Chief Executive Officer, Woods Services.

While their models have many differences, both Pittsburgh Mercy and Woods use a health home model to delivery integrated primary care for complex consumer populations. And Ms. Murtaugh and Ms. Hansen-Turton shared similar advice for provider organizations considering an integrated care model—focus on performance measurement from the beginning and build your model around clinical quality outcomes. To do this, all members of the care team need access to real-time comprehensive clinical data. A common medical record allows clinical professionals to better coordinate care for consumers and allows the organization to utilize a population health management approach to managing care, while producing (and demonstrating) positive outcomes and value to payers.

The first model, Pittsburgh Mercy Family Health Center, is a person-centered health care home that integrates physical health, substance use disorder (SUD) treatment, mental health care, as well as social support services. They serve 7,000 consumers—40% of which are considered to be a “very high risk” population. They are a certified community behavioral health clinic (CCBHC), and their integrated care model utilizes a person-centered, team-based approach, focused on whole-person care. Their primary care team has access to real-time behavioral and psychiatric consultation and consulting psychiatrists are on-site to do warm hand offs with primary care physicians. They also employ five embedded specialty care managers.

The goal with this consumer population is to move consumers from the most restrictive level of care, to community-based and home-based care. Ms. Murtaugh explained to do that, the team assesses and discusses consumer risk and functioning according to biological, psychological, social, and engagement factors. This assessment allows for risk stratification and enables to team to determine the needs of the consumer population. The team conducts weekly, population-based “high risk” meetings to discuss a comprehensive care plan for highest risk consumers. The meeting includes the entire primary care team and clinical professionals operating in the community. They also have six assertive community treatment (ACT) teams, which review 100 people every morning.

The second model, Woods, is a population health management non-profit organization that supports children and adults with developmental disabilities, complex medical needs and genetic disorders, behavioral and other challenges. Last year Woods opened an expanded medical center, featuring a Patient-Centered Medical Home (PCMH) program for Keystone First members with intellectual and developmental disabilities (I/DD) and complex medical challenges (Keystone First is a Medicaid managed care plan, an affiliate of Independence Blue Cross, in five southeastern Pennsylvania counties – see A Patient-Centered Medical Home For The I/DD Population—The Woods Services Model). Woods and its 6,000 staff offer 200+ health and human service programs in Pennsylvania and New Jersey for 18,000+ children, adolescents, and adults, with referrals from 175 school districts and 23 States.

Population health management includes Woods’ “Care for the Whole Person Model” that addresses all the needs of the people it serves by coordinating social determinants of health, providing physical and behavioral health care and medication management directly or in partnership with health systems, all essential care to achieve positive health outcomes. At Woods a Nurse Navigator coordinates all the health care related services and a Care Coordinator coordinates access to all the services addressing social determinants of health, including housing services, long-term supports, job training and coaching, education, etc.

Two key points stood out from both case study presentations. First, access to comprehensive clinical data is essential. In both of these models, the organizations took a metrics-driven approach to assessing consumer risk and integrating information across the care team. To succeed in this, provider organizations need to build a pathway to capture claims data for analysis, access external records such as hospital records, criminal justice etc., share that information, and (ideally) integrate the behavioral health and physical health record.

And second, focus on outcomes and performance measurement. For these models to be successful at scale, there needs to be some form of bundled payment model. To gain capitated payment models with health plans, organizations need to demonstrate their value in outcomes. Specialty provider organizations can be at an advantage when it comes to integrated care delivery for the complex consumer population. The wider health care field usually does not understand how to serve complex consumer populations—people who are dually diagnosed with developmental disabilities and behavioral health challenges or behavioral health and addiction issues. Specialty provider organizations can utilize their expertise to deliver quality care and produce positive outcomes that demonstrate their value to payers.

There is no one, “right” model for integration. But as the market continues to move in this direction, now is the time for specialty provider organizations to consider what is the best model to serve their complex consumer populations. For more on identifying and responding to the disruptors in your market, check out these resources from the PsychU Resource Library:

  1. Can You Teach A Fish To Climb A Tree?
  2. David Versus Goliath?
  3. Innovation Isn’t Enough
  4. Don’t Let The Big Disruptors Out Of Your Sight
  5. What Does It Take To Outlast The Disruptors?
  6. Will Health Plan Backward Integration ‘Remake’ Specialty Care?

It is estimated that the United States will see up to a 12.8% shortage in physicians by 2032. Estimated physician demand in 2032 is about 953,100. This total equals approximately 283,400 primary care physicians; and 669,700 non-primary care physicians (165,200 medical specialty physicians; 177,200 surgery physicians; 38,000 hospitalists (dedicated in-patient physicians who work exclusively in a hospital); and 289,300 “other” physicians, such as pathologists, neurologists, radiologists, and psychiatrists.

These findings were reported in “The Complexities of Physician Supply and Demand: Projections from 2017 to 2032. The report was written for the Association of American Medical Colleges (AAMC). The AAMC engaged IHS Markit to conduct a new study, incorporating the latest modeling methods and available data on trends and factors affecting the physician workforce. Working with the AAMC Center for Workforce Studies, IHS Markit identified key trends likely to affect the supply and demand for health care services and physicians over the next decade and projected future national adequacy of physician supply through 2025 under multiple scenarios. The scenarios account for workforce growth in non-physician clinicians and new payment and delivery models such as patient-centered medical homes (PCMH) and accountable care organizations (ACO). They applied a microsimulation model, supply model, and demand model to develop supply and demand data.

This study used a microsimulation approach to project the supply of and demand for health care services and physicians. The projection models have been used for health workforce modeling for federal and state governments, and for trade and professional associations for physician and other health occupations. Although the modeling took place at the detailed specialty level, projections for individual specialties were aggregated into four broad categories for the final report: primary care, medical specialties, surgical specialties, and “other” specialties. To reflect future uncertainties in health policy, care use and delivery patterns, the projections are presented as ranges rather than a specific number. All supply and demand projections are reported as full-time equivalent (FTE) physicians, where an FTE is defined for each specialty as the average weekly consumer care hours for that specialty. The supply model, under a Status Quo scenario, simulated the likely career decisions of physicians taking into consideration current numbers, specialty mix and demographics of new entrants to the physician workforce, retirement and mortality patterns, and patterns of patient care hours worked. The demand model simulated the implications of changing demographics due to population growth and aging. This model accounts for projected changes in disease prevalence and other health risk factors among the population if health care use and delivery patterns remained unchanged.

Additional findings include:

  • The 12.8% shortage reflects a shortage of between 46,900 and 121,900 physicians by 2032. This includes a shortage of about 21,000 (at the 25th percentile) to 55,200 (at the 75th percentile) primary care physicians; and 24,800 to 65,800 specialists.
  • Of the projected shortage of specialists, 14,300 to 23,400 will be surgical specialists; and between 20,600 and 39,100 will be other specialists.
  • The projected demand for physicians in 2032 by region of the country is as follows: South (375,500), West (233,100), the Midwest (186,600), and the Northeast (157,900).

IHS is a publicly traded company providing comprehensive economic modeling and forecasting services covering more than 170 industries in over 200 countries. The Life Sciences team at IHS Markit conducts health economic and workforce studies for federal and state governments, trade and professional associations, for-profit life sciences companies, hospital systems, and non-profit organizations.

The full text of “The Complexities of Physician Supply and Demand: Projections from 2017 to 2032” was published in April 2019 by the Association of American Medical Colleges A copy is available online at https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf (accessed June 3, 2019).

PsychU last reported on this topic in “Top Recruiting Targets Of Rural Behavioral Health Provider Organizations – Occupational Therapists, Pharmacists & Nurse Practitioners,” which published on April 8, 2019. The article is available at https://www.psychu.org/top-recruiting-targets-of-rural-behavioral-health-provider-organizations-occupational-therapists-pharmacists-nurse-practitioners/.

PsychU also reported on this topic in “Nurse Practitioners May Represent 27% Of The Family Practice Workforce By 2025,” which published on May 23, 2019. The article is available at https://www.psychu.org/nurse-practitioners-may-represent-27-family-practice-workforce-2025/.

For more information, contact: Katherine Smith, Director, Public Relations, IHS Markit, 55 Cambridge Parkway, Boston, Massachusetts 02142-1201; 781-301-9311; Email: katherine.smith@ihsmarkit.com; Website: https://ihsmarkit.com/; or Association of American Medical Colleges, 655 K Street Northwest, Washinthe fgton,  District of Columbia 20001-2399; 202-828-0400; Website: https://www.aamc.org/

As of February 2019, about 71% of North Carolina Medicaid beneficiaries participating in a supportive housing program for people with serious mental illness (SMI) have remained in housing for two years. The program is called Transitions to Community Living Initiative (TCLI); it was launched by the North Carolina Department of Health and Human Services (DHHS) in 2013. Each of the state’s local management entities-managed care organizations (LME-MCOs) operate TCLI programs that provide Medicaid-eligible adults with SMI long-term housing, community-based services, supported employment, and community integration. At the end of February 2019 of the total 2,677 who have been housed through TCLI, 71% (1,900 people) were currently housed.

DHHS launched TCLI to help the state comply with a 2012 settlement agreement with the federal Department of Justice (DOJ) to increase the state’s capacity to provide supportive services in the least restrictive appropriate setting for individuals with SMI. The settlement featured an eight-year plan to gradually add 3,000 community-based supportive housing slots for adult Medicaid beneficiaries with SMI. DHHS also agreed to invest in job training and employment assistance for the class members and to launch a comprehensive, 24/7 crisis care program for people with SMI.

Specifically, the goal of TCLI is to ensure that people with SMI have access to safe and affordable housing plus community support, to help them become responsible renters. TCLI also teaches the participants, their friends, and their families about recovery, and about activities to control symptoms and promote wellness. The TCLI participants receive up to $2,000 in funding to assist with transition (household items, food, application fees, etc.), and an additional $3,000 if needed.

DHHS reported the TCLI retention rates in the “January 2019 Monthly Report On North Carolina Transition To Community Living Initiative.” Parallel data was also reported by Cardinal Innovations Healthcare (Cardinal Innovations) in “TCLI Performance Dashboard” on April 15, 2019. Cardinal Innovations is one of the state’s seven LME-MCOs that manage public mental health, developmental disability services, and substance use disorder services at the community level. The state DHHS also reported on the TCLI in both the “2017-18 Annual Report on North Carolina Transition to Community Living Initiative.”

The TCLI housing retention rates for the seven LME-MCOs ranged from 65.3% to 75.4%, as follows:

  • Alliance Behavioral Healthcare: 350 TCLI participants have been housed, with 264 remaining in housing, 75.4%
  • Cardinal Innovations: 780 TCLI participants have been housed, with 573 remaining in housing, 73.5%
  • Eastpointe: 251 TCLI participants have been housed, with 164 remaining in housing, 65.3%
  • Partners Behavioral Health Management: 358 TCLI participants have been housed, with 244 remaining in housing, 68.2%
  • Sandhills Center: 286 TCLI participants have been housed, with 204 remaining in housing, 71.3%
  • Trillium: 351 TCLI participants have been housed, with 243 remaining in housing, 69.2%
  • Vaya Health: 301 TCLI participants have been housed, with 208 remaining in housing, 69.1%.

For more information, contact:

  • Mandy Cohen, Secretary, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina 27699-2001; 919-855-4840; Email: news@dhhs.nc.gov; Website: https://www.ncdhhs.gov/
  • Mike Bridges, Director, Transitions to Community Living, Cardinal Innovations Healthcare, 2929 Crouse Lane, Suite B, Burlington, North Carolina 27215; 336-714-9344; Website: https://www.cardinalinnovations.org/

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).

The Joint Commission requires accredited behavioral health organizations to adopt “measurement-based care” by assessing every consumer using a validated tool or instrument to track progress during treatment. The results of the assessments are to be used to inform the goals and objectives identified in individual plans of care, treatment or services as needed. Data from the tools may also be used to improve organizational performance. The revised behavioral health outcome measurement standard is CTS.03.01.09.

To assist organizations in finding an appropriate standardized tool or instrument, The Joint Commission has developed a list of measurement-based care tools and instruments that are currently available to behavioral health care organizations. There are currently 64 possible tools listed. Other tools may be used to meet the requirement, but the Joint Commission list was developed to assist accredited organizations in finding a tool that may be appropriate for their setting. Instrument developers, owners, vendors, and other stakeholders can submit additional behavioral health care tools or instruments to The Joint Commission using the process described on The Joint Commission’s Behavioral Healthcare Instruments Listing, posted online at https://manual.jointcommission.org/BHCInstruments/WebHome?_ga=2.8402421.1312718284.1558630339-1255441414.1558630339 (accessed May 28, 2019).

The background for the new requirement was reported in “Complying With Standard CTS.03.01.09 Behavioral Health Care Accreditation Program” by The Joint Commission. The requirement applies to both currently accredited organizations and those seeking accreditation. However, the requirement is not applied the same way for organizations that are seeking accreditation for the first time. These organizations would be expected to have selected (and be using) an instrument, but they would not be expected to already have a track record with aggregating the data and using it for quality improvement at the time of their initial survey. With that exception, the steps for demonstrating compliance are as follows:

  1. Use a standardized tool or instrument to monitor each individual’s progress in achieving his or her care, treatment, or service goals. These tools have well-established psychometric properties that consistently measure the same outcomes on the basis of reliability and validity, and they have documented sensitivity to distinguish what is normal from the statistically significant. They can be used as a repeated measure so as to not skew outcomes, and to evaluate established norms to determine a benchmark. Ideally the tool used will monitor progress from the individual’s perspective.
  2. Gather and analyze the data generated through standardized monitoring. Collect the data at routine, regular intervals during service delivery. Use the results to inform the goals and objectives of the individual’s plan for care, treatment, or services as needed. The data can be used to identify potential treatment failures, reduce the unintentional influences of provider organization bias, and justify changes in treatment plans and levels of service.
  3. Evaluate the outcomes of consumer care, treatment, or services provided to the population(s) it serves by aggregating and analyzing the data gathered through the standardized monitoring effort. The analysis can be used to inform goals and objectives, monitor consumer progress, and to make decisions related to changes in plans for care, treatment, or services to the consumer. This data should also be used to implement organization-wide improvements related to care, treatment, or service care quality improvement. The data should also be used to evaluate progress of organizational quality improvement efforts, and to evaluate the effectiveness of the services provided.

The new requirement is part of The Joint Commission Accreditation process for behavioral health organizations. The organization currently accredits 3,168 behavioral organizations. This category includes a range of inpatient, residential, and outpatient behavioral health settings including: addiction treatment, adult day care, behavioral health homes, case management, child welfare, corrections-based, crisis stabilization, day treatment, eating disorders, family preservation and wraparound services, forensic services, foster care or therapeutic care, partial hospitalization, prevention and wellness promotion, psychiatric rehabilitative services, residential/group homes, shelters, technology-based, therapeutic schools, transitional, supervised or supportive living, and vocational rehabilitation.

Note: The previous version of this article had not been reviewed by The Joint Commission (TJC). It was amended on June 6, 2019 to reflect TJC clarifications.

The full text of “Complying With Standard CTS.03.01.09 Behavioral Health Care Accreditation Program” was published March 1, 2019, by The Joint Commission. A copy is available online at https://www.jointcommission.org/assets/1/6/Rationale_CTS.03.01.09_Revised.pdf (accessed May 28, 2019).

PsychU last reported on this topic in “The Joint Commission To Add Measurement-Based Care Requirements To Addiction Treatment Accreditation In 2018” which published on August 3, 2017. The article is available at https://www.psychu.org/joint-commission-add-measurement-based-care-requirements-addiction-treatment-accreditation-2018/.

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

A few weeks ago, we covered the announcement that the soon-to-launch Shatterproof Rating System for addiction treatment programs will go live in five states next year—Delaware, Louisiana, Massachusetts, New York, and West Virginia (see Five States To Pilot The Shatterproof Addiction Treatment Rating System). The system will provide a rating score for addiction treatment for all residential, outpatient, and intensive outpatient programs that are licensed, certified, or otherwise approved by participating states.

The Shatterproof Rating System website will display each program’s rating (which will reflect process or structure quality measures recommended by an expert committee convened by the National Quality Forum) and will also display its accreditation or certifications. Ratings for treatment programs in the pilot states will be free and publicly available on the website and will be searchable by commonly-sought treatment criteria (location, insurance, methods, etc.). The ratings will also be available on password-protected portals for treatment programs, payers, and states, providing more detailed information and data.

The new Shatterproof Rating System joins a growing list of ratings of health and human service stakeholders—health plans, state health systems, provider organizations, and individual clinical professionals. These range from the Centers for Medicare & Medicaid Services (CMS) Star ratings, ratings from accrediting organizations (NCQA, CARF, COA, CQL and others), private rating systems (the Commonwealth Fund, NAMI, World Health Organization, Consumer Health Ratings, HealthGrades, Leapfrog, A.M. Best), and consumer rating systems (RateMD, vitals.com, Yelp, ZocDoc, CareDash, Angie’s List).

Reactions to rating systems in health and human services (not specifically the Shatterproof Rating System) are mixed among provider organization executives. There are concerns about the validity of the rating systems and we have covered some of that criticism (see MedPAC Questions Validity Of CMS Hospital Star Ratings).

There are concerns that consumers aren’t aware of rating systems—including The 2019 HealthMine Medicare Survey that found that only 32% of Medicare Advantage plan members with chronic conditions are familiar with the CMS Star ratings system. And, critics point out that consumers don’t use rating systems even when they do know about them. The reasons are many, including an inability to understand the report cards or the systems used to deliver them; poor report card marketing; and the lack of “credible” report cards, as judged by consumers.

But, whether executives like these rating systems or not, or whether the ratings are completely valid, executives of health and human service systems ignore the many rating systems at their own risk. There are two issues. First, the rating systems become the “shorthand” for quality and value. For busy consumers and caregivers, it is a default selection process—think restaurant reviews on Yelp, hotel reviews on TripAdvisor, and movie reviews on Rotten Tomatoes. For payers, it is a means of differentiating between many competing options—and a proxy for quality that can be tied to reimbursement. From a market model perspective, the health and human service system is moving from a “commodity” market (all services by similarly licensed professionals or organizations are the same) to market driven by “value.” Value is a function of cost and performance. And, for better or worse, the rating systems represent the current proxy indicator for performance.

What we don’t know at this point is which of the rating systems will be here in the long-term or will have a lasting impact. But over time the dominant rating systems will shift market share and revenue. The shift in enrollment in the Medicare Advantage plans is an example.

We’ve covered a wide range of rating systems, ranking systems, and accreditation data over the past few years. For a quick look at the “state of the art,” check out this coverage:

  1. Medicare Advantage Star Ratings Create New Market Opportunities
  2. Consumer Star Ratings For Hospitals – It’s Only Going To Get Harder To Earn Those 5 Stars
  3. Succeeding In The Online Ratings Game – Second, You Need A Plan
  4. Performance Ratings In The Era Of Value-Based Purchasing
  5. Succeeding In The Online Ratings Game – First, Know The Score

Only four U.S. states (California, Minnesota, Oregon, and Rhode Island) have essential health benefits (EHB) benchmark plans that provide coverage for comprehensive addiction treatment that aligns with the parity standards established by the Patient Protection and Affordable Care Act of 2010 (PPACA) for individual health insurance marketplace plans. In the remaining states, the EHBs fail to address one or more elements of comprehensive addiction treatment at parity with medical and surgical benefits. Of the four states that offered comprehensive addiction treatment coverage, only Rhode Island offered comprehensive benefits for addiction treatment in two marketplace plans offered under the PPACA. California, Minnesota, and Oregon offered comprehensive coverage for addiction treatment in one marketplace plan.

The PPACA requires that health plans sold in the state’s individual health insurance marketplace offer a set of 10 EHBs, and the benefits in the EHB benchmark plan become the minimum level of coverage for PPACA plans sold in the state’s health insurance marketplace. The EHBs must include behavioral health benefits that must be provided at parity with medical and surgical benefits. Health plans sold in the individual health insurance marketplace must cover addiction and substance use disorder (including tobacco use) screening, treatment, counseling, and prescriptions. About 20% of states offered a marketplace plan that violated the Parity Act.

These findings were reported in “Uncovering Coverage Gaps II: A Review And Comparison Of Addiction Benefits In ACA Plans” by Center on Addiction. The researchers conducted a cross-state comparison of addiction treatment benefits within each state’s EHB benchmark plans sold in 2017. The analysis included all 50 states and the District of Columbia. Each plan was reviewed to evaluate the comprehensiveness of addiction treatment benefits and to determine whether the plan satisfied PPACA requirements regarding coverage of addiction treatment, and whether the plan complied with federal Mental Health Parity and Addiction Equity Act (Parity Act) requirements on coverage of services and medications without quantifiable or non-quantifiable treatment limitations. The goal was to determine whether PPACA plans sold in each state provide coverage for addiction benefits and comply with PPACA requirements. The researchers did not evaluate addiction treatment benefit coverage in other health insurance products, including Medicaid or employer-sponsored plans. The evaluation is limited to the benefits listed in plan documents; the researchers did not review requests for services or claims data.

Key findings about EHBs and benefits offered in individual marketplace plans were as follows:

  • Overall EHB coverage of comprehensive addiction treatment: About 66% of EHB plans did not provide comprehensive coverage, and 50% of states offered plans that did not cover comprehensive addiction treatment.
  • Tobacco cessation: 26 EHB plans were not in compliance, and plans sold in 28 states were not in compliance.
  • Medication assisted treatment: 45% of EHBs did not cover at least one medication used in MAT. Four plans did not cover medications used for tobacco cessation. Four states had plans that were in violation. Seven EHB benchmark plans exclude methadone for opioid use disorder.
  • Lifetime limits on behavioral health treatment: Two EHB plans set a lifetime dollar limit on addiction treatment benefits; no states offered a plan that imposed annual lifetime limits.
  • EHB addiction treatment services: Alaska covered only detoxification, and no other addiction treatment services. Louisiana had a possible exclusion for addiction treatment services. Thirteen EHB benchmark plans excluded residential treatment for addiction treatment.

The researchers analyzed transparency in EHB plan documents and documentation for marketplace plans to evaluate compliance with the PPACA addiction treatment benefits. The key findings were as follows:

  • EHB documents for 11 states lacked information to evaluate compliance; in four states they lacked coverage for smoking cessation; and in eight states they did not address coverage for either alcohol use screening for adults or alcohol and drug use screening for adolescents. In three states, the documents cover alcohol screening for adults but do not address coverage for alcohol and drug use screening for adolescents.
  • In 13 states, documentation for marketplace plans lacked sufficient information to evaluate compliance with the PPACA requirements for addiction treatment benefits. In four states, the plan documents did not address coverage for smoking cessation services. Documents for plans offered in seven states did not address coverage for either alcohol use screening for adults or alcohol and drug use screening for adolescents. Documents for plans offered in five states covered alcohol screening for adults but did not address coverage for alcohol and drug use screening for adolescents.

The researchers identified quantifiable parity violations or possible parity violations from “warning signs” for possible non-quantifiable treatment limitations (NQTL) violations in the plan documents as well unequal coverage of intermediate services. The review was limited to violations evidence from the plan documents. Additional findings about plan compliance with the Parity Act included the following:

  • Overall, nine EHB plan documents had omissions or limitations on benefits that violated the Parity Act, and 18 plans might violate the Parity Act with respect to coverage of intermediate services for behavioral health treatment. Ten states offered marketplace plans with parity violations, and 17 states offered plans with possible parity violations relating to coverage of MAT medications.
  • Quantifiable treatment limitations: Six EHB plans had quantifiable limitations or cumulative limitations that violated parity requirements. Five plans had violations because they imposed limits on the number of inpatient and/or outpatient visits for addiction treatment. Two plans are in violation because they impose lifetime limits on addiction treatment services. One state offered a plan containing a quantifiable treatment limitation that may violate parity requirements.
  • Cumulative financial requirements: Three EHB plans violated the Parity Act because the coinsurance on addiction treatment services does not apply to the out-of-pocket (OOP) maximum, but coinsurance for other medical/surgical services does apply to the OOP. No plans sold on in the insurance marketplace contained non-compliant cumulative financial requirements.
  • Intermediate services for addiction treatment (intensive outpatient, day/partial hospitalization and residential services), which are compatible with medical intermediate services (such as nursing homes): 18 EHB plans have possible violations because five have higher cost-sharing for addiction treatment intermediate settings, one plan has a restrictive visit limit, and 12 excluded addiction treatment intermediate settings but covered skilled nursing facility settings. Three states and the District of Columbia offered marketplace plans with possible parity violations due to disparate coverage of intermediate services for addiction. One state offered a plan that may have imposed a more restrictive limit on intermediate services for addiction than on intermediate medical services. Two states and the District of Columbia offered plans with possible parity violations because they covered intermediate medical services but excluded comparable intermediate addiction treatment services.

Non-quantifiable treatment limitations (NQTL) on behavioral health services evident in processes, strategies, evidentiary standards, and other factors, as compared to those used for medical/surgical benefits in the same classification. Key findings were as follows:

  • Two EHB plans contain language that appears to violate the Parity Act. Marketplace plans offered in 21 states and the District of Columbia contained apparent NQTL violations or warning signs of violations.
  • Plans offered in three states and the District of Columbia imposed treatment standards for addiction treatment that did not exist for medical/surgical services.
  • One state (Vermont) offered a plan that had a requirement for ongoing concurrent review for addiction treatment services that did not exist for medical services.
  • Five states offered plans that excluded coverage of court-mandated services for addiction treatment.

About 31% of the 2017 EHB benchmark plan documents do not provide comprehensive detailed information about the specific addiction treatment services that are covered. It was not possible to determine the degree of parity between addiction treatment and medical services. In 10 states, the EHB benchmark plans do not specify the addiction treatment services covered. In six states, the EHB benchmark plans do not address coverage for intermediate addiction treatment services. Documents for marketplace plans offered in 43% of states did not provide comprehensive information about the addiction treatment services covered.

The full text of “Uncovering Coverage Gaps II: A Review And Comparison Of Addiction Benefits In ACA Plans” was published in March 2019 by Center on Addiction. A copy is available online at https://www.centeronaddiction.org/addiction-research/reports/uncovering-coverage-gaps-ii-review-and-comparison-addiction-benefits-aca (accessed May 20, 2019).

PsychU last reported on this topic in “The Average Marketplace Health Plan Provider Network Includes 11% Of Mental Health Care Professionals,” which published on November 9, 2017. The article is available at https://www.psychu.org/average-marketplace-health-plan-provider-network-includes-11-mental-health-care-professionals/.

For more information, contact: Elizabeth Mustacchio, M.B.A, Senior Marketing and Communications Associate, Center on Addiction, 633 3rd Avenue, New York, New York 10017; 212-841-5293 ​; Email: emustacchio@centeronaddiction.org; Website: https://www.centeronaddiction.org/

Overdose deaths in California’s 36 correctional facilities increased by 160%, from 15 deaths in 2014 to 39 deaths in 2017. Emergency department visits and admissions for drug overdose increased 54% during this time, from about 310 in 2014 to about 500 in 2017. The number of persons in California correctional facilities decreased by 4%, from 135,484 in 2014, to 129,872 in 2017 during the same time period. During 2016, the overdose death rate was the fifth leading cause of death among inmates at California correctional facilities. California’s prison overdose death rates ranged from 5.3 deaths per 100,000 inmates in 2007 to a high of 22.5 deaths 100,000 inmates in 2016.

From 2001 to 2014, the California state prison system had 32% of all overdose deaths in state and federal prison systems in the country, although in 2014, California had only 8.7% of state and federal prison inmates. The national average overdose death rate from 2001 to 2014 was 3 per 100,000. From 2006 through 2016, the average overdose death rate in California prisons was 12.1 per 100,000.

These statistics were reported in “Treatment To Reduce The Burden Of Disease & Deaths From Opioid Use Disorder” by J. Clark Kelso, receiver for California Correctional Health Care Services (CCHCS) which provides health care services for the California Department of Corrections and Rehabilitation. This report includes data from “Substance-Use Disorder Treatment for Patients in the California Department of Corrections and Rehabilitation: An Evidence-Based Clinical Approach” by Renee Kanan, M.D., MPH, deputy director for CCHCS. Before 2016, CDCR and CCHCS provided addiction treatment counseling and behavioral therapies, but did not provide medication assisted treatment (MAT).

In 2016, CDCR’s mental health program started a small three-year pilot project to create, develop and implement a MAT program at one or more institutions. The medications are approved by the U.S. Food and Drug Administration (FDA) to treat AUD or OUD. The pilot was implemented in 2017 at the California Institution for Men (CIM), and at the California Institution for Women (CIW), and it is slated to end on June 30, 2019. The MAT program was expanded to the California Substance Abuse Treatment Facility in 2018; however, treatment outcome data for that facility is not yet available.

In March 2019, CDCR and CCHCS reported the pilot program outcomes in “California Correctional Health Care Services Medication-Assisted Treatment For Substance-Use Disorders, Final Legislative Report.” Since the launch, the MAT program has provided medication and psychosocial treatment to 246 individuals. Of these individuals, 79% (194 participants) continued with the MAT program during incarceration. The majority, 52%, reported opioids as their drug of choice, 29% reported alcohol, and 19% reported both alcohol and opioids. In total, 86 individuals were released on MAT during this time and all were linked to care. About 76% of those released attended their first post-release appointment.

To reduce the incidence of inmate overdoses, the revised 2020 state budget proposed by California Gavin Newsom includes a provision to offer MAT in prisons statewide. The proposal has three main components: MAT for inmates with OUD and alcohol use disorder AUD; a redesign of the current cognitive behavioral treatment curriculum; and the development and management of inmate treatment plans and substance use disorder-specific pre-release transition planning. The program would target three populations:

  • Inmates who were receiving MAT prior to entering prison
  • Inmates already in CDCR with high substance use disorder risk factors (such as a recent overdose)
  • Inmates scheduled for release within 15 to 18 months who have been assessed as having a high need for substance use disorder services

The program would offer MAT Medications; and would include enhanced cognitive behavioral therapy, post-release community-based treatment, peer support, education, and whole person care. An opioid overdose antidote medication would be distributed to at-risk inmates before release. The governor’s revised budget includes more funding for the program of than $71 million for the remainder of calendar year 2019, and nearly $162 million for 2020.

PsychU last reported on MAT in correctional facilities in “Corizon Health Expands Pilot Inmate Medication-Assisted Opioid Use Treatment Program,” which published on June 10, 2019. The article is available at https://www.psychu.org/corizon-health-expands-pilot-inmate-medication-assisted-opioid-use-treatment-program/.

For more information, contact: Vicky Waters, Press Secretary, California Department of Corrections and Rehabilitation, 1515 South Street, Sacramento, California 95811; 916-445-4950; Email: OPEC@cdcr.ca.gov; Website: https://www.cdcr.ca.gov/

Of individuals who have resolved a significant drug or alcohol problem in the United States, a median of two serious recovery attempts were needed for over half to achieve recovery. Compared to this median number of two, the average or mean number of recovery attempts to achieve recovery is 5.35. The number of attempts did not differ by primary addiction substance.

These findings were reported in “How Many Recovery Attempts Does it Take to Successfully Resolve an Alcohol or Drug Problem? Estimates and Correlates From a National Study of Recovering U.S. Adults” by John F. Kelly, Martha Claire Greene, Brandon G. Bergman, William L. White, and Bettina B. Hoeppner. The researchers analyzed data from the National Recovery Study to identify a nationally representative sample of 39,809 adults in the United States. Of the sample, 2,002 reported having overcome a significant drug or alcohol problem. The goal was to determine estimates of, and the factors associated with, needing fewer or greater attempts of serious recovery attempts made, based on medical history and demographics.

The researchers analyzed five quality-of-life indicators that may be associated with the success of recovery: quality of life (the degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events), happiness, self-esteem, psychological distress, and recovery capital (the volume of internal and external assets that can be brought to bear to initiate and sustain recovery from alcohol and other drug problems). Additional findings include:

  • The number of serious recovery attempts made among adults who have resolved a problem with alcohol or other drugs in the United States ranged from zero to 100 attempts.
  • Approximately 13% of those who reported having overcome a significant drug or alcohol problem also reported not making any “serious” recovery attempts.
  • Factors associated with needing a higher number of attempts to quit addiction included a history of depressive and anxiety disorders, prior use of treatment or recovery support services, and being single (rather than married or living with a partner).
  • Non-Hispanic black individuals were also associated with needing a higher number of attempts to quit their addiction.

The researchers concluded that while the mean and median number of recovery attempts are so different, the median figure of two attempts is the most appropriate measure to report: the difference in median and mean recovery attempts before achieving recovery is due to a a small group of individuals who need many more recovery attempts than most. The researchers hope this figure will offer hope to those struggling with an alcohol or drug use problem.

The full text of “How Many Recovery Attempts Does it Take to Successfully Resolve an Alcohol or Drug Problem? Estimates and Correlates From a National Study of Recovering U.S. Adults” was published May 15, 2019, by Alcoholism: Clinical and Experimental Research. An abstract is available online at https://onlinelibrary.wiley.com/doi/full/10.1111/acer.14067 (accessed May 28, 2019 2019).

For more information, contact: John F. Kelly, Ph.D., ABPP, Harvard Medical School, 151 Merrimac Street, Floor 6, Boston, Massachusetts 02114; Email: jkelly11@mgh.harvard.edu; Website: https://www.harvard.edu/.

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

Washington Governor Jay Inslee signed four bills into law on May 9, 2019, launching a transformation in Washington’s behavioral health system. The package includes two bills that affect community behavioral health services, one that will ensure timely court-ordered mental health competency evaluation and restoration services, and one to establish a behavioral health teaching hospital with the University of Washington. Of the two bills that directly affect community behavioral health, one will fully implement Medicaid behavioral health integration, and the other will support care in community-based facilities that are closer to an individual’s home and support network.

Behavioral Health Integration

The Medicaid behavioral health integration initiative, Senate Bill (SB) 5432, will go into effect by January 1, 2020. The provisions remove behavioral health organizations from law; clarify the roles and responsibilities among the Health Care Authority, the Department of Social and Health Services, and the Department of Health, and the roles and responsibilities of behavioral health administrative services organizations and Medicaid managed care organizations; and the bill makes technical corrections related to the behavioral health system.

In 2014, state legislation directed a transition to fully integrate the purchasing of medical and behavioral health services for Apple Health members through a managed care system no later than January 1, 2020. In each region, a behavioral health administrative services organization manages non-Medicaid services. Integrated managed care implementation began in 2016 with the Southwest Washington region (Clark and Skamania counties), and expanded in 2018 to the North Central region (Chelan, Douglas, and Grant counties). On January 1, 2019, integrated care went live in four more regions: Greater Columbia (Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walla, Whitman, and Yakima counties); King (King County); Pierce (Pierce County); and Spokane (Adams, Ferry, Lincoln, Pend Oreille, Spokane, and Stevens counties). At that time, Klickitat County joined the Southwest Washington region and Okanogan joined the North Central region. In July 2019, the North Sound region (Whatcom, Skagit, Snohomish, Island, and San Juan counties) will move to integrated managed care; and on January 1, 2020, the last three regions will transition: Great Rivers (Grays Harbor, Pacific, Wahkiakum, Cowlitz, and Lewis counties); Salish (Clallam, Jefferson, and Kitsap counties); and Thurston-Mason (Thurston and Mason counties).

SB 5432 requires: the establishment of a work group to determine how to appropriately manage access to adult long-term inpatient voluntary care and to the children’s inpatient program; charges the director of the state behavioral health authority to assure that any behavioral health administrative services organization, managed care organization, or community behavioral health program provides medically necessary services to Medicaid recipients; and requires authorities to enforce requirements in managed care contracts to ensure coordination and network adequacy issues are addressed as well as submitting a report to the governor and legislature annually.

Community-Based Facilities

The changes in the system to support community-based facilities are through House Bill (HB) 1394. The bill concerns licensing for community-based facilities that are needed to ensure a continuum of care for behavioral health consumers. The bill acknowledges the need for bed space and smaller community treatment facilities. The secretary will license or certify mental health peer respite centers and work with community hospitals to enter into contract and payment evaluations for treatment facilities and hospitals choosing to provide long-term mental health placements. The bill also exempts any entity seeking to construct, develop, or establish a psychiatric hospital from Certificate of Need requirements if the proposed psychiatric hospital will have no more than 16 beds and dedicate a portion of the beds to providing treatment to adults on 90-or 180-day involuntary commitment orders. The bill is effective on July 28, 2019.

Competency Evaluation & Restoration Services

The changes to court-ordered mental health competency evaluation and restoration services are through SB 5444, which goes into effect on July 28, 2019. The provisions are intended to ensure that the state provides competency evaluations and restoration services consistent with the Trueblood settlement agreement. That agreement requires the state to provide court-ordered competency evaluation within 14 days and begin competency services within seven days after the evaluation. Within this time period, a court may appoint an impartial forensic navigator employed by the department to assist individuals who have been referred for competency evaluation. The forensic navigator will assist the individual to access services to diversion and community outpatient competency restoration. The forensic navigator will also be responsible for helping the individual defense attorney, prosecuting attorney, and the court to understand the options available to the individual.

The fourth bill in the package, HB 1593 establishes a behavioral health innovation and integration campus within the University of Washington School of Medicine. The bill utilizes the Medicine Department of Psychiatry and Behavioral Sciences at the University of Washington in creating a clinical inpatient and outpatient care center. The innovation and integration campus is required to serve individuals with behavioral health needs while training the behavioral health professional workforce through an interdisciplinary curriculum and programs. The bill is effective on July 28, 2019.

To launch the behavioral health transformation, the governor’s operating budget includes $404 million and his capital budget includes $271 million in investments during the next biennium, primarily in five key areas. These areas include:

Expanding Behavioral Health Treatment Options:

  • More than $40 million to expand community alternative placements and creates new facility types for individuals who no longer need inpatient treatment.
  • More than $30 million in invested in community services—such as intensive outpatient treatment, partial hospitalization and intensive wraparound services to make sure discharge placements are successful and to divert individuals from inpatient care.

Developing Housing Support

  • $35 million in rental assistance for permanent supportive housing services to an estimated 1,000 vulnerable people.
  • $20 million in capital funding in the Housing Trust Fund for permanent supportive housing for people with chronic mental illness.

Workforce Development

  • $4 million to address behavioral health workforce shortages.

Appropriate Community-Based Facilities

  • $35 million for community provider organizations to serve people committed under the Involuntary Treatment Act.
  • $110 million for grants to community hospitals and community provider organizations.
  • $31 million to begin work on state-operated civil behavioral health facilities.
  • $2 million to conduct a predesign of a behavioral health-focused teaching hospital at the University of Washington.

Continued Investment In State Hospitals

  • $56 million for building improvements and critical infrastructure at Western and Eastern State hospitals.
  • $47 million is provided to construct two new wards and a modern treatment space at Western State Hospital.

PsychU last reported on this topic in “Washington State Approves New 120-Bed Psychiatric Hospital In Tacoma,” which published on March 16, 2016. The article is available at https://www.psychu.org/washington-state-approves-new-120-bed-psychiatric-hospital-in-tacoma/.

PsychU last reported on this topic in “Washington Medicaid Moving To Integrated Care,” which published on April 11, 2018. The article is available at https://www.psychu.org/washington-medicaid-moving-integrated-care/.

 For more information, contact: Tara Lee, Deputy Communications Director, Communications Office, Washington Office of the Governor, Post Office Box 40002, Olympia, Washington 98504-0002; 360-902-4136; Email: Tara.Lee@gov.wa.gov; Website: https://www.governor.wa.gov/

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/

Approximately 92% of Kaiser Permanente members report satisfaction with the convenience and quality of telemedicine visits with their primary care provider. Overall, 93% of members saying that the telemedicine visit met their needs, 92% felt that their provider was familiar with their medical history, and 90% were confident in the quality of their care via the telemedicine visit. Non-profit Kaiser Permanente provides health care services for more than 12.2 million members in eight states and the District of Columbia.

These findings were reported in “Patient–Provider Video Telemedicine Integrated With Clinical Care: Patient Experiences” by Mary E. Reed, DrPH; Jie Huang, Ph.D.; Rahul Parikh, M.D.; Andrea Millman, MA; Dustin W. Ballard, M.D., MBE; Irwin Barr, M.D.; and Craig Wargon, DPM. The researchers surveyed 1,274 adult (age 18 and over) health care consumers in Kaiser Permanente’s northern California region who scheduled a telemedicine visit from September through December 2015.

In 2014, Kaiser Permanente implemented new technology that allowed primary care providers to have video visits with their health care consumers. These telemedicine visits are provided through internet-connected and video-enabled computers or mobile devices. The primary reasons for Kaiser Permanente members to seek telemedicine visits included convenience, being able to see their primary care providers via telemedicine, and the perception that an in-person visit was not necessary. Additional findings for these Kaiser Permanente members include:

  1. About 89% of those who scheduled a telemedicine visit were interested in a future telemedicine visit.
  2. About 87% said that the telemedicine visit was more convenient than other ways of getting care.
  3. About 84% said that the telemedicine visit improved their relationship with their primary care provider.
  4. Telemedicine visits reduced office visits for 35% of members who would have otherwise needed to make other arrangements for in-person visits. For those who wouldn’t need to make other arrangements for in-person visits, telemedicine reduced office visits for 25% of these members.
  5. Of the 111 participants who scheduled a telemedicine visit but did not attend, about 26% reported technical difficulties as the reason for missing the appointment. Approximately 62% of those who did not attend their telemedicine visits communicated with the health care professional in some other way.

The full text of “Patient–Provider Video Telemedicine Integrated With Clinical Care: Patient Experiences” was published April 30, 2019, by Annals of Internal Medicine. An abstract is available online at https://annals.org/aim/article-abstract/2732082/patient-provider-video-telemedicine-integrated-clinical-care-patient-experiences (accessed May 20, 2019).

PsychU last reported on Kaiser Permanente in “Kaiser Permanente Invests $3 Million To Counter Homelessness,” which published on April 22, 2019. The article is available at https://www.psychu.org/kaiser-permanente-invests-3-million-to-counter-homelessness/.

For more information, contact: Mary E. Reed, Dr.PH, Research Scientist, Northern California Division of Research, Kaiser Permanente, 2000 Broadway Avenue, Oakland, California 94612; 510-891-3808; Email: mary.e.reed@kp.org; Website: https://divisionofresearch.kaiserpermanente.org/; or Janet Byron, Senior Communications Consultant, Northern California Division of Research, Kaiser Permanente, 2000 Broadway Avenue, Oakland, California 94612; 510-891-3115; Email: janet.l.byron@kp.org; Website: https://divisionofresearch.kaiserpermanente.org/

Hear from Jason Carter, Pharm.D., a Medical Science Liaison with Otsuka Pharmaceutical Development & Commercialization, Inc., as he explores the interrelation between chronic pain, opioid prescribing practices, and mental health conditions. Examine the Centers for Disease Control & Prevention (CDC) recommendations for opioid prescribing practices; prescription prevalence; the interrelated nature of mental health conditions and chronic pain for some patients, and assessment tools that can be utilized to screen for misuse risk and mental health conditions in this short presentation.

About 10% of law enforcement agencies’ total budgets in 2017 was spent responding to and transporting persons with mental illness. In total, law enforcement agencies spent an estimated $918 million on transport for people with severe mental illness (SMI). About 21% of total law enforcement staff time was used to respond to and transport individuals with mental illness, which accounted for 165,295 hours and 5.4 million miles. About 26% of all law enforcement transports of individuals with SMI were for people who had three or more law enforcement encounters in one month.

These findings were reported in “Road Runners: The Role and Impact of Law Enforcement in Transporting Individuals with Severe Mental Illness” by the Treatment Advocacy Center. The report was released in partnership with the National Sheriffs’ Association and the New York State Association of Chiefs of Police and funded by the Achelis and Bodman Foundation. The researchers surveyed sheriffs’ offices and police departments about the time and costs of transporting individuals with SMI. The report represents survey responses from 355 sheriffs’ offices and police departments in the United States. Law enforcement officers provide emergency and non-emergency transport for individuals with mental illness.

  • Emergency transport occurs in response to a 911 call, or a police response to a situation with a person at risk of immediate harm; destinations include: general hospital emergency department, psychiatric emergency room, inpatient facility, or jail. About 56% of all transports were emergency transports.
  • Non-emergency transport occurs in response to a court order or other planned event for a person with SMI who is not at immediate risk of harm resulting in transport between facilities such as an emergency department to an inpatient bed; destinations include: emergency department, inpatient facility, courtroom, or jail. About 44% of all transports were non-emergency.

Key Findings

  • The average distance to transport an individual in mental illness crisis to a medical facility was five times farther than the distance to transport them to jail.
  • Transporting a person with SMI to a medical facility required that law enforcement officers wait 2.5 hours longer than transporting the individual to a jail. The average wait was 37 minutes to transfer custody of an individual with SMI to jail. However, at a medical facility, law enforcement officers reported waiting with the individual as long as 72 hours before a bed became available and custody could be transferred.
  • The 355 survey respondents reported that more than $17.7 million was spent in 2017 transporting people with SMI, representing about 10% of the respondents’ budgets. At that spending level, nationwide spending on transport for people with SMI estimated at $918 million.
  • About 32% of emergency psychiatric encounters resulted in transport to a hospital emergency department, 22% to a psychiatric emergency department, 12% to an inpatient facility, and 15% to jail. In 19% of encounters no transport took place.
  • About 34% of non-emergency transports were to a hospital emergency department, 30% to an inpatient facility, and 16% to jail. About 20% were to a court.
  • For individuals with SMI transported by law enforcement to a medical facility, on average 55% were admitted for evaluation, 37% were evaluated and then released, and 8% were immediately released.

The survey analysis reported qualitative themes that emerged from the responses. The respondents expressed concerns about community treatment capacity, the criminalization of mental illness, the stress on law enforcement resources, the need for training law enforcement to respond to psychiatric crisis, and public safety. Additional details were as follows:

  • Time and resource issues caused by psychiatric transports are due to an inadequate supply of community-based psychiatric crisis beds, and that collaboration is needed between the criminal justice, health care, and social service systems.
  • Using law enforcement as the primary response and source of transportation for people in psychiatric crisis leads to criminalization of mental illness.
  • The time and funds required to provide psychiatric crisis response and transport creates difficulty in scheduling officers. The unpredictable nature of psychiatric crisis calls puts a disproportionate strain on operations, especially for small agencies, and takes officers away from regular public safety duties.
  • Law enforcement budgets often lack funding and staff availability to provide staff training on crisis intervention techniques and other forms of law enforcement training.

The survey respondents expressed an understanding of the positive effect of mental health training on an officer’s ability to interact with individuals with mental illness and keep them out of the criminal justice system. The respondents were willing to work with other agencies to improve outcomes for individuals with serious mental illness but expressed frustration with the health system’s lack of accountability in caring for people with SMI.

The full text of “Road Runners: The Role and Impact of Law Enforcement in Transporting Individuals with Severe Mental Illness” was published in May 2019 by Treatment Advocacy Center. A copy is available online at https://www.treatmentadvocacycenter.org/road-runners (accessed May 20, 2019).

For more information, contact: Matt Farrauto, Communications Director, Treatment Advocacy Center, 200 North Glebe Road, Suite 801, Arlington, Virginia 22203; 703-294-6003; Email: info@treatmentadvocacycenter.org; Website: https://www.treatmentadvocacycenter.org/index.php.

In creating proposed models for value-based reimbursement of specialty provider organizations, one of the goals of our team is to link specialty provider organization “performance” to the total cost of consumer care. This is a bigger goal—but also provides a bigger role for specialty provider organizations in the health care system since behavioral health and longterm
care services together are only about 15% of the total health care spend.

We were reminded of this while reading the recent article, “U.S. Economic Burden Of Chronic Diseases Reaches $3.7 Trillion,” about the cost of chronic health care conditions—of which the direct and indirect costs of chronic illness total $3.7 trillion, or about one-fifth of the 2018 gross domestic product of $20.50 trillion. The direct health care cost of those conditions is $1.1 trillion, about 33% of total U.S. health care spending. What was interesting to us was that this report found the costs for specific chronic diseases but didn’t discuss the costs of behavioral health disorders that commonly cooccur with the specific chronic diseases—and usually raise the costs significantly. We looked at a few of these conditions and found a robust set of research on the behavioral management as a solution.

Diabetes— The total annual cost of diabetes is estimated at $327 billion. Research shows that among adults with diabetes, 10.2% had unrecognized depression (for $2,872 in added cost), 13.6 % had asymptomatic depression ($3,347),and 8.9 % had symptomatic depression ($5,170). Successful interventions for behavioral management of diabetes include programs that prioritize frequency of feedback, problem solving, community support, personalized approaches, andscreenings for psychological.

Heart disease—The total annual cost of heart disease is estimated at $555 billion, but consider that the cost of care for health failure increases by 29% when the consumer also has depression; and women with depression have annual cardiovascular costs $1,550-$3,300 higher than consumers without depression. Successful interventions for behavioral management of heart disease are those that help consumers manage poor dietary habits, physical inactivity/low fitness, and smoking.

Arthritis—The total annual cost of arthritis is estimated at $304 billion in 2013, but the mean annual total health care costs for coexisting rheumatoid arthritis (RA) and depression are 7.2% higher than RA alone. In addition, consumers with osteoarthritis (OA) and depression have 38.8% higher direct health care expenditures as compared to those without OA. Successful interventions for behavioral management of rheumatoid arthritis include cognitive behavioral therapy.

Obesity—The total cost of care for obesity is estimated at $114 billion. Obesity makes it more likely that a consumer will become depressed, and that depression makes it more likely that a consumer will become obese; 43% of consumers with depression are obese. Successful interventions for behavioral management of weight include training in collaborative goal setting; accountability; nutrition consultation and meal planning; and self-monitoring food intake, weight, and activity.

Cancer—The total cost of cancer is estimated at $80 billion in 2015, and consumers with cancer and depression had total annual health care costs 113% higher ($235,337) than consumers with cancer but without depression ($110,650).  Successful interventions for behavioral management of cancer include cognitive behavioral therapy.

The high (and growing) costs of chronic disease—and the very real impact of behavioral health conditions and behavior management—are likely going to reshape care coordination programs and primary care. Payers will be looking for innovative approaches that can demonstrate a return-on-investment in the chronic disease management space.

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/

Medicaid expansion may have reduced the number of addiction-related deaths between 2014 and 2015. From 2002 through 2015, the national rate of addiction-related deaths was 21.15 per 100,000 population. During this period, the national addiction-related death rate rose by 71.9%, from 16.0 per 100,000 population to 27.5 per 100,000 population. Without the Medicaid expansion under the Patient Protection and Affordable Care Act of 2010 (PPACA), the addiction-related death rate would have been higher. In the 22 non-expansion states that had net contractions in their Medicaid eligibility thresholds between 2005 and 2015, there was an estimated increase of 570 addiction-related deaths. The number of deaths was lower than predicted in the 28 states that expanded Medicaid eligibility to at least 138% of the federal poverty level (FPL), as allowed by the PPACA. In these states, an estimated 1,045 addiction-related deaths may have been prevented.

These findings were reported in “Association Between State Medicaid Eligibility Thresholds and Deaths Due to Substance Use Disorders” by Julia Thornton Snider, Ph.D.; Margaret E. Duncan, M.D., Ph.D.; Mugdha R. Gore, Ph.D.; et al. The researchers conducted an economic evaluation using a retrospective analysis of state-level data between 2002 and 2015 for a total of 700 state-year observations. The goal was to determine the association between the Medicaid eligibility threshold and addiction disorder-related deaths. The analysis controlled for other relevant policies state socioeconomic characteristics, fixed effects, and a time trend. As controls, the researchers included state policies related to mental health, overdose treatment, and law enforcement of drug crimes.

During the period under analysis, the average Medicaid eligibility threshold increased from 87.2% to 97.1% FPL. By 2015, 58% of states had expanded Medicaid eligibility under the PPACA to at least 138% FPL. The average threshold was not higher because 22 states contracted their eligibility thresholds.

They ran two scenario simulations.

  • In the first, they predicted changes in national addiction-related deaths in 2015 if all states with eligibility thresholds below the median of 133% FPL had raised the threshold to the median in 2014. This scenario indicated a 2.67% reduction in addiction-related deaths, totaling 2,359 fewer deaths in 2015.
  • In the second, they predicted changes if all states raised their eligibility threshold in 2014 to match that of the state with the highest threshold (Minnesota, with a threshold of 205% FPL). This scenario indicated a 5.89% reduction in addiction-related deaths, totaling 5,207 fewer deaths in 2015.
  • Raising any given state’s Medicaid eligibility threshold by a 100-percentage point increase was associated with 1.373 fewer projected addiction-related deaths per 100,000 population, a reduction of 6.5%.

The researchers also compared their findings to an analysis issued by the federal Department of Health and Human Services (HHS) who reported that states that expanded Medicaid, experienced a greater increase in addiction-related deaths. The HHS analysis used a data set for 2010 through 2015. The researchers found that the longer data set for 2002 to 2015 resulted in outcomes different than the HHS outcomes. They said the HHS data set may have been too short in duration.

They concluded that the Medicaid eligibility threshold increase, was the only policy that was significantly associated with lower rates of addiction-related deaths. Mental health parity, mandatory minimum sentencing, and Good Samaritan laws showed little evidence of association with addiction-related deaths. Increases in addiction-related deaths were associated with receipt of federal grant funding from the Substance Abuse and Mental Health Administration (SAMHSA), the number of drug courts, and the existence of a medical cannabis program. The researchers said the increases could be the result of reverse causality because states experiencing a more severe opioid epidemic would be more likely to implement addiction-specific policies. They noted that Medicaid policies are less responsive to the prevalence of addiction disorder or other events in the state.

The full text of “Association Between State Medicaid Eligibility Thresholds and Deaths Due to Substance Use Disorders” was published April 26, 2019 by JAMA Network Open. A copy is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2731689 (accessed May 3, 2019).

For more information, contact: Dana P. Goldman, Ph.D., Precision Health Economics, 11100 Santa Monica Boulevard, Los Angeles, California 90025; Email: dana.goldman@precisionhealtheconomics.com; Website: https://www.precisionmedicinegrp.com/phe/.

Humana’s Medicare Advantage members had an average 2.7% reduction in the number of “unhealthy days” during 2018, and the reduction was linked to an increase in screening for social determinants of health (SDOH), such as food insecurity and loneliness. The percentage change of “unhealthy days” ranged from a 3.6% increase in Broward County, Florida to a 9.8% decrease in San Antonio, Texas. “Unhealthy days” are defined as the overall number of days during the previous 30 days when the respondent felt that either his or her physical or mental health was not good.

These findings were reported the Humana Bold Goal 2019 Progress Report. Humana, along with community partners and physician practices, screened more than 500,000 members for food insecurity and loneliness, and connected those who screened positive to community resources. Humana’s Bold Goal is a population health strategy for primarily Medicare Advantage Members, launched in 2015.

The Bold Goal effort targets social determinants of health and community behavioral health to help the communities it serves become 20% healthier by 2020 and beyond. Bold Goal communities are those where Humana has a large presence, in terms of corporate offices or member enrollments. These include, but are not limited to, Baton Rouge, Louisiana; Broward County, Florida; Knoxville, Tennessee; Louisville, Kentucky; New Orleans, Louisiana; San Antonio, Texas; and Tampa Bay, Florida. Compared to those Humana members in Bold Goal communities, members in non-Bold Goal communities saw an average 0.6% increase in ‘unhealthy days.’ Results varied for Medicare Advantage members in each location (the report did not list the same percentage categories for each location):

  • Baton Rouge, Louisiana had an average 5.1% decrease in unhealthy days: members with disabilities saw a 5.8% reduction; low-income members (individuals whose taxable household income for the preceding year did not exceed 150% of the federal poverty level) amount saw a 4.9% reduction; and those living with diabetes saw a 3.7% reduction.
  • Broward County, Florida had an average 3.5% increase in unhealthy days: members with disabilities saw a 3.9% reduction, while those with depression saw a 12% increase.
  • Knoxville, Tennessee had an average 1.5% decrease in unhealthy days: low-income members showed a 2.9% reduction.
  • Louisville, Kentucky had an average 1.5% increase in unhealthy days: members with diabetes, depression, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) saw a significant reduction in unhealthy days, however exact figures are not available.
  • San Antonio, Texas had an average 9.8% reduction in unhealthy days: members with diabetes, disability, and low-income subsidies saw improvements, however exact figures were not available.
  • Tampa Bay, Florida had an average 3.8% reduction in unhealthy days: this is despite members living with depression seeing a 2% increase in unhealthy days.

Humana Inc. is a for-profit health insurance company that covers over 13 million members in the United States. Humana is committed to helping its millions of medical and specialty members achieve their best health.

The full text of “Bold Goal 2019 Progress Report” was published April 22, 2019 by Humana. A copy is available online at http://populationhealth.humana.com/wp-content/themes/humana/docs/Humana_2019_%20BoldGoal_ProgressReport.pdf (accessed May 10, 2019).

PsychU last reported on this topic in “Severe Loneliness Can Increase Health Care Costs By Over $300 Per Month,” which published on April 25, 2018. The article is available at https://www.psychu.org/severe-loneliness-can-increase-health-care-costs-300-per-month/.

For more information, contact: Marvin Hill, Jr., Corporate Communications Lead and National Public Relations Manager, Humana, 500 West Main Street, 8th Floor, Louisville, Kentucky 40202; 502-580-3950; Fax: 502-508-3493 Email: mhill1@humana.com; Website: https://www.humana.com/

Coming Soon!

In the meantime, please check out the 2017 inaugural report.

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 Orange County, California Health Care Agency is preparing to launch an online addiction treatment registry by summer 2019; the system is currently in testing. The registry will require private addiction treatment programs in unincorporated Orange County to provide the program/ center name business address and state license number; services provided; accepted methods of payment for each location; the identity of each owner, director, partner and officer; and the identities of each organization’s affiliated entities. The stated purpose of the registry is to prevent industry fraud and to promote a coordination of effort in the county.

The registry was proposed by the District Attorney’s office but will be overseen by the county’s Health Care Agency. While compliance timelines and roll-out specifics are still being discussed, the target date for the ordinance to go into effect is July 1, 2019. Failing to register honestly and completely is scheduled to be a misdemeanor carrying fines of up to $1,000 and jail time of up to six months. The following provider organization must participate:

  1. Residential programs
  2. Drop-in centers
  3. Crisis telephone lines
  4. Free clinics
  5. Detoxification centers
  6. Narcotic treatment programs
  7. Chemical dependency programs
  8. Alcohol and other drug prevention programs
  9. Non-specific programs that provide or offer to provide, in whole or in part, for counseling, therapy, referral, advice, care, treatment, or rehabilitation as a service

Organizations affected by the new registry requirements will be notified by mail. Following roll-out, new rehabilitation centers will be required to register within 30 days of opening. The cost of the registry, and a source of funding, has not been released.

For more information, contact: Annette Mugrditchian, Chief of Operations, Behavioral Health Services, Orange County Health Care Agency, 405 West 5th Street, Santa Ana, California 92701; 714-834-5026; Email: AMugrditchian@ochca.com.

More than half of clinical health care professionals said they felt unprepared to provide behavioral health screening and brief intervention (SBI) during regular consumer visits. About 57% do not feel adequately prepared to provide screenings for substance use or mental health disorders, or to provide consumers with information about the impact of behavioral health disorders. About 64% feel inadequately prepared to use motivational interviewing to encourage consumers to change their behaviors or seek help. About 62% feel inadequately prepared to collaborate with consumers to create an action plan.

These findings were reported in “Are Healthcare Professionals Ready to Address Patients’ Substance Use and Mental Health Disorders?” by Glenn Albright, Ph.D., co-founder and director of research at Kognito, and Deborah S. Finnell, DNS, CARN-AP, FAAN, faculty consultant at Johns Hopkins School of Nursing. The authors surveyed 676 health care professionals (physicians, nurses, and nurse practitioners) from over 50 organizations. The participants completed the survey immediately prior to enrolling in one of Kognito’s online simulations on substance use and mental health screening and brief intervention, which were implemented by their organizations as a professional development activity. The researchers analyzed the participants’ health care competency in delivering clinical strategies for substance use and mental health, the likelihood that they would implement these activities as part of routine care, and the number of consumers for whom the health care professionals currently provided these activities.

Additional findings include:

  • About 84% are likely or very likely to provide a health screening, brief interventions, and referrals to treatment for substance use or mental health needs.
  • On average, each health care professional screened 17.6 individuals, engaged in brief intervention with 5.6 individuals, and referred 1.3 individuals to treatment for substance use or mental health needs.
  • On average, each nurse and nurse practitioner screened 8.5 individuals, engaged in brief intervention with 4.7 individuals, and referred 3.5 individuals to treatment for substance use or mental health needs.

The authors recommended better screening and brief intervention training for health care professionals. Because many health care professionals were educated prior to integration of screening and brief intervention training into standard curricula, they may not have been trained on this topic at all. Health care professionals therefore feel unprepared to offer these services to individuals that they treat.

The full text of “Are Healthcare Professionals Ready to Address Patients’ Substance Use and Mental Health Disorders?” was published in March 2019 by Kognito. A copy can be requested at https://go.kognito.com/Are_Healthcare_Professionals_Ready_Substance_Use-Mental_Health_Whitepaper.html (accessed May 3, 2019).

For more information, contact: Glenn Albright, Co-founder and Director of Research, Kognito, 135 West 26th Street, Floor 12, New York, New York 10001; 212-675-9234; Email: glenn@kognito.com.

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.

Between January 2005 and December 2016, rural emergency department visit rates increased by more than 50%, from 36.5 to 64.5 per 100 persons. At the same time, there was a 5% decline in the overall U.S. rural population. In urban areas, emergency department visits increased from 40.2 to 42.8 visits per 100 persons. The higher rate of increase in rural areas occurred among those aged 18 to 64 years, non-Hispanic white individuals, Medicaid beneficiaries, and individuals without insurance.

Rural Emergency Department Utilization Rates
Population Classification # Per 100 in 2005 # Per 100 In 2016
Non-Hispanic Whites 39.2 65.3
Medicaid Beneficiaries 56.2 112.6
Aged 18 To 44 Years 46.9 81.6
Aged 45 To 64 Years 27.5 53.9
Those Without Insurance 44.0 66.6

These findings were reported in “Trends in Emergency Department Use by Rural and Urban Populations in the United States” by Margaret B. Greenwood-Ericksen, M.D., MSc; and Keith Kocher, M.D., MPH. The researchers analyzed data from the National Hospital Ambulatory Medical Care Survey for January 2005 to December 2016. Emergency departments were categorized as urban or rural in accordance with the U.S. Office of Management and Budget classification. Visit rates were calculated using annual U.S. Census Bureau estimates. The goal was to determine urban and rural differences in emergency department use over a 12-year period by demographic characteristics, payers, and characteristics of care, including trends in ambulatory care–sensitive conditions and emergency department safety-net status.

Additional findings include:

  1. During the time studied, overall rural emergency department visit estimates increased nearly over 50%, from 16.7 million to 28.4 million. During this time, overall urban visits increased an estimated 20%, from 98.6 million to 117.2 million overall. This equates to nearly one-fifth of all emergency department visits which occurred in the rural setting in 2016 (28.4 million of 145.6 million).
  2. Rural emergency department visits increased about 66.7% for non-Hispanic white individuals, from 13.5 million to 22.5 million during this time.
  3. Rural emergency department visits increased about 120.5% for Medicaid beneficiaries, from 4.4 million to 9.7 million.
  4. Rural emergency department visits increased about 74.0% for those aged 18 to 64 years, from 9.6 million to 16.7 million.
  5. Rural emergency department visits increased about 25.9% for those without insurance, from 2.7 million to 3.4 million).
  6. Overall rural emergency departments categorized as safety-net status increased about 26.75%, from 769 per 2009 total hospitals, 1,187 out of 1,855 total hospitals.

The researchers concluded that rural emergency departments are increasingly serving a larger proportion of traditionally disadvantaged groups. Increased visits by young to middle-aged white rural patients—particularly Medicaid beneficiaries and those without insurance—may indicate an increased burden of illness or challenges in access to alternative care sites. This places greater financial pressure on rural emergency departments, especially for those with safety-net status because they generally operate in the traditional fee-for-service mode. Rural areas may require tailored and innovative payment and delivery model strategies to achieve improvements in the access to and availability of health care in their communities.

The full text of “Trends in Emergency Department Use by Rural and Urban Populations in the United States” was published April 12, 2019, by JAMA Open. A copy is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2730472 (accessed April 29, 2019).

PsychU last reported on this topic in “Can A New Reimbursement Model Stabilize Rural Hospitals?” which published on May 20, 2019. The executive briefing is available at https://www.psychu.org/can-a-new-reimbursement-model-stabilize-rural-hospitals/.

For more information, contact: Margaret B. Greenwood-Ericksen, M.D., MSC, Department of Emergency Medicine, University of New Mexico, 700 Camino de Salud, Albuquerque, New Mexico 87109; Email: mgreenwoodericksen@salud.unm.edu.

On May 2, 2019, Shatterproof announced that West Virginia would be joining Delaware, Louisiana, Massachusetts, and New York as the fifth and final state to participate in a pilot of a new quality rating system for addiction treatment programs.  The Shatterproof Rating System is intended to standardize the evaluation of addiction treatment across all levels of care, settings, and types of treatment.

Starting in August 2019, all specialty addiction treatment programs in the five pilot states will be asked to respond to an online survey developed by Shatterproof. When possible, information will be pre-populated in order to reduce the programs’ reporting burden. The pilot states are implementing varying participation requirements. Programs that do not respond to the survey will still be included in the system, but with a note that quality data is not available. To validate the treatment program survey, there will be an attestation as well as random checks in the form of additional questions or documentation review. When feasible, data from alternative sources will also be used to validate self-reported information.

The Shatterproof rating program will rate any residential, outpatient, and intensive outpatient programs that are licensed, certified, or otherwise approved by the state to provide substance use disorder (SUD) treatment; as well as facilities that the state does not fund, license, or certify. The evaluation will also include programs operated by federal agencies, such as the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service. It will not examine individual clinical professionals or prescribers. Shatterproof is working with its state partners and with commercial payers on strategies that incentivize and reward participation in the Rating System. These may include highlighting early adopters and using the Rating System to deploy technical assistance and support. In some cases, payers have also committed to requiring reporting to the Rating System in their payment contracts. While completion of the survey is the only mandatory requirement for participation set by Shatterproof, programs may choose to engage further with the pilot and learn more through monthly provider organization roundtables during the pilot.

The Rating System website is slated to go live as early as April 2020. It will include information on all of the programs in the five pilot states. The ratings primarily focus on process or structure quality measures recommended by an expert committee convened by the National Quality Forum (NQF). In addition to the self-reported treatment program survey responses, the ratings will also incorporate data from insurance claims and consumer experience surveys evaluating treatment. The ratings will be available for use by the public, private payers, states, and referral sources. The treatment programs will have a preview period to review their data before it is posted publicly.

The Rating System website will display each program’s rating, and will also display its accreditation or certifications, if provided during the data collection process. Ratings for treatment programs in the pilot states will be free and publicly available on the Rating System website. The Rating System website will not post aggregate outcomes across all states; although the website may include benchmarking information to compare quality of a given treatment program to similar programs within that state or region. States will have access to the treatment program rating data, and may choose to publicize aggregate data for the programs in their state.

The goal is to provide ratings for treatment programs in each state that are helpful to those in need of care and their families. The ratings reflect how consistently the programs delivers care that aligns with Shatterproof’s “National Principles of Care.” These principles of care include:

  1. Routine screenings in every medical setting
  2. A personal plan for every health care consumer
  3. Fast access to treatment
  4. Disease management rather than a current 28-day treatment standard approaches to drug and alcohol rehabilitation
  5. Coordinated care for every illness
  6. Behavioral health care from legitimate provider organizations and clinical professionals
  7. Medication-assisted treatment
  8. Recovery support services beyond medical care

Funding for the pilot totals $5 million in contributions by the Laura and John Arnold Foundation; the Robert Wood Johnson Foundation; and health insurers Aetna, Anthem, Beacon Health Options, Cigna, Magellan Health, and UnitedHealth Group. According to Holly Jespersen, senior communications manager at Shatterproof, after analyzing the pilot outcomes, Shatterproof anticipates expanding the rating system nationwide.

PsychU last reported on this topic in “Shatterproof Launching Addiction Treatment Rating System,” which published on February 25, 2019. The article is available at https://www.psychu.org/shatterproof-launching-addiction-treatment-rating-system/.

For more information, contact:

  • For Shatterproof: Holly Jespersen, Senior Communications Manager, Shatterproof, 135 West 41st Street, New York, New York 10036; 646-334-1024; Email: RatingSystem@Shatterproof.org.
  • For Massachusetts: Alison Cohen, Communications Director, Massachusetts Department of Public Health, 250 Washington Street, Boston, Massachusetts 02108; 617-624-6000; Email: alison.b.cohen@state.ma.us.
  • For New York: Evan Frost, Assistant Director, Communications & Public Information, New York State Office of Alcoholism and Substance Abuse Services, 1450 Western Avenue, Albany, New York 12203; 518-473-3460; Email: communications@oasas.ny.gov.
  • For Louisiana: Karen Stubbs, Assistant Secretary, Office of Behavioral Health, Louisiana Department of Health, Post Office Box 629, Baton Rouge, Louisiana 70821-0629; Email: Karen.Stubbs@la.gov.
  • For Delaware: Elizabeth Romero, Director, Division of Substance Abuse and Mental Health, Delaware Department of Health and Social Services, 1901 North Du Pont Highway, Main Building, New Castle, Delaware 19720; 302-255-9399; Fax: 302-255-4427 or Jill Fredel, Communications Director, Office of the Secretary, Delaware Department of Health and Social Services, 1901 North Du Pont Highway, Main Building, New Castle, Delaware 19720; 302-255-9047.
  • For West Virginia: Bill J. Crouch, Cabinet Secretary, West Virginia Department of Health and Human Services, One Davis Square, Suite 100 East, Charleston, West Virginia, 25301; 304-558-7899; Fax: 604-558-7075; Email: DHHRCommunications@wv.gov.

The good news: 84% of specialty provider organizations have an electronic health record (EHR). The bad? Hardly any specialty provider organizations have health information exchange (HIE) capabilities—at last count, less than half could exchange data (see IT Spending Follows The Money).

Why is this bad news? Our team has written before why HIE is essential for specialty provider organization survival. It’s the key for participating in integrated care, whole person care, social determinants initiatives, and much more. But, HIE and more data sharing flexibility may become mandatory. Last year, the Centers for Medicare & Medicaid Services (CMS) final rule for the Medicare and Medicaid Promoting Interoperability Programs emphasized measures that require the exchange of health information between provider organizations and consumers (see CMS Finalizes ‘Promoting Interoperability’ Rule For Hospitals and CMS Shifting Data Control To Consumers: Are You Ready To Share?).

Now the other shoe has dropped: In February CMS issued another proposed rule that requires health plans to provide members with immediate electronic access to medical claims data and other electronic health information (EHI), such as diagnoses, procedures, tests, and the provider organizations/clinical professionals seen, by 2020. The rule affects Medicare Advantage organizations, Medicaid managed care plans, state Medicaid agencies, state Children’s Health Insurance Program (CHIP) agencies and CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) in the federally-facilitated health insurance marketplace exchange (FFE). The proposed rule requires that organizations do the following:

  • Implement an openly-published Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®) application programming interface (API). This will make patient claims and other health information available to patients through third-party applications and developers.
  • Support electronic exchange of data for transitions of care as consumers move between plan types (Medicare, Medicaid, CHIP, QHP issuers in the FFEs). This data includes information about diagnoses, procedures, tests, and the provider organizations/clinical professionals seen.
  • Use an API to display and facilitate member search of the health plan provider organization network.
  • Participate in a trusted exchange network with other health plans and with provider organizations which would allow them to join any health information network they choose and be able to participate in nationwide exchange of data.

What this means for stakeholders is a need to commit to finding a common understanding of what they are measuring and what measurements will provide value in the exchange of data. Most health plans already have mechanisms in place to provide this information electronically and chances are that this information could be made available to other health plans, health information exchanges, or other data sharing applications. OPEN MINDS Senior Associate Sharon Hicks noted that long-term success relies on reaching this common market definition of “value”:

The issue is less a technical data sharing issue than it is a question about what information is meaningful and useful. Paid claims information is not clinical information, it is simply a record of a clinical service that was delivered and proof of payment for same. It’s utility for medical decisionmaking has not been tested and may in fact be limited. We need to assure that we have a common language before we assume that sharing information will help improve health care.

To prepare, what should your management team do? OPEN MINDS Senior Associate Chris Williams explained that provider organizations need to start with an assessment of their current data sharing capabilities and a comprehensive review of the organizations they should be exchanging consumer data with in their market. In the new market realty, organizations need to understand who they need to connect with specifically and find the tech tools that enable that data sharing capability. He explained:

Which entities will you be required to connect with and share information—health plans? State payers? Other provider organizations? How will that process work? Understand at a deep level, how your reimbursement model functions within information exchange model. This is critical because under these new regulations, health plans will need to provide consumers access to every one of their claims. (Let that sink in for a moment.) Your starting point is to assess and understand the technology you have, compared to the technology you’ll need to comply, execute, and exchange information within your immediate network of payers and other provider organization partners—and potentially beyond.

EHRs, HIEs, and EHI are all critical to provider organization participation in the evolving health and human service system-critical for long-term sustainability. For more on meeting that challenge, check out these resources from the PsychU Resource Library:

  1. Is Your Organization Data Reactive – Or Data Predictive?
  2. Moving EHR Investments From ‘Must Do’ To ‘Must Have’
  3. IT Spending Follows The Money
  4. You Have An EHR, But Can You Share Data?
  5. Data Exchange Via Mail & Fax? In Today’s Market?
  6. Moving Out Of Your Comfort Zone: The VBR Technology Continuum
  7. Are You Strategically Interoperable?

Background

Burnout – measured in terms of emotional exhaustion, cynicism, and sense of professional efficacy – continues to be an issue among health care providers. Mental health providers are believed to be at a high risk for burnout due to the very nature of their jobs; they are often exposed to traumatic material and must withhold emotions and reactions while providing services. The Veterans Health Administration (VHA) is the largest single provider of mental health services, with a high percentage of the population they treat seeking services for posttraumatic stress disorder (PTSD).

There are many factors that may contribute to provider burnout at the VHA – a heavily monitored and highly public agency governed by bureaucratic and political oversight. Quality and performance of the agency is regulated by a vast number of administrative performance metrics alongside a myriad of rules and policies. On top of the sheer amount of evaluative metrics, care at the VHA must constantly live up to public scrutiny, as VHA performance is often reported to Congressional Oversight Committees and through national media outlets. Lastly, political pressure to provide specific diagnoses and treatment options to patients under their care may be a unique experience among providers at the VHA. Accessing benefits and treatment, or continuing treatment, is a major and highly-publicized concern amongst beneficiaries – and the pressure to conform to specific diagnoses or treatment against independent judgement may exist, as providers don’t want to be labeled “anti-veteran.”

A recently published article in Mental Health & Prevention, “Occupational burnout among PTSD specialty clinic providers in the Veterans Health Administration: Perceptions of bureaucratic and political oversight,” written by Hector A. Garcia, Justin K. Benzer, Elizabeth Haro, and Erin P. Finley, attempts to measure the impact of such pressures amongst VHA staff providing services through PTSD specialty clinic teams (PCTs). Specifically, the authors investigated the burnout risk and protective variables presented in Figure 1.

 

Background & Purpose

Unfortunately, for many individuals living with serious mental illness (SMI), presentation of their illness may include experienced lethargy, leaving them less active than their otherwise healthy peers. Additionally, some antidepressant and antipsychotic medications can place patients at a higher risk for metabolic disorder, which is associated with poorer physical health and comorbid physical health conditions like cardiovascular disease. Physical health problems can in turn depress patient mood, affect psychosocial functioning, and negatively impact other lifestyle outcomes. There is a plethora of research indicating that increased physical activity and changes to diet can positively impact patient quality of life (QoL). However, populations included in these studies have mostly been recruited from or treated in outpatient programs. Due to the limited population, findings may not be generalizable to patients living with SMI receiving treatment within an inpatient setting.

Recently, a program aimed at improving sedentary lifestyle and metabolic health was implemented amongst a patient population with SMI in an inpatient setting. This Multidisciplinary Lifestyle Enhancing Treatment For Inpatients With SMI (MULTI) demonstrated overall improvements in the physical health of patients over the long-term. If improving QoL for patients with SMI is one of mental health treatment’s key outcomes, professionals cannot ignore the benefits of physical activity and healthy lifestyle habits. However, more intangible factors of improved patient lifestyle – like psychosocial functioning and QoL – are also important, though less well-studied. Jeroen Deenik and colleagues examine the improvements in these factors amongst the MULTI participants in a secondary, cohort analysis of the program’s findings. Their study results were released in, “Improved psychosocial functioning and QoL in inpatients with severe mental illness receiving a multidisciplinary lifestyle enhancing treatment. The MULTI study II,” published in October 2018 in Mental Health & Physical Activity. In addition to investigating whether MULTI improved other lifestyle factors for inpatients with SMI, the authors also examine if physical health improvements have an amplifying effect on demonstrated positive outcomes.

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.

Psychiatric facilities in the United States spend about $1.7 billion annually to comply with Medicare Conditions of Participation (CoPs) set by the Centers for Medicare & Medicaid Services (CMS). The cost of compliance represents about 4.8% of an average facility’s annual revenue for all inpatient psychiatric services from all sources. Key sources of compliance costs include the following:

  • Federal regulatory domains attached to participation in the Medicare program: standards for consumer screening and evaluations, medical records and treatment plans, and director qualifications for inpatient psychiatric facilities. These are called B-Tag requirements.
  • The burden of standards focused on “ligature risk points” in the facility physical environment. These standards are intended to help prevent self-strangulation.
  • The burden posed by the Emergency Medical Treatment and Labor Act (EMTALA) requirements to screen all consumers for emergency medical conditions, and, if an emergency condition is identified, involuntary admission to stabilize the individual before the individual may be discharged or transferred. The services must be provided without regard for whether or not the consumer can pay for the services.

There were 1,738 inpatient psychiatric hospitals in 2016, which included 580 freestanding psychiatric hospitals and 1,158 general acute hospitals. In fiscal year 2019 psychiatric hospitals provided 25.4 million inpatient days, and received an estimated $35.4 billion in all-payer net revenue according to data collected by the federal Substance Abuse and Mental Health Services Administration (SAMHSA). The cost of compliance with the Medicare CoPs in the three domains was based on survey responses provided by 62 inpatient psychiatric facilities. Overall, the 62 facilities reported their annual per-day cost of complying with the CoPs, and the share of revenue represented by that cost. On average, the responding facilities devoted 4.84% of revenue to cover the CoPs. Using the 4.84% cost of compliance reported by the survey participants, across all 1,738 inpatient psychiatric facilities, with revenue estimated at $35.4 billion the total cost of complying with the CoPs was estimated at $1.7 billion. The estimated per-facility cost was $985,822. The estimated per-bed cost was $18,362.

These findings were reported in “The High Cost of Compliance: Assessing the Regulatory Burden on Inpatient Psychiatric Facilities” by researchers with Manatt Health for the National Association for Behavioral Healthcare (NABH). The researchers worked with members of NABH’s Regulatory Overload Task Force. A total of 62 inpatient psychiatric facilities were surveyed. The goal was to determine the level of financial resources required to fulfill the Medicare CoPs in three domains: regulatory (B-Tag requirements), physical environment and monitoring to mitigate/abate ligature risk, and screening and stabilization requirements of Emergency Medical Treatment and Labor Act (EMTALA).

B-Tag Requirements

  • National annual costs for regulatory burden are estimated at $622 million, representing 1.8% of all-payer revenue. The average annual cost per bed is estimated at $6,698.
  • About 77% of freestanding psychiatric hospitals report at least one B-tag citation in their most recent three compliance surveys.
  • B-tags produce frequent citations and impose large costs on providers, mostly through low-value documentation requirements.
  • Neither the rules nor the guidance for psychiatric patient evaluations, medical records, and staffing have been meaningfully updated since they were issued in 1966. Most believe these requirements are no longer appropriate in today’s environment of care.

Ligature Risk

  • National annual costs for ligature risk regulatory burden are estimated at $880.4 million, representing 2.5% of all-payer revenue. The average annual cost per bed for the most recently complete fiscal year was $9,422.
  • On average, provider organizations spent more than $15,600 per psychiatric bed on physical plant and equipment costs to address ligature-related issues over the past five years and is projected for the next fiscal year.
  • About 61% of respondents reported a ligature-related citation in the last two years.
  • Some surveyors demand major changes to psychiatric facilities’ infrastructure or staffing to address perceived issues that carry only minimal risk for consumers in that setting.

Emergency Medical Treatment and Labor Act (EMTALA)

  • National annual costs for EMTALA regulatory burden are estimated at $209.6 million, representing 0.6% of all-payer revenue. The average annual cost per bed is estimated at $2,243.
  • Some regulators have begun interpreting EMTALA in a manner that imposes new requirements on psychiatric facilities that goes above and beyond. These include raising the baseline licensure requirements for “qualified medical persons” (QMPs) who may screen patients for emergency medical conditions; and requiring all inpatient psychiatric facilities with an emergency department to accept involuntary commitments,  even if properly trained staff are not available to handle a particular individual.

The researchers recommended that CMS rationalize these regulations to minimize the burden on provider organizations, especially in areas where provider organization compliance costs could be reduced without significantly affecting consumer care. Consumers may also benefit from these strategies because health care professionals can shift more of their attention and resources from compliance to care. Specifically the researchers recommended the following for each domain:

  • For B-tag requirements, CMS should remove unnecessary documentation requirements, and direct surveyors to limit their review to whether a provider has adopted a reasonable approach to compliance.
  • For ligature risk, CMS should issue updated guidance to standardize survey practices for ligature risk, minimize the risk of redundant renovations related to ligature risk, and clarify the level of ligature-resistant physical spaces that are actually required.
  • For EMTALA, CMS and the U.S. Department of Health & Human Services Office of Inspector General (OIG) should ensure that surveyors respect EMTALA’s clear direction that each provider’s medical staff may decide for itself which clinical professionals are competent to screen for emergency medical conditions, subject to applicable state licensure laws that define clinical scope of practice; EMTALA should not be used to address the shortage of facilities that treat involuntarily committed consumers; and Federal regulators should respect state procedures for involuntary commitment, including state arrangements for facility designation and consumer transfer.

The full text of “The High Cost of Compliance: Assessing the Regulatory Burden on Inpatient Psychiatric Facilities” was published on March 19, 2019 by the National Association for Behavioral Healthcare. A copy is available online at https://mazusw1wa001.azurewebsites.net/getattachment/e788505e-5485-409c-b24f-efa19144dfd2/attachment.aspx (accessed April 9, 2019).

PsychU last reported on this topic in

For more information, contact: Jessica Zigmond, Director of Communications, National Association for Behavioral Healthcare, 900 17th Street Northwest, Suite 420, Washington, District of Columbia 20006; 202-393-6700; ext. 101; Email: jessica@nabh.org.

Clinical practice patterns in the U.S. have always had great variance. Over the past 35 years, since The Dartmouth Atlas Study, research has documented great geographic variations in health care practices. These variances do not necessarily correlate with quality of care. These issues are magnified for consumers with complex care conditions and chronic conditions—with often unstudied complications of comorbid conditions and unmet social support needs.

This variance, and how actual service delivery varies from clinical guidelines, has always been of concern to policymakers—because of the implications for quality of care and cost. Two recent changes in the health and human service delivery landscape are bringing new attention to clinical practice patterns and clinical guidelines. The first is the move to include financial risk in the reimbursement contracts of health plans, health systems, and provider organizations—particularly risk that is focused on reducing duplicative and unnecessary care delivery. The second is the addition of consumers with behavioral and cognitive conditions, and consumers with more complex social support needs, to these risk-based and value-based contracting models.

The challenge is one of incentives. In fee-for-service (FFS) and cost-based reimbursement models, while there was significant variance in clinical practices, there was only a financial incentive to provide too many services to consumers. As we move to more financial risk borne by health plans and provider organizations, the financial incentives skew to providing too few services. While “over treatment” is not great for consumers, “under treatment” can be life threatening.

I think this means we can’t continue to separate clinical practice guidelines from risk-based and value-based reimbursement models. When the management team of an organization develops rates for any type of alternate payment model, they make assumptions about the needs of the consumers they will serve—and the number and types of services those consumers will use. Essentially, the clinical practice guidelines become part of their pricing methodology. And, if the payers don’t specify the clinical guidelines to be used, the organization will use their own clinical guidelines as assumptions in that rate development.

The results of the disconnect around clinical guidelines are bubbling up in press coverage and lawsuits (see To Improve Consumer Care In Medicaid & Beyond: Define Value & Make It Public and Judge Rules United Behavioral Health Medical Necessity Criteria More Restrictive Than Accepted Standards). I think this conflict will continue and grow more acute. The Patient Protection & Affordable Care Act (PPACA) requires health plans to publish their clinical guidelines. Are they easy to understand or specific enough about clinical decisionmaking? Take a look at these examples:

  • UnitedHealthCare’s clinical guidelines for the treatment of bipolar disorder refer clinical professionals to the American Psychiatric Association’s practice guidelines.
  • Aetna’s clinical policy for the treatment of Autism Spectrum Disorders (ASD) relies on information from the American Academy of Child And Adolescent Psychiatry and the National Academy of Sciences and outlines specific services that may be included in treatment and assessment.
  • Cigna’s clinical practice guidelines for the treatment of depression refer clinical professionals to the American Psychiatric Association’s practice guidelines for the treatment of depression and the U.S. Preventive Services Task Force guide for screening for depression.

The question is how to get clinical practices in sync with the emerging VBR models. When I asked my colleagues, the consensus was the financial incentives that go beyond cost reductions are critical—as well as public performance data that is available to consumers, advocates, and clinical professionals. OPEN MINDS Senior Associate, David Young noted:

States and sometimes the Feds talk about quality care but in reality, health plans and provider organizations provide ‘legally’ acceptable care; they meet the terms of the contracts. Despite what that means to end users, that care is what we get.

OPEN MINDS Senior Associate Ken Carr went on to talk about incentivizing consumer outcomes and quality of care. He noted:

I agree that commonly accepted standards of care, or those standards included in contracts, may not represent “best practice” outcomes, especially for unique situations. With most politically charged issues like this, understanding the root causes of what causes unacceptable results is key. It is easier to blame bad people and organizations—and they do exist. But the issues are often a result of how resources flow, who has the power to make decisions, and whether fair, efficient processes (with an element of compliance) have been established.

The question is what the best approach for is driving results—implementing strict regulatory controls or aligning funding with incentives to motivate and empower results.

From a value-based perspective, aligning how resources flow to motivate health plans and provider organizations to achieve agreed upon results—care coordination, integrated services, consumer access, for instance—has been shown to deliver results. There are many examples of how this incentivized approach has increased quality services and driven down service costs. I like the concept of making health plan and provider organization results public because transparency addresses the compliance element. While we will always need regulations and compliance committees for those who lack ethical behavior, transparency of results motivates most of us (health plans and provider organizations alike) who really want to do the right thing for the consumers that we serve.

“Standards of care”—medical necessity, clinical appropriateness, social/legal necessity, consumer entitlement, community standards—are certainly not agreed upon across the health and human service field. But, even with agreement on a set of clinical guidelines doesn’t end the challenges for consumers. Published guidelines don’t necessarily change clinical practice patterns and the clinical decision support tools needed to do just that are not in common practice. As we see more “pay for performance” across the health and human service systems, managers of every organization will be looking for tools to measure clinical practice variance in their own organizations—and tools make the use of “best practices” the rules, rather than the exception.

A series of news stories released over the past year out of Texas has caught my attention—and the attention of legislators and advocates in Texas. Last year The Dallas Morning News published a series of investigative reporting articles, Pain & Profit, on the services delivered under the state’s Medicaid health plans. The series is extensive, but the overall theme was that the state’s Medicaid consumers suffer from “poor state oversight” allowing “companies to skimp on essential care for sick kids and disabled adults” and that “8,000 and 14,000 people were probably not receiving the care they needed.”

The article ends with a series of recommendations, including pushing state policymakers to address the problems with capitated funding (specifically medical loss ratio requirements), mandating care coordination, addressing access issues, approving medical guidelines, standardizing the appeals process, providing opt outs of bad health plans for vulnerable populations, and tracking performance. As is common in the wake of investigative journalism that publicizes problems, there is now a bipartisan groundswell to revamp the Texas Medicaid system, with more than a dozen bills.

I think there are two issues at play here: One, there needs to be some standards of care that are uniformly agreed to by policymakers, payers, health plans, and provider organizations. And two, it is important to have standardized systems for incentivizing health plans and provider organizations to meet and exceed those standards of care.

The first issue comes down to the challenge of defining what constitutes “good care.” One of the ubiquitous challenges across the U.S. health and human service system is in definitions. This is not limited to Medicaid health plans. Determining what is “legally acceptable care” is one issue—this relates to the contract terms when states and counties buy health care systems and services from health plans, ACOs, provider organizations, and individual professionals. Less clear is what the “commonly accepted standards of care” are and whether these “commonly accepted standards of care” are what we want. Finally, there is the question of what “guidelines” (for medical/clinical necessity, appropriateness, and/or entitlement) should be incorporated in service contracts. These issues are some of the most fundamental to health and human service policy, budgeting, operations management, and consumer experience. Performance cannot be measured until it is defined.

The second issue is about incentives and accountability. I’m all for incentivizing health plans and provider organizations to deliver “value”, however it is defined. But the usual caveats apply: Aligning measures to performance objectives is key. The cost of tracking and measuring performance must be taken into consideration. And, incentives (particularly financial incentives) do change behavior, which means states, counties, and health plans must “choose wisely” when it comes to those incentives. Our team has designed enough value-based contracting systems that we have created a standard development process that starts with objectives, focuses on priorities and feasibility testing, and requires structured implementation testing. Measuring performance should be a given—and paying for that performance should be incorporated in contracting plans.

In addition, states and counties buying health and human services should move beyond measuring and paying for performance—and introduce consumerism into the equation with public performance reporting. Making performance metrics public—in a format that allows easy comparisons between health plans or provider organizations by both consumers and professionals—is key to creating a continuously improving delivery system. Even if the state, county, or health plan doesn’t pay financial incentives, public performance data is powerful. I once worked for a state Medicaid director who created a public performance dashboard for mental health service provider organizations in his state. When I asked why he did this, since he wasn’t allowed to pay penalties or bonuses, he said it changed the behavior of the worst performers. His exact phrase: “No CEO wants to be on the bottom of the list for more than one quarter.” That lesson has stuck with me.

I’m not hopeful that there is an easy path to resolving the issue of health and human service “best practice” guidelines. There is great work going on for some disease states, in some geographies—but there appears little agreement about how best to make decision support a reality across the system of care. I do think that payers can agree on some minimum metrics of what constitutes good performance. And, I think that the payers can speed the discussion of “best practices” by making their performance data comparable and public. I believe that most people working in the health and human service field—at every level, in most types of organizations—want to do well for the consumers they serve. Making performance data available (for their own organization and others) is a fundamental piece of making that happen.

For more on public performance reporting in the health and human service field, check out our coverage of these performance-based programs:

  1. CMS To Resume Terminating Medicare Advantage Plans With Low Quality Star Ratings
  2. ACOs Saved Medicare $660 Million Over Four Years
  3. CMS Awards 7 Agreements For Performance Measure Development For Medicare’s Quality Payment Program
  4. Nearly 11,000 Skilled Nursing Facilities Receive Medicare Rate Cut Due To Hospital Readmission Rates
  5. New Hampshire Medicaid Implements MCO Capitation Rates Linked To Performance
  6. New York Medicaid Releases Revised 2019 Health & Recovery Plan VBP Quality Measure Set

Denver’s pay-for-success, supportive housing social impact bond (SIB) has seen an 85% success rate from its creation in January 2016 through December 2017. During that period, the five-year program had served 285 individuals experiencing chronic homelessness, and 241 (85%) of these individuals had successfully retained their housing from the time that they signed their lease.

The Denver SIB program was created in a partnership of the City and County of Denver and Denver PFS LLC, an entity established by the Corporation for Supportive Housing and Enterprise Community Partners. The program’s goal is to assist those in a homelessness-jail cycle by providing them with supportive housing and accompanying services. Individuals are referred to the SIB through the Colorado Coalition for the Homeless (CCH) and Mental Health Center of Denver (MHCD) by the Denver Police Department (DPD). CCH and MHCD then go through a location process to offer individuals the chance to take part in the SIB program. If individuals elect to participate, assistance is given to locate a housing option and submit a housing application. Once an individual’s housing application is approved, they can choose to start a lease and continue to fully participate in the program. The housing stability outcomes are based on a measure of total adjusted days in housing. Success is achieved when the participant remains in housing for at least 365 days without any episodes away from housing for greater than 90 days or has a planned exit from housing at any point.

The SIB combines two assistance methods to help those with permanent supportive housing (PSH) needs:

  • Housing First: a homeless assistance approach that prioritizes providing permanent housing to people experiencing homelessness. The approach combines immediate housing with supportive services to both offer a sense of security, and the ability to pursue personal goals and improve their quality of life. A Housing First approach can benefit both homeless families and individuals with any degree of service needs.
  • Assertive Community Treatment (ACT): a mental illness assistance approach that aims to eliminate or reduce the symptoms of severe mental illness and to enhance the individual’s quality of life. ACT offers education about an individual’s illness; individualized treatment in either health care facilities, or an individual’s own home; long-term services; vocational assistance, and integration into the community.

Specifically, the Denver SIB program provides the following services:

  1. Subsidized housing
  2. An Assertive Community Treatment (ACT) team
  3. Behavioral health services, including psychiatric services, individual and group therapy, and substance use treatment
  4. Links to community resources (e.g., food resources, legal referrals and advocacy) and to integrated health services (e.g., medical, dental, vision, and pharmacy services)
  5. Transportation assistance and referrals

These findings were presented in “From Homeless to Housed: Interim lessons from the Denver Supportive Housing Social Impact Bond Initiative,” by the Urban Institute, The Evaluation Center at the University of Colorado Denver, and The Burnes Center on Poverty and Homelessness at the University of Denver. The evaluators used a randomized, controlled trial design, assigning eligible individuals to a treatment group and a 361-person control group. Analysis is restricted to the treatment group so that engagement patterns can be tracked for the six months after referral. To measure outcomes and impact for these individuals, the evaluators collected administrative data from a number of sources of interest, such as jails, courts, detox units, homeless shelters, and hospitals. The goal was to determine the success of Denver’s SIB.

Additional findings of the report include:

  • Between January 2016 and December 2017, 363 individuals were referred to supportive housing.
  • During this time, it took an average of 20 days to engage participants in the program. This includes locating those referred to the program, and the time it took for the individuals to agree to participate in the program.
  • Within six months of referral, 68% of individuals had approval to move forward with supportive housing. About 63% of individuals signed a housing lease within these six months.
  • During the three years before referral to the program, individuals in the program had an average of 14 arrests per person between 2013 and 2015: on average, 12 of these arrests happened when the individual identified as transient.

The social impact bond was created after the discovery that the cost of providing safety-net services to 250 of Denver’s homeless individuals is approximately $7 million per year. This includes 14,000 days in jail, 2,200 visits to detox facilities, 1,500 arrests, and 500 emergency room visits. These services add up to an average yearly cost to taxpayers of $29,000 per individual served. The SIB program was put in place through a $23.7 million total investment. About $15 million of this investment was from federal resources, while the other $8.7 million was provided by eight local organizations, which have received repayments totaling $1,025,968 from the city, based on the program’s outcomes so far:

  1. The Denver Foundation
  2. The Piton Foundation
  3. Ben and Lucy Ana Walton Fund of the Walton Family Foundation
  4. Laura and John Arnold Foundation
  5. Living Cities
  6. Nonprofit Finance Fund
  7. The Colorado Health Foundation
  8. Northern Trust Company

In launching the program, the City and County of Denver developed an agreement with Denver PFS LLC, an entity established by the Corporation for Supportive Housing and Enterprise Community Partners, to execute the Denver SIB. In the first year, CCH provided supportive housing services. Along with CCH, Mental Health Center of Denver (MHCD) provided supportive housing services in the second year of the program. Denver Crime Prevention and Control Commission provided staff for the program referral process, and the Denver Police Department (DPD) provided administrative data for the evaluation. The Urban Institute is conducting a five-year randomized controlled trial evaluation and implementation study in collaboration with partners from the Evaluation Center at the University of Colorado Denver and the Burnes Center on Poverty and Homelessness at the University of Denver.

The full text of “From Homeless to Housed: Interim lessons from the Denver Supportive Housing Social Impact Bond Initiative” was published in November, 2018 by the Urban Institute. A copy is available online at https://www.urban.org/research/publication/homeless-housed-interim-lessons-denver-supportive-housing-social-impact-bond-initiative/view/full_report (accessed April 2, 2019).

PsychU last reported on this topic in “Denver Supportive Housing Social Impact Bond Initiative Earns The First ‘Success Payment’ For Project Investors,” which published on June 13, 2018.

For more information, contact:

  • Cathy Alderman, J.D., MSPH, Vice President of Communications and Public Policy, Colorado Coalition for the Homeless, 2111 Champa Street, Denver, Colorado 80205; 303-312-9638; Email: calderman@coloradocoalition.org
  •  Kiki Turner, Communications Associate, Department of Finance, City and County of Denver, 201 West Colfax Avenue, Denver, Colorado 80202; 720-913-1589; Email: Kiki.Turner@denvergov.org
  • Dan Fowler, Senior Media Relations Manager, Urban Institute, 2100 M Street NW, Washington, District of Columbia 20037; 202-261-5554; Email: DFowler@urban.org

Where do mandated staffing ratios fit in value-based care? Do lower staffing ratios for clinical professionals improve the quality of care? The data isn’t clear about the benefits of lower staffing ratios and there is a wide range of state-specific regulations related to clinical staffing ratios.

Across the health and human service market, staffing ratios play a big role, but look very different depending on the type of organization, type of program, and the state where the program in operating. For residential and inpatient care for behavioral health and intellectual and developmental disability (I/DD) services for children and adults, staff ratios are a historically integral component to program description and design. There are no federal regulations, and these ratios are outlined by each states as a part of their licensing and operations standards. Ratios are found for 24-hour residential sites and inpatient psychiatric care, but not for outpatient-based care.

In community-based behavioral health residential care, the compliment of staff by education and experience is what is mandated through state regulation (i.e., one BA-level staff for each eight-hour awake shift and one master’s level clinical professionals for every 24-hour period). This is the states’ oversight activity to insure public safety and presumably provide a minimum standard of care. Broadly across the industry—including nursing homes, 24-hour behavioral health facilities, and 24-hour I/DD facilities—ratios exist as determined by the type of facility license issued. This is determined by acuity of population served, number of beds, age of consumers, and environment of care. Formulas vary by state but generally follow a 1:5 (staff-to-consumer) ratio during waking hours. For example, sampling the category of community-based residential care in three states (New Jersey, Illinois, and Texas) shows:

  1. New Jersey—On awake hours, a 1:6 ratio must be met. On overnight hours a 1:12 ratio must be met.
  2. Illinois—A 1:5 ratio must be met, or a 2:6 for six or more consumers.
  3. Texas—No minimum ratios.

In each of these examples staff is defined as a direct care support worker with a high school education. In looking across state regulations for community-based residential care the phrase, “Minimum staffing required to meet the needs of the population” is common along with definition of qualifications to fill roles such as manager, social worker, psychiatrist, and residential care worker.

Contrast this to the health care field where, though not standardized or regulated at the federal level, some states do require specific nurse staffing ratios for inpatient hospitals and inpatient rehabilitation facilities. A total of 14 states have some form of nurse staffing regulations. Of these states, California is the only one that has both mandated and implemented staff-to-consumer ratios.

In nursing homes and skilled nursing facilities, there are some basic federal discipline-specific requirements related to nurse staffing. The Centers for Medicare and Medicaid Services (CMS) guidelines for skilled nursing facilities and nursing homes that accept Medicare and Medicaid require facilities to provide licensed nurses 24 hours a day, which are “sufficient” staff to meet the needs of each resident and a registered nurse (RN) a minimum of eight consecutive hours per day, seven days a week. Most states have additional staffing requirements addressed through regulations and licensing standards. These staffing requirements are more often in the form of discipline-specific requirements for a specified number of hours. For example, there may be state regulations for skilled nursing facilities that must be staffed by a full-time master’s level social worker for 100 or more beds. For less beds, social work functions can be carried out by a variety of staff.

With this variety of regulations and lack of clear definitions, staffing ratios have become a political issue. There are two bills at the federal level, one in the House of Representatives and one in the Senate mandating nursing ratios in acute care settings including skilled nursing care facilities, psychiatric facilities, and rehabilitation facilities. Most recently we saw a ballot initiative placing limits on the number of consumers that a nurse would have responsibility for, fail to pass with voters after a record-breaking $25 million was spent by the Massachusetts Health & Hospital Association to defeat it. According to the MHA, the initiative would have reduced access to services and significantly increased cost of health care. In contrast, the Massachusetts Nurses Association spent $12 million to advocate in favor of the ballot initiative. This is just one example of the opposing forces that are continuously at odds when it comes to staff-to-consumer ratios. The reasoning of the opposition is that if staffing ratios are mandated and unable to be met, units will “limit” the number of consumers admitted, causing a negative cascading effect on care, while those in favor of mandated ratios say that it will enable better quality consumer care.

One issue is whether the use of technology is going to change how we view staffing ratios. We’ve written about how technology is replacing some health care service functions and making workers more “efficient” (Workforce Problems? Technology As Strategy; The Staffing Equation For Community-Based Services). Technology can bridge some of the gaps in staffing by augmenting the delivery of care. Remote monitoring of consumer conditions, medication monitoring systems, electronic appointment reminders, online cognitive therapy, and telehealth are all virtual care options that create efficiencies and can help to amplify staff. As we move into a more value-based financing systems, there is a much bigger bang for your buck by spending health care expertise on innovation and virtual care than simply adding more staffing.

For many executives of provider organizations, standards around staffing issues don’t represent a value-add, but rather another strategic and administrative challenge to overcome—particularly when faced with no increases in fee-for-service (FFS) rates and workforce shortages. As we have discussed before, knowing your numbers and understanding your drivers of cost are critical. Leading and managing by well-defined key performance indicators help drive your strategy for sustainability and growth. This squeeze is part of the formula of strategic decisionmaking for the future and how to achieve the size and scale to sustain an organization with programs that have a design based in a FFS world.

The cost of mandated staffing levels is one of many reasons behavioral health care provider organizations have been slower to jump into value-based care arrangements—fixed costs aren’t correlated with value added. Executives of provider organization are somewhat squeezed between the state regulatory requirements to operate a facility and the costs that are not necessarily compensated in newer reimbursement rates and models. Prescribed staffing ratios serve a purpose, but are best compensated in an FFS model.

Regulation of health care provider organizations is necessary to assure public safety. Reexamining what should be regulated based on the phasing out of FFS reimbursement models and the growth of value-based care models is worth exploration. This brings us back to the question—do mandated staffing ratios add value? I think in terms of timeliness and safety the answer is yes. I think in terms of improving care outcomes the answer is less clear. The compliment of care inputs drive quality and that is reflected by diverse care teams and innovative treatment offerings augmented by technology. Outcome measures should be defined by providers that directly correlate to the delivery of positive outcomes versus prescriptive input such as staffing ratios. In a value-based care environment, mandated staffing ratios hold less relevance.

The question for executive teams to answer is about balance—is it quality versus quantity? Or is it a little bit of both? In a market focused on value and driven by consumerism, it might be beneficial for provider organizations to ramp up their staffing ratios to deliver a more positive consumer experience. Consumers don’t do well with long waits for service, whether waiting for care while on an inpatient unit or waiting for an appointment as an outpatient. Consumer satisfaction, engagement, and progress declines the longer the consumer waits for a positive outcome. Clearly adequate staffing to provide care is necessary; that is not a question. Quality care is experienced when a consumer has a positive outcome as a result of the input, or efforts, of staff to provide care. Quality care is not experienced just because of the numbers of staff seen by a consumer.

A key to creating reasonable staffing levels is giving health care provider organizations input into defining those numbers based on acuity levels, environmental factors, staff skill, technology augmentation, and measured outcomes of care. Offering care that prioritizes safety, compassion, and individuality as the core components drive far better outcomes than administering programs by the numbers.

While staffing levels do play a role in operations of health care and need to remain a part of standards of care, without clear reasoning for the levels they are just numbers to be dealt with.

On March 7, 2019, the California Department of Health Care Services (DHCS) released draft Medi-Cal value-based payment (VBP) performance measures. The measures are grouped into four domains, and each domain has five measures. The Governor’s budget for fiscal year 2019 -2020 proposed that DHCS implement VBP through Medi-Cal managed care health plans (MCPs) to provide incentive payments to provider organizations for meeting specific measures aimed at improving care for certain high-cost or high-need populations. These risk-based incentive payments will be targeted at physicians who meet specific achievement on metrics targeting areas such as behavioral health integration; chronic disease management; prenatal/post-partum care; and early childhood preventive care. To address and consider health disparities, DHCS proposes to pay an increased incentive amount for events tied to beneficiaries diagnosed as having a substance use disorder or serious mental illness, or who are homeless.

In the draft VBP notice, “California Medi-Cal Value Based Payment Program Performance Measures, March 2019: Proposal For Comment,” DHCS noted that the final set of VBP measures may include some or all of the proposed measures. DHCS also sought comment on additional measures that should be considered for inclusion. When determining these draft measures, DHCS took into consideration several factors including: whether a measure aligned with other DHCS quality efforts; the number of affected beneficiaries; and whether or not the measure could be run administratively, among others. The four domains and the proposed measures eligible for incentive payments are as follows:

  • Prenatal/Postpartum Care, with five measures: prenatal pertussis vaccinations, first trimester prenatal visits, completion of two postpartum care visits, postpartum depression screening within 12 weeks after delivery, and provision of postpartum birth control methods or devices for women between three and 60 days after delivery.
  • Early Childhood, with five measures: Completion of eight well child visits by age 15 months, completion of four well child visits between ages three and six years, completion of full vaccinations for two-year-olds, blood lead screening for children up to age two, and applying dental fluoride varnish for children ages six months to five years.
  • Chronic Disease Management, with five measures: Each event of adequately controlled blood pressure for members ages 18 to 85 years being seen for a diagnosis of high blood pressure, each event of diabetes HbA1c glucose testing that shows better than poor control for members ages 18 to 75 years diagnosed with diabetes, control of persistent asthma for members between age five and 64 years, tobacco use screening provided to members age 18 and older, and influenza vaccine administered to members 19 years and older for individuals with a chronic disease diagnosis.
  • Behavioral Health Integration, with four measures: screening for clinical depression among members age 12 and older, antidepressant medication adherence among members age 18 and older diagnosed with major depression who take an antidepressant for at least 12 weeks, screening for unhealthy alcohol use among members age 18 and older, and member visits to co-located primary care and behavioral health services.

DHCS intends to release additional details about the proposed measure specifications after the measure set has been finalized. The Governor’s budget proposal funds the measure at $360 million annually. The VBP program is to be implemented for at least three years in the managed care delivery system. In the draft VBP proposal, DHCS did not propose dollar values for each program or measure. DHCS intends to set the value of incentive payments after finalizing the measure set and assessing projected achievement. Comments were accepted through March 22, 2019.

PsychU last reported on this topic in “California Revises Medi-Cal Managed Care RFP Schedule; Moves Release Of All RFPs To 2020,” which published on April 22, 2019.

For more information, contact: California Department of Health Care Services; Email: DHCS_PMMB@dhcs.ca.gov.

A Blue Cross Blue Shield of Massachusetts Foundation report has identified emergency room use caused by gaps in the state’s behavioral health continuum. Between 2011 and 2016, the number of behavioral health-related emergency department visits for mental health disorders rose by 9%; the number of emergency department visits for alcohol use disorders rose by 40%; and the number of visits for other substance use disorders (SUD) rose by 54%. Between 2011 and 2015, the share of emergency department visits for behavioral health disorders with length of stay (LOS) lasting 12 hours or more rose from 17.4% in 2011 to 22.8% in 2015. For non-behavioral health-related emergency department visits, the share with LOS lasting 12 hours or more rose slightly from 1.3% in 2011 to 1.4% in 2015. For emergency department visits, the median LOS for those visits with a primary behavioral health diagnosis was 5.4 hours. For visits with a non-primary behavioral health diagnosis, the median LOS was 3.4 hours. For non-behavioral health visits, the median LOS was 2.6 hours.

These statistics and others documenting unmet need and barriers to care in the existing system were reported in “The Massachusetts Behavioral Health Care System: Strengths, Gaps, And Opportunities For Improvement” chartpack released by the Blue Cross Blue Shield of Massachusetts Foundation. The chartpack was issued to accompany the Foundation’s “Ready for Reform: Behavioral Health Care in Massachusetts” report prepared by Stephanie Anthony, Patricia Boozang, Benjamin Chu, and Adam Striar from Manatt Health for the BlueCross BlueShield Foundation of Massachusetts. On behalf of the Foundation, the researchers analyzed the Massachusetts Health Policy Commission’s Annual Cost Trends Report, interviewed behavioral health experts, facilitated discussion groups, and analyzed the Massachusetts behavioral health care system (inclusive of mental health and SUD). The goal was to document and describe the current behavioral health care system for children, adolescents, and adults in Massachusetts, including its strengths and weaknesses; describe a vision for behavioral health care in the Commonwealth; and develop recommendations to strengthen the system to address gaps in the state’s behavioral health continuum that create access problems.

The researchers identified gaps across the behavioral health care service continuum. Some of these include (but are not limited to): training for health care professionals, SUD treatment, emergency service programs, outpatient programs, acute settings, and consumer and data transitioning. Additional details about each were as follows:

  • Primary Care/Screening/Early Intervention: Primary care and other physical health care professionals lack training on techniques for identifying individuals with behavioral health needs, treating those who can be managed in a primary care setting, and providing appropriate referrals for more complex cases.
  • Community-Based Treatment/Recovery Supports: Wait times for outpatient mental health and SUD treatment are long, and the supply of evidence-based treatment (including medication-assisted treatment for addiction) is inadequate. Clinical professionals lack expertise in treating co-occurring mental health and SUD and co-occurring behavioral and physical health conditions.
  • Emergency Services/Crisis Intervention/Urgent Care: Mobile crisis interventions, emergency services programs, and other urgent care programs are underfunded and struggle to hire qualified staff. Commercial insurers do not widely cover emergency services programs. Emergency services programs have historically focused on treating those with mental health conditions, as opposed to SUDs or co-occurring conditions.
  • Intermediate Care Settings: Wait times for partial hospitalization and intensive outpatient programs are long. Financial viability for outpatient programs remains a challenge; this is driven in part by burdensome staffing and licensure requirements.
  • Acute Inpatient Mental Health/SUD Treatment: Capacity is lacking for specialized beds for children with autism and individuals of all ages with intellectual and developmental disabilities. The lack of capacity is driven in part by difficulty hiring and retaining adequate clinical staff.
  • Care and Case Management: Consumers are often “lost” in navigating the transition between settings. Lack of interoperability and ability to exchange data across entities hinders seamless care management.

The full text of “The Massachusetts Behavioral Health Care System: Strengths, Gaps, And Opportunities For Improvement” chartpack was published in January 2019 by the Blue Cross Blue Shield Foundation of Massachusetts. A copy is available online at https://bluecrossmafoundation.org/sites/default/files/download/publication/MA_Behavioral_Health_System_Chartpack_Jan2019_FINAL.pdf (accessed March 20, 2019).

The full text of “Ready for Reform: Behavioral Health Care in Massachusetts” was published in January 2019 by the Blue Cross Blue Shield of Massachusetts Foundation. A copy is available online at https://bluecrossmafoundation.org/sites/default/files/download/publication/Model_BH_Report_January%202019_Final.pdf (accessed March 4, 2019).

Additional information on the Blue Cross Blue Shield of Massachusetts Foundation’s “2018 Massachusetts Health Reform Survey” can be found at https://bluecrossmafoundation.org/publication/2018-massachusetts-health-reform-survey (accessed March 20, 2019).

PsychU last reported on Massachusetts behavioral health services in “Massachusetts Rebids One Care Plans For Duals Demonstration,” which published on March 25, 2019.

For more information, contact: Kaitlyn Kenney Walsh, Ph.D., Senior Director, Policy and Research, Blue Cross Blue Shield of Massachusetts Foundation, 101 Huntington Avenue, Suite 1300, Boston, Massachusetts 02199-7611; 617-246-6116; Email: policy@bluecrossmafoundation.org.

Physicians generate an average of $2,378,727 (per physician) in annual revenue for hospitals. This includes $2,133,273 generated by each primary care physician; and $2,446,429 generated by each specialist physician. This is an increase of about 52% over average annual net revenue generated by all specialties in 2016. Primary care is defined as family practice, general internal medicine, and pediatrics. Specialist care is defined as care in a specific field of medicine.

Revenue generation generally came from direct hospital admissions, procedures performed, lab tests and treatments ordered, and prescriptions written. Indirect revenue that primary care physicians may have generated from patient referrals to specialists utilizing the hospital was not included in the study. While the study collected no solid evidence regarding the large increase from 2016 numbers, researchers propose that the increase may be from:

  • The growing number of employed physicians.
  • The growing volume and cost of hospital services, many of which are provided by physicians or are ultimately derived from physician activities (such as hospital admissions).

These findings were reported in the “Merritt Hawkins’ 2019 Physician Inpatient/Outpatient Revenue Survey.” Merritt Hawkins emailed the 2019 Physician Inpatient/Outpatient Revenue Survey to approximately 3,000 hospital chief financial officers (CFOs) and other financial managers in the U.S. The survey for this report was conducted to track the average annual net revenue that physicians generate for their affiliated hospitals. A total of 62 completed surveys were returned, which provided data on 93 separate hospitals. The goal was to offer benchmark data for hospitals to use to analyze their physician recruiting programs.

Additional findings for the 2019 survey include:

  • The specialty in which physicians generate the most average net annual revenue generated by physicians for their affiliated hospitals is cardiovascular surgery ($3,697,916), followed by invasive cardiology ($3,484,375) and neurosurgery ($3,437,500).
  • The specialty in which physicians’ average annual salaries are highest is neurosurgery ($687,000), followed by invasive cardiology ($590,000), and orthopedic surgery ($533,000).
  • In 2018, 49.1% of physicians were employed by a hospital, a hospital owned group, or physician owned group; 31.4% were independent employment, and 19.5% identified themselves as having “other” employment. No information was given about what constituted “other” employment.

The full text of “Merritt Hawkins’ 2019 Physician Inpatient/Outpatient Revenue Survey” was published February 25, 2019, by Merritt Hawkins. An abstract is available online at https://www.merritthawkins.com/news-and-insights/thought-leadership/survey/2019-physician-inpatient-outpatient-revenue-survey/ (accessed March 8, 2019).

For more information, contact: Phillip Miller, Vice President, Communications, Merritt Hawkins and Staff Care, 8840 Cypress Waters Boulevard, Suite 300, Dallas, Texas 75019; 469-524-1420; Fax: 972-983-0707; Email: phil.miller@amnhealthcare.com.

About 35.7% of psychiatrists accepted appointments for new consumers covered by Medicaid, compared to 70.8% of physicians overall. Psychiatrists accepted appointments for new consumers covered by Medicaid at a much lower rate (35.7%) than they did for Medicare beneficiaries (62.1%) or consumers with private insurance (62.2%). Overall, physicians were less likely to accept appointments for new consumers covered by Medicaid (70.8%) than those with Medicare (85.3%) or private insurance (90.0%).

These findings were reported in, “Physician Acceptance of New Medicaid Patients” by Kayla Holgash and Martha Heberlein. The Medicaid and CHIP Payment Access Commission (MACPAC) contracted with the State Health Access Data Assistance Center (SHADAC) to explore physician acceptance of new Medicaid patients. SHADAC assisted in the analysis of data points collected by the National Ambulatory Medical Care Survey (NAMCS), a survey used to collect data on ambulatory services provided by office-based physicians. The NAMCS represents physicians’ answers of whether their offices were accepting appointments for new consumers, and among those that were, which payment sources they accepted (Medicaid, Medicare, or private insurance). The researchers assessed state factors that could affect acceptance of Medicaid beneficiaries. These factors included managed care penetration rates in 2015, state Medicaid expansion status, and state Medicaid payment rates in comparison to Medicare. The researchers conducted a multivariate analysis to control for state share of the population in poverty, state share of population with Medicaid coverage, state physician supply, physician demographics, and physician employment characteristics.

Pediatricians (78.0%), general surgeons (88.4%), and obstetrician/gynecologists (81.1%) all accepted new Medicaid beneficiaries at a higher rate than physicians overall (70.8%). However, pediatricians accepted new Medicaid beneficiaries at a lower rate (78.0%) than they did consumers with private insurance (91.3%). Additional findings were as follows:

  • Physicians overall in states with high managed care penetration rates were less likely (66.7%) to accept new consumers covered by Medicaid than physicians in states with low managed care penetration rates (78.5%). However, psychiatrists in states with high managed care penetration rates were only slightly less likely (35.4%) to accept new consumers covered by Medicaid than psychiatrists in states with low managed care penetration rates (36.1%).
  • As of January 2015, there was no difference between expansion and non-expansion states in overall rates of acceptance of new consumers covered by Medicaid. Before and after the Patient Protection and Affordable Care Act went live on January 1, 2014, acceptance rates for Medicaid beneficiaries in both expansion and non-expansion states remained the same.
  • Physicians overall in states with a high Medicaid-to-Medicare payment ratio were more likely (81.1%) to accept Medicaid beneficiaries than physicians in states with a low Medicaid-to-Medicare payment ratio (64.5%). Psychiatrists were only slightly more likely (37.4%) to accept Medicaid beneficiaries than psychiatrists in states with a low Medicaid-to-Medicare payment rate (35.3%).

Based on their analysis of other factors that might affect acceptance rates, the researchers found that state Medicaid expansion status and managed care penetration rates were not associated with physician decisions to accept new consumers covered by Medicaid. Medicaid acceptance was associated with the Medicaid-to-Medicare fee ratio. Overall, each one percentage point increase in the ratio increased physician acceptance of new Medicaid beneficiaries by 0.78 percentage points.

For more information, contact: Kathryn Ceja, Director of Communications, Medicaid and CHIP 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.

On February 15, 2019, the New Hampshire Department of Health and Human Services (DHHS) announced the next New Hampshire Medicaid Care Management (MCM) managed care organization (MCO) contracts with AmeriHealth Caritas, New Hampshire Healthy Families, and Well Sense. The plans will be at-risk for physical and behavioral health, as well as pharmacy services, and will feature capitation rates linked to performance. The state’s performance measures seek to ensure MCO accountability for results in addressing addiction disorder, integrating physical and behavioral health, providing robust care management, and reducing unnecessary use of high-cost services.

As of March 19, 2019, the contracts were still pending approval. Once signed, the four-year contracts are collectively valued at $924.1 million over the contract term. The contracts are slated to begin July 1, 2019 and run through June 30, 2024.

The contracts will feature performance measures and a withhold and incentive program; several measures are focused on behavioral health. According to “New Hampshire Medicaid Care Management Program 2020 Withhold & Incentive Guidance,” during the first year the MCOs’ performance will be assessed in three performance categories: Quality Improvement (six measures), Care Management (three measures), and Behavioral Health (two measures).

New Hampshire DHHS Medicaid Care Management Program 2020 Withhold & Incentive Performance Measures
Quality Improvement Care Management Behavioral Health
Frequent (4+/year) emergency department users age 6 and older The percent of MCM members that received a health risk assessment within 90 days of enrollment The percent of community mental health program eligible MCM members that receive Assertive Community Treatment (ACT) services consistent with a fidelity score of 85 or more
Timeliness of prenatal care (HEDIS PPC) The percent of newborns diagnosed with neonatal abstinence syndrome (and parents) who receive care management from the MCO directly, or via a designated local care management entity The percent of MCM members in an emergency department or a hospital setting that are awaiting psychiatric placement for 24 hours or more
Percent of members with polypharmacy who completed a comprehensive Medicaid review and counseling The percent of MCM members that received care management from the MCO directly, or via a designated local care management entity
Adolescent well-care visits (HEDIS AWC)
Follow-up after emergency department visit for alcohol and other drug abuse or dependence – 7 day (HEDIS FUA)
Follow-up after hospitalization for mental illness – 7 day (includes members discharged from NH hospital) (HEDIS FUH modified to include unreimbursed NH hospital stays)

The state intends to withhold 2% of the MCO capitation rate that the MCOs can earn back. The withhold percentages will not be applied to directed payments, such as the MCO capitated payments to community mental health programs. The incentive program, based on the MCO’s performance, will provide an additional payment of up to 5% of the MCO’s qualifying capitation revenue. The MCO performance against the measures in each performance category will be assessed based on the following:

  • The minimum performance standard, which is used to determine whether the MCO is eligible to earn back the withhold payment. The 2020 Withhold & Incentive Guidance document reports the performance measures but does not report the minimum performance standards.
  • The earned withhold performance standard, which will be used to determine the earned withhold amount. To qualify for an earned withhold, the MCO must meet all the minimum performance standards for all measures within a performance category. Failure to meet the minimum performance standards will disqualify the MCO from receiving any earned withhold for the contract year in the relevant performance category. Each performance measure will be score from 0 to 3 points; the measure points will be weighted by performance category and totaled across all measures. The MCOs will be scored relative to the maximum possible points. The earned withhold will be calculated as the total withhold amount in dollars times the percent of possible total points.
  • The incentive payment performance standard, which will be used to determine if the MCO is eligible for any incentive payment. If any MCO does not meet any of the minimum performance standard or all the earned withhold performance standards, DHHS will use the unearned withhold funds to fund an incentive pool through which each MCO that met all the minimum performance standards can earn an incentive payment. The incentive payment will be calculated based on the MCO’s performance relative to its peers in each performance measure for measures where the MCO exceeded the earned withhold performance standard.

PsychU last reported on this topic in “New Hampshire Medicaid Selects Three Health Plans – AmeriHealth Caritas, New Hampshire Healthy Families & Well Sense,” which published on March 25, 2019.

For more information, contact: Public Information Office, New Hampshire Department of Health and Human Services, 129 Pleasant Street, Concord, New Hampshire 03301; 603-271-9389; Fax: 603-271-4332; Email: PIO@dhhs.nh.gov.

Between 2006 and 2014, emergency department visits attributed to International Statistical Classification of Diseases and Related Health Problems, ninth edition (ICD-9) codes related to opioids rose 217% among those aged 65 and older. The adjusted emergency department visit rate for opioid-related ICD codes from 37.8 per 100,000 population in 2006 to 119.9 visits per 100,000 in 2014. Opioids were associated with an increased number of chronic conditions, greater injury risk, and higher rates of alcohol dependence, and mental health diagnoses for this group.

These findings were reported in “Increasing Rates of Opioid Misuse Among Older Adults Visiting Emergency Departments” by Mary W Carter, Ph.D.; Bo Kyum Yang, Ph.D., RN;  Marsha Davenport, M.D., MPH; and Allison Kabel, Ph.D. The researchers analyzed data from the Nationwide Emergency Department Sample, specifically for adults aged 65 years and older with diagnostic codes related to opioid misuse disorder. A total of 28,167 unweighted (126,931 weighted) observations were identified as opioid-related emergency department visits by older adults. The goal was to determine factors associated with opioid misuse-related emergency department visits among older adults changes in outcomes associated with these visits.

Over time, the number of adults aged 65 to 84 years per 100,000 population who visited the emergency room due to opioid misuse was at least double that of the rate for those aged 85 or older. The rate rose 218% among adults ages 65 to 84, and rose 203% among those age 85 and older.

Number Of Older Adults With Emergency Room Visits Due To Opioid-Related ICD-9 Codes Per 100,000 Population
Age 2006 2009 2011 2014
65 to 84 40.5 63.4 89.1 129.0
85 and older 20.0 26.9 44.6 60.6

Additional findings about older adults with emergency room visits due to opioid-related reasons include:

  • The percentage of these visits that resulted in hospitalization decreased from 71.2% in 2006, to 66.0% in 2014 (with a slight increase to 72.3% in 2009).
  • The percentage of these visits that resulted in death remained constant (averaging about 1.4%) for all years.
  • Medicaid and self-pay rates were higher among opioid-related emergency department visits than Medicaid and self-pay rates for emergency department visits that were not opioid related. Medicaid was the primary expected payer for 3.3% of opioid-related visits. Self-pay was the expected payer for 6.7% of opioid-related visits compared to 1.1% of other visits. Medicare was the primary payer for 87.2% of opioid-related visits and other emergency department visits. Other payers (such as commercial health insurance) were the primary payer for 2.9% of opioid-related visits and 10% of other visits.

The researchers concluded that emergency department visits due to opioid misuse by older adults increased from 2006 through 2014. They said the rise indicates the need to better understand the scope and impact of opioid misuse among older adults. It also indicates a need to better inform policy responses to meet the needs of this age group.

The full text of “Increasing Rates of Opioid Misuse Among Older Adults Visiting Emergency Departments” was published March 7, 2019, by Innovation in Aging. A copy is available online at https://academic.oup.com/innovateage/article/3/1/igz002/5369972?preview=true (accessed March 18, 2019).

PsychU last reported on this topic in “Opioid-Related Hospitalizations Among 65+ Population Increased 34% Over Five Years,” which published on November 5, 2018.

For more information, contact: Todd Kluss, Director of Communications, The Gerontological Society of America, 901 1220 L Street Northwest, Washington, District of Columbia 20005; 202-587-2839; Email: tkluss@geron.org; Mary W. Carter, Ph.D., Gerontology Program Directory, Towson University, 8000 York Road, Towson, Maryland 21252; 410-704-4643; Email: mcarter@towson.edu.

During its first year, a social determinants of health pilot project in Newark cut the participants’ total cost of care by 25%. The “Newark Initiative” launched in 2017 as a collaboration between Robert Wood Johnson Barnabas Health (RWJBH) and Horizon Blue Cross Blue Shield of New Jersey (Horizon). For the pilot, Horizon and RWJBH assembled a care team with a Horizon care transformation specialist, nurses, a personal health assistant, a health system-based social worker, and community health workers recruited from the target neighborhoods. The care team members met with the identified Horizon members to learn about the non-medical problems preventing the individuals from receiving care for their chronic health conditions. The team found barriers such as lack of transportation to appointments, pressing immediate problems such imminent eviction, and family members in crisis. The team worked to resolve the barriers facing the individuals by connecting them to health care professionals and to non-medical resources.

Horizon recently released the initial outcomes for the 1,000 “Newark Initiative” participants. In addition to reducing the overall cost of care by 25% as of October 2018, the participants had 20% fewer hospital inpatient admissions and 24% fewer emergency department visits. Their visits to behavioral health professionals increased by 35%.

The “Newark Initiative” identified Horizon members living in four Newark ZIP Codes who, based on Horizon claims data, were found to have gaps in care; chronic health conditions (such as diabetes, hypertension, or heart failure); and high utilization of emergency department services at RWJBH’s Newark Beth Israel Hospital. Horizon and RWJBH followed the population analysis model used by the Camden Coalition when it launched the Good Care Collaborative in 2014.

Horizon has not released information about the cost per person for the care team or whether the initiative paid for social services. The focus of the initiative was on connecting the participants to needed non-medical services provided by other community entities.

Horizon intends to work with more health care partners to turn the Newark Initiative from a pilot to a statewide program starting later this year. Horizon is planning to turn the Newark Initiative from a pilot to a statewide program starting later this year. As of March 20, 2019, no further details about the expansion have been announced. A Horizon spokesperson said that the expansion may involve more of Horizon’s partners in the OMNIA Alliance, which includes: AtlantiCare, Atlantic Health System, Hackensack Meridian Health, Hunterdon Healthcare, Inspira Health Network, RWJ Barnabas Health, and Summit Medical Group.

For more information, contact: Thomas Vincz, Public Relations Manager, Horizon Blue Cross Blue Shield of New Jersey, Post Office Box 820, Newark, New Jersey 07101; 973-466-6625; Email: Thomas_Vincz@horizonblue.com.

Following the Centers for Disease Control and Prevention (CDC) issuance of its opioid prescribing guidelines in early 2016, payers, provider organizations, and physicians misapplied the guidelines to the detriment of people with chronic non-cancer pain by requiring involuntary dose reduction or discontinuation. Among its recommendations, the CDC prescribing guidelines directed that opioids should rarely be a first option for chronic pain, that clinical professionals must carefully weigh the risks and benefits of maintaining opioids for people already taking them, and it directed that established or transferring consumers should be offered the opportunity to re-evaluate their continued use at high dosages, such as more than 90 morphine milligram equivalents (MME). However, many physicians and regulators incorrectly interpreted the guideline to believe the CDC established a threshold of 90 MME as a daily dose limit. Because of this interpretation, many payers imposed payment barriers, and pharmacies demanded medical charts or taper plans for opioid doses as a precondition for filling prescriptions. These actions caused many health care professionals to consider many health care consumers with chronic pain as institutional and professional liabilities to be contained or eliminated.

On March 6, 2019, a group of physicians called Health Professionals for Patients in Pain (HP3) sent a letter to the CDC calling for the CDC to clarify the opioid prescribing guideline issued in early 2016. The claim is that, due to misapplication of the guidelines resulting in opioid drawdown or discontinuation, health care consumers with chronic pain previously controlled by prescription opioids have experienced adverse effects such as unnecessary pain due to dose reduction; some may have begun illicit substance use, and others may have completed suicide due to uncontrolled pain. The letter was signed by 300 physicians and medical experts.

The HP3 letter noted that the CDC recommendations said that opioids should rarely be the first option for treating chronic pain. Clinical professionals must carefully weigh the risks and benefits of maintaining people on opioids, and that established consumers or those transferring to a new health care professional should be offered to reevaluate continued use if they were taking 90 MME or more per day. The CDC recommendations indicated that high prescribed MME doses pose risk for adverse events, and supported dose reductions when the reduction can be achieved without adverse effect. For this group of people, the guideline does not endorse mandated involuntary dose reduction or discontinuation because data does not support the effectiveness and safety of such actions.

HP3 requests that the CDC take further action regarding its goals to protect health care consumers. They urge that the CDC:

  • Follow through with the commitment to evaluate the impact of opioids by “consulting directly with a wide range of patients and caregivers; and by engaging epidemiologic experts to investigate reported suicides, increases in illicit opioid use and, to the extent possible, expressions of suicidal ideation following involuntary opioid taper or discontinuation.”
  • Issue a “clarification about the 2016 Guideline regarding what it says and what it does not say, particularly on the matters of opioid taper and discontinuation.”

For more information, contact: Stefan G. Kertesz, M.D., Professor, Division of Preventative Medicine, University of Alabama at Birmingham, 717 11th Avenue, Medical Towers 608, Birmingham, Alabama 35205; 205-996-2866; Fax: 205-934-7959; Email: skertesz@uab.edu; Sally Satel, M.D., Scholar, American Enterprise Institute, 1789 Massachusetts Avenue Northwest, Washington, District of Columbia 20036; 202-862-7154; Email: slsatel@gmail.com.

Over the past few years, payer and health plan interest in social support services—housing, transportation, nutrition, and more—has reached a new peak. A quick scan of the headlines illustrates the wave of health plan investments in social support services:

  1. Blue Cross Launches Food Delivery Program To Address Social Determinants
  2. 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
  3. Health Partners Plans Shows Positive Outcomes From “Food As Medicine’ Nutrition Program

In addition to these health plan-specific program examples, there are also more systematic approaches afoot. A recent reports show that 80% of health plans now use one or more methods to identify and address social determinants of health—with 42% of payers integrating referrals to community-based social service programs and resources; 33.7% integrating consumer medical information with consumer financial, census, and geographic data; 31.1% offering a “social needs” assessment along with health risk assessments; and 70% of payers are integrating awareness of social determinants of health directly into clinical processes. A good example of more systematic health plan initiatives include the recent announcement from UnitedHealthcare to expand its efforts to identify consumers who have non-medical needs considered social determinants of health (see UnitedHealthcare Expands Initiative To Use Diagnostic Codes To Capture Social Determinants Of Health).

But coverage of a recent conference on the issues surrounding social determinants put this interest in perspective for me—and solidified the challenge for provider organizations that are looking for long-term sustainable service opportunities addressing social determinants. The health plan presenters described their current initiatives as “a smattering right now” and “random acts of kindness.” They said that the current social determinant initiatives are “too fragmented” to have an impact and “a strategic challenge most health systems encounter is trying to build a business case showing a return-on-investment (ROI) based on reduced cost or improved health outcomes.”

This is a call to action for any provider organization management team that hopes that their social services-infused approaches to health care will become a long-term market. Without proof of ROI, these initiatives will become one-time public relations investments, rather than long-term programmatic approaches adopted by payers and health plans.

So, like any new service approach, management teams with a “great new idea” need to embrace the need for a proof of concept, a measure of ROI, and a plan to take the service to scale. There are a few basic steps:

  1. Assess your organization’s ability to deliver social support programs—services, geographic reach, consumers, and more
  2. Review health plan/ACO enrollment in your the geographic service area to identify target consumers
  3. Develop a concept statement about your social support services that are appropriate to the health plan consumers—services, costs, and performance metrics
  4. Meet with health plan/ACO managers to start the dialogue and present your service line concept
  5. Refine your concept statement based on the conversation with health plan/ACO managers
  6. Continue the dialog until you get to the demonstration pilot stage

But getting to the demonstration pilot stage is just the first step on this journey. The pilot project needs to be designed to measure performance and conduct an ROI analysis for your organization’s proposed approach. Without a solid ROI, your approach runs the risk of becoming another one-time interesting experiment without long-term adoption. This is a tall order—and one that I think will need to be led by entrepreneurial provider organization executives.

For more on ROI, check out For Telehealth, The ROI Is Where You Plan For It and More Tools For Tech ROI from the PsychU Resource Library.

The projected national health expenditure (NHE) for 2018 is $3.65 trillion, representing 4.4% growth over the $3.49 trillion NHE in 2017. Between 2018 and 2027, the annual NHE is projected to grow at an average of 5.5% per year to reach nearly $6.0 trillion by 2027.

Due primarily to higher projected enrollment growth, Medicare spending is projected to increase at a higher rate than Medicaid or private health insurance. Average annual Medicare spending growth is projected at 7.4%, compared to 5.5% for Medicaid and 4.8% for private health insurance. By 2027, the share of health care spending sponsored by federal, state, and local governments is projected to increase by two percentage points from 45% in 2018 to 47% in 2027. The increase is largely due to the projected rise in Medicare enrollments, from 58.7 million in 2018 to 73.5 million in 2027. Medicaid enrollment is projected to increase from 73.4 million in 2018 to 82.5 million in 2027.

These findings were reported in “National Health Expenditure Projections 2018 to 2027; Forecast Summary” by the Office of the Actuary in the Centers for Medicare & Medicaid Services (CMS). The Office of the Actuary published its full analysis of the data in “National Health Expenditure Projections, 2018-27: Economic And Demographic Trends Drive Spending And Enrollment Growth.” The CMS Office of the Actuary annually produces projections of health care spending for categories within the National Health Expenditure Accounts, which track health spending by source of funds, type of service, and sponsor. These projections begin after the latest historical year (2017) and go through 2027.

From 2018 through 2027, about 90% of the population in each year is projected to have insurance coverage. However, in 2019, the insurance rate is projected to start declining slightly, from 90.9% in 2018 to 90.6% in 2019 and by 2027 to 89.7%. The decline in 2019 is largely attributed to the Tax Cut and Jobs Act of 2017, which repealed the individual mandate penalty in the Patient Protection and Affordable Care Act. The repeal of the individual mandate is projected to contribute to a reduction in the number of people with private health insurance of 0.6%, but that drop will be partially offset by growth in other types of health coverage.

The uninsured population is projected to increase from 29.9 million in 2018 to 36.2 million in 2027. The total U.S. population is projected to grow less than 1% per year, from 327.9 million in 2018 to 352.7 million in 2027.

During 2019, national health expenditures are projected to rise by 4.8%. Medicare spending is projected to rise by 7.1%, largely due to higher fee-for-service payment updates. Expanded eligibility for Medicaid in five new states (Idaho, Maine, Nebraska, Utah, and Virginia) is projected to contribute to faster Medicaid spending growth, from 2.2% in 2018 to 4.8% in 2019.

Out-of-pocket (OOP) spending growth is projected to have grown by 3.6% in 2018, up from 2.6% in 2017, rising from $365.5 billion in 2017, to $378.6 billion in 2018. The growth was consistent with higher average deductibles for private health insurance enrollees with employer sponsored insurance. OOP is projected to grow by 4.8% in 2019 to reach $396.9 billion, in part because fewer people are projected to have private insurance coverage due to the effective repeal of the individual mandate in the Tax Cut and Jobs Act of 2017. Over 2020 through 2027, annual OOP spending growth is expected to average 5.0%, and reach $585.8 billion by 2027.

Prescription drug spending is projected to have grown by 3.3% in 2018, up from growth of 0.4% in 2017. The growth is driven by higher utilization, higher medication adherence rates, and new drug introductions. In 2019, prescription drug spending growth is projected to rise to 4.6% in 2019. From 2020 to 2027, prescription drug spending is projected to rise by an average of 6.1% per year.

Hospital spending is projected to have grown by 4.4% in 2018, down from growth of 4.6% in 2017. The growth is slower due to slower growth in Medicaid and private insurance hospital spending in 2018. In 2019, hospital spending growth is projected to rise to 5.1% in 2019 due to faster Medicare spending growth. From 2020 to 2027, hospital spending is projected to rise by an average of 5.7% per year.

Physician and clinical services spending are projected to have grown by 4.9% in 2018, up from 4.2% in 2017. The spending growth projection reflects price growth of 0.3 percentage points to 0.7% and higher utilization. In 2019, growth in this sector is projected to rise by 5.4%; this increase is primarily associated with higher use arising from the Medicaid expansion in five additional states. Between 2020 and 2027, spending in this sector is projected to grow by an average of 5.4% per year.

Medicare spending on the physician and clinical services sector is expected to be faster than growth in private health insurance spending for this sector as the baby-boom generation ages into Medicare eligibility. Prices are projected to increase due to anticipated rising wages growth related to increased demand from older adults.

The full text of “National Health Expenditure Projections, 2018-27: Economic And Demographic Trends Drive Spending And Enrollment Growth” was published in the March 2019 issue of Health Affairs. An abstract is available online at https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05499 (accessed March 4, 2019).

PsychU last reported on NHE projections in the following articles:

 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.

During 2017, 130 health insurers offering plans sold through the Health Insurance Marketplace denied an average of 19% of claims. These insurers denied 42.9 million of the 229.8 million in-network claims received for the 2017 plan year. The denial rates for in-network claims ranged from 1% for a Celtic Insurance Company plan in Indiana to 45% for a Celtic Insurance Company plan in Texas. About 30.7% of insurers had a 10% or lower denial rate, about 33.1% of insurers had denial rates between 11% and 20%; and about 36.2% denied more than 20% of in-network claims in 2017.

For the 2016 plan year, health insurers offering plans through healthcare.gov about 17% of in-network claims were denied. That year, denial rates across all issuers ranged from less than 1% to more than 65%. For 2015, about 19% of in-network plans were denied. That year, denial rates across all issuers ranged from less than 1% to more than 90%.

These findings were reported in “Claims Denials and Appeals in ACA Marketplace Plans,” by Karen Pollitz, Cynthia Cox, and Rachel Fehr for the Henry J. Kaiser Family Foundation (KFF). The researchers analyzed Affordable Care Act (ACA) Transparency Data for 2015, 2016, and 2017 from the Centers for Medicare & Medicaid Services (CMS). The researchers analyzed these public files, with a focus on major medical plans and issuers that primarily offered stand-alone dental coverage. They excluded plans and issuers with incomplete data. For the 2017 plan year, of the total 180 major medical issuers offering plans through healthcare.gov, 130 had complete data on in-network claims received and denied. The goal was to examine claims denials and appeals among issuers offering individual market coverage on healthcare.gov from 2015 through 2017.

Transparency data is periodic data reported by group health plans and by health insurance issuers in the individual and group markets to provide transparency on how coverage works in practice. The law requires this data to be available to state insurance regulators and to the public. Plans should report on:

  1. Claims payment policies and practices
  2. Periodic financial disclosures
  3. Data on enrollment
  4. Data on disenrollment
  5. Data on the number of claims that are denied
  6. Data on rating practices
  7. Information on cost-sharing and payments with respect to any out-of-network coverage
  8. Information on enrollee and participant rights under this title
  9. Other information as determined appropriate by CMS

In February 2019, CMS announced in a transparency data collection notice that it will require reporting of plan level (rather than issuer level) claims data beginning with the 2019 collection year. Issuers offering plans on healthcare.gov will be required to report six denial reason categories beginning with the 2019 data collection, as follows:

  1. Referral or prior authorization required
  2. Out-of-network
  3. Services excluded or not covered
  4. Not medically necessary, excluding behavioral health
  5. Not medically necessary, behavioral health
  6. All other

The researchers noted that the wide range in denial rates across the 130 issuers and markets in 2017 could be due to differences in the following factors:

  • The plan’s determination of medical necessity
  • The plans limits, such as day or visit limits on covered services
  • The degree to which issuers’ automated claims processing systems routinely deny certain claims
  • Provider organization knowledge about which claims will be covered and how to properly submit claims
  • Issuer reporting methods, for example, in how to count partial approvals

They further noted that the impact of a denial varies. For some, the consumer is held harmless and would not realize that a claim had been denied. For others, the consumer might not be held harmless and could face a large medical bill. Consumers rarely appealed a denied claim. During 2017, consumers appealed 200,000 (0.5%) of the more than 42 million denied claims. Data for 2015 and 2016 show even lower consumer appeal rates, at 0.1% and 0.2%, respectively.

Appeals have a low success rate, and in 2017, only 14% of the 200,000 appeals resulted in overturning the denial. Across 118 insurers whose appeals outcomes were reported, the overturn rate ranged from 1% to 88%. The data does not indicate reasons for the low appeals rate which could include: validity of an initial denial, the consumer was unable to pursue the appeal or deficiency in consumer notices. State Consumer Assistance Programs, created by the Patient Protection and Affordable Care Act are charged with helping consumers file appeals for denied claims. However, Congress has not appropriated funding for the programs since 2010.

The full text of “Claims Denials and Appeals in ACA Marketplace Plans” was published February 25, 2019 by the Henry J. Kaiser Family Foundation (KFF). A copy is available online at www.kff.org.

PsychU last reported on this topic in “Pennsylvania Fines Aetna $190,000 Over Coverage Violations Involving Autism & Addiction Treatment,” which published on March 11, 2019.

For more information, contact: Craig Palosky, Director of Communications, The Henry J. Kaiser Family Foundation, 1330 G Street Northwest, Washington, District of Columbia 20005; 202-347-5270; Email: cpalosky@kff.org.

Of the total U.S. resident population in 2017, Maine has the highest percentage (44.7%) of individuals of all ages with cognitive disability living in the community, followed by Rhode Island (44.0%), and Idaho (42.2%). The District of Columbia had the lowest percentage (31.8%) of individuals with cognitive disability living in the community, followed by South Dakota (33.3%), and Nevada (33.5%). In 2017, there were 40,675,305 individuals living in the community with disabilities, 15,378,144 of which were individuals with a cognitive disability (37.8%). For this survey, “disability” is defined as self-reported difficulty with activities, work, or social situations; and activities of daily living includes self-care disabilities and independent living disabilities.

These findings were reported in the “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” by the Institute on Disability at the University of New Hampshire. The researchers analyzed data from the U.S. Census Bureau’s 2017 American Community Survey. The survey classifies disability in terms of physical, cognitive, or sensory deficits. The data sources do not report rates of disability by primary diagnosis, so the researchers do not report on the prevalence of disability due to chronic conditions such as back pain, mental illness, addiction, or intellectual/developmental disability. The goal was to calculate statistics related to disability in the U.S.

Additional findings for 2017 include:

  • Of the 8,836,223 individuals with cognitive disabilities, ages 18 to 64 years and living in the community, 2,456,526 individuals were employed (27.8%).
  • The percentage of people with cognitive disabilities employed was highest in South Dakota (44.7%), followed by North Dakota (42.7%), and Minnesota (41.8%).
  • The percentage of people with cognitive disabilities employed was lowest in Puerto Rico (15.5%), followed by West Virginia (18.5%), and Mississippi (19.2%).

The full text of “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” was released in February 2019 by the Institute on Disability at the University of New Hampshire. Copies of each available online at disabilitycompendium.org (accessed March 4, 2019)

PsychU last reported on this topic in “23.4% Of Adults With Cognitive Disabilities Employed, Most Work 20 Hours Per Week,” which published on February 17, 2015.

For more information, contact: Sarah Boege, Policy Analyst, University of New Hampshire Institute on Disability, 10 West Edge Drive, Suite 101, Durham, New Hampshire 03824; 603-862-0165; Email: sarah.boege@unh.edu.

Is “unblackboxing” the key to reducing health care costs? The answer to that question was in part the focus of Bill Green, Chief Executive Officer of Homestead Smart Health Plans, in his 2019 OPEN MINDS Performance Management Institute keynote session, “Building A New System For Private Insurance: Innovations & Emerging Models For Employer-Sponsored Health Plans.”

What is “blackboxing?” It’s the practicing of hiding information that would otherwise let you know how something works. Unblackboxing means bringing transparency to that information – or put another way, seeing inside the black box.

In health care, the focus of “unblackboxing” is in two areas – hospital chargemasters and rebates for pharmaceuticals. Together, spending on hospitals and pharmaceuticals account for 43% of total U.S. health care costs.

The hospital chargemaster is a comprehensive listing of items billable to a hospital consumer or a consumer’s health insurance provider. And traditionally, chargemaster information has not been available to the public, including consumers of hospital services. Tina Rosenberg explained the imbalance in this arrangement in her The New York Times article, “Revealing a Health Care Secret: The Price,” as:

Chargemaster prices are set by the hospital alone and reflect what the hospital would like you to pay. They are the basis for calculating the discounts given to insurers, and they are generally what’s billed to people without insurance. These charges are commonly three times the Medicare price or more.

As of January 1, 2019, hospitals are required by the Centers for Medicare & Medicaid (CMS) to post their chargemaster fee data. Consumers can now compare the price of services across different hospitals. But how useful this data is remains to be seen. The ruling has largely been touted as symbolic. Critics say that the newly-posted chargemaster rates are hard to understand (see Medicare To Require Hospitals To Post Standard Charges Online).

Then there are the rebates for pharmaceutical purchases. The rebates are pricing discounts paid by the pharmaceutical company to payers and health plans when they purchase a medication. The actual amount of these rebates is largely unknown (part of the reason for the debate). There are many critics of the rebate system. Dr. Sarah Sachs explained in a Health Affairs blog post that pharmacy benefit managers and payers often negotiate with pharmaceutical companies to receive rebates on drugs after point-of-sale. This means that pharmaceutical companies can raise their list prices, but increase the rebate for better formulary placement. Since consumers often pay cost-sharing on the actual list price of the drug, the higher list price can make many drugs unaffordable.

On February 1, 2019, the U.S. Department of Health and Human Services (HHS) proposed a new rule that will eliminate prescription drug rebates between pharmaceutical companies and Medicare Advantage and Medicaid health plans (and/or their pharmacy benefit managers). Instead, those rebates would have to be passed directly to the consumer at point-of sale, who often pays out-of-pocket costs based on the list rate and not the price with the rebate applied. The goal of the new rule is to lower the price of prescription drugs to consumers, to slow increases in drug prices year-over-year, and to make pharmacy benefit management more transparent.

One reimbursement solution to the challenges of the chargemaster and of pharmaceutical rebates proposed by Mr. Green is a concept called reference-based pricing According to the Commonwealth Fund in “Pharmaceutical Reference Pricing: Does It Have a Future in the U.S.?,” reference-based pricing is:

An emerging health insurance benefit design aimed at reducing health costs. In this model, an insurer establishes a maximum payment that it will contribute toward covering the price of a product or service in situations where there is wide price variation for therapeutically similar drugs, diagnostics, or procedures. 

Reference-based pricing is most often pegged to Medicare pricing – but not always, as some services are not covered by Medicare. To address this, prices are often pegged to average commercial costs.

I think we’ll see more reference-based pricing. Donald Trump specifically talked about reference-based pricing and cost transparency in his state of the union. Research also shows that employers are beginning to see reference-based price as a solution to high health benefit costs, even if they have not yet adopted this model.

But reference-based pricing doesn’t solve all of the health care cost drivers. It doesn’t address some of the core issues in health care spending like overutilization and lack of care coordination. Mr. Green explained that while reference-based pricing can help bend the cost curve, plans need to consider other benefit plan design changes, utilization review, and other cost containment programs in an overall strategy. In tandem, a multi-faceted approach is more likely to bend the needle.

For more of our recent coverage on health care costs, check out:

  1. Per-Employee Health Care Costs Expected To Increase 4.4% In 2019
  2. 14% Of Families Had Out-Of-Pocket Health Care Expenses Exceeding $2,500 In 2015
  3. Spending For Consumers With Comorbid Medical & Behavioral Conditions At 34% Of Total U.S. Health Care Spending
  4. Long-Term Care Costs Rise 4.5% Between 2016 & 2017
  5. U.S. National Health Spending Grew At A Rate Of 3.9% In 2017
  6. U.S. Health Care Expenditures Expected To Grow 5.5% Annually Through 2026

On February 6, 2019, the Centers of Medicare & Medicaid Services (CMS) announced that an 18-month moratorium on its ability to terminate Medicare Advantage (MA) organization contracts based on low star ratings in the Five-Star Quality Rating System has ended. Contracts may be terminated if they fail to receive at least a three-star drug or health plan Summary Star Rating for three consecutive years. The 2020 Star Ratings for MA and Part D plans, which are slated for release in the fall of 2019, will be the first set of ratings where performance below three stars would be counted toward qualification for termination. The first contract terminations would occur after the 2022 Star Ratings are released.

The Star Ratings system is intended to help people with Medicare, their families, and their caregivers compare the quality of health and drug plans being offered. Medicare Advantage and Part D prescription drug plans are given a rating on a 1- to 5-star scale, with 1 star representing poor performance and 5 stars representing excellent performance.

According to the “Medicare Advantage Part C & Part D 2019 Star Ratings Fact Sheet,” for the 2019 plan year, about 3.27% of the 376 Medicare Advantage plans with prescription drug (MA-PD) coverage in 2019 achieved a rating of less than three stars. In 2018, about 3.64% of the 385 MA-PD plans were rated below three stars. In 2017, about 2.48% of the 363 MA-PD plans were rated below three stars. In 2016, about 2.98% of the 369 MA-PD plans were rated below three stars. In each year, more than 70% of enrollees were enrolled in a MA-PD that achieved four or five stars.

The 21st Century Cures Act of 2016 prohibited CMS from terminating MA organization contracts through December 31, 2018. The Medicare Part C and Part D regulations allow CMS to terminate an MA contract for failing to achieve a Part C summary rating of at least three stars for three consecutive years. The Part D sponsor contract can be terminated for consistently low Part D summary ratings.

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.

Approximately 90.1% of those with disabilities (about 39.1 million), ages 18 to 64 years and living in the community, have health insurance coverage, as of 2017. In contrast, 87.5% of those without disabilities, ages 18 to 64 years and living in the community, had health insurance coverage. This equals a health insurance coverage gap between those with and those without disabilities of 2.6 percentage points. In other words, 2.6% more individuals with disabilities had health insurance than individuals without disabilities.

These findings were reported in the “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” by the Institute on Disability at the University of New Hampshire. The researchers analyzed data from the U.S. Census Bureau’s 2017 American Community Survey, and the Center of Disease Control and Prevention’s (CDC’s) 2009-2016 Behavioral Risk Factor Surveillance Survey. For this survey, “disability” is defined as self-reported difficulty with activities, work, or social situations. The survey classifies disability in terms of physical, cognitive, or sensory deficits. The data sources do not report rates of disability by primary diagnosis, so the researchers do not report on the prevalence of disability due to chronic conditions such as back pain, mental illness, addiction, or intellectual/developmental disability. The goal was to calculate statistics related to disability in the U.S.

Additional findings for 2017 include:

  • About 45.8% of individuals with disabilities, ages 18 to 64 years and living in the community, had private health insurance. Puerto Rico (28.1%) had the smallest percentage of people with private health insurance, followed by West Virginia (37.1%); Hawaii (57.8%) had the largest percentage of people with private health insurance.
  • About 55.8% of individuals with disabilities, ages 18 to 64 years and living in the community, had public health insurance (some had both public and private). Utah (40.2%) had the smallest percentage of people with public health insurance; Puerto Rico (71.9%) had the largest percentage of people with public health insurance, followed by New Mexico (68.8%).
  • About 9.9% of individuals with disabilities, ages 18 to 64 years and living in the community, did not have health insurance. Massachusetts (2.8%) had the smallest percentage of people with disabilities without health insurance coverage, while Oklahoma (20.2%) had the largest percentage of people with disabilities without health insurance coverage.

The full text of “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” was released in February 2019 by the Institute on Disability at the University of New Hampshire. Copies of each available online at https://disabilitycompendium.org/ (accessed March 4, 2019).

 For more information, contact: Lindsay Allsop, Communications and Information Coordinator, University of New Hampshire Institute on Disability, 56 Old Suncook Road, Suite 2, Concord, New Hampshire 03301; 603-228-2084; Email: lindsay.allsop@unh.edu.

On February 11, 2019, the U.S. Department of Health and Human Services (HHS) issued proposed rules about the standards for application programming interfaces (APIs) for (EHI) sharing across health plans, provider organizations, and acute and post-acute care settings. The rule, issued by the HHS Office of the National Coordinator for Health Information Technology (ONC), to adopt Health Level Seven’s (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standards as the standard to which developers must certify their 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 EHI.

The ONC proposed rule, “21st Century Cures Act: Interoperability, Information Blocking, & The ONC Health IT Certification Program,” would update the existing 2015 Edition certification criteria. It also implements the information blocking provisions of the 21st Century Cures Act, and identifies activities that will not be considered information blocking. Additionally, ONC seeks comments on how pricing information could be included as part of EHI so that the public could better understand the cost of their health care.

The goal is to ensure that certified health information technology (IT) systems can do the following:

  • Send and receive EHI in a structured format.
  • Make EHI available without special effort using APIs. ONC believes this approach could lead to industry standard interfaces—interfaces where app developers can develop effective apps that use API technology without special effort to access a patient’s data.
  • Export a single consumer’s or multiple consumers’ EHI from the health IT system to a location designated by the consumer.

Information blocking is defined as any action of a health care-related entity that is likely to interfere with, prevent, or materially discourage the access, exchange, or use of EHI. Under the proposed rule, certain actions of a health care professional or provider organization, developer of certified health IT, health information network, or health information exchange that interfere with the access, exchange, or use of EHI would not be considered information blocking under certain circumstances. The proposed exceptions to information blocking are as follows:

  1. Engaging in practices to prevent consumer harm.
  2. Engaging in consistent, non-discriminatory practices to protect the privacy of electronic health information.
  3. Implementing practices to promote the security of EHI.
  4. Recovering costs reasonablly incurred to allow for the access, exchange, and use of EHI.
  5. Responding to a request to provide access, exchange, or use of EHI that is infeasible because the request would impose a substantial burden that is unreasonable under the circumstances.
  6. Licensing of interoperability elements on reasonable and non-discriminatory terms.
  7. Performing maintenance or improvements to health IT performance with the agreement of the user.
  8. Maintaining and improving health IT performance with the agreement of the user.

Comments on the proposed rules will be accepted through May 3, 2019. Don Rucker, M.D., National Coordinator for Health IT at ONC, said, “We encourage everyone – patients, patient advocates, health care providers, health IT developers, health information networks, application innovators, and anyone else interested in the interoperability and transparency of health information – to share their comments on the proposed rule.”

For more information, contact:

  • Attention: 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program Proposed Rule, Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services, Mary E. Switzer Building, Mail Stop: 7033A, 330 C Street Southwest, Washington, District of Columbia 20201; or Michael Lipinski, Office of Policy, 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; 202-690-7151.
  • 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.

People with disabilities, aged 18 to 64 years and living in the community, comprised about 13.2% (nearly 43 million) of the total U.S. resident population in 2017. About 35.5% of this population with disabilities were unemployed.

These findings were reported in “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” by the Institute on Disability at the University of New Hampshire. The researchers analyzed data from the U.S. Census Bureau’s 2017 American Community Survey, and the Center of Disease Control and Prevention’s (CDC’s) 2009-2017 Behavioral Risk Factor Surveillance Survey. For this survey, “disability” is defined as self-reported difficulty with activities, work, or social situations. The survey classifies disability in terms of physical, cognitive, or sensory deficits. The data sources do not report rates of disability by primary diagnosis, so the researchers do not report on the prevalence of disability due to chronic conditions such as back pain, mental illness, addiction, or intellectual/developmental disability. The goal was to calculate statistics related to disability in the U.S.

Additional findings include:

  • The state with the largest number of individuals with disabilities was California, with 4,151,044 individuals; while the state with the smallest number of individuals with disabilities was North Dakota, with 75,801 individuals.
  • The state with the highest percentage of the population with disabilities was West Virginia at 20.2%; the lowest was Utah at 9.6%
  • The employment-to-population ratio of people without disabilities was 76.5%. This is nearly double that of people with disabilities and amounted to an employment gap of 41.0 percentage points.
  • Between 2016 and 2017, the employment-to-population employment gap of those without disabilities versus those with disabilities decreased 0.4 percentage points from 41.4%.
  • Since 2008, the employment-to-population employment gap of those without disabilities versus those with disabilities increased a total of 1.5 percentage points.

The full text of “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” was released in February 2019 by the Institute on Disability at the University of New Hampshire. Copies of each section are available online at https://disabilitycompendium.org/ (accessed March 4, 2019).

For more information, contact: Lindsay Allsop, Communications and Information Coordinator, University of New Hampshire Institute on Disability, 56 Old Suncook Road, Suite 2, Concord, New Hampshire 03301; 603-228-2084; Email: lindsay.allsop@unh.edu.

The focus on consumerism and the consumer experience in health and human services is increasingly important—and our work with provider organizations over the years has found that it will require a new perspective on service line development (see Considering Cash—& Consumerism—In Service Line Planning). But for all that talk, how often do provider organizations—even those that are talking with consumers to find out what is necessary for a great consumer experience—ask those same consumers what would be necessary for great services? Have you, for example, thought of asking your consumers what it would take to keep them out of the emergency room (ER)—one of the primary drivers of avoidable health care costs?

A recent survey of high-need, high-cost (HNHC) health care consumers, with chronic health conditions, did just that, and found that this group believes five solutions would help them avoid unnecessary ER use. These five solutions were (and they should sound familiar): care management; readily available at-home physical therapy and nursing services; home delivery of prescription medications and easier refills; telemedicine; and more after-hours clinics.

It’s interesting to me that this study produced such “elemental” recommendations—but in truth, these system features are not there in any consistent kind of way. Why not? I think part of the issue is that many provider organizations are too focused on the “low hanging fruit” of the consumer experience, like improving wait times, or ease of appointment scheduling, or the friendliness of staff. It would be a mistake not to include these in consumer service efforts—but for a truly consumer-centric business model, provider organizations need to re-engineer whole service lines and service resources to meet a much broader demand: consumerism—the understanding that consumers understand that health care costs and quality are important and will making purchasing decisions to achieve it.

Or put it another way: Most of the managers at provider organizations don’t know how to think in terms of “what consumers want,” and even if they try, many fail to translate that into a service line design that delivers on the above basics. Considering how much consumers are now paying for health care—the average annual deductible for single adults with employer-sponsored health insurance was $1,077 and out-of-pocket (OOP) payments where at $656  (see The Challenges Of Rising Consumer Spending On Health Care and Out-Of-Pocket Health Care Costs – Down For Most, Up For Some)—this is a mistake. Additionally, health plans are focused on better and quicker access in a drive to lower wait times and produce both better consumer engagement and more satisfied consumers, as measured by the Centers for Medicare & Medicaid Services (CMS) STARS ratings and HEDIS scores (see ‘Rapid Access’ Might Just Be Your Next Health Plan Conversation and Oh, Those Consumer Reviews).

The key to really leveraging this trend isn’t to just give consumers a choice of the services you already have, it’s to build service redesigns that offer the options that you should already know that consumers want.

For more, check out these resources from the PsychU Resource Library:

  1. Making Consumer-Centricity A Reality For Medicaid Consumers With Complex Needs
  2. Integration, Interoperability & Consumer Engagement
  3. Get Your Price List Ready!
  4. Consumer Sovereignty As Success Strategy

Approximately 7.8 million direct care support positions will need to be filled by 2026. For all states, there were 4.52 million direct care jobs in the United States as of 2016 — and a projected 5.85 million will be required by 2026. In that intervening period, an estimated 6.4 million direct care workers will leave the labor force either for retirement or for positions in another field. This creates about 7.8 million new direct care positions in the health care field.

These findings were reported in “New Research: 7.8 Million Direct Care Jobs Will Need to Be Filled by 2026” by Stephen Campbell, a data and policy analyst at PHI. The author analyzed job growth and occupational separations data from the Bureau of Labor Statistics Employment Projections Program’s 2016 to 2026 Occupational Separations and Openings. Aggregate figures for the period reported were determined by multiplying annual average occupational separations by 10. The goal was to determine expected employment trends for direct care occupations through 2026. Direct care workforce will add the greatest number of new jobs (as compared to other occupations) in 38 states.

Direct care employment positions include:

  • Personal care aides are responsible for light cleaning, cooking, running errands, and doing laundry, as well as assisting clients with bathing, showering, grooming, and other personal hygiene tasks. They also engage clients in activities like reading, talking, and playing games.
  • Home health aides care for people who have disabilities, chronic illnesses, cognitive impairments, or age-related problems, who have the need or desire to still live in their own home. The home health aide provides basic services that include assisting medications, changing bandages, and checking vital signs like temperature, and pulse and respiration rates.
  • Nursing assistants work in nursing homes, home care, assisted living, hospice, hospitals, community based long-term care, correctional institutions, and other long-term care settings. Nursing assistants help patients of all ages perform the most basic daily tasks.

Additional findings include:

  • Direct care job growth through 2026 will be highest in California (about 274,700 positions); New York (190,550 positions); and Texas (126,140 positions).
  • Direct care job growth through 2026 will be lowest in Wyoming (about 1,000 positions); South Dakota (1,230 positions), and Alaska (1,800 positions).
  • The direct care workforce will grow the fastest in Arizona, with 59% job growth rate and 154,700 total job openings in 2026.
  • The direct care workforce will grow the slowest in Maine, with 8% job growth rate and 37,400 total job openings in 2026.
  • Personal care aide positions are projected to make up the largest overall personal care occupation need through 2026.

Occupations with the Most Projected Total Job Openings, 2016 to 2026 (Courtesy of PHI).

Mr. Campbell concluded that both the long-term care sector, and potential employers, can take steps to mitigate the effect of large number of projected job openings in direct care. The long-term care sector should reduce unnecessary turnover through steps such as: improve the quality of jobs through higher wages, better training, and opportunities for advancement. Employers should consider expanding the labor pool for the direct care workforce. This might be accomplished through education campaigns that increase awareness of direct care workers; targeted recruitment of new populations (including men, younger workers, and older workers, among others); and partnerships with community institutions such as schools, churches, and workforce development agencies.

The full text of “New Research: 7.8 Million Direct Care Jobs Will Need to Be Filled by 2026” was published January 24, 2019, by PHI. An abstract is available online at phinational.org

For more information, contact: Stephen Campbell, Data and Policy Analyst, Paraprofessional Healthcare Institute, 400 East Fordham Road, 11th Floor, Bronx, New York 10458; Email: scampbell@PHInational.org.

Knowing how to develop bundled payments and case rates is an executive team skill set that will become more important as value-based reimbursement models mature. While the majority of VBR contracts remain in fee-for-service models with a bonus or penalty, the use of case rate reimbursement is on the rise, and this brings a new level of financial risk to provider organizations (see VBR @ Scale—Changes Required).

As we learned at a recent institute, these reimbursement models are not “one size fits all”—the models require new approaches in both developing the rates and managing them successfully. That was the primary message from the session, Rate Setting For Value-Based Reimbursement: A Guide To Developing Capitated Payment Models, featuring Debbie Cagle Wells, Chief Marketing Officer at Centerstone, and Maggie Labarta, Ph.D., President and Chief Executive Officer at Meridian Behavioral Healthcare.

The panelists both have working experience with VBR. Centerstone—a large non-profit behavioral health provider organization—currently has 97 contracts in negotiation and 17 that are value-based. The contracts include pay-for-coordination (upside risk only), pay-for-performance, bundled payments, and shared savings (upside and downside risk). Dr. Labarta provided a brief review of Meridian Behavioral Healthcare, which has clinics in 11 Florida counties, covering a combined 500,000 consumers in a high-health disparity population.  Meridian is currently negotiating VBR, after its most recent capitated contract ended last year. Meridian has had several capitated arrangements under carve-in and carve-out scenarios, and the contracts covered the range of behavioral health services.

They offered five key pieces of advice developing case rates, and then managing to those rates.

Develop a “roadmap to capitation”—In a lot of ways, adopting risk comes down to understanding revenue predictability and a clear understanding of the scenarios that will help the organization sustain the necessary work under VBR contracts. This means understanding the “roadmap” that will let you build on a payer relationship, and work through the process to develop the necessary contract and then manage to that contract. Ms. Wells shared this roadmap:

Figure 1. Threnhauser, S. Developing Case Rates? Better Find Your ‘Single Source Of Truth’ [PowerPoint Slide] Retrieved from www.openminds.com

Start ahead and stay ahead—Managing VBR contracts effectively means that you must hit the ground running as effectively and efficiently as possible. This is not a scenario where you can figure out your services, costs, performance, or process as you go. All these things need to be balanced within the “risk corridor” that the organization needs to operate within. Dr. Labarta explained:

You must start ahead and stay ahead if you are going to manage these contracts effectively. You can’t provide too many services, or you are spending more than you bring in, but you also can’t offer too few if you want to meet the contract requirements and achieve the needed outcomes.

The data needs to be agreed upon—This is the “single source of truth” that the provider organization and the payer will agree upon. This means coming together to select and/or develop key performance indicators (KPI) that will best reflect the outcomes needed to achieve cost savings and population health management. Dr. Labarta explained.

What we discovered was that the data can’t be siloed in separate IS systems. You need to get to a place where there is a single source of truth that everyone agrees on. Pull all the data into a ware house. From there, develop the KPIs. Then make decisions about who needs access to what. The line staff, management staff, and executive staff will need something different, and the data must be available to you to help make decisions, in almost real time.

Internal champions are key—When Ms. Wells thinks of VBR success, she doesn’t immediately think of operations, or incentive bonuses, or quality outcomes. Those are all important, but the first thing that comes to mind are the people on the team who are leading those initiatives. Having commitment and support from both the leadership, as well as the staff who are leading those programs is mandatory. Ms. Wells noted:

Are you ready? I can talk about processes, but really you must be honest with yourself on your staff capabilities so that together you can be successful. And you must recognize that this is a new culture that touches both the staff and the consumers. I think of success, and I see the faces of the people who lead this.

Every cost counts—The new approach to finances means putting much greater importance on costs, including a focus on cost accounting, cost management, understanding population-based payment mechanisms, and unit costs. This is all about managing each service line, and each of these service line costs needs to be factored into risk in a very granular way (as detailed as possible). Ms. Wells explained:

You must take a good hard look at every cost that goes into your model. You need to stratify risk for the kinds of services and benefits you will manage. You can’t manage risk if you can’t manage the services and benefits you are at risk for. An example of a key incentive measurement that we control is every treatment plan contains a health care goal, and we document to that goal. Sounds easy? It is not easy.

Consumer engagement is top of mind for many reasons. Engaged consumers are consumers who have a better “experience.” Engaged consumers are activated consumers who take part in managing their health. Engaged consumers give provider organizations a significant edge over their competitors.

For many provider organization management teams, it’s not clear how to best go about achieving better consumer engagement. The executive got some words of wisdom about consumer engagement in the session Keeping Consumers In The Equation: Best Practices In Consumer Experience and Engagement, featuring Blake A. Martin, Executive Vice President and Chief Development Officer at Monarch; Chief Operations Officer at Monarch; and Philip O. Toal, Ed.D., Senior Vice President, Residential Services at Aspire Health Partners.

What does consumer engagement look like in practice? The panel shared five keys that will help provider organizations provide better consumer service, faster services, and better outcomes.

Invest in an up-to-date electronic health record—No strategic plan can be successful without the resources and infrastructure to support it. To properly manage consumer engagement and experience, you can’t just focus on the consumer’s experience when they are in the same room as a clinical provider. True engagement means tracking consumer data so that you can determine what they want or need and are prepared to provide that in real time. Mr. Martin explained that you can’t keep telling your payers and consumers that they have to wait for the data and the information they need to make decisions about care.

Expand and improve access—Contractual agreements drive consumers to your door, but if they can’t get in the door, or don’t like their experience when they do, they will be neither engaged nor likely to come back. Mr. Thompson explained that old-fashioned appearance and amenities can really help the consumer experience, noting:

We gave our facilities a face lift, including free Wi-Fi and phone charging. We made sure our front desk staff are welcoming and that our clinical staff understood customer service. We also focused on waiting room aesthetics and process components. We brought in a centralized call center with nine operators trained on mental health first aid and customer service. All calls go to corporate office and our team will transfer the consumer to where they need to go.

Provide stages of change education—Mr. Toal explained these as “motivational enhancement services” that are designed to convince staff that they want to change and take a greater role in providing a consumer-centered approach. Organizations need to ask themselves if they have a consumer-centered approach that isn’t being properly demonstrated. It’s not just about looks, it’s about core values

Comprehensive assessment that includes social determinants of health—It’s hard to know how best to engage with any given consumer if you don’t really know a lot about them. From a consumer services standpoint, it’s worth spending time on assessments. This also means investing in things like telehealth that can help you ask consumers about their goals, their environments, as well as get their feedback on your services.

Care coordination—Care coordination and case management are key and essential to achieving the kinds of consistency across systems that lead to greater consumer experiences in the short-term, and better consumer engagement in the long-term. Mr. Toal noted that organizations need to be available 24/7, 365 days a year because that brings consumer health satisfaction.

Last month I took on a difficult question—why has there been so little adoption of measurement-based care (see Why So Little Measurement-Based Mental Health Care?)? Response rate to treatment is 87% when measurement-based care is used, compared to 63% when the standard of care is used. Even more startling, measurement-based care results in a 74% remission rate, compared to 29% when the standard of care is used. Yet, measurement-based care is an exception rather than the rule in the field.

That piece sparked a lot of reader feedback, including a few interesting perspectives from Scott Zeiter, Executive Vice President, Chief Operating Officer, Grafton Integrated Health Network. Mr. Zeiter spoke about the challenges—and rewards—of making Grafton a “measurement-based” organization when it comes to planning services for children, adolescents, and adults with complex behavioral health challenges.

I sat down with Mr. Zeiter to learn more about why and how Grafton implemented measurement-based care. He explained the “why” this way:

Instead of stories that make us feel good, and feedback from families and referral sources, we wanted to be more data driven. And we wanted to answer the simple question, how do we know this is effective? The oncoming freight train of value-based reimbursement (VBR) means we need to know how to make good judgments as we will now be assuming financial risk for defined outcomes—we need a better idea of what worked and what didn’t work.

His description of the “how”—the journey to measurement-based care—was even more interesting. He had four key elements on how Grafton arrived at data-informed service planning for consumers: creating a culture around outcomes, determining which evidence-based practices (EBP) Grafton would adopt, implementing the right technology to implement this model, and choosing a partner to analyze the data.

Creating a culture around outcomes—After the decision to use data for consumer treatment planning, the next step is getting your clinical team to embrace the concept. Mr. Zeiter was surprised how easily the clinical professional staff agreed to the model and were willing to at least to see if it could work. Mr. Zeiter attributes this to the fact that the organization already has a culture focused around outcomes as a result of their ten-year-old goal mastery initiative, which requires clinical professionals to create actionable, measurable goals for consumers. He explained further:

I was expecting clinicians to say, “don’t tell me what to do.” What we got was the feedback, “let us give this a shot.” The biggest challenge is doing our best to ensure the behavioral data tracking that ends up falling on the people who are very busy and very stressed doesn’t overwhelm them. We needed to make sure the data entry is as simple as it could be.

Determining which EBPs to include—My key question for Mr. Zeiter was how Grafton selected measurements, and evidence-based practices, to include in their decision support model. His answer was that, based on their own data, Grafton developed service models that were “most effective” for consumers; an approach referred to as practice-based evidence. Mr. Zeiter said:

First, you must understand how “evidence” makes its way into EBPs. The first path is to a controlled experimental approach that is conducted in an academic setting to identify the effect of a treatment; this approach is long, costly, and often hard to apply in a treatment setting. The second path, and the one that offers the clearest path forward for organizations that make a commitment to measuring data and then using that to inform their practices, is a practice-based evidence approach that allows organizations to analyze their own “real world” practices.

We have a new clinical model that forces the clinician to choose the evidence-based practice they are using. And under that, there are “intervention objectives”—broad statements of method for that evidence based practice. Our hope is to link these approaches with outcomes data, so we can say that the most effective methodology was “X.” Our whole treatment process is methodologically driven. Choose a behavior to attack, clearly express the target of the goal in good behavioral terms, choose the evidence-based practice you will use, and then show how good you did.  We can then correlate all of the data in our EHR with those outcomes to drive practice-based evidence.

Implement the right technology—In order to implement a measurement-based model of care at scale, technology is essential. Grafton is implementing a new electronic health record (EHR) and has customized the EHR to both collect the consumer data they need for clinical decision making and facilitate the selection of preferred clinical pathways for each consumer.

Select a partner to analyze the data—Finally, Mr. Zeiter said they hope to select an academic partner to help them ensure the fidelity of the model and do a deep dive into the data. While the Grafton team analyzes the data, an academic partner will add bandwidth and expertise. The academic affiliation also brings additional interest and credibility to any data that Grafton may choose to publish.

The Grafton model of measurement-based care is still in its infancy and Mr. Zeiter noted that they are certain the decision support model will change over time. This is not a small undertaking but one that Grafton—and other specialty provider organizations—need to optimize outcomes and standardize service delivery for success in a value-based environment.

For more on bringing standardized decision support models to your organization, check out these resources in the PsychU Resource Library:

  1. The ‘Best Practice’ Challenge
  2. Challenges In Changing To A Culture Of Value (Or Making Any Culture Change)
  3. Building A Workforce For Value-Based Reimbursement = Advice From Four Executives
  4. ‘Virtual Psychiatrist’ Telemedicine Decision Support System Effective In Diagnosing Mental Disorders
  5. Preparing For Your ‘Augmented’ Workforce

Last week, we spent the week taking a deep dive into the changing landscape of performance and its link to value-based reimbursement.

One of my big takeaways from the many discussions I had at the event is that the current landscape is creating a new role for chief financial officers (CFO). Best practice strategy development and planning for sustainability require robust internal performance metrics—and benchmarks to customer expectations and competitor performance. This changes the role of financial management to one with a broader and more strategic function.

How ready are CFOs for this new performance-driven landscape? If recent findings are any indication, there’s work to do. Only 13% of CFOs say their organizations are “very prepared” to manage evolving payment models and only 23% are very confident in their team’s ability to quickly and easily adjust strategies and plans. These were the findings of the recently-published “2019 CFO Outlook: Performance Management Trends and Priorities in Healthcare.” And, these statistics reflect a deterioration in CFO confidence from the last survey period.

I think some of the perceived problems result from a few new capability requirements that have been discussed before. First, “performance” is a broader concept and leadership teams should consider having all required information reside in one system accessed by all managers and leaders. In the survey, CFOs identified “financial health” as the most important (85%) performance measure. But consumer experience and quality outcomes followed closely.

Figure 1. Threnhauser, S. CFO Version 3.0. [Powerpoint Slide] Retrieved from www.openminds.com

Second, new cost accounting tools are a must. There is the need for new cost accounting tools and models to re-engineer service delivery. In addition, the field will need specialized cost accounting tools to re-engineer and manage service delivery within value-based payment arrangements that span across service continuums.

Third, budget processes need to change—allowing for more rapid budget development and the ability to adjust budgets within a shorter time frame. In the survey, 37% of CFOs reported having a budget process that takes six or more months from initial rollout to board presentation, up from 27% in 2018. And, 46% say their budgets cannot be easily adjusted when new strategic information or analyses are available.

Finally, CFOs need to lead the push for better performance reporting across their organization. This includes creating better dashboards and visuals (67%), pulling data from multiple source (64%); and accessing trusted data sources (52%).

Figure 2. Threnhauser, S. CFO Version 3.0. [Powerpoint Slide] Retrieved from www.openminds.com

About 15 years ago, we wrote about the need for “reinventing the CFO”. It’s probably time for CFO Version 3.0.

For more on the changes surrounding your CFO in response to the era of VBR and added financial pressures, check out these resources from the PsychU Resource Library:

  1. Income Statement Vs. Balance Sheet? The CFO Dilemma
  2. Can You Tell If Your Organization Is On The Financial Brink?
  3. ‘Surprise!’ A Word You Don’t Want To Hear From Your CFO
  4. Digital Transformations Demand Digital Dexterity
  5. Do You Have A Leadership Strategy For Tech ROI?
  6. Income Statement Vs. Balance Sheet? The CFO Dilemma
  7. The Art & Science Of Replacing Key Executives
  8. VBR @ Scale-Changes Required

In 2018 about 28% of American adults (ages 19 to 64) with employer-sponsored health coverage and 42% of those with individual coverage were underinsured in terms of the amount of their plan out-of-pocket costs compared to their household income. Since 2010, the greatest growth in the underinsured rate has occurred among Americans in employer-based health plans; in 2010 about 17% were underinsured compared to 28% in 2018. However, those who would purchase plans on their own through the individual market or the marketplaces were the most likely overall to be underinsured. In 2010 about 27% were underinsured, compared to 42% in 2018.

People who are underinsured are defined as:

  • Those whose out-of-pocket medical costs, excluding premiums, over the prior 12 months are equal to 10% or more of household income.
  • Those with income under 200% of the federal poverty level ($24,120 for an individual or $49,200 for a family of four) whose out-of-pocket medical costs, excluding premiums, over the prior 12 months are equal to 5% or more of household income.
  • Those whose deductible constitutes 5% percent or more of household income.

These findings were reported in “Health Insurance Coverage Eight Years After the Affordable Care Act (ACA); Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured” by Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty. The researchers presented facts from the Commonwealth Fund’s 2018 Biennial Health Insurance Survey. The telephone survey included a nationally representative sample of 4,225 adults ages 19 to 64 between June 27, 2018 and November 11, 2018. The goal was to summarize updates in the American health insurance population.

Additional findings include:

  1. The overall percentage of adults (45%) who are inadequately insured is about the same as in 2010, however there are shifts in the details surrounding the inadequate insurance.
  2. Compared to 2010, the duration of coverage gaps people experience has shortened significantly: the percentage experiencing a coverage gap of one year or more was 31% in 2016, compared to 39% in 2012.
  3. The 2018 adult uninsured rate was 12.4%, and statistically unchanged since the 2016 survey.
  4. The percentage of adults in 2018 who did not have long-term insurance coverage for more than two years was 54%, compared to 63% in 2010.
  5. People who are underinsured or spend any time uninsured report cost-related problems getting care and difficulty paying medical bills at higher rates than those with continuous, adequate coverage.

The researchers concluded that since 2010 when the PPACA became law, working-age adults are much more likely to have health insurance. However, the improvement in uninsured rates has stalled. More people are covered by health plans that fail to adequately protect them from high health care costs, and the erosion in cost protection has several possible sources, as follows:

  • Although the PPACA’s reforms—the essential health benefits package, cost sharing reductions for lower-income families, and out-of-pocket cost limits— have provided many consumers with greater protection against health care costs, the protections have primarily benefited consumers with incomes at or below 250% of the federal poverty level (FPL). Consumers earning more are not eligible for cost-sharing reductions on plans purchased through the Health Insurance Marketplace. Further, the PPACA reforms do not apply to plans purchased through an insurance broker.
  • The bans against insurers excluding people from coverage because of a preexisting condition and rating based on health status have meant that individuals with greater health needs, and thus higher costs, are now able to get health insurance in the individual market. Because they have health insurance, the population has higher costs because they are seeking care.
  • While plans in the employer market historically have provided greater cost protection than plans in the individual market, businesses have tried to hold down premium growth by asking workers to shoulder an increasing share of health costs, particularly in the form of higher deductibles.
  • Growth in Americans’ incomes has not increased at the same rate as the growth in health care costs.

The full text of “Health Insurance Coverage Eight Years After the ACA; Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured” was published February 7, 2019, by the Commonwealth Fund. An abstract with access to the full text is available online at www.commonwealthfund.org.

For more information, contact: Bethanne Fox, Vice President, Outreach and Strategy, Commonwealth Fund, 1 East 75th Street, New York, New York 10021; 212-606-3853; Email: bf@cmwf.org.

The prevalence of employer-sponsored health insurance did not change significantly after the Medicaid expansion provisions of the Patient Protection and Affordable Care Act (PPACA) of 2010 went into effect. A comparison of employer offers of insurance coverage, employee acceptance rates, and the amount employees paid for out-of-pocket premiums found little change that could be attributed to Medicaid expansion. There may have been an inverse relationship between expanded Medicaid eligibility and the share of employees who were eligible for employer-sponsored insurance.

These findings were reported in “The Impact Of Medicaid Expansion On Employer Provision Of Health Insurance” by Jean M. Abraham, Anne B. Royalty, and Coleman Drake. The researchers analyzed data from the 2010–2015 Medical Expenditure Panel Survey-Insurance Component for approximately 141,900 private sector employers that inluded all data for workforce characteristics. The goal was to detect change in four employer-sponsored insurance outcomes: offers of health insurance, eligibility, take-up, and the out-of-pocket premium paid by employees for single coverage. The researchers compared differences in the four outcomes between Medicaid expansion states and non-expansion states. The researchers merged information from the U.S. Bureau of Labor Statistics’ Local Area Unemployment Statistics file, and information about state minimum wage laws. They also controlled for a possible association between the employer shared responsibility requirement (ESRR) that applied to companies with 100 or more employees. Under the ESRR, companies were required to offer health insurance to full-time employees working at least 30 hours per week.

The researchers compared employer characteristics for 2010 to 2013, and for 2014 to 2015. Key findings were as follows:

  • The percentage of establishments (the physical locations of an employer, as opposed to the firm, which is the entirety of the employer’s operations) offering insurance declined from 49.13% to 44.19% between the two periods.
  • The percentage of workers eligible for insurance decreased from 80.57% to 79.53%.
  • The percentage of eligible workers who accepted the employer insurance decreased from 74.94% to 73.83%.
  • The share of establishment workforces that are low wage declined from 33.55% to 30.56%. Low wage is defined as the percentage of workers earning under $11.50 per hour.
  • Annual out-of-pocket premiums remained essentially the same after adjusting for inflation; they averaged $1,026.31 from 2010 to 2015 in 2015 dollars. However, establishments with higher percentages of low-wage workers have higher out-of-pocket premiums.

The researchers found no support for the hypothesis that expansion and non-expansion states exhibited significant differences in any of the four outcomes of interest. They concluded that the PPACA did not produce the large-scale changes in employer-sponsored insurance that some policymakers predicted. They noted that the PPACA provisions had incentives that encouraged employers to offer insurance and encouraged employees to accept, which may have countered the incentives to stop offering insurance and allow employees to seek Medicaid expansion eligibility or purchase Marketplace policies. The researchers also said that employers may have continued to offer insurance due to the legal challenges that created uncertainty about whether PPACA would remain law.

The full text of “The Impact Of Medicaid Expansion On Employer Provision Of Health Insurance” was published December 15, 2018, by International Journal of Health Economics and Management. An abstract is available online at link.springer.com.

For more information, contact: Jean Abraham, Ph.D., Wegmiller Professor and Master of Healthcare Administration Program Director, Division of Health Policy and Management, University of Minnesota, 420 Delaware Street SE, MMC 729, Minneapolis, Minnesota 55455; Email: abrah042@umn.edu.

More competition and more value-based reimbursement (VBR) are making performance management more important for health and human service management teams—they need to run business operations, track and correct staff performance, negotiate contracts—all the while out positioning other competitors in the market. The question is, does your management team have useful data available to make these decisions?

Creating a performance management system that reports metrics in a way that promotes action and performance improvement takes planning. Without a dashboard to display what data usable, answering that you have the data might not matter all that much. Data is great, but hardly useful without a good dashboard. You can measure and show outcomes, but they must be articulated in a way that the audience (your management staff) understands. That was my takeaway from the session, Building A New Performance Management Dashboard: How To Use KPIs To Manage Performance In A Value-Based Market, featuring Ashley Sandoval, Associate Chief Executive Officer, Emergence Health Network and Diana Salvador, Psy.D., Vice President, Quality Assurance and Risk Management, CPC Behavioral Healthcare.

The session called out five keys to building an effective KPI system:

  1. Prioritize high utilizers—The consumers using the most services are responsible for the highest spend, which isn’t a surprise to anyone in the field, but is where provider organizations need to focus their KPIs for maximum effect.
  2. Prioritize measurement of evidence-based practices— The performance expectations of value-based reimbursement will likely be demand that more provider organizations invest in standardized treatment protocols, meaning they need to measure evidence-based practices.
  3. Create infrastructure to share data—You need to be able to collect the data, analyze the data, exchange the data, and display the data in real-time. Otherwise, you have a file of information that no one internally, or externally, can use.
  4. Know the limits of technology—Technology won’t tell your value story. That takes staff that understands how to use the technology to extend the value-proposition that is critical to leveraging the power of data.
  5. Know the limitations of staff who use the technology—You can measure and show outcomes, but they must be articulated in a way that the audience understands. This isn’t necessarily a given, and the reports need to be built with staff understanding in mind.

Figure 1. Threnhauser, S. Five Rules For Building An Effective KPI System. [Powerpoint Slide] Retrieved from www.openminds.com

Ms. Salvador explained that CPC Behavioral Healthcare pursued KPIs in response to federal grants and a VBR pilot that forced the organization to reconsider what it would take to stay in business while telling their value story to different target audiences that included board members, payers, consumers, and staff.

Figure 2. Threnhauser, S. Five Rules For Building An Effective KPI System. [Powerpoint Slide] Retrieved from www.openminds.com

Ms. Sandoval explained that Emergence pursued KPIs as part of their three-year strategic plan to align service with the Certified Community Behavioral Health Clinic (CCBHCs) model which Texas doesn’t have yet but that Emergence has identified as the future of the market. As a result, Emergence chose 16 measures for their 1115 waiver funding, nine of which are attached to CCBHC core measures.

Figure 3. Threnhauser, S. Five Rules For Building An Effective KPI System. [Powerpoint Slide] Retrieved from www.openminds.com

Both expressed the need for organizations to move KPIs from the tactical to the strategic, or as Peter Drucker put it, “Management is doing things right; leadership is doing the right things.” Being strategic with your KPIs means choosing those KPIs that will most effectively define “truth” by reaching an internal consensus on what metrics will be the most valuable to know. The tactical work will then be how to display that data to the teams that need it.

A survey of high-need, high-cost (HNHC) health care consumers, with chronic health conditions, found that this group believes five solutions would help them avoid unnecessary emergency room use. The solutions are: care management, readily available at-home physical therapy and nursing services, home delivery of prescription medications and easier refills, telemedicine, and more after-hours clinics. HNHC is defined as the 5% of health care consumers who account for 50% of health care spending who have limited ability to perform activities of daily living, multiple chronic health conditions, and psychosocial needs.

These findings were reported in “High-Need, High-Cost Patients Offer Solutions for Improving Their Care and Reducing Costs” by Lala Tanmoy Das, MS, Erika L. Abramson, M.D., MSc; and Rainu Kaushal, M.D., MPH of Weill Cornell Medicine. The researchers led several focus group discussions with 21 high-need, high-cost consumers, as identified by clinical care coordinators at each site; and 3 primary caregivers. The participants represented an urban health care system in New York City, and a second one in Gainesville, Florida. The consumers were identified as having at least one chronic medical condition and either three or more emergency visits, or two or more inpatient admissions, during the six months prior to initiation of the study. Three consumers were too ill to participate, so their primary caregivers acted as proxies. The goal was to determine the best care and cost-reduction solutions for HNHC health care consumers, according to the consumers themselves.

In the year prior to the discussions, the participants had, on average visited their primary health care professionals six times, had visited the emergency department 16 times, and been hospitalized five times. Commonly reported medical conditions included arthritis, asthma, chronic obstructive pulmonary disease (COPD), depression , diabetes, epilepsy, heart disease, hypertension, and obesity.

Participants identified five solutions that they felt would help prevent overuse of hospital and emergency department services for symptoms and conditions, and would therefore reduce overall cost of care. The majority of the solutions relate to alleviating unnecessary and inconvenient travel for the consumer, especially in cases where means of travel do not easily exist for a consumer. These five solutions were:

  1. Care management, including appointment scheduling and reminders, and accessibility to health care professionals by telephone or internet chat to obtain professional advice.
  2. Readily available at-home physical therapy and nursing services to alleviate inconvenient and uncomfortable travel to health care locations following major surgery, and to allow the comfort of healing at home.
  3. Home delivery of prescription medications and easier refills to alleviate inconvenient (and sometimes impossible) travel to pharmacies.
  4. Telemedicine, including accessibility to health care professionals by telephone or internet chat to obtain professional advice about non-life-threatening conditions.
  5. More after-hours clinics in convenient locations for needed non-emergency assistance.

The researchers concluded that it is important to heed recommendations that come directly from HNHC health care consumers. Due to the consistent recommendations of this small sample, the group is likely an accurate representation of the HNHC consumer group as a whole. While almost all of the suggested solutions are being piloted in various settings across the country, the researchers recommended that health care systems consider expanding these solutions and offering education to HNHC consumers to continue lowering costs for this population overall.

The full text of “High-Need, High-Cost Patients Offer Solutions for Improving Their Care and Reducing Costs” was published February 5, 2019, by the New England Journal of Medicine (NEJM) Catalyst. A copy is available online at catalyst.nejm.org.

For more information, contact: Anna Sokol, Office of External Affairs, Weill Cornell Medicine, 1300 York Avenue, Box 314, New York, New York 10065; 646-962-9272; Email: ana2059@med.cornell.edu.

After three days of discussion about performance, my thoughts went to Peter Drucker and his leadership adage in The Effective Executive, “plan, organize, integrate, motivate, and measure.” I would just make one slight addition:” measure, plan, organize, integrate, motivate, and measure again.”

This afternoon in Monica E. Oss’s wrap up at The 2019 OPEN MINDS Performance Management Institute, Fit For Growth-Performance Management & The Growth Imperative, her focus was on the often broken link between performance, strategy, and growth in specialist health and human service organizations. For most organizations in the field, growth is an imperative-whether to achieve scale or just replace revenue streams that dry up due to changing customer preferences. But many of these organizations are not ready for growth and are missing the organizational characteristics that enable successful growth.

To spur growth in a turbulent market, our team encourages provider organization executive teams to use a four-step process: One, use market metrics and performance metrics to develop strategy; Two, use strategy to prioritize investment of both time and money; Three, focus the organization’s managers on executing strategy, with an emphasis on the strategic priorities; and Four, continually update market metrics and performance metrics in order to update strategy. This process is simple in concept and extremely difficult to actualize.

Figure 1. Oss, M. From Metrics To Action—Making Strategy A Reality [PowerPoint Slides] Retrieved from www.openminds.com

I’ve written before about the importance of performance metrics in management (see Putting Performance Into Compensation, and Performance Metrics Matter). But one of the big questions for managers is, how do you use metrics to create strategy? There are three very similar approaches that management teams can use:

  1. The blue ocean model
  2. The Amazon flywheel model (see The Amazon Leadership Principles & The Amazon Flywheel – What They Could Mean For Your Organization and Getting That ‘Preferred’ Role With Health Plans)
  3. The strategic quality model

What the three models share is a structured, metrics-based approach to increasing value to customers-by cost reductions and improvements in performance attributes-that result in superior market positioning and growth. The key is to develop a growth strategy that is both market-driven (identifying market opportunities) and capabilities-driven (identifying what the organization does better than its competition).

Once the strategy is written, the hard works begins. (Peter Drucker’s other adage that comes to mind is “strategy is a commodity, execution is an art”.) Executives need to create a budget that reflects the growth priorities—which may result in decreased funding of low-priority services and initiatives. And then executives need to hold their teams accountable for executing that strategy. The “art” is in that execution—which may involve new team members, new management styles, and new infrastructure. All these “new” elements equal big change within an organization.

I’ve found the greatest challenge in strategy execution for health and human service organizations is often about changing culture and tradition. “Unfunding” traditional programs and activities is hard. Assessing the ability of team members to execute plans and bringing in new talent when needed is a challenge. Assessing executives on their results alone, rather than their style, knowledge, or other contributions, can be problematic. For non-profit organizations, incorporating a concrete plan that funds mission-based activities, is often an uncomfortable exercise.

Figure 2. Oss, M. From Metrics To Action—Making Strategy A Reality [PowerPoint Slides] Retrieved from www.openminds.com

These are the building blocks of success for health and human service organizations—good strategy needs to be informed by data. I’m not saying that with data, strategy will magically write itself. Rather, good metrics provide leaders with the guideposts for great strategy. In the end, decisionmaking is the burden of executives and I’m reminded again of Peter Drucker: “There is nothing quite so useless, as doing with great efficiency, something that should not be done at all.”

Just a few years ago, most executives’ relationships with their team members took place in the same location—face-to-face meetings and working on problems side-by-side. But commerce has changed—larger multi-jurisdictional (and international) organizations with service locations and team members in many states (and time zones), more home-based and virtual services, more travel, and more virtual employee communication.

This evolving environment has affected work in health and human services in almost every way. Clinical professionals’ relationships with consumers, customer relationship management, supervision practices, and management roles are increasingly virtual. Virtual work environments also have important implications for leadership. How do leaders communicate a new vision and affect culture change in a virtual organization? That was the question posed to John Stupak, President & Chief Executive Officer, Sequel Youth and Family Services and Peggy S. Terhune, Ph.D., President & Chief Executive Officer, Monarch, by OPEN MINDS Senior Associate, Sharon Hicks in the session When Technology Becomes Integral To Strategy: Leading In A Virtual Environment.

The overall takeaway of the day was summed up by Mr. Stupak when he noted that both discipline and communication are vital in remote management situations. Team members who lack either of these skills are team members who won’t do well in a virtual environment. And, he had an observation that I found very interesting—the “risk” of virtual teams is much higher with your leadership team than your staff delivering consumer services. He said, “I don’t really worry about service providers, because there is service documentation, encounter and outcome data, and consumer satisfaction that reveals if one hasn’t done their job. It’s the leadership and managers where it may not be as apparent for a couple weeks or months down the road whether they have done their job or not. Not all managers and executives have the personal characteristics to be successful when not in an office environment. They can feel isolated and have trouble remaining focused. Solutions to those human issues must be part of your plan.”

During the discussion between leaders and participants, there were four best practices for virtual team leadership that emerged—in hiring, communication, employee operating process, and performance management.

Hire intentionally—Not all people can work in a virtual environment, either in your facility or remotely. Personality, work style, discipline, communication skills, and reliability are just as important as the specific skill sets you are looking for. Make sure that assessing these characteristics is part of your hiring processes.

Communicate clearly, deliberately, and quickly—When two team members work in the same location, the opportunities for communicating are much greater. This is particularly true for informal communication that uncovers problems and builds rapport. When team members are separated by distance and use virtual platforms for communication, this informal communication channel is lost. Leaders must both strengthen formal communication and find substitutes for informal communication. On the formal communication side, it is much more important to publish formal policies and procedures; to have regularly scheduled, structured team meetings, and one-on-one reviews.

But compensating for the informal communication is much harder and takes much more work on the part of managers. Managers need multiple communication channels (telephone, email, text, Twitter, LinkedIn, etc.) and need to be available and respond quickly to their team members. It is a big commitment from managers.

Understand Your Team Members’ Work Experiences—The introduction of the virtual work environment changes so much. Do team members who are physically distant from their managers have the same likelihood of promotion? Do managers understand the location-specific challenges of consumer service in a distant location? Do supervisors pay enough attention to virtual communication platforms? It is incumbent on executives to make sure these issues are addressed in virtual environments.

Additionally, people work best when they feel that they are part of team, and they feel most like a team when they can interact with one another in person. It’s hard to bond with a group of people that staff only knows through email and chat messages. To overcome this, leadership needs to plan and budget for events that bring the team together on a semi-regular basis.

Manage By Performance Metrics—When you can’t see what a team member is doing, it puts more pressure on supervisors and managers to manage their team using performance metrics. There are a few guidelines. Choose your performance measures wisely. Set clear performance and productivity benchmarks and communicate them frequently. Maximize the use of shared data to promote collaborative work approaches.

As I think about these best practices, I see the need for reorientation of managers who assume responsibility for virtual team members—and more thought to deliberate virtual team building. For more on digital challenges, check out these resources from the PsychU Resource Library: Digital Transformations Demand Digital Dexterity‘Going Digital’ For A Better Consumer Experience, and The Digital Revolution In Mental Health Hasn’t Happened Yet.

By the end of 2018, the uninsured rate rose to 13.7%, an increase of 2.8% since 2016. This represents a net increase of about seven million adults total without health insurance as of 2018. Prior to the 2014 implementation of the Patient Protection and Affordable Care Act (PPACA), 18% of U.S. citizens were uninsured, and while the percentage of women uninsured in 2018 was less than men, women showed a 3.9% increase since 2016, compared to a 1.6% increase for men.

These findings were presented in “U.S. Uninsured Rate Rises to Four-Year High,” by Dan Witters for the Gallup National Health and Well-Being Index (Gallup). Data for the report was collected as part of the Gallup National Health and Well-Being Index, based on Americans’ answers to the question, “Do you have health insurance coverage?” The researchers randomly surveyed approximately 28,000 adults per quarter in 2018 (a total of 115,929 adults) who lived in all 50 U.S. states and the District of Columbia. The goal was to determine the current rate, and trend, of those uninsured in the U.S.

Additional findings include:

  • While the uninsured rate increased in all age groups since 2016, those aged 18 to 34 years had the largest increase (4.8%), compared to those age 35 to 64 (a 2.7% increase), and those aged 65 and older (a 1.4% increase).
  • The increase in uninsured since 2016 was largest in households making between $24,000 and $48,000 per year (3.0%); followed by those making under $24,000 (a 2.8% increase); and those making between $90,000 and $120,000 per year (a 2.7% increase).
  • Those who live in the eastern U.S. states saw a 0.4% decrease in uninsured rates since 2016 (from 7.5% to 7.1%). In comparison, those who lived in the south saw a 3.8% increase; those who lived in the west saw a 3.6% increase, and those who lived in the Midwest saw a 3.2% increase in uninsured rates.

The full text of “U.S. Uninsured Rate Rises to Four-Year High” was published January 23, 2019 by Gallup. An abstract is available online at news.gallup.com.

PsychU reported on this topic in “12.2% Of U.S. Adults Are Uninsured, Up 1.3 Percentage Points From Record Low In 2016,” which published on February 21, 2018.

For more information, contact: Dan Witters, Research Director, Gallup National Health and Well-Being Index, Gallup, 1001 Gallup Drive, Omaha, Nebraska 68102; 402-951-2003; Fax: 888-500-8282; Email: Dan_witters@gallup.com.

On December 12, 2018, the New York Department of Health (DOH) issued a quality measure set for its Medicaid Health and Recovery Plans (HARP). The HARPs are specialized Medicaid managed care organization (MCO) plans that integrate physical health, behavioral health, and Medicaid waiver home- and community-based services (HCBS) for beneficiaries diagnosed with serious mental illness (SMI). The quality measure sets includes 38 measures, which will be reported by provider organizations to MCOs in 2019. The measures will be used to support value-based purchasing contracts between provider organizations and Medicaid managed care plans.

The quality measure sets are updated annually. For 2019, DOH added one measure to the 2018 measure set (Asthma Medication Ratio) and removed five measures related to diabetes care.

New York HARP 2019 Quality Measurement Set, Category 1 Measures

Measure Measure Steward Classification, Pay-For-Performance (P4P) or Pay-For-Reporting (P4R)
Adherence to Antipsychotic Medications for Individuals with Schizophrenia Centers for Medicare & Medicaid Services (CMS) P4P
Asthma Medication Ratio National Committee for Quality Assurance (NCQA) P4P
Breast Cancer Screening NCQA P4P
Cervical Cancer Screening NCQA P4P
Chlamydia Screening in Women NCQA P4P
Colorectal Cancer Screening NCQA P4P
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA P4P
Comprehensive Diabetes Care: Medical Attention for Nephropathy NCQA P4P
Comprehensive Diabetes Screening: All Three Tests (HbA1c, dilated eye exam, and medical attention for nephropathy) NCQA P4P
Continuity of Care from Inpatient Detox to Lower Level of Care NYS P4P
Continuity of Care from Inpatient Rehabilitation for Alcohol and Other Drug Abuse or Dependence Treatment to Lower Level of Care NYS P4P
Controlling High Blood Pressure NCQA P4P
Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications NCQA P4P
Follow–Up After Emergency Department Visit for Alcohol and Other Drug Dependence NCQA P4P
Follow–Up After Emergency Department Visit for Mental Illness NCQA P4P
Follow–Up After Hospitalization for Mental Illness NCQA P4P
Initiation of Pharmacotherapy upon New Episode of Opioid Dependence NYS P4P
Maintaining/Improving Employment or Higher Education Status NYS P4R
Maintenance of Stable or Improved Housing Status NYS P4R
Medication Management for People with Asthma NCQA P4P
No or Reduced Criminal Justice Involvement NYS P4R
Percentage of Members Enrolled in a Health Home NYS P4R
Potentially Preventable Mental Health Related Readmission Rate 30 Days NYS P4P
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow–Up Plan CMS P4R
Preventive Care and Screening: Influenza Immunization American Medical Association Physician Consortium for Performance Improvement (AMA PCPI) P4R
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention AMA PCPI P4R
Statin Therapy for Patients with Cardiovascular Disease NCQA P4R
Statin Therapy for Patients with Diabetes NCQA P4R
Use of Pharmacotherapy for Alcohol Abuse or Dependence NYS P4R
Use of Spirometry Testing in the Assessment and Diagnosis of COPD NCQA P4R

There are no changes to the Category 2 HARP measure set for 2019. All Category 2 measures are classified as P4R in measurement year 2019.

New York HARP 2019 Quality Measurement Set, Category 2 Measures

Measure Measure Steward
Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder CMS
Asthma Action Plan American Academy of Allergy, Asthma & Immunology (AAAAI)
Asthma: Assessment of Asthma Control – Ambulatory Care Setting AAAAI
Asthma: Spirometry Evaluation AAAAI
Continuing Engagement in Treatment (CET) Alcohol and Other Drug Dependence NYS
Initiation of Pharmacotherapy upon New Episode of Alcohol Abuse or Dependence NYS
Mental Health Engagement in Care 30 Days NYS
Percentage of HARP Enrolled Members Who Received Personalized Recovery Oriented Services (PROS) or Home and Community Based Services (HCBS) NYS
Use of Opioid Dependence Pharmacotherapy NYS

To reimburse the MCOs for participating in the VBP, the state implemented a stimulus adjustment in the 2018 MCO rate setting process to increase the managed care capitation premium for those MCOs that have captured more provider-payment dollars in VBP arrangements at higher levels. The adjustment lasts for two years.

The state described the arrangements in “A Path Toward Value Based Payment: Annual Update November 2017: Year 3, New York State Roadmap For Medicaid Payment Reform,” which was released in November 2017. From 2018 on, based on the prior year’s VBP contracts, MCOs that fall behind the goals for VBP contracting as outlined in the Roadmap will receive a penalty. Additional details are as follows:

  • For 2018, MCOs were subject to a penalty if they had less than 10% dollars of total MCO expenditure captured in Level 1 or above VBP contracts as of April 1, 2018. The penalty was 0.5% on the marginal difference between 10% of Medicaid managed care expenditure and their total expenditure on Level 1 or above VBP contracts.
  • For 2019, fully capitated and non-fully capitated MCOs are both subject to penalties if as of April 1, 2019, their contracts fail to have at least 50% of the total MCO expenditures captured in a Level 1 or higher arrangement. The penalty is 1% on the marginal difference between 50% Medicaid managed care expenditure and the MCO’s total expenditure on Level 1 or above VBP contracts. Both types of MCOs are subject to penalties based on the share of expenditures captured in a Level 2 or higher arrangement. Fully capitated MCOs must have 15% in Level 2 or higher contracts; non-fully capitated MCOs must have at least 5%. Failure to meet the Level 2 target results in a penalty of 1.0% on the marginal difference between the contracting target and the total expenditure on Level 2 or above VBP contracts. If both penalties are incurred, then only the larger penalty will be applied.
  • As of April 1 2020, fully capitated and non-fully capitated MCOs are both subject to penalties, if their contracts fail to have at least 80% of the total MCO expenditures captured in a Level 1 or higher arrangement. The penalty for fully capitated MCOs is 1% on the marginal difference between 80% Medicaid managed care expenditure and the MCO’s total expenditure on Level 1 or above VBP contracts; for non-fully capitated MCOs, the penalty is 1.5%. Fully capitated MCOs must have 35% in Level 2 or higher contracts; non-fully capitated MCOs must have at least 15%. Failure to meet the Level 2 target results in a penalty of 1.0% (or 1.5% for the non-fully capitated MCOs) on the marginal difference between the contracting target and the total expenditure on Level 2 or above VBP contracts. For the fully capitated MCOs, if both penalties are incurred, both will be applied. For the non-fully capitated MCOs, only the larger penalty will be applied.

HARPs are a Medicaid Special Needs Plan (SNP) operated by New York’s Medicaid MCOs. The HARPs have a specialized staff with behavioral health expertise, and the plan provides all covered services available through Medicaid managed care, in addition to an enhanced benefit package that includes BH HCBS for eligible enrollees. HARP eligibility criteria has been determined by the state. Beneficiaries eligible for HARP cannot be dual enrolled (receiving both Medicare and Medicaid) or participating in a program with the New York State Office for People With Development Disabilities (OPWDD).

The state launched the first VBP pilot in the Fall of 2016. The long-term goal is that by April 2020, 80% to 90% of MCO payments to provider organizations will  be made using VBP methodologies. The VBP pilot lasted for two years to help create momentum in the transition from fee-for-service to a VBP environment and to provide data about the design of VBP. The pilot included six provider organizations and eight MCOs working together on 12 distinct contracts. The contracts pilot three types of VBP arrangements: HARP subpopulations, Integrated Primary Care (IPC), and Total Care for the General Population (TCGP). The HARP pilots included MCO Healthfirst PHSP, Inc. and provider organizations Maimonides Medical Center and Mount Sinai Health Partners. The pilot organizations helped evaluate the validity, feasibility, and reliability of quality measures for their respective arrangements, and they shared feedback on core aspects and best practices of the VBP process for statewide implementation. The 2018 performance results, in terms of penalties and bonuses, were not reported. The Measurement Year (MY) 2019 HARP Quality Measure Set was created in collaboration with the Behavioral Health/ HARP Clinical Advisory Group (CAG), as well as the New York State Value Based Payment (VBP) Workgroup. For measure year 2019, the quality measures in place for 2018 were reviewed by the VBP Measure Support Task Force.

The VBP Measure Support Task Force sorted the measures into three categories:

  • Category 1 measures are approved measures that are deemed to be clinically relevant, reliable, valid, and feasible. VBP contractors report Category 1 measures to the managed care organizations (MCOs). These measures are intended to be used to determine the amount of shared savings for which VBP contractors are eligible. VBP contracts must include at least one Category 1 pay-for-performance measure.
  • Category 2 are measures that are clinically relevant, valid, and reliable, but where the feasibility could be problematic. These measures were investigated during a 2017 and 2018 pilot program. These measures will be further investigated in the VBP Pilots. The state requires that VBP Pilots select and report a minimum of one Category 2 measure per VBP arrangement for measurement year 2019 (or have a state and plan approved alternative). VBP Pilot participants will be expected to share meaningful feedback on the feasibility of Category 2 measures when the CAGs reconvene. The state will discuss measure testing approaches, data collection, and reporting requirements with VBP Pilots as a part of the Measure Support Task Force.
  • Category 3 measures are those that were identified as unfeasible at this time, or as presenting additional concerns including accuracy or reliability when applied to the attributed member population for an arrangement. As a result, Category 3 are not included in the measure set.

PsychU reported on the HARPs in “New York Medicaid Releases RFQ For Adult Behavioral Health Benefit Plans Outside New York City,” which published on July 30, 2015.

For more information, contact: Delivery System Reform Incentive Payment (DSRIP) Program, New York State Department of Health, Empire State Plaza, Corning Tower, Albany, New York 12237; Email: dsrip@health.ny.gov.

Your organization has prepared. You’ve done your homework and built partnerships with health plans. You have the contract. The real question is, once you have the contract, then what? That was the topic of the session, Mapping Performance To Manage Value: The Clinical Data You Need To Manage The Risk Of Value-Based Reimbursement, featuring Luke Crabtree, J.D., MBA, Chief Executive Officer, Project Transition; Jason Turi, MPH, RN, Vice President of Population Health, Centerstone; and moderated by OPEN MINDS Senior Associate Joseph P. Naughton-Travers, EdM.

This question assumes that your executive team has done the obvious—made sure that the organization has “the basics” for value-based reimbursement (VBR) operations. Those basic competencies include the right technology-driven capabilities, the financial management skills, the clinical models, and more. For more on VBR competencies, see Four Ps For Leading A VBR Evolution (Or Any Change).

But once you “go live” with VBR, then what? Being ready and being successful are two separate issues. Mr. Crabtree and Mr. Turi shared their insights on VBR success and what is required to make those partnerships work. Their keys for success include:

Agree on what “value” means—Every payer and health plan are going to have a different definition of the “value” they are looking for from your services. Those value measures will have different priorities. Be sure you understand the many perspectives on value, perspectives that will vary by different executives in the same organization. And once you have that understanding, do another review to make sure that those “value priorities” are in sync with your VBR contract so your team spends their time on the right priorities. I am reminded of the Peter Drucker adage, “There is nothing so useless as doing efficiently that which should not be done at all.”

Define each performance measure—Defining a big concept like “value” is important, but that doesn’t outline a path for achieving that value. Value is all about quantifying performance and being able to show “how much” value is being produced, using measures that are important to the payer or health plan. If it’s not measurable, it really doesn’t count. Mr. Crabtree noted the use of data dictionaries and nationally recognized normed measurements.

Establish and maintain performance improvement initiatives—Once defined, your team needs to focus on metrics-based performance management. And, it is not enough to have a good dashboard. It’s all about using that data for on-going performance improvement.

Realize there is no “one” perfect software solution—What technology should your organization invest in, and which vendors are the best fit to partner with? For success with VBR, it is likely that your organization will need to have several software platforms—for EHRs, dashboards, care coordination, population health management, consumer engagement, clinical outcome measures, and more. The important part is understanding the functionality needs of your team.

Integrate “all” of your data—Beyond technology-facilitated functionality, in VBR arrangements your executive team needs a performance management tool that combines data from all sources to get the “big picture” of your organization’s performance (see Thinking About Partnering With A Tech Start-Up? and Preparing For The Very Glacial VBR Rollout In Some Markets). This is one of the most fundamental strategic issues for specialty provider organizations that want to participate in pay-for-performance initiatives. Health information exchange is an essential capability (see Are You Strategically Interoperable? and HIE 3.0?).

Engage consumers—Making consumers a partner in managing their wellness is critical to success in VBR arrangements. The data is clear: engaged consumers are activated consumers are healthier consumers (see Getting, & Keeping, Consumers Engaged With Technology).

Acknowledge that the transition is hard—It is unfortunate but there will be a long period of time for most organizations where there are both FFS and VBR contracts. This creates challenges in organizational structure, in performance management, and in hiring. And, it means that staff can easily be confused about priorities and often asked to perform extra work with two systems in place. Communicate this and engage your team in how best to optimize overlapping workflows (see The Future Has Arrived For VBR).

About 70% of Medicare Advantage members surveyed report having one or more chronic conditions, however 44% of respondents said their health care plan does not communicate with them about their chronic condition. Just 10% report that their health plan offers reminders about chronic conditions, but these reminders are often general reminders not tailored to their needs. Chronic conditions reported include:

  • Hypertension (65% of respondents)
  • Hyperlipidemia (37%)
  • Diabetes (22%)
  • Obesity (22%)
  • Asthma (11%)
  • Depression (11%)

These findings were based an analysis of the HealthMine Medicare Survey. During June and July 2018, the survey queried 781 Medicare Advantage-insured consumers, aged 65 and above. The goal was to give health plan sponsors insight into member attitudes and desires about health plan communication and help in informing and planning members’ health.

Members want communication from their health plan on several topics. These include:
Health Plan Communications By Topic

Topic Members Who Want Communication On This Topic Members Who Receive Communication On This topic
Chronic condition 28% 15%
Fees/coverage after service 43% 37%
How to lower health costs 47% 11%
Information from digital health tools 12% 12%
Recommended health screenings 53% 48%

About 86% of respondents believe that their health care provider knows best how to help manage their health care, while only 3% believe their health plan best provides health care. Additional findings include:

  • About 53% said they do not receive any follow up from their health plan after a health care provider visit. About 31% report follow-up regarding coverage, benefit, and bills only; while 16% report follow-up regarding quality of care.
  • About 48% report that their preferred communication method is by telephone; 31% prefer digital communication via email, text, web portal, or a mobile app; and 21% prefer communication via the U.S. mail.
  • About 47% are connected to their plan through a portal.
  • Approximately 52% say that their health care plan portal answers most or some of their questions. About 14% say the portal rarely answers their questions, and 33% said the portal never answers their questions.
  • About 31% report that they are informed when health care providers drop out of their health care network.
  • About 77% use digital health tools. These primarily include blood sugar monitors, physical health trackers, electronic health or electronic medical records, medication trackers, heart rate monitors, food or nutrition trackers, and sleep monitors.
  • About 57% of members know if their plan offers telemedicine; about 31% believe telemedicine is not offered.
  • About 79% do not have easy access to their electronic medical records.

The researchers concluded that getting correct information to health plan members in a timely manner is critical to the success of health care management. Follow-up can be important in better managing both physical health for the members, and cost-related factors for health plans.

Health Mine reported the top-line findings in “60 Percent of Medicare Advantage Beneficiaries Say Plan Does Not Incentivize Action to Improve Health”, which published January 6, 2019, as a press release at www.PRNewswire.com.

For more information, contact: Bryce Williams, President and Chief Executive Officer, HealthMine, Inc., 2911 Turtle Creek Boulevard, Suite 1010, Dallas, Texas 75219; 469-730-5320; Email: ITSupportTeam@healthmine.com.

“Unfit” organizations aren’t likely to be successful with growth. That’s a bold statement but one that I see as a growing problem among specialty provider organizations. Changes in the market and leadership inaction have let the fitness of many organizations atrophy—financially, operationally, and in terms of market positioning. In a market where successful growth strategies are both market-driven and capabilities-driven, organizational fitness is key. It’s hard to grow from a position of weakness.

So which organizations are “fit” and ready for the challenges of growth? These organizations have clear priorities, their investments and management team attention mirror those top priorities, they understand how their services stack up in terms of customer preference and the competition, and the focus of the management team is on improving those metrics. The big issue is that most organizations don’t have the performance data they need to set priorities, create services lines with competitive market positioning, and put forward a winning value proposition for customers.

Figure 1. Oss, Monica. Is Your Organization Fit For Growth? [PowerPoint Slides] Retrieved from www.openminds.com.

The right metrics are essential to understanding the distinctive capabilities that your organization has that can fill an “unfilled” gap in the market and continue to remain competitive. And, that’s not enough—managing the performance of your organization to hit the performance you promised is essential for the long-term. (For more, check out these resources from PsychU Resource Library What Does It Take To Outlast The Disruptors?Make Change Or Be Changed, and Innovation Success In Three Steps.)

This ability to identify unique capabilities—and keep ahead of the competition using data is the critical factor. The organization that is most successful in continually positioning and repositioning its service lines—and delivering on that positioning promise—will be the winner. The key is keeping your portfolio stocked with services that are relevant and competitive. While these are challenges of technology, they are also challenges of executive culture. For more on defining unique capabilities, check out these resources from the PsychU Resource Library:

  1. ‘Productizing’ Services For Competitive Success
  2. Consumer Sovereignty: Better Care = Financial Success
  3. The Enablers Of Competitive Advantage
  4. Health Plan Relationship Building Skills Key To VBR Success

For much of my career, provider organization executive teams have talked about performance management, but left the tough issues on the table with the thought that they would get to it at some point in the future. I think that future has arrived.

The late Peter Drucker said, “If you can’t measure it, you can’t improve it.”

I think that is a statement that most managers would agree with. So my question—raised by Roland Larkin, NP, Ph.D., MBA, Medical Science Liaison, Otsuka Neuroscience and Srikanth Gottipati, Ph.D., M.Phil, Associate Director, Think Team, Otsuka Pharmaceutical Development & Commercialization, Inc., in their session, Measurement Informed Treatment Assistant for Mental Health—why do only 7% of psychiatrists routinely use measurement based psychiatric scales when planning consumer treatment?

We know measurement-based care works. One study found that response rate to treatment is 87% when measurement-based care is used, compared to 63% when the standard of care is used. Even more startling, measurement-based care results in a 74% remission rate, compared to 29% when the standard of care is used. (For more, see The Moving Target—Best Practices In ‘Complex’ Care Management.)

So why the lack of adoption of measurement-based care? Especially now that digital technology gives provider organizations the decision support tools and ability to analyze data as they talk to consumers. Examples of these tools include mHealth sensors, digital interventions and assessments, and medication adherence technology.

A lot of it comes down to issues with digital tech adoption. First, both clinical professionals and consumers must accept the use of the technology and trust that it will improve care. There must be the infrastructure to support the technology and integrate it into clinical practice. Then there are the regulatory and privacy concerns. Finally, consumers must be comfortable with technology and engage with it. Many times, one (or more) of these elements isn’t present.

Figure 1. Mandros. A. Why So Little Measurement-Based Mental Health Care? [Powerpoint Slides] Retrieved from www.openminds.com

Another issue is the way in which the field approaches evidence-based practices. For example, of the 10 million adults in the United States who were living with serious mental illness (SMI), only 32% received medication management and only 19% received support for illness self-management (see Why Do Only A Third Of Consumers With SMI Receive Evidence-Based Treatment?). Culprits for this include not including EBPs as part of a clinical professional’s initial education and training, and a lack of continuing education around EBPs for front-line staff.

Also, there hasn’t traditionally been a lot of financial incentives (like value-based care) to drive this adoption. The performance expectations of value-based purchasing arrangements will likely be demand that more provider organizations invest in standardized treatment protocols—protocols that will need more digital tech to achieve the necessary scale, efficiency, and return-on-investment.

Whatever the challenges with measurement-based care and the use of digital tools in the treatment of mental illness, there will be increasing pressure to use these approaches as value-based reimbursement becomes more common. To be successful in VBR, there are a couple of steps organizations need to follow. The first is to set performance standards. In this stage, organizations decide what to measure and how to measure it. The second step is metrics-based management. This is where you develop the systems and processes to use performance measurement in management. The final step is creating a performance-driven culture. In this step, you use the metrics agreed upon and integrated into your management in the first two steps to make changes to the system as necessary. Without this your organization is much more likely to be surprised when reconciling your value-based reimbursement.

For the past year, in almost every meeting that I’ve attended that focused on provider reimbursement from health plans, the number one concern is the definition of “value.” The question—if we are going to reimburse some organizations more than others for a particular service based on the “value” of that service, who defines “value” and how is it measured?

As a reminder, the “value equation” is quite simple—”performance” for the “cost.” But while cost is easy to determine, defining “performance” is a continuing challenge in the health and human service field.

Where are we now? The big payers—Medicare, Medicaid, and employers—predominantly rely on either National Committee on Quality Health Assurance (NCQA) Healthcare Effectiveness Data Information Set (HEDIS) measures, or their own set of measures (like CMS STARS) to assess the quality of health plans and accountable care organizations (ACO). The health plans and ACOs—over 90%—are focused on improving those “big picture” payer metrics.

But one key question is whether those measures really work for consumers with complex conditions in general, and for behavioral health in particular. And even on the limited number of NCQA HEDIS and CMS STARS measures that might apply to this consumer population, the performance isn’t great. It’s a work in progress. According to the latest Centripetal reference guide, health plan performance on the behavioral health measures has been mixed, with some measures showing performance gains, and others showing performance declines (see Trends in Behavioral Health: A Reference Guide On The U.S. Behavioral Health Financing & Delivery System).

This issue—and how it affects the emerging value-based contracts between specialty provider organizations and health plans—was the topic of the session, What Do We Mean By “Value”? A Discussion Session On Defining, Measuring & Reporting Value. The session, facilitated by OPEN MINDS Senior Associate Joseph P. Naughton-Travers, brought together three health plan executives who are making this happen—Angie Costello, Assistant Vice President, Value-Based Payment Products, Beacon Health Options; Matt Miller, Senior Vice President, Public Sector, Magellan Healthcare; and Zoe Webb, Network and Contract Director, Cigna Behavioral Health-Northeast Region.

The panel discussed that at this point, there are few alternatives to the focus on HEDIS and CMS STARS measures. And their overall message was that in negotiations with health plans, it up to the executives of specialty provider organizations to “prove” how they can deliver “value” as currently defined. The panel offered four pieces of advice on this process.

Understand your impact on HEDIS measures—One of the primary and most important data sets that provider organization executives need to keep in mind are HEDIS measures (see ‘Rapid Access’ Might Just Be Your Next Health Plan Conversation and Solve The Problem, Gain A Partner.) Ms. Webb explained that provider organizations come with data and Cigna compares that with the HEDIS measures to designate who has have met those benchmarks.

Know what you are good at—Once a provider organization’s executive team understands the perspective of a potential health plan customer, the next step is for that team to know what they are good at today, and how incremental improvements can be made from a partnership built on the data (see Digital Transformations Demand Digital Dexterity). The panel was adamant that before a value-based discussion can happen, there needs to be a discussion about data and complete buy-in at all levels of the organization. Mr. Miller explained, “Two things jump out. The whole organization needs to be ready for change. And second, you need to understand what data you are being measured by. That needs to be transparent.” Ms. Webb also noted that this is incremental and starts with a partnerships, and building those partnerships has to happen on the data. Before there is even a value-based discussion, there has to be a discussion about the data.

Start the conversation with a value story—The data, both provider organization data and health plan data, is key to developing a contract. But a key is to put organizational performance in context and create a narrative of how the provider organization services can improve specific performance metrics and “value” to consumers. Ms. Webb explained that Cigna looks at member satisfaction outcomes as one of the primary measurements, and if providers want to begin to track what they think are the metrics for proving better quality of life, and what that means, that is a big positive. This will vary depending on the population and what their challenges are.

Ms. Costello added, “As a payer, we are focusing on VBPs with providers where membership attributions are high. Those relationships will yield great opportunities for us to recognize value to our members. Know your membership and how you can demonstrate your value to their total care.”

Be prepared operationally—As the field shifts away from fee-for-service (FFS) operations, provider organizations do need new operational processes for the wholeprocess of delivering and managing services within a value-based model. Mr. Miller explained:

We can write the contract that you need, but there must be someone who can administer it, for both the payer and provider. If we can’t play the claim, it won’t do any good. Most of the value-based reimbursement we’re participating in today is at the grass roots level and in partnership with the provider. It must be, “can we do this?”

Ms. Costello added, “No matter how solid your clinical expertise and performance, strong administrative and billing support at the payer/provider level is essential to a positive VBP relationship.”

The panel’s final takeaway for the day—approach this process with patience. This kind of transformation and contracting isn’t the kind of thing that will happen quickly, but will involve a lot of relationship building, time, and hurdles along the way. Mr. Miller noted, “It’s not going to be this monumental thing that happens tomorrow. It is happening, and we know it’s happening. It’s nothing to be frightened of. It’s something to be excited about.”

Ms. Costello added, “Establishing the right outcomes and payment model takes time. It’s a collaborative effort between the payer and provider. Be patient, as we build those VBPs together. We all are striving for the same primary outcome…better care for our members.”

About 54.7% of those diagnosed with major depressive disorder (MDD) stopped treatment after five months following their diagnosis. For those with MDD, a single treatment method (pharmacological or psychotherapy) of treatment was more common (58.5%) than treatment using both methods combined (36.2%).

These findings were reported in “Rates and Determinants of Use of Pharmacotherapy and Psychotherapy by Patients With Major Depressive Disorder” by Fraser W. Gaspar, Ph.D., M.P.H.; Catherine S. Zaidel, M.E.M.; and Carolyn S. Dewa, Ph.D., M.P.H. Through a data use agreement, researchers analyzed records from the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant IBM MarketScan Commercial Claims and Encounters database. This database contains records for over 260 employers and 40 health plans and is a convenience sample of employees with employer-sponsored health insurance: the data come mostly from large employers. The researchers identified 24,579 anonymous individuals with a diagnosis of major depressive order and focused on those individuals with a first diagnosis of “single-episode, major depressive disorder” and categorized as in remission, mild, moderate, or severe depression. The goal was to determine rates and factors of pharmacological and psychotherapy use after a diagnosis of MDD.

MDD is defined as having three phases:

  • The acute phase is when the individual is actively experiencing symptoms of depression. Successful treatment of the acute phase is the induction of remission. This phase has a minimum of six to eight weeks of time.
  • The continuation phase follows the acute phase, in which remission is preserved and relapse is prevented. This phase usually lasts 16 to 20 weeks.
  • The maintenance phase protects susceptible individuals against recurrence or relapse of subsequent major depressive episodes. Duration of this phase varies with the frequency and severity of previous episodes.

Antidepressant adherence is defined as having a proportion of days covered (PDC) by antidepressants of greater than, or equal to, 0.8 in the first 231 days following a diagnosis of MDD.

Most individuals were not receiving antidepressants or psychotherapy after the first five months following initial diagnosis of MDD, however the percentage of those with depression who received treatment was higher in this study then reported in previous studies. In the 12 months following diagnosis of MDD, 94.7% received either pharmacotherapy or psychotherapy, or both. Additional findings include:

  • For the 13,524 individuals prescribed antidepressants, 41.7% were adherent in the acute phase, while 32.0% were adherent during the continuation phase.
  • For initial antidepressant dosage prescriptions, 34.5% were outside guideline recommendations: 23.1% were below the recommendation, and 11.4% were above the recommendation.
  • When psychotherapy was initiated, the median number of visits in the year after a patient’s diagnosis was seven.
  • Initiating antidepressant treatment within 30 days of the first diagnosis of MDD was associated with increased odds of adherence. Adherence dropped similarly for all levels of diagnosed MDD as prescription time from the first diagnosis of MDD increased, with rates falling sharply after the first 30 days.

The researchers concluded that a shorter time from diagnosis to treatment, and a lower percentage of treatment costs paid by the health care consumer, were associated with increased antidepressant adherence and intensive psychotherapy use. Treatment guideline recommendations are not followed for a large group of those with MDD.

The full text of “Rates and Determinants of Use of Pharmacotherapy and Psychotherapy by Patients With Major Depressive Disorder” was published January 11, 2019 by Psychiatric Services. An abstract is available online at ps.psychiatryonline.org.

For more information, contact: Fraser W. Gaspar, Ph.D., M.P.H, Epidemiologist, MDGuidelines, 10355 Westmoor Drive, Westminster, Colorado 80021; Email: Fraser.gaspar@reedgroup.com

The National Quality Forum (NQF) recently endorsed two quality measures focused on consumer satisfaction of assisted living residents and their families. The resident satisfaction measure is focused on those living in an assisted living facility for two or more weeks. Satisfaction levels are based on responses to the four-item CoreQ: AL Resident Satisfaction questionnaire. The family (or designated responsible party) satisfaction measure is from the three-item CoreQ: AL Family Satisfaction questionnaire. The measure developer and steward is the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).

The CoreQ questionnaires measure individual experience with staff, care and overall satisfaction. Residents are also specifically surveyed on the food offered. Each measure calculates the percentage of individuals who are satisfied, thus yielding an overall score of satisfaction. AHCA/NCAL developed and released CoreQ in 2016 as part of the association’s Quality Initiative to ensure at least 90% of residents and/or family members are satisfied with their assisted living experience. CoreQ is a set of five measures for skilled nursing care centers (SNCC) and assisted living communities to use to assess satisfaction among residents, and their families. More than 15 customer satisfaction vendors offer CoreQ in questionnaires issued to assisted living customers, as well as automatically upload results on a member’s behalf into AHCA/NCAL’s quality and data tracking tool, LTC Trend Tracker. AHCA/NCAL member provider organizations may then monitor their customer satisfaction results over time and in relation to their peers.

NQF reported on the new measure endorsements in “Patient Experience and Function Final Report – Spring 2018 Cycle.” During the spring cycle of 2018, the NQF Patient Experience and Function Standing Committee evaluated the two newly submitted measures for assisted living settings against NQF’s standard evaluation criteria. Both new measures submitted for evaluation were endorsed. The NQF Patient Experience and Function measure topic area encompasses measures that address health-related quality of life and the many factors that influence it, including communication, care coordination, transitions of care, and use of health information technology.

The resident satisfaction measure (3420) and family satisfaction measure (3422) are not currently used in any accountability program. The Committee agreed that the resident satisfaction measure could be extremely helpful for quality improvement given the variability of performance in assisted living facilities. However, if the measure is used as a national benchmark, the Committee said the measure would need more constraints on how data are obtained to reduce gaming.

For the resident satisfaction measure (3420), the numerator is the sum of the individuals in the facility that have an average satisfaction score of =>3 for the four questions on the CoreQ: AL Resident Satisfaction questionnaire. The denominator includes all of the residents that have been in the AL facility for two weeks or more regardless of payer status; who received the CoreQ: AL Resident Satisfaction Questionnaire who responded within the two-month time window who did not have the questionnaire completed by somebody other than the resident, and who did not have more than one item missing. The denominator excludes residents with poor cognition, those receiving hospice, and those with a legal court appointed guardian.

For the family satisfaction measure (3422), the numerator is the sum of the family or designated responsible party for assisted living residents that have an average satisfaction score of =>3 for the three questions on the CoreQ: AL Family Satisfaction questionnaire. The denominator includes the family or designated responsible party members of a resident residing in the facility for at least two weeks. The denominator includes all the individuals in the target population who respond to the CoreQ: AL Family Satisfaction questionnaire within the two-month time window who do not meet the exclusion criteria. The denominator excludes court-appointed guardians; family of residents receiving hospice; family members who reside in another country, and family of residents who have lived in the assisted living facility for less than two weeks.

NQF is a non-profit, non-partisan, membership-based organization that works to catalyze improvements in health care. AHCA/NCAL represents more than 13,500 non-profit and proprietary skilled nursing centers, assisted living communities, sub-acute centers and homes for individuals with intellectual and development disabilities.

The full text of “Patient Experience and Function Final Report – Spring 2018 Cycle” was published in January 2019 by NQF. A copy is available online at www.qualityforum.org

More information about CoreQ is posted at www.coreq.org/

For more information, contact:

  • Media Relations and Online Communications, National Quality Forum, 1030 15th Street NW, Suite 800, Washington, District of Columbia 20005; 202-478-9326; Email: press@qualityforum.org
  • Rachel Reeves, Director of Communications, Press Office, National Center for Assisted Living, 1201 L Street NW, Washington, District of Columbia 20005; 202-898-2803; Fax: 202-842-3860; Email: rreeves@ncal.org; or American Health Care Association, 1201 L Street NW, Washington, District of Columbia 20005; 202-898-3165; Email: AHCAPressOffice@ahca.org

On December 18, 2018, Shatterproof announced plans to launch a rating system for addiction treatment programs; the ratings will be available for use by the public, private payers, states, and referral sources. The Shatterproof Rating System will standardize the evaluation of addiction treatment across all levels of care, settings, and types of treatment. The roughly $5 million project is supported by The Laura and John Arnold Foundation and the Robert Wood Johnson Foundation, as well as a group of health insurers: Aetna (a CVS Health business), Anthem, Inc., Beacon Health Options, Cigna, Magellan Health, and UnitedHealth Group.

The initiative will make the addiction treatment program’s ratings public –  showing whether or not each program offers services that align with proven, evidence-based best practices outlined in Shatterproof’s 2017 “National Principles of Care” for substance use disorder treatment. The National Principles of Care recommend that treatment be individualized, feedback-informed, and encompass the following eight principles:

  1. Routine screenings in every medical setting
  2. A personal plan for every health care consumer
  3. Fast access to treatment
  4. Disease management rather than inpatient treatment
  5. Coordinated care for every illness
  6. Behavioral health care from legitimate providers
  7. Medication-assisted treatment
  8. Support for recovery outside the health care professionals’ office

The Shatterproof rating program will rate any residential, outpatient, and intensive outpatient programs that are licensed, certified, or otherwise approved by the state to provide substance use disorder (SUD) treatment; as well as facilities that the state may not fund, license, or certify. The evaluation will also include programs operated by federal agencies, such as the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service, but will not examine individual clinical professionals or prescribers. The ratings will be based on data from insurance claims, provider organization surveys, and consumer experience to evaluate treatment, and will be based on recommendations by an expert committee convened by the National Quality Forum (NQF).

Publicly-available ratings will be reported on a single website with a public-facing dashboard, which will be searchable by commonly-sought treatment criteria (location, insurance, methods, etc.). The ratings will also be available on password-protected portals for treatment programs, payers, and states. The password-protected information will include more detailed information and the ability to compare and examine the data in different cross sections.

The initial rating system will launch in a five-state pilot during 2019, and ratings are expected to be published in 2020. The five states will be announced in the first quarter of 2019. Shatterproof will invite all addiction treatment programs in the pilot states to be included in the rating system by self-reporting. Data collection portals for the pilot states will open from July 2019 through November 2019. Shatterproof will then analyze the data and will offer a provider organization preview period before the ratings are published online in 2020. Shatterproof anticipates sustained implementation in the pilot states before phased expansion begins in 2020, which will be based on lessons learned from the initial five states.

Shatterproof is a national non-profit organization dedicated to ending the devastation the disease of addiction causes families. Shatterproof is focused on one specific, urgent goal: To transform America’s broken addiction treatment system. The organization is working to ensure every American with a substance use disorder has access to treatment based on proven research. Shatterproof advocates for changes to federal and state policy, payer reform, and provider ratings, and provides public education through family and workplace programs.

The full text of “National Principles of Care” was published February 14, 2018 by Shatterproof. A copy is available online at http://shatterproof.prod.acquia-sites.com

PsychU reported on this topic in “16 Health Insurers Endorse Standard Principles For Addiction Treatment,” which published on January 3, 2018.

For more information, contact: Holly Jespersen, Senior Communications Manager, Shatterproof, 135 W 41st Street, New York, New York 10036; 646-334-1024; Email: info@shatterproof.org

I think that the executives managing Medicaid programs have one of the toughest jobs in the field. All the regulations, the state and federal political factors, the budget pressures, and the changing factors affecting health care costs and utilization make “success” a moving target.

Medicaid is of growing importance to the U.S. health care system—with 19% of the population covered under Medicaid. So, when Medicaid executives make big changes in their program, the impact is substantial—on consumers, families, advocates, professionals, provider organization executives, and health plan managers. So how do Medicaid directors think about the system change and about improving quality and managing budgets? To answer that question, we turned to Linda Zeller, currently the Senior Behavioral Health Fellow of the Michigan Health Endowment Fund and formerly Michigan’s Deputy Director for the Behavioral Health and Developmental Disabilities.

Her take? Decisions about Medicaid policy and practice are increasingly made using analytics. And, those analytics are changing along with the tools for analyzing large data sets that include capturing data, data storage, data analysis, search, sharing, transfer, visualization, querying, updating, and information privacy.

But even with data, we’ve seen organizations struggle to turn that information into a meaningful strategy or operational practice. Many organizations lack the digital dexterity to yield results, and when compared to other industries, health care struggles with preparedness for disruptive business models (see Crossing The Digital Health Chasm). What are the biggest impediments that Ms. Zeller has seen, to using data analytics to manage care for the complex consumer population? How has she seen state Medicaid plans, health plans, and provider organizations working to address these challenges?

The challenge is targeting what we need to look at and not being overwhelmed by the amount of data. It’s easy to lose sight of the purpose and focus. And now that so much of Medicaid coverage is managed by health plans, there is also a challenge at the health plan level of synthesizing Medicaid and Medicare data. Until Medicare and Managed Care Advantage Plan data is available in a parallel format to Medicaid data, we are going to have a really hard time using that data. You need both data sets to really understand what is happening at the consumer level.

There is a lot of investment going into innovation in health care space—both among traditional provider organizations and in new start-up organizations. The leaders of these organizations are trying to understand how State Medicaid directors look at innovation and new service delivery approaches. Ms. Zeller provided some insight into innovation at the state level:

I think we are going to see a move at the Medicaid program level to a real population health model. We’ll see more of a focus on prevention and early intervention. And a focus on specific targeted populations with a subset of strategies for different populations, including addressing the social determinants of health (SDH). This will shift the interest of Medicaid Directors to how systems of care can work better within Medicaid.

A great example is homelessness. We have continued to struggle to get our homeless management information systems to connect with the Medicaid claims data. When we did, we saw a high correlation of those without housing who also had psychiatric inpatient or addiction related residential inpatient. This is a nontraditional data source for a Medicaid Director to use, but that is something I think they increasingly want to happen.

To learn more about the specific Medicaid initiatives in every state, check our 50-state profile series—the PsychU Behavioral Health System State Profiles. Each profile includes detailed information about health care coverage; managed care programs and benefits; care coordination initiatives; health homes and medical homes; and dual eligible care management.

The costs of the 25 most frequently prescribed drugs in 2017 represented about 42.8% of the total $8.7 billion in total drug spending for California commercial health plans. These drugs represented 47.7% of prescription drugs dispensed through retail or mail order pharmacies and paid directly by commercial health plans. For the 25 most frequently prescribed drugs, enrollees paid 2.9% of the cost of specialty drugs and 56.6% of the cost of generics.

The California Department of Managed Care (DMHC) reported these findings in “2017 Prescription Drug Cost Transparency Report.” The report was compiled in response to state Senate Bill (SB) 17, which required health plans and health insurers that file rate information with the DMHC and/or the California Department of Insurance (CDI) to report specific data related to prescription drugs beginning October 1, 2018, and annually thereafter. In addition, SB 17 requires health plans that file annual large group rate information to the DMHC and CDI to also file specified information regarding plan spending and year-over-year cost increases for covered prescription drugs. Large group rate information will be included in the DMHC’s annual public meeting regarding large group rates but is not discussed in this report. The bill also requires that drug manufacturers provide advance notice for significant prescription drug cost increases; certain information in the notices will be public information.

According to a parallel report issued by CDI, costs of the 25 most frequently prescribed drugs in 2017 represented about 34.8% of the total $1.2 billion drug spending for nine commercial health plans that report to CDI. These drugs represented 39.9% of the 10.5 million prescription drugs dispensed through retail or mail order pharmacies and paid directly by commercial health plans. Members paid about 23% of the cost for the 25 most frequently prescribed drugs. For the 25 most frequently prescribed drugs enrollees paid 6.1% of the cost of specialty drugs and 58.5% of the cost of generics.

The data to be reported includes the proprietary drug names and therapy classes for generic, brand name, and specialty drugs. The number of prescriptions was measured in terms of units. DMHC and CDI are required to issue an annual report that summarizes how prescription drug costs affect health plan premiums; the data is aggregated to ensure that health plans’ specific data remains confidential. For 2017, DMHC analyzed data reported by 25 commercial health plans; and CDI analyzed data reported by 9 commercial health plans. Each reported the following information:

  • The 25 prescription drugs most frequently prescribed to health plan enrollees
  • The 25 most costly prescription drugs by total annual health plan spending
  • The 25 prescription drugs with the highest year-over-year increase in total annual plan spending

For this report, the DMHC and CDI considered the total volume of prescription drugs prescribed, and the total cost paid by health plans for these drugs, on both an aggregate spending level and a per member per month basis. The analysis focused on the impact on health plan premiums created by the 25 most frequently prescribed drugs, the 25 most costly drugs, and the 25 drugs with the highest year-over-year increase in total annual spending.

DMHC reported the following key findings:

  • Brand name drugs accounted for 10.6% of prescriptions and constituted 24.8% of the total annual spending on prescription drugs
  • Specialty drugs accounted for 1.6% of all prescription drugs and accounted for 51.5% of total annual spending on prescription drugs.
  • Generic drugs accounted for 87.8% of all prescribed drugs and accounted for 23.6% of the total annual spending on prescription drugs.
  • Overall, plans paid 91.2% of the cost of the 25 Most Costly Drugs across all three categories (generic, brand name and specialty).
  • Prescription drugs dispensed through retail or mail order pharmacies accounted for about 13.1% of total health plan premiums. Health plan prescription drug costs increased by 5.0% in 2017; medical expenses increased by 5.9%. Overall, from 2016 to 2017, total health plan premiums increased by 4.8%.

CDI reported the following key findings:

  • Brand name drugs accounted for 27% of all 10.5 million prescriptions, and constituted 13% of the total $1.2 billion annual spending on prescription drugs
  • Specialty drugs accounted for 3% of all prescription drugs and accounted for 52% of total annual spending on prescription drugs.
  • Generic drugs accounted for 84% of all prescribed drugs and accounted for 21% of the total annual spending on prescription drugs.
  • Overall, plans paid 88.7% of the cost of the 25 Most Costly Drugs across all three categories (generic, brand name and specialty).
  • The cost of prescription drugs (net of rebates) dispensed through retail or mail order pharmacies accounted for about 13.6% of total health plan premiums.
  • Health plan prescription drug costs increased by 6.1% in 2017; medical expenses increased by 7.6%. Overall, from 2016 to 2017, total health plan premiums increased by 4.6%.

Each report includes three separate lists of the 25 most frequently prescribed generics, the most frequently prescribed branded, and the most frequently prescribed specialty drugs. Neither released an aggregated list of the top 25 most frequently prescribed drugs across generic, branded, and specialty.

For more information, contact:

  • Stakeholder Relations, California Department of Managed Health Care, 980 9th Street, Suite 500, Sacramento, California 95814-2725; Email: stakeholder@dmhc.ca.gov.
  • Communications & Press Relations Branch, California Department of Insurance, 300 Capitol Mall, Suite 1700, Sacramento, California 95814; 916-492-3566; Fax: 916-445-5276; Email: cdipress@insurance.ca.gov.

It’s not uncommon to meet with an executive team and have them share that they think their organization is “underperforming.” Revenue are down, margins are down, productivity is down, performance bonuses are missed, plans aren’t implemented … the stated list of reasons for poor performance are many. Most often, I hear the “staff” isn’t performing. But what does that mean?

Beyond a list of lagging indicators, most managers I meet with can’t take the performance discussion much further. What are leading indicators that predict “poor performance” outcomes (leading indicators that allow manager intervention)? What are the causes of poor performance on those leading indicators? What supervisory interventions in process and practice would correct those causes of poor performance? And are supervisors willing and able to make those interventions? The answers to these questions are the “secret sauce” of metrics-based management.

With a more competitive market for health and human services—and a growing reimbursement focus on value—metrics-based management is more important than ever. Success with performance management was the topic of the session, “How To Adapt Your Organization To The Future: A Guide To Managing Data For A Performance-Driven Environment,” featuring OPEN MINDS Senior Associate Joseph P. Naughton-Travers along with the Kings View Corporation team including Anthony Prieto, Director of Health information Analytics; Leon Hoover, Chief Executive Officer; Alex Rocha, Quality Improvement Director; and Jim Rodriguez, Chief Financial Officer.

The Kings View team gave a great case study of metrics in action. And, in their presentation, they identified their four keys to creating a metrics-based, performance-driven environment.

Widespread cultural commitment—A performance-based culture demands commitment at all corners of the organization, and the baked-in ability to encourage staff to consider their performance in terms of value to both the organization and consumers. Mr. Hoover noted, “It takes a lot of people working together and focused on the mission. It’s ‘The One Team Culture.’ And it takes a lot of executive team effort to have the culture and the information.” Mr. Rodriguez noted that to do this, there needs to be cultural adoption across the system, and that value must be shown across the system. He explained that this is an organizational project—it’s not only an “IT” project. The dialog and the commitment of resources must be shared organization wide, with a commitment to the investment-money, time, and staff.

Set goals—Just like strategic plans, budgets, and new service lines, performance culture won’t implement itself. Building a culture of performance means just that. Take the time to deliberately build it, with achievable goals set along the way. Mr. Rodriguez gave examples of setting these goals, noting that organizations need to keep pace with the internal and external factors. They need to be good and cutting edge at analytics in a way that gives them an advantage. Organizations also need a standard and consistent reporting system that was compatible with other systems we may bring online.

See “all” the data—A performance culture really is a data-driven culture, and it’s built on measuring value for consumers and payers alike. Does everyone know what measures will reflect their job performance and how they can improve that performance? Do the necessary executives know, collect, and review all the available metrics as a standard way of managing? Mr. Prieto noted:

When we have the data we need, we are better prepared to have meaningful conversations with our staff. Having the data in a visual dashboard allows us to focus on executing our high-performance strategy without wasting time searching for data buried in spreadsheets. How do we solve the need for constant “follow up” questions? By having dashboards that pull data from all our systems.

Leadership must own the process—Staff at all levels comprehend and respond to cultural expectations based on how leadership communicates and acts on that culture. When an organization’s leadership reflects a performance-oriented, problem-solving approach, staff respond more positively. Mr. Hoover noted that when it comes down to people embracing this or not, your leadership really needs to have ownership of the process. Look at this in management meetings, and then drill down to find out how staff like it and are embracing it.

I couldn’t agree more with these four keys. And I have a few tips for making performance management a reality in health and human service organizations, based on my own experience. First, measure what you can now and build your performance management metrics over time. From your organizational strategy, do create an overarching “dream” set of metrics your management team needs. But, don’t put off measuring and using what you can now. The important part is creating management practices focused on performance. Second, transparency is your friend (in the long run). Organizational performance data shouldn’t be a secret-openness about performance and discussions about the validity of the performance data and the reasons for poor performance are critical to creating that culture. I have found that the initial push back to transparency of performance data is fierce for many reasons. But getting every team member, from the c-suite on down, to embrace an open review of performance is a critical cultural step. Finally, executive leaders have the obligation to make sure that every team is “positioned and prepared” for success—and that every team has a leader that can execute on managing by the metrics. This is a tall order, but it is the transition that successful health and human service organizations need to make to succeed in an environment if disruptive competition and margins dependent on customer-defined performance.

For more, check out these resources from the PsychU Resource Library:

  1. Becoming A ‘Blue Chip’ Provider Organization
  2. Using Consumer Experience Data As Management Tool
  3. The Five-Step Process To Demonstrate Your “Performance” To Health Plans

California behavioral health professionals in health plan networks scheduled at least 57% of urgent appointments within the standards set by the state’s 2010 Timely Access Regulation. At least 71% of non-urgent appointments were scheduled within the time set by the standards. Overall, individual behavioral health plan performance ranged between 64% and 83% of urgent and non-urgent appointments scheduled within the standards. This was the result of an analysis of six behavioral health plans conducted by the state Department of Managed Health Care (DMHC). For urgent appointments, the percentage of surveyed network professionals who had appointments available within the wait time standards ranged from 57% to 80%. For non-urgent appointments, the percentage of surveyed network professionals who had appointments available within the wait time standards ranged from 71% to 87%.

ValueOptions of California, Inc. (ValueOptions) had the highest overall rating at 83%, and OptumHealth Behavioral Health Solutions of California (OptumHealth) had the lowest overall rating at 64%. For urgent appointments, Holman Professional Counseling Centers (Holman) had the highest rating at 80% and Optum, had the lowest rating at 57%. For non-urgent appointments, Human Affairs International of California (HAI-CA), Managed Health Network (Managed Health), and ValueOptions had the highest rating at 87% and Optum, had the lowest rating at 71%.

California Behavioral Health Plan Timely Appointment Access Survey Findings, Measurement Year 2017

Plan Overall Urgent Non-Urgent
Cigna Behavioral Health of California, Inc. (Cigna) 75% 64% 85%
Holman Professional Counseling Centers (Holman)  77% 80% 78%
Human Affairs International of California (HAI-CA) 79% 71% 87%
Managed Health Network (Managed Health) 80% 72% 87%
OptumHealth Behavioral Health Solutions of California (OptumHealth)  64% 57% 71%
ValueOptions of California, Inc. (ValueOptions) 83% 79% 87%

The Timely Access Regulation, which became effective in 2010, requires that health plan networks be sufficiently large to meet a set of standards, which include specific timeframes under which enrollees must be able to obtain care. These standards include wait times to access urgent and non-urgent care appointments, as well as the availability of telephone triage or screening services during and after regular business hours. The wait time standards are as follows:

  • Urgent care (prior authorization not required by health plan): 48 hours
  • Urgent care (prior authorization required by health plan): 96 hours
  • Non-Urgent Doctor Appointment (primary care physician): 10 business days
  • Non-Urgent Doctor Appointment (specialty physician): 15 business days
  • Non-Urgent Mental Health Appointment (non-physician, including counseling professionals, addiction treatment professionals and qualified autism service providers): 10 business days
  • Non-Urgent Appointment (ancillary provider, including purposes such as lab work or diagnostic testing, such as mammogram or MRI, and treatment of an illness or injury such as physical therapy): 15 business days

DMHC reported the findings in “Timely Access Report Measurement Year 2017.” The DMHC required full service health and behavioral health plans to utilize external vendors to validate the health plans’ Timely Access data and conduct a quality assurance review of their compliance reports prior to submitting them to the DMHC, a requirement that was first implemented for measurement year 2016. The goal was to summarize California provider appointment availability data that health plans submitted to DMHC for 2017. The survey included non-physician mental health professionals, psychiatrists, and child and adolescent psychiatrists for both urgent and non-urgent appointments. The analysis focused on findings of an appointment wait time survey of network professionals’ participating in behavioral health plans’ Commercial, Individual/Family, and Medi-Cal products during 2017. All six plans offered a commercial product, but only two of the six plans offered all three products: HAI-CA and OptumHealth

Timely Access For Commercial Behavioral Health Plans, Overall, Urgent & Non-Urgent Appointments
Plan Overall Urgent Non-Urgent
Cigna 75% 64% 85%
Holman 77% 80% 78%
HAI-CA 80% 72% 88%
Managed Health 80% 72% 87%
OptumHealth 64% 57% 71%
ValueOptions 83% 79% 87%
Timely Access For Individual/Family & Medicaid Behavioral Health Plans, Overall, Urgent & Non-Urgent Appointments
Individual/Family Plans Overall Urgent Non-Urgent
HAI-CA 80% 72% 88%
OptumHealth 64% 57% 71%
Medicaid Behavioral Health Plans Overall Urgent Non-Urgent
HAI-CA 78% 70% 87%
OptumHealth 62% 54% 69%

PsychU reported on access standards in “State Medicaid Managed Care Access Standards Did Not Improve Access To Specialists,” which published on September 25, 2017.

For more information, contact: Rachel Arrezola, Communications and Planning, California Department of Managed Health Care, 980 9th Street, Suite 500, Sacramento, California 95814-2725; 916-445-7442; Fax: 916-322-2579; Email: media@dmhc.ca.gov.

On November 29, 2018, in a revision to its National Patient Safety Goal, The Joint Commission announced that it will require hospitals to screen individuals being treated or evaluated for behavioral health conditions for suicide risk using a validated tool. These revisions are effective starting July 1, 2019. However, the revised Goal does not require universal screening for all individuals. Organizations must develop a plan to mitigate suicide based on an individual’s overall level of risk, and organizations must follow written policies and procedures for counseling and follow-up care for individuals identified as at risk for suicide.

The Joint Commission explained the changes in “Approved: Revisions to National Patient Safety Goal Regarding Suicide Prevention.” The rationale is to provide specific instructions that align with current research and the recommendations of The Joint Commission’s Suicide Risk Reduction expert panel. The Goal was revised because there has been no improvement in suicide rates in the United States since the Goal was introduced in 2007, and suicide is the 10th leading cause of death in the country.

In addition to requiring screening at-risk individuals, the revised Goal calls for behavioral health care organizations, psychiatric hospitals, and psychiatric units in general hospitals to conduct environmental risk assessments to be ligature resistant. Non-psychiatric units in general hospitals are not expected to be ligature resistant; however, The Joint Commission requires that non-psychiatric units in general hospitals minimize risks in the environment for individuals identified at risk for suicide by removing hazards that can be removed without affecting a patient’s medical care, and by 1:1 monitoring for patients that are at high-risk for suicide.

The Joint Commission classifies suicide attempts and deaths by suicide as sentinel events, defined as any unanticipated event in a health care setting resulting in death or serious physical or psychological injury to a consumer or consumers, not related to the natural course of the consumer’s illness. Sentinel events signal the need for immediate investigation and response.

In 2016, The Joint Commission had issued an action alert focused on enhancing suicide prevention efforts by health care organizations. The goal was to help clinical professionals in emergency, primary care, and behavioral health settings detect suicide ideation and ensure that at-risk consumers receive an appropriate evaluation, evidence-based treatment, and follow-up care. The key focus is on care transitions for people with suicidal ideation, especially among those discharged from a psychiatric facility who are at a higher risk of suicide for up to four years after discharge.

Between June 2017 and March 2018, The Joint Commission held five technical expert panel meetings on the topic of suicide in health care settings. After reviewing the panel’s recommendations and research, The Joint Commission announced in March 2018 that it intended to revise the National Patient Goal for suicide screening in health care settings.

The full text of “Approved: Revisions to National Patient Safety Goal Regarding Suicide Prevention” was published November 29, 2018 by The Joint Commission. A copy is available online at JointCommission.org.

PsychU reported on this topic in “The Joint Commission Updates Suicide Prevention Guidelines, Recommends Greater Vigilance In Non-Acute & Acute Care Settings,” which published on June 13, 2016.

For more information, contact: Maureen Lyons, Corporate Communications, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181; 630-792-5171; Email: mlyons@jointcommission.org.

From December 10 to 14, 2018, the approximately 4,000 Kaiser Permanente behavioral health professionals represented by the National Union of Healthcare Workers (NUHW) held a strike at Kaiser facilities across California to protest staffing ratios. They say Kaiser’s ratio of one professional to 3,000 Kaiser members is inadequate to ensure that members making new and follow-up appointments, receive appointments within state timeliness standards. Kaiser Permanente is in contract negotiations with the NUHW for behavioral health professionals employed by Kaiser Permanente’s Northern and Southern California affiliates. The previous contract expired in September 2018.

The California Department of Managed Health Care (DMHC), which oversees health maintenance organizations (HMOs) such as Kaiser, requires that urgent appointments when prior authorization is not required must be scheduled within 48 hours of request. Non-urgent mental health appointments with a non-physician (psychologists, therapists, social workers, psychiatric nurses and addiction medicine specialists) must be scheduled within 10 business days of the member request.

The behavioral health professionals believe that the ratio of one professional to 3,000 members is inadequate because it is the same ratio that existed in the DMHC’s February 2015 Kaiser follow-up survey report, which found that 22% of Northern California members and 9% of Southern California members experienced excessive appointment delays. When NUHW settled the last contract in late 2015, Kaiser had committed to working with the NUHW to improve access and had agreed to contractual language in Northern California that was aimed at increasing staffing. However, due to turnover and growing membership, the ratio has remained unchanged. A NUHW spokesperson said some Kaiser members wait one to two months for follow-up behavioral health appointments.

The NUHW spokesperson said the behavioral health professionals have proposed that Kaiser require that for every new initial appointment with a patient, a therapist be able to schedule six return appointments. They believe this would reduce the wait for return appointments and set a mechanism for improving staffing. They also proposed that Southern California Kaiser commit to moving away from its model of outsourcing mental health care and bring the service in-house, just like Kaiser medical services. In press releases, NUHW said its contract proposals are intended to help Kaiser meet the DMHC appointment timeliness standards.

In a public statement released on December 9, 2018, Kaiser provided the following information about the dispute:

  • NUHW wants to reduce the amount of time clinical professionals spend seeing members to below the average of 75% of time, a performance standard NUHW agreed to in 2015. Kaiser believes doing so would mean fewer appointments for members.
  • NUHW has asked Kaiser Permanente to stop working with non-Kaiser community therapists that serve as extenders to ensure access to care for members.
  • Kaiser seeks no takeaways in its contract proposal and is offering wage increases.
  • Since 2015, Kaiser has hired more than 500 new behavioral health professionals in California, which increased its behavioral health staff by 30%,

In 2011, NUHW members reported Kaiser to the DMHC in 2011 for failing to meet the appointment timeliness standards. In 2013, the DMHC levied a $4 million fine on Kaiser for violating the California’s Mental Health Parity Act and state standards for timely access to care. In February 2015, the DMHC released a follow-up survey, which found that 22% of Northern California members and 9% of Southern California members experienced excessive appointment delays. In June 2017, the DMHC released results from a full survey of the Kaiser Health Plan, which found that Kaiser had not fully resolved member access issues for its mental health services. In July 2017, the DMHC and Kaiser announced a settlement agreement in which Kaiser agreed to a three-year program of outside monitoring of its mental health services by a state-approved firm with the authority to impose up to $1 million in additional fines against Kaiser if it fails to remedy access issues.

PsychU reported on this topic in “Kaiser Permanente In California Recruiting 350+ Mental Health Therapists By End Of Year,” which published on October 8, 2015.

For more information about the NUHW position, contact: Matthew Artz, Communications, National Union of Healthcare Workers, 5801 Christie Avenue, Suite 525, Emeryville, California 94608; 510-435-8035; Fax: 510-834-2019; Email: martz@nuhw.org.

For more information about Kaiser Permanente’s position, contact: Jessie R. Mangaliman, National Media Relations, Kaiser Permanente, 1950 Franklin Street, Oakland, California 94612; 510-301-5414; Email: National-Media-Relations@kp.org.

Meeting the management challenges for a health and human service workforce is one of the more challenging aspects that many provider organization executives must face: including recruiting for tough positions in remote markets (see Where Have All The Psychiatrists Gone?); the high turnover rate of these positions (see High Turnover, The Other Staffing Issue); and the compensation demands for both direct care workers (see Will Clinical Professional Compensation Drive Task Shifting?) and executives.

As if that weren’t enough, there is the shifting demands of staff performance in the face of value-based contracting requirements. This was the topic addressed in the session, “Best Practice Staffing Models For The New Value Equation: An Executive Discussion On Compensation, Retention & Productivity,” delivered by OPEN MINDS Senior Associate Ken Carr; Lori M. Schmidt, the former Director of Behavioral Health, HealthPartners; and Jeremy Gatto, LICSW, Clinical Manager, HealthPartners. The blueprint for the day—how to develop a performance-based compensation strategy and use productivity measurement to maximize revenue.

After you have decided that performance-based compensation at the staff level is a strategic imperative, there are three basic compensation models to see keep in mind—fixed salary, base plus incentive, and bonus pure productivity. But, beyond the model, managers need to develop a compensation model that is both metrics-driven (you can track and compare performance over time) and easily understood by staff (the staff member must be able to connect their performance with the reward). Our faculty identified four considerations to make sure a performance-based compensation plan works—build the infrastructure, populate a dashboard with the data, update financial forecasting models, and adopt a complete organizational philosophy.

Build the infrastructure necessary to implement an incentive-based compensation system—There are three critical infrastructure components that need to be in place before moving ahead—the ability to capture accurate data, implementation of a dashboard to make that data available to providers and supervisors on a weekly basis, and financial tools to forecast incremental revenue and expenses resulting from the incentive system. Mr. Carr explained:

The EHR will need to capture the units of service productivity—visits, charges or weighted relative value units (wRVUs). Visits and charges are standard measures of service activity that are easy to capture, but don’t consider the time and intensity of services. However, wRVUs, were created by CMS as a means of recognizing that some service activities time more time and have greater value. For instance, procedure code 90837, 60 minutes of psychotherapy, is one visit, but it is assigned a wRVU of 3.0. Some EHRs have the capability of capturing and reporting the wRVUs in addition to charges associated with procedure codes.

Populate a dashboard with the data—After capturing accurate service data, a system is needed to get that data into a timely dashboard. Providers need access to this information to inform them on their progress toward monthly or quarterly goals. Mr. Carr explained:

The data can be connected to a dashboard using business intelligence software or downloaded and distributed using spreadsheets. The key is to have staffing experience to summarize and analyze data, a tool that works, and a process to ensure that the data is used to drive results.

Update financial forecasting models— The financial forecasting model also needs to be updated to reflect the potential revenue and expense scenarios based on performance – and the impact on cash. Mr. Carr explained

Status quo budgets and business models are not effective when multiple performance factors can impact operating results. This includes tightening the revenue cycle process since incentives will need to be paid from incremental increases in cash collections.

Adopt a complete organizational philosophy—Ultimately, using productivity measurement to maximize revenue comes down to adopting a successful plan that is not just a model of payment, but offers a complete organizational philosophy for who gets paid how much, and tracks the performance to make sure those two things are aligned. Ms. Schmidt explained:

Focus on sustainable financial performance and developed a payment model for that. We worked to set a percentage target for that, and then when we have a clinical professional that isn’t meeting their goals, we work with them to adjust their scheduling template or their work style to help them reach their goals. Remember, the goal must be attainable. You don’t want to deflate your staff by making a goal that no one can attain.

The second thing is, know how you want to add your performance measure. In our case, we took the target salary and reduced it by two performance measures, so that gave us “the target salary of productivity.” For example, if your target salary is $90,000, and the incentives add up to $2,000, then the target salary of productivity is $88,000. But if you choose a productivity bonus on top of the salary, then your target salary with bonus could be $92,000.

For more on the staffing challenges facing today’s health and human service organizations, check out Aligning Clinical Compensation For The New Value Equation, Staff Vacancies Just Got A Little More Important & Complicated, The Staffing Equation For Community-Based Services, and How Do You Engage Employees & Improve Performance?.

Last week, we provided an update on the current state of credentialing of peer support specialists (PSS) and changes in reimbursement for their services. For most organizations, the question is not whether to add PSS to their service delivery team—but how. And how to bring those services to scale across a service location.

The article brought some interesting comments from my colleague and OPEN MINDS Senior Associate Sue Bergeson. She noted:

Provider organizations should leverage peers in the areas of activation, engagement, reduction of isolation/increase support, communication, and education. Involve peers as you would other staff in the organization’s decision-making process. Peers will see things differently and can give you feedback, and insights others will not see that can positively impact the effectiveness of your programs. Effectively on-board peers into the organization, supervise, and promote them as a part of the overall treatment team. Pay them a fair wage and offer them access to continuing education so they can continue to build skills and serve your clients.

Done right, she observed that this approach can improve consumer outcomes, including increased consumer empowerment, increased sense that treatment is responsive, and increased social support and social functioning. But she noted that there are six key issues that consistently diminish the effectiveness of peers in the workforce—role confusion, lack of integration, performance measures, management training, career paths, and specialties of focus.

Role confusion—Often job descriptions are unclear, and staff does not know what to do with peer staff. This can lead to peers used simply as extra hands to drive a bus, to do filing, or to clean. Its fine if peers are hired to do these roles specifically but they are not peer roles – they do not used the skills or leverage the experience of trained and certified peer specialists. It’s no more appropriate for peer specialists to drive the bus than it is for clinicians to drive the bus. Peer job descriptions and roles need to align with the core competencies or the system employing them is missing out on the benefits of adding peer support to the system of care – in short, they will not achieve the very benefits they were hoping to achieve by adding peers to the workforce.

Being treated as separate from the rest of the workforce—Because the staff team has usually not had any orientation to the work of peers, often peers are not invited to the table, not involved in committees, not involved in meetings, not informed or asked about organizational changes. Because peers have different experiences and can see things differently, the system misses important feedback if they do not involve peers as they create and implement new policies, programs and systems.

Not being held to the same standard—Peers are sometimes treated as fragile and the company might make special allowance for behavior not acceptable in other staff. This does the peer a disservice. Peers need to be held accountable for the same kind of professional behavior as other staff members. Sometimes hired peers are new to the workforce and so a mentor that helps them acclimate can be a great addition to the onboarding process

Training for supervisors—Because the role is often new to a system, supervisors often need additional support in learning how to effectively supervise this new role. It is not unusual for the peer to mistakenly be supervised as a “mini therapist” or “junior social worker” because that is the field the supervisor knows best. This diminishes the effectiveness of the peer worker.

Career paths—Hiring peers as supervisors is an effective way to ensure peer roles remain peer and are optimized for success. Successful peers should also be considered for other leadership and administrative roles as they demonstrate their effectiveness.

Areas of focus—We are seeing additional areas of focus emerging within the field, each with its with corresponding training. For example, peer support within later life populations, within transition age youth, within co-occurring health conditions like diabetes and depression.

Like any change in the service delivery system, planning for incorporating PSS demands planning. Managers of health and human service organizations will need to make this a priority to remain competitive in the coming years.

Opioids for chronic non-cancer pain provide small improvements in pain and physical function. Non-opioid medications were found to also offer similar outcomes.

These findings were reported in “Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis” by Jason W. Busse, DC, PhD; Li Wang, PhD; Mostafa Kamaleldin, MB BCh; et al. The researchers conducted a systematic review that included 96 randomized clinical trials, with 26,169 participants, to compare opioids with placebo and nonopioid alternative pain medications for the treatment of chronic non-cancer pain. The goal was to determine whether opioids are associated with greater benefits or harms compared to placebo and nonopioid alternatives for chronic non-cancer pain.

None of the studies provided rates of developing opioid use disorder. Another review by some of the authors, done to support the 2017 Canadian opioid guideline, found evidence suggesting that 5.5% of patients prescribed opioid therapy for chronic non-cancer pain develop addiction (opioid use disorder). Risk of developing opioid use disorder was not associated with opioid dose; however, higher doses of prescribed opioids were associated with increased risk of non-fatal and fatal overdose.

Of the 96 included studies, there were 25 trials of neuropathic pain (e.g. diabetic neuropathy), 32 trials of nociceptive pain (e.g. osteoarthritis), 33 trials of central sensitization (pain present in the absence of tissue damage), and 6 trials of mixed types of pain. Treatment effects did not differ across categories of chronic pain conditions. The review findings include:

  • Compared to placebo, opioids are associated with small improvements in pain, physical functioning, and sleep quality. Benefits for pain and sleep become smaller the longer opioids are used.
  • Compared to nonsteroidal anti-inflammatory drugs (NSAIDs), synthetic cannabinoids, and tricyclic antidepressants, low- to moderate-quality evidence suggested similar associations of opioids with improvement in pain and physical function. Opioids provided better pain relief, but similar functional improvement compared with anticonvulsants.
  • Opioids are associated with an increased risk of vomiting, compared to both placebo and nonopioid treatment.

The review found average pain improvement with opioids vs. placebo was below what consumers would consider important. However, some patients will experience more pain relief and some less with opioids; therefore, focusing on average effects alone has limitations. The researchers concluded that, versus placebo, an estimated 12% of patients living with chronic non-cancer pain will achieve important pain relief. Given the harms associated with opioids, health care providers should consider prescribing non-opioid alternatives that show similar efficacy (e.g. NSAIDs, tricyclic anti-depressants) before turning to opioids for chronic non-cancer pain relief.

The full text of “Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis” was published December 18, 2018, by JAMA Network. An abstract is available online at JAMANetwork.com

For more information, contact: Veronica McGuire, Communications for Corresponding Author Jason W. Busse, D.C., Ph.D., Faculty of Health Sciences, McMaster University, 1280 Main Street West, Chester New Hall, Room 111, Hamilton, Ontario Canada; L8S 4L9; 905-525-9140, ext. 22169; Email: vmcguir@mcmaster.ca.

As of 2016, the United States has among the highest average costs among wealthy countries for both inpatient and outpatient hospital visits. For inpatient stays, the average cost in the United States is $22,543 per person per stay; followed most closely by Switzerland at $15,670, and Maldives at $12,829 on average. For outpatient visits, the average cost in the United States is $478 per visit per person, topped only by Switzerland at $502, and followed by Norway at $459 on average. An outpatient visit is defined as a visit to a health facility that did not result in admission. Outpatient visits included four categories: curative visits, rehabilitative visits, facility-based preventive maternal and child care visits, and vaccination visits. Inpatient admissions included curative and rehabilitative.

These findings were reported in “Funding And Services Needed To Achieve Universal Health Coverage: Applications Of Global, Regional, And National Estimates Of Utilisation Of Outpatient Visits And Inpatient Admissions From 1990 To 2016, And Unit Costs From 1995 To 2016” by Mark W. Moses, MHS; Paola Pedroza, MPH; Ranju Baral, Ph.D.; Sabina Bloom, BA; Jonathan Brown, MAIS; Abby Chapin, BA, et al. The researchers analyzed surveys and administrative date from the Global Health Data Exchange, compiling outpatient utilization data from 130 countries, and inpatient data for 128 countries. The goal was to compile utilization and unit costs of both inpatient and outpatient visits to inform health care plans to achieve universal health coverage (UHC) in every country. UHC is one of the United Nations’ Sustainable Development Goals for 2030.

Additional findings for the 1990 to 2016 period include:

  • Outpatient admissions increased by nearly 59%, from about 24.80 billion in 1990, to 39.35 billion visits globally during 2016.
  • Of the 59% global increase in outpatient admissions 43.0% were due to population growth, 8.1% were due to population aging, and 7.6% were due to an increase in use rates.
  • Inpatient admissions increased 68.0%, from 0.42 billion in 1990, to 0.71 billion admissions by 2016.
  • Of the 68.0% global increase in inpatient admissions, 44.3% were due to population growth, 13.6% were due to increases in use rates, and 10.0% were due to population aging.

Other researchers commented that the quality of health care services is likely to differ substantially between countries, and inefficiencies in current health care systems should be considered when calculating UHC costs. In relation to implementing UHC for all nations, the effort would cost nearly $576 billion, and would result in a 49% increase in admissions and 27% increase in outpatient visits worldwide.

The full text of “Funding And Services Needed To Achieve Universal Health Coverage: Applications Of Global, Regional, And National Estimates Of Utilisation Of Outpatient Visits And Inpatient Admissions From 1990 To 2016, And Unit Costs From 1995 To 2016” was published December 12, 2018 by The Lancet Public Health. An abstract and article are available online at www.TheLancet.com.

For more information, contact: Marcia Weaver, Ph.D., Research Professor, Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue, Suite 600, Seattle, Washington 98121; Email: mweaver@uw.edu.

RAND researchers found that physician practices lack data management and analysis skills needed for value-based payments. Some medical practices report aversion to financial risk that include penalties for cost of care overruns, causing some organizations to renegotiated contracts with payers to reduce their downside risk or transfer some of that risk to partners.

These findings were reported in “Effects of Health Care Payment Models on Physician Practice in the United States: Follow-Up Study” by Mark W. Friedberg, Peggy G. Chen, Molly Simmons, Tisamarie Sherry, Peter Mendel, Laura Raaen, Jamie Ryan, Patrick Orr, Carol Vargo, Lindsey Carlasare, Christopher Botts, and Kathleen Blake. The study is a follow-up to a 2014 study that also assessed how physician practices were responding to alternative payment models. Researchers attempted to re-interviewed the same physicians and practice leaders that participated in the previous study. The project conducted interviews between January and June 2018, speaking with 84 people from 31 physician practices in six geographic markets (Little Rock, Arkansas; Orange County, California; Miami, Florida; Boston, Massachusetts; Lansing, Michigan; and Greenville, South Carolina). Researchers also spoke to leaders of eight health plans, 10 hospitals or hospital systems, 10 state and local medical societies, and four Medical Group Management Association chapters. The goal was to discover the effects of alternative health care payment models (APM) on those organizations.

Additional findings included:

  1. Payment models are changing at an accelerating pace— Physician practices, health systems, and consultants are struggling to keep up with the number of new models, which put additional pressure on them before they have adapted to the previous models.
  2. Payment models are increasing in complexity—Practices that have adapted to the complexity of APM report earning financial awards for preexisting quality of care without changing it.

Researchers provided three recommendations, including:

  1. Simpler APMs might help practices focus on improving consumer care—Many new APMs are confusing, causing provider organizations to avoid them. Simplifying the models “might help tip the balance back toward improving patient care as the preferred strategy for earning financial rewards.”
  2. Practices need new capabilities and timely data to succeed in APMs—Many survey respondents report that they lacked the internal skills and experience necessary to perform well in APMs. Helping them invest in those skill sets and supplying them with timely, understandable performance data is a critical contributor to success with APMs.
  3. Designing APMs to encourage clinical changes that individual physicians see as valuable might improve their effectiveness—Co- designing APMs with practicing physicians and other leaders of their practices might help improve physician engagement and the chances that APMs will produce real improvements in patient care.

The full text of “Effects of Health Care Payment Models on Physician Practice in the United States Follow-Up Study” was published on October 24, 2018, by RAND. A copy is available online at RAND.org.

For more information, contact: Warren Robak, Office of Media Relations, RAND Corporation, 1776 Main Street, Post Office Box 2138, Santa Monica, California 90401-2138; 310-393-0411; Fax: 310-393-4818; Email: media@rand.org.

On October 1, 2018, 10,976 (72%) of 15,306 skilled nursing facilities (SNFs) received cuts of up to 2% to their Medicare rates for high hospital readmission rates. Another 3,983 SNFs received a rate increase and 347 SNFs neither received a rate increase or decrease. The rates cuts and increases are part of the Medicare value-based purchasing (VBP) program for skilled nursing facilities (SNFs). The VBP measure focuses on improvement in all-cause 30-day hospital readmission rates, based on a baseline established with 2015 claims data and SNF performance during calendar year 2017. The baseline hospital readmission rate is 19%.

The total amount of incentive payments distributed to SNFs will be 60% of the total amount withheld from SNFs’ Medicare payments for that fiscal year. CMS estimated that during fiscal year 2019, the SNF VBP program would reduce aggregate Medicare payments to SNFs by $211 million.

The SNF VBP applies to hospital readmissions for fee-for-service Medicare beneficiaries discharged from a Medicare-participating hospital, a critical access hospital (CAH), or a psychiatric hospital. The program applies to freestanding SNFs, SNFs affiliated with acute care facilities, and all non-CAH swing-bed rural hospitals.

The program is initially using the Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM). However, in the final rule “Medicare Program; Prospective Payment System and Consolidated Billing For Skilled Nursing Facilities (SNF) Final Rule For FY 2019, SNF Value-Based Purchasing Program, & SNF Quality Reporting Program,” CMS noted that for later years it intends to transition to the Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure to replace SNFRM.

Individual SNF performance on the SNF VBP measures will be published on the Nursing Home Compare website. The information to be published will include SNF performance scores and rankings, the range of SNF performance scores, the number of SNFs receiving value-based incentive payments, and the range and total amounts of those payments.

Since October 2016, CMS has been providing SNFs with quarterly confidential feedback reports containing information regarding their performance on the readmission measure specified for the SNF VBP Program. These quarterly reports are disseminated to SNFs via the Quality Improvement and Evaluation System (QIES)/Certification and Survey Provider Enhanced Reports (CASPER) system.

PsychU reported on the final rule that included the SNF VBP in “Medicare SNF Final Rule Increases Skilled Nursing Rates By $820 Million,” which published on October 8, 2018.

For more information about the SNF VBP Program, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: SNFVBPInquiries@cms.hhs.gov.

The value that peer support specialists (PSS)—a person who has lived-experience with mental illness and/or addiction recovery and combines that with training to deliver services in behavioral health settings—is well documented. These PSS provide a path to lower relapse rates, social support, social functioning, decreased psychotic symptoms, and reduced hospitalization rates (see Peer Support Groups In Addiction Treatment Boost Odds Of Long-Term Recovery). Currently, about 51% of health and human service specialty provider organizations have adopted PSS in their organization.

For managers of health and human service organizations looking to expand the role of PPS, there are two primary questions: Are the positions reimbursable and what are the credentialing criteria?

Reimbursement of peer support services—Medicaid is the primary payer for peer support services, although many state departments of behavioral health offer grant funding for these services as well. Currently 39 state Medicaid programs provide reimbursement for some form of PSS services. States have two options for funding the reimbursement of peer support services under their Medicaid program—either adding peer support services through a Medicaid state plan amendment (usually under the Medicaid Rehabilitation Option) or as part of a waiver program.

My colleague Athena Mandros looked at the reimbursement question earlier this year and determined who could be reimbursed and how reimbursement happens varies by state. If state Medicaid program covers peer support under the fee-for-service benefit, the health plans are also required to cover these services. Some states have special provisions that allow them to only cover peer supports for limited groups of individuals, such as those enrolled in managed care. Some states also allow peer support specialists to act as qualified health care professionals for certain types of behavioral health services, but do not allow for the specific reimbursement of peer support services. A review of selective states’ Medicaid fee for services (FFS) reimbursement found that group rates for a 15-minute period with a peer support specialist ranged from less than $2.00 to over $5.00. Individual billing by peer support specialists ranged from $6.50 to $24.36 per 15 minutes. Most of the states also use SAMHSA grants and state general funds to develop and sustain their peer support programs. In 2016, 32 states voluntarily reported that part of their block grants were used to fund peer recovery coaching activities for Medicaid—either training or service provision (see States Use Six Practices To Certify Competency Of Mental Health Peer Support Specialists).

Credentials of peer support team members—Peer support service credentialing also varies by state. A 2016 national overview of PSS done by The University of Texas at Austin found that 41 states and the District of Columbia have programs to certify PSS. The issue is that these certifications are just as unique to the states as the array of mechanisms the states use to reimburse for them. Most require some type of formal application process with references, training, and a competency exam. Some of these training programs are short (Kansas, five days) and include establishing healing relationships and understanding the role of trauma. Other programs are longer (Oregon, two weeks) and include core competency training that includes chronic disease management, health promotion, and health literacy. For example, in Florida, services provided by a certified peer specialist are billable to Medicaid. To become certified Florida requires a minimum of a high school diploma or GED, attestation of lived experience, 40 hours of training within the past  five years, 500 hours of supervised work or volunteer experience providing peer-to-peer recovery support services, and letters of recommendation—as well as passing the Florida Certified Recovery Peer Specialist Exam.

A recent review from the Government Accountability Office (GAO) highlights that as the PSS workforce grows, the is a need for “increased attention to standardizing the competencies of peer support specialists through certification” (see Mental Health: Leading Practices For State Programs To Certify Peer Support Specialists). To achieve this, the GAO looked at several states and identified six practices that researchers said should become a standard part of certifying PSS competency, including:

  1. Systematic and objective screening of the PSS’ understanding of recovery and the peer role.
  2. Ensure in-person core training to strengthen PSS interpersonal and relationship building skills.
  3. Incorporate physical health and wellness into PSS training or continuing education.
  4. Educate provider organization staff about the peer support role, and how to effectively use and supervise PSS.
  5. Require that PSS participate in continuing education specific to peer support.
  6. Engage PSS in the leadership and development of certification programs for applicants.

For more, we reached out to OPEN MINDS Senior Associate Bob Dunbar, who noted that while states have a primary responsibility for determining required competencies, best practices, and training needed to become certified as a peer support specialist, the fact that each state determines certification requirements means there will be a lot of variability. And that means, there is a lot of pressure on provider organizations to understand how to best prioritize peer recovery services as an “essential” component of a continuum of services. He noted:

This prioritization will be facilitated by an increased focus upon “recovery” and by the transition from a fee-for-service to a value-based payment system. Behavioral health professionals need to better understand and value the unique contributions of PSS. The development and operation of team-based models of care, including “health homes,” in which Peer Support Members are contributing equal “partners” would help. Also, behavioral health providers must avoid the temptation to hire PSS as a “cheap” alternative to other essential perhaps more “costly” staff. Behavioral health providers also need to increase their knowledge of “peer recovery” competencies, best practices, certification requirements, and funding sources.

If the decision is made to incorporate peer recovery as an essential service, behavioral health providers must identify the recovery needs of the target population to be served by PSS. Once these needs have been identified, the behavioral health provider must see that the PSS participate in training that assures the existence of competencies necessary to serve the identified target population in collaboration with their recovery team.

The likelihood that we will continue to see provider organizations adopt peer support is high, considering that value-based reimbursement models will focus on outcomes and make the return-on-investment (ROI) of peer support services a better deal. I suspect the market forces that are redefining every other aspect of behavioral health care will also alter the professional roles that allow provider organizations to expand access and reduce costs. We’ll keep you updated.

For more, check out these resources from the PsychU Resource Library:

  1. Will Clinical Professional Compensation Drive Task Shifting?
  2. Workforce Shortages As A Strategy Issue
  3. Wake Forest Baptist Medical Center Finds Addiction-Focused Peer Support Program Reduces Readmissions

The Illinois Medicare-Medicaid Alignment Initiative (MMAI) demonstration reduced inpatient utilization by 14.8% in the first year. Before the demonstration began, during the pre-demonstration comparison period (March 1, 2012 through February 28, 2014) dual eligible beneficiaries had an average of 0.0507 hospitalizations per person per month. During the first demonstration period (March 1, 2014 through December 31, 2015), beneficiaries enrolled in the demonstration had an average of 0.0434 hospitalizations per month.

Illinois and the Centers for Medicare & Medicaid Services (CMS) launched the MMAI demonstration in March 2014 to integrate care for Medicare-Medicaid beneficiaries in two regions: The Greater Chicago region, and the Central Illinois region. Under the demonstration Illinois and CMS contract with health plans to coordinate the delivery of and be accountable for all covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees. Eight health plans were competitively selected by the state and CMS to operate Medicare-Medicaid Plans (MMPs) under the demonstration: six in the Greater Chicago region and two in Central Illinois. The MMPs receive capitated payments from CMS and the state to finance all Medicare and Medicaid services. MMPs also provide care coordination and flexible benefits, depending on the coverage plan. As of December 2016, about 30% of eligible Medicare-Medicaid beneficiaries were enrolled in MMAI, representing about 46,000 enrollees of the more than 153,000 who were eligible.

The findings were reported in “Financial Alignment Initiative Illinois Medicare-Medicaid Alignment Initiative: First Evaluation Report” by RTI International for the CMS Center for Medicare & Medicaid Innovation (CMMI). The report includes findings from qualitative data for March 1, 2014 through February 28, 2017, and quantitative results for demonstration year 1 (March 1, 2014 through December 31, 2015). Data for the report comes from key informant interviews, beneficiary focus groups, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results, Medicare claims data, the Minimum Data Set nursing facility assessments, MMP encounter data, and other demonstration data. For admissions and visits, the report provides savings estimates for inpatient admissions, emergency room visits, physician evaluation and management visits, skilled nursing facility admissions, and probability of any long-stay nursing facility use. The demonstration and comparison groups were similar across many of the service utilization measures in each of the pre-demonstration years and the demonstration year.

Measured against the comparison group, the Illinois demonstration group had fewer monthly inpatient admissions, emergency room visits, and skilled nursing facility admissions. The demonstration group had a higher probability of any long-stay nursing facility use. There was no statistically significant difference in monthly physician visits between the demonstration and comparison groups. Results differed for beneficiaries with use of long-term services and supports (LTSS) and for beneficiaries diagnosed with serious and persistent mental illness (SPMI).

Summary Of Illinois Medicare-Medicaid Alignment Initiative Impact Estimates For First Demonstration Period (May 1, 2014, To December 31, 2015), For All, LTSS, & SPMI Beneficiaries (adapted from Table ES-1)

All LTSS SPMI
Inpatient admissions  Lower Not Statistically Significant (NS)  Lower
Probability of ambulatory care-sensitive condition (ACSC) admissions, overall  Lower NS NS
Probability of ACSC admissions, chronic Lower NS NS
All-cause 30-day readmissions  NS  Higher  NS
Emergency room (ER) visits  Lower  NS  Lower
Preventable ER visits Higher NS Lower
Probability of monthly follow-up after mental health discharges Lower  NS Lower
Skilled nursing facility (SNF) admissions Lower Higher  Lower
Probability of any long-stay nursing facility (NF) use Higher N/A  N/A
Physician evaluation and management (E&M) visits  NS Higher  NS

PsychU reported on this topic in “Illinois Medicaid Launches Redesigned Mandatory Managed Care Program Statewide,” which published on January 18, 2018.

For more information, contact: John K. Hoffman, Director of Communications, Illinois Department of Healthcare and Family Services, 401 South Clinton, Chicago, Illinois 60607; 312-793-4792; Email: John.K.Hoffman@illinois.gov.

During its first full year, the Ohio Medicaid MyCare demonstration project for people dually eligible for Medicare and Medicaid reduced inpatient utilization by 21%. The probability of inpatient admissions for ambulatory care sensitive conditions dropped by 14.3%. The probability of an inpatient admission for a chronic, but ambulatory care sensitive condition dropped by 13.2%. Skilled nursing facility (SNF) admissions were 15.3% lower. The probability of SNF stays longer than 90 days was also lower. However, the demonstration also resulted in a 10.3% increase in preventable emergency room visits.

These findings were reported in “Financial Alignment Initiative MyCare Ohio: First Evaluation Report” by the National Academy of State Health Policy and RTI International for the Centers for Medicare & Medicaid Services (CMS). CMS contracted with RTI International to monitor and evaluate the implementation of the MyCare Ohio capitated model demonstration, which began on May 1, 2014. The evaluation includes findings through December 2016 and quantitative results through December 2015, and looked at the demonstrations effect on beneficiary experience, quality, utilization, and cost.

MyCare Ohio is a capitated model demonstration in which five competitively selected Medicare-Medicaid Plans (MMPs), called MyCare Ohio plans, are paid a blended, capitated rate to provide Medicare and Medicaid integrated primary, acute care, behavioral health, and long-term services and supports (LTSS) to enrollees age 18 and older who live in one of the 29 demonstration counties. The five health plans are Aetna, Buckeye, CareSource, Molina, and United. Of the 100,000 Medicare-Medicaid dual enrollees eligible for MyCare Ohio, approximately 69,000 had enrolled in the capitated model demonstration as of December 2016. Approximately 43% of eligible MyCare beneficiaries had an diagnosis of serious and persistent mental illness (SPMI).

Results for the LTSS and severe and persistent mental illness (SPMI) populations, when compared with similar beneficiaries in the comparison group, varied somewhat from the results for all eligibles.

Summary Of MyCare Demonstration Impact Estimates For Demonstration Period (May 1, 2014, To December 31, 2015), For All, LTSS, & SPMI Beneficiaries (adapted from Table 22)

All LTSS SPMI
Inpatient admissions  Lower Lower  Lower
Probability of ambulatory care-sensitive condition (ACSC) admissions, overall  Lower Not Statistically Significant (NS) Lower
Probability of ACSC admissions, chronic Lower Higher Lower
All-cause 30-day readmissions  NS  Lower  NS
Emergency room (ER) visits  NS  NS  NS
Preventable ER visits Higher Higher Higher
Probability of monthly follow-up after mental health discharges NS  NS NS
Skilled nursing facility (SNF) admissions Lower Higher  Lower
Probability of any long-stay nursing facility (NF) use Lower N/A  N/A
Physician evaluation and management (E&M) visits  Lower NS  Lower

The demonstration reduced monthly inpatient admissions by 0.0112 admissions per beneficiary per month, which corresponds to 0.1343 fewer inpatient admissions per eligible beneficiary per year. The demonstration decreased physician evaluation and management (E&M) visits by 0.0728 visits per month; it decreased SNF admissions by 0.0022 visits per month. The likelihood of long-stay SNF use (101 days or longer) decreased by 1.59 percentage points. There was no statistically significant demonstration effect on emergency room visits.

Using a difference-in-differences (DID) approach to evaluate the impact of the demonstration on Medicare costs, RTI found that the predicted capitated rate of $1,498 when compared to actual fee-for-service (FFS) expenditures ($1,577) showed the potential for gross Medicare savings compared to the non-enrolled beneficiary population, but did not find “statistically significant Medicare savings or losses during the first 32 months of the Ohio demonstration.” Demonstration enrollees had lower expenditures in base year two ($1,280 for enrollees vs. $1,797 for non-enrollees).

The savings calculation was based on capitation rates paid by CMS to MyCare Ohio plans for enrollees, and the fee-for-service expenditures and Medicare Advantage capitation rates for eligible beneficiaries who did not enroll in the demonstration. The estimates do not take into account actual payments for services incurred by enrollees and paid by the MyCare Ohio plans. The researchers did not calculate Medicaid savings due to lack of data. They intend to rerun the analyses to calculate Medicaid savings when more data is available.

PsychU reported on this topic in “MyCare Ohio Duals Demo Average Claim Cost PMPM Drops 6.8%,” which published on June 9, 2017.

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; or Melissa Ayers, Director of Communications, The Ohio Department of Medicaid, 50 W Town Street, #400, Columbus, Ohio 43215; 800-324-8680; Email: Melissa.Ayers@medicaid.ohio.gov.

From 2013 through 2016, net savings generated by Medicare accountable care organizations (ACOs) totaled more than $660 million, representing about 0.026% of the more than $2.5 trillion in Medicare spending over the four-year period. Over the four years, gross savings generated by Medicare ACOs totaled $2.7 billion, about 1% of the $2.5 trillion in Medicare spending. The net savings accounts for about $2.1 billion in bonuses paid to ACOs that met their spending and quality targets.

These estimates were calculated using a difference-in-difference approach, rather than the benchmark-based approach used by the Centers for Medicare & Medicaid Services (CMS) in its most recent analysis of the ACO program. CMS calculated that ACOs have saved Medicare $1.6 billion, but resulted in a net loss of $384 million to the Medicare Trust Fund after shared savings were paid to ACOs.

The estimates were reported in “2016 Updates: MSSP Savings Estimates Program Financial Performance 2013-2016” by the National Association of Accountable Care Organizations (NAACOs). The report was written by researchers with Dobson|DaVanzo: Allen Dobson, Ph.D.; Sarmistha Pal, Ph.D.; Alex Hartzman, M.P.A., M.P.H.; Luis Arzaluz, M.S.; Kimberly Rhodes, M.A.; and Joan E. DaVanzo, Ph.D., M.S.W. For their analysis, the researchers compared spending by ACO provider organizations to spending of similar provider organizations not participating in the ACO program. The goal was to estimate Medicare spending in the absence of the ACO program. In its analysis, CMS judges ACO financial performance relative to the annual ACO benchmarks set as the pre-determined spending target. NAACOs believes that the CMS approach underestimates the savings generated by the ACO program.

Gross Savings in the Medicare Shared Savings Program for 2013 To 2016 Dobson | DaVanzo Analysis Compared to CMS Benchmark Approach (in millions)

Performance Year Difference-In-Difference Analysis CMS Benchmark Analysis
2013 $372.9 $233.6
2014 $637.2 $291.5
2015 $786.8 $429.3
2016 $858.8 $651.9
Total $2,655.7 $1,606.3

The full text of “2016 Updates: MSSP Savings Estimates Program Financial Performance 2013-2016” was published in December 2018 by NAACOs. A copy is available online at NAACOs.com.

PsychU reported on the most recent CMS estimates in “ACOs Shared Savings Raised Federal Costs By $384 Million Between 2013 & 2016,” which published on May 9, 2018.

PsychU reported on another aspect of this issue in “In Medicare Shared Savings Program, ACO Tenure Linked To Greater Spending Reductions,” which published on November 30, 2017.

For more information, contact: David Pittman, Health Policy and Communications Advisor, National Association of Accountable Care Organizations, 601 13th Street NW, Suite 900 South, Washington, District of Columbia 20005; 202-640-2689; Email: dpittman@naacos.com.

During 2017, national health spending in the United States increased by 3.9%. In 2016, the increase was about 3%. Between 2016 and 2017, national health spending rose from $3.36 trillion (or about $10,402 per person) in 2016 to $3.49 trillion (or about $10,739 per person) in 2017. Health care spending accounted for 17.9% of gross domestic product (GDP) in 2017, which was similar to 2016 when health care spending accounted for 18.0% of GDP. Growth in overall health care spending slowed for the second consecutive year, following elevated rates of growth in 2014 (5.2%) and 2015 (5.8%). These years were affected by expanded Medicaid and private health insurance coverage, and increased spending for prescription drugs – particularly for drugs used to treat hepatitis C.

Growth in national health spending decreased among all payers—private health insurance, Medicare, Medicaid, out-of-pocket spending, and federal government sponsor spending. Private health insurance saw the greatest decrease in health spending at 2.0 percentage points. This is a result of lower growth in medical benefits and a decline in fees and taxes resulting from the Consolidated Appropriations Act 2016, which suspended collection of the health insurance provider fee in 2017. Medicare saw the smallest decrease in health spending growth at 0.1 percentage points.

Changes In Growth Of National Health Spending By Payer, 2016-2017

Category % growth in 2016 % growth in 2017 Change in Growth Total 2017 Spending & % Of Total
Private Health Insurance 6.2% 4.2% – 2.0 $1.2 trillion (34%)
Medicare 4.3% 4.2% – 0.1 $705.9 billion (20%)
Medicaid 4.2% 2.9% – 1.3 $581.9 billion (17%)
Out-Of-Pocket Spending 4.4% 2.6% – 1.8 $365.5 billion (10%)
Federal Government Sponsor Spending 4.9% 3.2% – 1.6 $982.4 billion (19%)

These findings were reported in “National Health Expenditures 2017,” by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS). Researchers analyzed information from several sources, including (but not limited to) Medicare Trustees Reports, the Medicaid & Children’s Health Insurance Program (CHIP) Expenditure Tracking System, The U.S. Census Bureau, the Bureau of Labor Statistics, the Bureau of Economic Analysis, and a number of other surveys and statistical sources. The goal was to determine information regarding 2017 health care spending.

Overall national health spending for growth slowed in 2017 for the three largest goods and service categories. Hospital care growth decreased by 1 percentage point due to lower growth in the use and intensity of hospital services. Physician and clinical services decreased by 1.4 percentage points due to lower use and intensity of physician and clinical services. Retail prescription drugs decreased by 1.9 percentage points due to slower growth in the number of prescriptions dispensed, a continued shift to lower-cost generic drugs, slower growth in the volume of some high-cost drugs, declines in generic drug prices, and lower price increases for existing brand-name drugs.

Changes In National Health Spending Growth By Goods & Service Category

Category % growth in 2016 % growth in 2017 Change in Growth Total 2017 Spending
Hospital Care 5.6% 4.6% – 1.0 $1.1 trillion
Physician & Clinical Services 5.6% 4.2% – 1.4 $694.3 billion
Retail Prescription Drugs 2.3% 0.4% – 1.9 $333.4 billion

Data tables for “National Health Expenditures 2017” were published on November 27, 2017 by CMS, and are available at www.CMS.gov

The full text of “National Health Care Spending In 2017: Growth Slows To Post–Great Recession Rates; Share Of GDP Stabilizes” was published in the December 2018 issue of Health Affairs. An abstract is available online at www.healthaffairs.org.

PsychU reported on this topic in the following articles:

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.

Employers offering Cigna plans with integrated coverage for medical, behavioral, and pharmacy benefits saved an average of $193 per member per year. Cigna attributed the savings to greater member engagement with managing their health.

These results were announced as part of the findings from Cigna’s third annual Value of Integration Study. Cigna conducts the Value of Integration Study annually to assess and evaluate opportunities to optimize health plan benefit designs. Cigna’s 2018 Value of Integration Study examined approximately 4.9 million of its customer medical claims for group benefit plans from January 2016 to December 2017. Approximately half of the population had comprehensive medical, behavioral, and pharmacy benefits administered by Cigna, while the other half had only medical benefits with basic behavioral benefits administered by Cigna. Basic behavioral benefits are a carve-in fee-for-service (FFS) option that allows employers to choose between inpatient care management only (this is called the FFS Low Option). Customers were matched between the two groups on key attributes, including demographics, health condition, access to health improvement services, plan design and geographies. Cigna engaged KPMG LLP to review Cigna’s analysis of medical cost savings benefits from integration; KPMG reviewed the approach and methods used to conduct the study of medical cost savings benefits and found them to be sound.

The analysis compared outcomes during 2017 for Cigna members with only medical coverage to outcomes for those with integrated coverage (medical, behavioral, and pharmacy). For this analysis a “consumer with a health improvement opportunity” was defined as a member identified via claims for medical, pharmacy, or behavioral health claims or by self-report as eligible for chronic condition coaching programs (for diabetes, congestive heart failure, chronic obstructive pulmonary disease), lifestyle or wellness coaching (hypertension, smoking, healthy eating), or case management (complex oncology, transplants). Cigna defines engagement as completion of two health maintenance activities and one health improvement activity. Examples of the activities associated with health improvement include Goal complete – phone, online or onsite, Gaps in Care –credited closure, Pre/Post admission counseling, Case Management, Treatment Decision Support, and Healthy Pregnancies Healthy Babies.

Key findings were as follows:

  • A greater share of Cigna members with integrated benefits engage in health coaching, complex case management, and specialty drug management compared to Cigna members with only medical coverage.
  • About 22% more Cigna members enrolled in an integrated plan (medical, behavioral, and pharmacy benefits) participated in health coaching and case management.
  • Members with integrated benefits completed 15% more health improvement activities.
  • Members with integrated benefits had 10% lower out-of-network claims.
  • Among Cigna members with integrated benefits who were identified with a specific health improvement need, employers saved $645 per member per year for covered members with a known health improvement opportunity.
  • Employers saved $9,792 per member per year for an engaged member with a specialty condition.
  • Employers saved $5,900 per member per year for an engaged member with diabetes.

Jon Maesner, PharmD, chief pharmacy officer at Cigna, said “When people are actively engaged in their health and well-being, we see improvement across all metrics. Offering a fully-connected pharmacy benefit allows us to maximize every opportunity available to engage the people we serve, and we’re encouraged by the consistent value shown by connecting medical, behavioral and pharmacy benefits.”

For more information (and a copy of the top-line findings), contact: Ellie Polack, Media Contact, Cigna, 900 Cottage Grove Road, Bloomfield, Connecticut 06002; 860-902-4906; Email: elinor.polack@cigna.com.

In 2017, the life expectancy for the U.S. population declined to 78.6 years, down from 78.7 years in 2016. Life expectancy first declined in 2014, falling from 78.9 years, to 78.8 years in 2015. This was the first drop since 1999. Since then, life expectancy at birth has continued to decline for the past three years. For males, life expectancy changed from 76.2 in 2016 to 76.1 in 2017. For females, life expectancy remained the same at 81.1. The 10 leading causes of death in 2017 remained the same as in 2016. These include:

  1. Heart disease
  2. Cancer
  3. Unintentional injuries
  4. Chronic lower respiratory diseases
  5. Stroke
  6. Alzheimer disease
  7. Diabetes
  8. Influenza and pneumonia
  9. Kidney disease
  10. Suicide

These findings were reported in “Mortality in the United States, 2017” by Sherry L. Murphy, B.S., Jiaquan Xu, M.D., Kenneth D. Kochanek, M.A., and Elizabeth Arias, Ph.D. The researchers analyzed information collected by the National Center for Health Statistics (NCHS) from death certificates filed nationally into the National Vital Statistics System. The goal was to determine trends in mortality in the United States.

Additional findings include:

  • The age-adjusted death rate increased by 0.4% from 728.8 deaths per 100,000 standard population in 2016, to 731.9 in 2017.
  • Age-specific death rates increased significantly from 2016 to 2017 for age groups 25 to 34 (from 129.0 to 132.8 per 100,000), 35–44 (from 192.2 to 195.2 per 100,000), and 85 and over (from 13,392.1 to 13,573.6 per 100,000)
  • Age-specific death rates decreased for the age group 45–54, from 405.5 to 401.5 per 100,000 standard population.
  • The infant (aged under one year) mortality rate of 579.3 infant deaths per 100,000 live births in 2017 was not significantly different from the 2016 rate of 587.0.
  • The 10 leading causes of infant death in 2017 remained the same as in 2016 although four causes changed ranks. These include: congenital malformations, low birth weight, maternal complications, sudden infant death syndrome (SIDS), unintentional injuries, cord and placental complications, bacterial sepsis of newborn, diseases of the circulatory system, respiratory distress of newborn, and neonatal hemorrhage.

PsychU reported on this topic in in “U.S. Life Expectancy Falls For The First Time This Century,” which published on January 19, 2017.

For more information, contact: Robert Anderson, Chief of the Mortality Statistics Branch, National Center for Health Statistics, U.S. Centers for Disease Control and Prevention, 3311 Toledo Road, Hyattsville, Maryland 20782; 301-458-4800; Email: paoquery@cdc.gov.

The Washington State managed fee-for-service (MFFS) Medicaid health home duals financial alignment initiative saved Medicare 9.7%, or $103.4 million, from 2014 through 2016, compared to what would have spent without the demonstration. During the first demonstration year in 2014, Medicare savings totaled $35.4 million. During the second year, from January to December 2015, Medicare savings before adjustment for outliers totaled $30.4 million. For the third demonstration year, from January to December 2016, Medicare savings before adjustment is estimated at $37.7 million.

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 the riskiest beneficiaries. The program was implemented in 14 counties in July 2013, 23 additional counties were added in October 2013, and the remaining 2 counties (King and Snohomish) joined in April 2017. During the demonstration period under review, the state paid the health homes for delivery of services on a per-beneficiary, per-month basis, using three payment tiers. The payments included a one-time $252.93 fee for initial outreach and engagement, a $172.61 payment for intensive-care coordination and a $67.50 payment for each month that low-level care coordination was provided. The organizations selected to operate the health homes were Community Choice (a provider organization consortium); Northwest Regional Council (an Area Agency on Aging); Optum (a Mental Health Regional Support Network); and Southeast Washington Aging and Long Term Care (an Area Agency on Aging). Two managed care plans were also selected to be health homes, Community Health Plan of Washington and United Health Care Community Plan.

The findings were reported in “Report for Washington Health Home Managed Fee-for-Service: Final Demonstration Year 2 and Preliminary Demonstration Year 3 Medicare Savings Estimates: Medicare-Medicaid Financial Alignment Initiative” by Actuarial Research Corporation (ATC) and RTI International for the Centers for Medicare & Medicaid Services (CMS) Center for Medicare & Medicaid Innovation (CMMI).For Medicare, this preliminary report covers the 24-month period from January 1, 2015 through December 31, 2016. This 24-month period covers Medicare data only for demonstration period 2 for the Washington demonstration (January 1, 2015 through December 31, 2015) and demonstration period 3 (January 1, 2016 through December 31, 2016). It provides final Medicare savings estimates for demonstration period 2 and preliminary estimates for demonstration period 3.

The report has no analysis of Medicaid savings or outcomes. The report covers Medicare only because sufficient Medicaid data for 2015 and 2016 was not available. The authors intend to issue a savings report after each demonstration period and future reports will include Medicaid data for demonstration periods 1, 2, and 3 when available.

To calculate savings, the researchers compared trend of per member per month Medicare expenditures for each cohort in the demonstration group with the trend of per member per month expenditures of those in a comparison group. For Medicare, the per member per month amounts are calculated by dividing total Medicare Parts A and B expenditures by the number of member months of eligibility. Medicare-paid amounts do not include the amounts for deductibles, coinsurance, or balance billing. For hospital claims, the paid amount is reduced for Medicare Disproportionate Share (DSH) payments and Indirect Medical Education (IME) payments, because these payments are not directly related to the cost of care provided to individual beneficiaries.

The mean per member per month Medicare expenditures during demonstration year 2 decreased an average of $167.84 for the demonstration group. The target cost was $1,783.70, and the demonstration group cost was $1,615.86. The demonstration group baseline was $1,649.33, which dropped to $1,615.86 during the year. The comparison group baseline was $1,624.10, which increased to $1,754.60.

Washington State MFFS Demonstration Year 2, Medicare Per Member Per Month Costs By Type Of Service

Service Type Intervention Comparison Target Savings
Baseline $1,649.33 $1,624.10 N/A N/A
Durable Medical Equipment $73.68 $89.91 $90.62 $16.94
Home Health $65.74 $105.33 $104.99 $39.25
Hospice $20.60 $45.93 $45.92 $25.32
Inpatient $622.64 $648.16 $660.17 $37.52
Outpatient $385.01 $354.22 $359.89 -$25.12
Professional $298.39 $373.34 $380.64 $82.25
Skilled Nursing Facility $149.79 $137.73 $141.47 -$8.32
Total $1,615.86 $1,754.60 $1,783.70 $167.84

The mean per member per month Medicare expenditures during demonstration year 3 decreased an average of $178.07 for the demonstration group. The target cost was $1,749.99, and the demonstration group cost was $1,571.92. The demonstration group baseline was $1,649.33, which dropped to $1,571.92 during the year. The comparison group baseline was $1,624.10, which decreased to $1,703.93 from the demonstration year 2 total of $1,754.60.

Washington State MFFS Demonstration Year 3, Medicare Per Member Per Month Costs By Type Of Service

Service Type Intervention Comparison Target Savings
Baseline $1,649.33 $1,624.10 N/A N/A
Durable Medical Equipment $60.64 $74.63 $76.15 $15.51
Home Health $64.61 $102.01 $103.01 $38.41
Hospice $18.86 $56.97 $56.86 $38.00
Inpatient $605.54 $633.57 $652.03 $46.48
Outpatient $391.07 $354.24 $363.76 -$27.31
Professional $293.15 $354.80 $365.45 $72.31
Skilled Nursing Facility $138.06 $127.71 $132.73 -$5.33
Total $1,571.92 $1,703.93 $1,749.99 $178.07

In November 2018, the state issued a monthly update on the current status of the demonstration in “Washington State’s Fee-For-Service Dual Eligible Demonstration Monthly Report.” As of October 2018, there were 33,906 dual beneficiaries eligible for the duals demonstration, and 58% (19,593 beneficiaries) were actively enrolled with a health home lead entity. The remaining 21% chose not to participate. There are now nine lead entities: Community Choice, Community Health Plan of Washington, Northwest Regional Council, Optum Health, Southeast Washington Aging and Long Term Care, United Health Care Community Plan, Molina, Full Life, and Coordinated Care. Each lead entity has a different geographic coverage area. Full Life became a health home lead entity beginning in April 2017 in King County. Coordinated Care became a lead entity beginning in January 2018.

PsychU reported on this topic in “First Year Of Washington State Managed FFS Duals Demonstration Shows 6% In Medicare Savings,” which published on March 16, 2016.

PsychU reported on this topic in “Washington State To End Medicaid Health Home Program,” which published on January 13, 2016.

For more information, contact: Communications Office, Washington State Health Care Authority, Post Office Box 45502, Olympia, Washington 98504-5502; 360-725-1057; Email: communications@hca.wa.gov; or 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.

Humana’s value-based contracts (VBC) are supporting physicians in improving member health and reducing medical costs. During 2017, condition-specific screening rates and cancer screening rates were higher among Humana Medicare Advantage members attributed to physicians participating in Humana VBC compared to those whose physicians received fee-for-service (FFS) reimbursement. Medical costs were 15.6% lower among Humana members whose physicians participated in VBC compared to costs for beneficiaries enrolled in original Medicare.

Members with diabetes whose physicians participated in Humana VBC had more condition-specific screenings and better adherence to medications compared to members with physicians who received Humana FFS reimbursement. Key improvements were as follows:

  • About 2% more had controlled blood glucose levels, 2% more had controlled renal disease, and 3% more had nephropathy screenings/tests.
  • About 9% more got regular eye examinations.
  • Across all members whose physicians participated in VBC, 11% more received colorectal cancer screenings, and 10% more had breast cancer screenings.
  • Receipt of screenings and medication adherence were higher among members whose physicians participated in VBC, with 4% more receiving an assessment of their body-mass index, and 8% more with controlled blood pressure.
  • Medication adherence rates were also higher, with 3% higher adherence to statin medications, hypertension medications, and diabetes medications.

Across Humana Medicare Advantage members, medical costs were 1% lower for those whose physicians participated in VBC compared to members whose physicians received Humana FFS reimbursement. A contributing factor to the difference in medical costs was associated with a difference in utilization of emergency room care and hospitalization. Outcomes for Humana Medicare Advantage members affiliated with VBC physicians in 2017 (compared to Humana FFS physicians) were as follows:

  • 7% fewer emergency room visits per thousand
  • 5% fewer hospital admissions per thousand

Humana reported these findings in “The Intersection Of Health + Care, Value-based Care Report.” It is Humana’s fifth year for reporting on the outcomes of its value-based care agreements. The section that discussed cost outcomes, “2017 Key insights,” was written by Kathryn Lueken, M.D., M.M.M. corporate medical director, Medical Market Clinical Integration. The data about outcomes and cost were from a study of approximately 1.5 million Humana Medicare Advantage members affiliated with physicians in value-based agreements compared to 146,000 Humana Medicare Advantage members affiliated with physicians under standard Medicare Advantage FFS reimbursement, and compared to original FFS Medicare.

In 2017, Humana had a total of 3.3 million Medicare Advantage members in individual and group plans. About 67% of Humana Medicare Advantage individual members are affiliated with primary care physicians participating Humana VBC, representing 1.9 million of the 2.9 million Humana Medicare Advantage individual members.

About 70% of physician practices participating in the Humana value-based program in 2017 earned shared savings. About 16.8% of every dollar Humana spent on member care in 2017 went to primary care physician (PCP) practices in value-based agreements (percent taken of total Medicare Advantage-covered claims expense). Non-value-based PCP practices contracted with Humana received 6.9% of total payments Humana distributed in 2017. The national average is 6%.

Results also showed that members affiliated with physicians in Humana Medicare Advantage VBC had more favorable outcomes in all Healthcare Effectiveness Data and Information Set (HEDIS) Star measures compared to members affiliated woth physicians who received Humana FFS reimbursement. HEDIS is a measurement tool developed by the National Committee for Quality Assurance (NCQA) to assess health plans’ performance on various dimensions of care and service. Members with diabetes who were affiliated with value-based physicians had more condition-specific screenings and better adherence to medications, demonstrating tighter control of blood glucose and blood pressure levels. Cancer screening rates were also higher for members affiliated with value-based physicians.

A section by Fernando Valverde, M.D. regional president, Medicare South Florida described Humana’s value-based continuum. There are two primary categories of payment models: FFS plus a quality bonus and value-based care. The share of members receiving care through each is as follows:

  • 8% of the members receive care via FFS arrangements
  • 25% receive care via FFS plus bonus for meeting quality of care targets.
  • 35% of members are in a shared savings plus bonus arrangement, which consists of FFS plus bonus plus potential for limited shared savings (upside only) in Medicare Parts A, B and D.
  • 6% of members are in a limited value arrangement, which consists of FFS plus bonus plus care coordination payment plus higher portion of shared savings in Medicare Parts A, B and D
  • 6% are in full value arrangements, which consist of FFS plus 100% responsible for Medicare Part B expenses and sharing of Part A (may have shared savings or complete responsibility for Part D)
  • 20% are in global value arrangements, which consist of full responsibility for Medicare Parts A, B and D through monthly capitated payments

Humana offers bundled payment agreements in select clinical specialties—Total Joint Replacement and Maternity. In 2018, there were 62 bundled payment agreements, up from 28 in 2017, and 12 in 2016.

The full text of “The Intersection Of Health + Care, Value-based Care Report” was published in November 2018, by Humana. A copy is available online at ValueBasedCare.Humana.com.

For more information, contact: Alex Kepnes, Corporate Media Relations, Humana, 500 W Main Street, Louisville, Kentucky 40202; 502-580-2990; Email: akepnes@humana.com.

On November 14, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to ease and streamline the managed care regulatory framework for Medicaid and the Children’s Health Insurance Plan (CHIP). The proposed rule modifies the 2016 managed care final rule. The key proposed revisions focus on promoting flexibility, strengthening accountability, and maintaining and enhancing program integrity. The major changes in the proposal give states flexibility to set rate ranges and set network standards based on quantitative measures that account for telehealth. Comments on the proposed rule will be accepted through January 14, 2019.

Under the provisions to promote flexibility:

  • States will be able to develop and certify a rate range under specific conditions and limitations, including that the rate range be actuarially sound.
  • States will have more flexibility to set meaningful network adequacy standards using quantitative standards, such as “wait time for an appointment” that can account for telehealth and other new service delivery models. This approach can replace the current “time and distance” standards.
  • States will have a three-year transition period to meet requirements related to pass-through payments.
  • A current requirement that managed care plans must enter into a coordination of benefits agreement directly, will be eased. Instead contracts with managed care plans would be required to specify the methodology by which the state would ensure that the managed care plans receive all appropriate crossover claims for which they are responsible.
  • Administrative requirements will be updated to remove outdated and overly prescriptive provisions that govern how plans communicate with beneficiaries to better align with standards used across federal programs and enable the use of modern means of electronic communication when appropriate.

To strengthen accountability, CMS will issue guidance to help states move more quickly through the federal rate review process and to allow for submission of less documentation in certain circumstances while providing appropriate oversight to ensure patient protections and fiscal integrity. CMS will maintain the requirement for states to develop a Quality Rating System (QRS) for health plans to facilitate beneficiary choice and promote transparency. However, states will have greater ability to tailor an alternative QRS to their unique program while requiring a minimum set of mandatory measures to align with the Medicaid and CHIP Scorecard.

The provisions related to program integrity maintain the current regulatory framework for program and fiscal integrity, including provisions related to the actuarial soundness of rate setting, provider organization screening and enrollment standards, and medical loss ratio (MLR) standards. States will be prohibited from retroactively adding or modifying risk-sharing mechanisms and ensuring that differences in reimbursement rates are not linked to enhanced federal match.

Additionally, CMS is also asking states for data that could support revising the current 15-day limit on stays in an institution for mental disease (IMD) for Medicaid managed care beneficiaries. In this proposed rule, CMS did not propose any changes to the IMD policy but did note that states have expressed concerns with the administrative challenges created by the current limit. CMS will continue to support state waivers to the IMD exclusion for Medicaid managed care members diagnosed with addiction disorder; to date, CMS has approved a total of 15 such waivers, and is exploring further options to remove barriers to treatment in an IMD setting.

CMS said the proposed rule supports its efforts to streamline the Medicaid and CHIP managed care regulatory framework and reflects a broader strategy to relieve regulatory burdens; support state flexibility and local leadership; and promote transparency, flexibility, and innovation in the delivery of care.

PsychU reported on this topic in “The Final Medicaid Managed Care Rules = Lots Of State Discretion,” which published on June 6, 2016.

PsychU also reported on the final rule in “Medicaid Finalizes Managed Care Rules, Including Qualified End To IMD Exclusion,” which published on May 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.

Six state public behavioral health systems that have implemented mental health peer support specialists (PSS) reported using a group of similar practices to certify the skills and competencies of PSS workers. A PSS worker, as defined by the federal Substance Abuse and Mental Health Administration (SAMHSA), is a person who has lived-experience and is in recovery from mental illness and/or addiction and who uses that “lived experience, plus skills learned in formal training, to deliver services in behavioral health settings to promote mind-body recovery and resilience.” The key practices are as follows: objective screening, in-person core training, training modules on physical health and wellness, technical assistance to provider organizations using PSS; and engagement of PSS in leadership and development of certification programs.

The six states are: Florida, Georgia, Michigan, Oregon, Pennsylvania, and Texas. Each of these states has had a PSS certification program for at least two years. The review was conducted by the Government Accountability Office (GAO). The six practices are as follows:

  1. Systematic and objective screening of the PSS’ understanding of recovery and the peer role.
  2. Ensure in-person core training to strengthen PSS interpersonal and relationship building skills.
  3. Incorporate physical health and wellness into PSS training or continuing education.
  4. Educate provider organization staff about the peer support role, and how to effectively use and supervise PSS.
  5. Require that PSS participate in continuing education specific to peer support.
  6. Engage PSS in the leadership and development of certification programs for applicants.

As of July 2016, 41 states and the District of Columbia had programs to certify PSS. The 41 states and District of Columbia were also receiving federal Medicaid reimbursement for PSS services. Most of the states used SAMHSA grants and state general funds to develop and sustain their peer support programs. For 2016, 32 states voluntarily reported that part of their block grants were used to fund peer recovery coaching activities—either training or service provision. In fiscal year 2018, 40 states and the District of Columbia reported using the funds from the Community Mental Health Services Block Grant for peer support.

The GAO reported its findings in “Mental Health: Leading Practices for State Programs to Certify Peer Support Specialists.” From November 2017 to November 2018, the GAO interviewed state program officials in the six states; and reviewed online, publicly available information about the state peer support programs. The GAO also interviewed SAMHSA officials and 10 stakeholders familiar with PSS certification, including mental health researchers and officials from training organizations. The 21st Century Cures Act included a provision for GAO to conduct a study to identify best practices related to training and certification in PSS programs in selected states that receive funding from SAMHSA. This report describes programs and leading practices for certifying PSS as identified by program officials in selected states.

The GAO selected the six states based on the following criteria:

  • Recommendations from officials at SAMHSA, researchers in the field of peer support, and national-level mental health organizations on states with well-established programs.
  • SAMHSA data that indicated that a state had reported using SAMHSA’s Community Mental Health Services Block Grant for peer support generally.
  • The age of the state’s certification program was at least two years old. This was to ensure that the selected states had certified PSS for at least one full certification cycle. PSS certifications are typically valid for 12 to 24 months.
  • Geographic diversity across the United States.
  • The prevalence of serious mental illness among adults in the state.
Summary Of Peer Support Specialist Program Screening, Training, And Certification Requirements In Six Selected States, As Of May 2018
SCREENING
Florida Georgia Michigan Oregon Pennsylvania Texas
State certification title Certified Recovery Peer Specialist Certified Peer Specialist Certified Peer Support Specialist Peer Support Specialist Certified Peer Specialist Certified Peer Specialist
Level of education High school or equivalent High school or equivalent High school or equivalent Not required High school or equivalent High school or equivalent
Prior work or volunteer experience 500 hours Not required At least 10 hours per week for the past 3 months Varies Minimum of 12 months of work or volunteer experience in the past 3 years Not required
Number and type of letters of recommendation 1 supervisory, 1 professional, 1 personal Not required 2 professional Varies Not required 2, type unspecified
Recovery experience Lived experience with mental illness or addiction disorder and in recovery for at least 2 years Must have been in recovery for at least 1 year between diagnosis of mental illness or addiction disorder, and application for the training program Must have been diagnosed with mental illness and in recovery for at least 1 year Must currently be or formerly have been receiving services for mental illness or addiction disorder Must currently be or formerly have been receiving services for mental illness Must self-identify as being in recovery from a mental health challenge
TRAINING REQUIREMENT
Florida Georgia Michigan Oregon Pennsylvania Texas
Length of core training 40 hours 72 hours 56 hours 40 hours 75 hours 43 hours
Training curriculum State has a single, approved core training curriculum State has a single, approved core training curriculum State has a single, approved core training curriculum State allows applicants to choose their curriculum from approved training vendors State allows applicants to choose their curriculum from approved training vendors State has a single, approved core training curriculum
Training fees None $85 $600 Varies $900 to $1,400 $650
CERTIFICATION REQUIREMENT
Florida Georgia Michigan Oregon Pennsylvania Texas
Examination Yes Yes Yes Yes Yes Yes
Signed code of ethics Yes Yes Yes Yes Yes Yes
Length of certification 1 year Lifetime Lifetime 3 years Lifetime 2 years
Continuing education requirement 10 hours per year 12 hours per year Not required 20 hours every 3 years 36 hours every 2 years 20 hours every 2 years

The GAO noted that while states generally use the six practices for certifying PSS competency, there is some variation in screening requirements. The 10 stakeholders GAO interviewed generally agreed that the six practices should become a standard part of certifying PSS competency in every state for a stronger quality of services for individuals with serious mental illnesses.

PsychU reported on this topic in “Wake Forest Baptist Medical Center Finds Addiction-Focused Peer Support Program Reduces Readmissions,” which published on June 18, 2018.

For more information, contact: Mary Denigan-Macauley, Assistant Director, U.S. Government Accountability Office, 441 G Street, NW, Room 7149, Washington, District of Columbia 20548; 202-512-7114; Email: deniganmacauleym@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.

The American Psychiatric Association (APA) and APA Foundation Center for Workplace Mental Health recommend employers take a more active role in improving access to behavioral health care. They recommend improving access by ensuring network adequacy, mental health parity compliance, collaborative care, and telepsychiatry in employer-sponsored health plans. The recommendations include:

  1. Network adequacy of health plans: Health plans and behavioral health organizations should ensure network adequacy: increase in-network providers for all mental health and substance use services, provide updated and accurate provider directories, understand and improve network participation to enhance access to in-network treatment, provide incentive payments to fully network-participating providers who meet quality metrics.
  2. Benefit parity: Employers and employer coalitions should improve mental health parity compliance: ask plans about differences in frequency of in-network and out-of-network care for mental health and substance use care; denial of care rates for mental health and substance use disorder; an explanation of disparities, corrective action, and action timelines; and organizational legal department familiarity with parity laws.
  3. Measurement-based care: Employers and employer coalitions should advance measurement-based care: request health plan action plans that require provider organizations to use standardized measurement-based tools for decision-making, and that requires aggregate-level outcomes data for employees being treated for mental health and substance use conditions; and assure that health plans are screening enrollees for depression, anxiety, psychosis, bipolar disorder, suicide, substance use and that the plans track and report on treatment outcomes. Health plans and behavioral health organizations (BHOs) should provide incentive payments and minimize administrative requirements to primary care, mental health, and substance use provider organizations who participate in network and in quality improvement programs that require the use of standardized measurement tools at regular intervals.
  4. Integration with primary care: Health plans and BHOs should expand the collaborative care model: pay for the evidence-based collaborative care model (CoCM); ensure that primary care practices implement the CoCM with appropriate methodology; provide health care professionals a link to APA’s collaborative care training module, and provide technical assistance and training on the module; and provide employers with data on the use of CoCM Current Procedural Terminology (CPT) codes. Employers and employer coalitions should request a plan for ongoing technical assistance and training regarding the CoCM and CPT codes from health plans.
  5. Expansion of virtual care: Health plans and BHOs should offer a link to the APA’s telepsychiatry toolkit to their in-network primary care and mental health providers for best-practice use; and identify and notify employers of barriers to expanding care through telepsychiatry, and methods to overcome these barriers. Employers and employer coalitions should educate providers and plan enrollees about telepsychiatry, and ensure training for in-network providers regarding telepsychiatry delivery; and require health plans to reimburse telehealth care at the same rate as in-person health care.

These recommendations were reported in “Recommendations for Improving Access to Mental Health and Substance Use Care.” The APA partnered with the APA Foundation’s Center for Workplace Mental Health and consulted with psychiatrists, large employers, health plans, business groups on health and other mental health professionals. The goal was to develop these recommendations to assist employees in locating and accessing timely and effective mental health and substance use treatment.

The full text of “Recommendations for Improving Access to Mental Health and Substance Use Care” was published in August 2018 by the Center for Workplace Mental Health and the American Psychiatric Association. An abstract is available online at workplacementalhealth.org.

For more information, contact: Darcy Gruttadaro, JD, Director, Center for Workplace Mental Health, American Psychiatric Association Foundation, 800 Maine Avenue SW, Suite 900, Washington, District of Columbia 20024; 202-559-3888; Email: dgruttadaro@psych.org.

In 2017, about 56% of American adults (141 million of the 252 million population age 18 and older) sought mental health services for either themselves or someone else. Of those who had not sought treatment, 46% said they would not know where to go if they needed to obtain mental health services for themselves or someone else.

About 38% of those who sought treatment for themselves had to wait longer than one week for the appointment, representing about 90 million people. About 21% of those who wanted to obtain mental health services for themselves were unable to for reasons outside their control. About 34% of people seeking treatment for themselves said the out-of-pocket cost (or the terms of their insurance coverage) presented their primary barrier to obtaining mental health services.

These findings were reported in “America’s Mental Health 2018” by Ketchum Analytics for Cohen Veterans Network and the National Council for Behavioral Health. The researchers conducted an online survey between July 31 and August 12, 2018, among 5,000 Americans. Through the survey, the researchers identified veterans, those with a secondary relationship to a veteran, and more broadly those who have sought mental health treatment. The researchers ranked each state from 0 to 100 according to its mental health service access. The ranking was based on the number of clinical mental health professionals, the number of behavioral health facilities, state funding for mental health services, and consumer satisfaction surveys. The goal was to gain a better understanding of Americans’ current access to and attitudes towards mental health services.

Additional findings include:

  • Those who sought treatment tended to be younger, lower-income, and involved with the military.
  • The top three reasons given for seeking mental health treatment are unhappiness, anxiety, and “I didn’t feel like myself.”
  • Among those who sought treatment, 37% were Millennials (born between 1981 and 1996). About 27% of those who did not seek treatment were Millennials.
  • About 53% of those who sought treatment had annual income under $50,000. About 47% of those who did not seek treatment had income below $50,000.
  • About 66% of those who sought mental health treatment were involved with the military, either directly or through a secondary relationship. About 53% of those who did not seek mental health treatment were involved with the military.
  • About 25% of American adults believe that mental health services are extremely accessible.
  • About 39% of those who live in rural areas say that mental health services are extremely accessible, compared to 45% of those in suburban areas, and 46% of those in urban areas.

The full text of “America’s Mental Health 2018” was published in October 2018 by Cohen Veterans Network. A copy is available online at  www.cohenveteransnetwork.org.

PsychU reported on this topic in “The Average Marketplace Health Plan Provider Network Includes 11% Of Mental Health Care Professionals,” which published on November 9, 2017.

For more information, contact: Paul Wood & Anthony Guido, Communications, Cohen Veterans Network, 72 Cummings Point Road, Stamfort, Connecticut 06902; 203-569-0289 or 203-569-0284; Email: communications@cohenveteransnetwork.org

By 2040, the U.S. life expectancy will drop to a ranking of 64th of all high-income countries, compared to a rank of 43rd in life expectancy in 2016. By 2040, Spain is projected to have the world’s longest life expectancy, with an average lifespan of 85.8 years. Spain will be followed by Japan (85.7 years), Singapore (85.4 years), and Switzerland (85.2 years). U.S. life expectancy in 2040 is expected to be 79.8 years, up from 78.7 years in 2016.

These findings were reported in “Forecasting Life Expectancy, Years Of Life Lost, And All-Cause And Cause-Specific Mortality For 250 Causes Of Death: Reference And Alternative Scenarios For 2016–40 For 195 Countries And Territories” by Kyle J Foreman, Ph.D.; Neal Marquez, BA; Andrew Dolgert, Ph.D.; Kai Fukutaki, BA; Nancy Fullman, MPH; Madeline McGaughey, BA; et al. The researchers analyzed data from the 2016 Global Burden of Diseases project, to generate predictions from 2017 to 2040. The impacts of diseases such as diabetes, HIV/AIDS and cancers, as well as risk factors including diet and smoking rates were taken into account by the researchers.

Additional findings include:

  • The worldwide top three causes of years of lost life in 2040 are projected to remain the same as in 2016: heart disease, stroke, and lower respiratory infections.
  • In 2040, the top three causes of years of life lost due to disease or injury death in high-income North America (including the U.S.) will be: heart disease; Alzheimer’s disease and other dementias; and tracheal, bronchitis, and lung cancer.
  • In 2040, the worldwide top three environmental, behavioral, metabolic and occupational risks contributing to years of life lost will be high blood pressure, high body mass index, and high fasting plasma glucose.

The full text of “Forecasting Life Expectancy, Years Of Life Lost, And All-Cause And Cause-Specific Mortality For 250 Causes Of Death: Reference And Alternative Scenarios For 2016–40 For 195 Countries And Territories” was published October 16, 2018, by The Lancet. An abstract is available online at www.thelancet.com

PsychU reported on this topic in “Between 2000 & 2015 U.S. Life Expectancy Rose, But At A Slower Rate Than Expected Due To Opioid Overdose Deaths,” which published on October 16, 2017.

For more information, contact: Christopher J.L.. Murray, M.D., D.Phil., Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121; Email: cjlm@uw.edu.

In this series of interviews, Sloan Manning, MD, discusses a variety of screening tools that may be used in primary care (or mental health) settings to screen for mental health symptoms and associated risks, and measure response and change in symptoms over time.

For this installment, Dr. Manning focuses on a variety of screening tools related to suicide risk, including the Substance Abuse & Mental Health Services Administration’s (SAMHSA) Suicide Assessment Five-Step Evaluation & Triage (SAFE-T) and the 3-Item Patient Safety Screener (PSS-3) which was developed by the University of Massachusetts Medical School. He discusses their measures and scoring mechanisms, and the potential value of each tool’s practical application within the clinical setting.

Dr. Manning is the Medical Director and Adjunct Associate Professor, School Of Medicine, as well as the Co-Director of the Mood Disorder Clinic at Novant Health Urgent Care & Occupational Medicine at the University Of North Carolina.

If you or someone you know is in crisis, call the Suicide Prevention Hotline / Lifeline at: 1-800-273-TALK (8255); or text the Crisis Text Line at 741-741.

Check out the other videos in this series:

Approximately 75% of clinical episodes had lower costs in the Medicare Bundled Payments for Care Improvement (BPCI) initiative for Models 2, 3, and 4. CMS released the outcomes for the fifth year of the Medicare BPCI on October 9, 2018. Under the BPCI initiative, Medicare payments declined for most clinical episodes and over half of the relative payment reductions were statistically significant. The declines were primarily due to relative reductions in the use of post-acute care. Medicare payments declined for three-quarters of the clinical episode combinations evaluated, with little change in quality of care.

The BPCI initiative rewards participants financially for reducing Medicare payments for an episode of care relative to a target price. The participants’ agreements with CMS specified their model choice, and their choices among 48 clinical episodes and other episode characteristics. Participants could enter the risk-bearing phase of the initiative during a two-year period through September 2015 and could enter additional clinical episodes into the risk-bearing phase through December 2015. At any time, the participants could stop participating in a given clinical episode or terminate their participation entirely. Model 1 began earlier than Models 2, 3, and 4 and was evaluated separately.

The BPCI outcomes were presented in “CMS Bundled Payments for Care Improvement Initiative Models 2 to 4: Year 5 Evaluation & Monitoring Annual Report,” by The Lewin Group and partners for CMS. Data for the report was obtained through analyses of Medicare claims and enrollment data, post-acute care (PAC) provider organization and consumer assessments, awardee-submitted data, beneficiary surveys, participant interviews, and participant site visits. The evaluation includes all analyses conducted during the five-year evaluation contract and describes the experience under BPCI for over three years of the initiative, from the fourth quarter (Q4) of 2013 through Q4 2016. The goal was to update previous outcomes reports to include the new analysis; it is the first report to include results of episodes initiated by physician group practices (PGPs). Over the first 13 quarters of the BPCI, there were more than 796,000 episodes initiated across Models 2, 3, and 4; most (87%) were Model 2 episodes.

Model 2: Retrospective acute care hospital stay plus post-acute care—The 48 bundles of care include inpatient services, physicians’ services, care by the post-acute provider organization, and related readmissions within 30 days. In total, 221 awardees that represented 423 hospital episode initiators (EIs) and 272 PGP EIs joined the risk-bearing phase of Model 2. During the first 13 quarters of the BPCI initiative, 20% of all Model 2 hospital EIs and 26% of all Model 2 PGP EIs withdrew completely from the initiative. The average Model 2 EI participated in eight clinical episodes, and the most commonly selected clinical episode was major joint replacement of the lower extremity (MJRLE). Approximately 27% of BPCI hospital episodes and 25% of BPCI PGP episodes initiated through Q4 2016 were for a beneficiary who was aligned with a Medicare accountable care organization (ACO). The outcomes were as follows:

  • There was a relative decline in total Medicare payments during the inpatient stay plus 90 days post discharge for 24 of the 32 Model 2 hospital clinical episodes for which there was a sufficient sample size during the first 13 quarters of the BPCI initiative. Twelve of the 24 declines were statistically significant.
  • Skilled nursing facility (SNF) payments declined for nearly all the clinical episodes. Smaller shares of patients were discharged to institutional post-acute care (PAC) settings, and there were fewer SNF days for SNF users. These declines led to reduced Medicare payments.
  • Home health agency (HHA) payments increased, which was expected because smaller shares of PAC users were discharged to institutional PAC.
  • In general, quality of care as measured through Medicare claims did not change under BPCI.
  • Beneficiary resource intensity did not change for most clinical episodes from the baseline to the intervention period relative to a comparison group.

Model 3: Retrospective post-acute care only—The 48 bundles of care include post-acute care services provided within 30 days of discharge from the inpatient stay; ending either 30, 60, or 90 days after initiation of the episode. In total, 135 awardees that represented 873 SNF EIs, 144 PGP EIs, 116 HHA EIs, 9 inpatient rehabilitation facility (IRF) EIs, and one long-term care hospital (LTCH) EI participated in the risk-bearing phase in Model 3 of BPCI. The participants represented 5% of all SNFs and 1% of all HHAs. During the first 13 quarters of the initiative, 27% of all Model 3 SNF EIs and 30% of all Model 3 HHA EIs withdrew from BPCI. The impact analysis was conducted on 11 SNF and 3 HHA clinical episodes. The study sample included 493 SNFs and 71 HHA EIs that initiated 28,121 and 9,306 episodes of care, respectively, during their tenure in the BPCI initiative. The Model 3 outcomes were as follows:

  • Seven of the 11 SNF clinical episodes and one of the three HHA clinical episodes that were examined had statistically significant declines in Medicare allowed payments among BPCI participants relative to the comparison group.
  • The total allowed payment amount (Medicare program payments plus coinsurance and/or copayments) included in the bundle declined from baseline to intervention for BPCI HHAs episodes relative to the comparison group in two of the three clinical episodes, and the decline was statistically significant for one clinical episode.
  • There were no statistically significant relative changes in SNF or HHA payments during the 90-day post-discharge period in any of the three clinical episodes.
  • BPCI-participating SNF and HHA EIs were larger and more likely to be for-profit and members of a chain than non-participating providers. They also had higher standardized Part A payments prior to joining BPCI for the clinical episodes they selected.

Model 4: Prospective acute care hospital stays only—The 48 bundles of care include inpatient services, physician services, and related readmissions within 30 days. Participation in Model 4 was low. There were no statistically significant changes in total payments and there were few statistically significant changes in utilization, quality of care, or patient satisfaction among the two clinical episodes analyzed through September 2015.

PsychU reported on a new BPCI model in “New Medicare Bundled Payment Model Has 1,299 Participating Provider Organizations,” which published on November 19, 2018.

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.

The time that consumers are waiting for health care services appears to be getting longer. The average wait time for consumers seeking a new appointment with a physician increased 30% (24.1 days) since 2014. For mental health services this wait time can be up to 25 days. Thirty-eight percent of consumers have had to wait longer than one week for mental health services.

And a survey out of Massachusetts found that on average, provider organizations there reported seeing 81% percent of new consumers within two weeks of first contact, 93% within one month, 7% in five weeks more. For 3% of new consumers, access took over eight weeks.

Once consumers have an appointment, the on-time performance of most health care systems for those appointments isn’t great. These wait times in-office vary widely, with the average wait time for consumers to see their doctor at about 18 minutes. Patient Engagement HIT reports that the average in-office wait times for an appointment at a hospital range from 13 to 29 minutes—with 30% of consumers reporting that they had left the appointment because the wait was too long. Not surprisingly, in-person wait times in the emergency room are much longer, with average wait times before seeing a physician ranging from 53 minutes in Maryland, to 13 minutes in Colorado.

The reasons for long times to appointments and long in-office waiting times are many. Possible reasons include the increase in consumers needing services due to expanded insurance coverage; staff shortages; and administrative burdens due to electronic health records (EHR). Scheduling is also to blame when it comes to in-office wait times, with many offices booking as many consumer appointments as possible to increase productivity, maximize revenue potential, and account for consumer no-shows.

The consumer access issue is a big one if you’re either a manager of a provider organization or a manager of a health plan. On the provider organization side, consumers with long wait times are generally consumers with low satisfaction scores. Health care consumer engagement group Vitals found that hospitals that achieved the highest satisfaction rating (5 stars) have a 13-minute in office wait time, compared to the lowest rated hospitals (1 star), which had a 33-minute wait time. And, consumers with long wait times to make an appointment are more likely to “no show”—or to leave an appointment. Thirty percent of consumers who have long wait times leave before seeing a clinical professional, and 20% will change provider organizations after experiencing a long wait time. Both scenarios are very costly for a provider organization.

Health plan managers are focused on timely access for similar reasons—lower wait times produce better consumer engagement and more positive consumer satisfaction scores when it comes to CMS STARS and HEDIS scores. Longer wait times to get appointments also can provide costly for health plans, as long wait times can result in increased emergency room and inpatient utilization. One study found that at Geisinger, among consumers waiting for specialty appointment, the 30-day rate of emergency room or inpatient utilization was 8.7 times higher than those consumers who were not waiting for appointments.

Therefore, health plan managers are now paying more attention to access. For more, I reached out to OPEN MINDS Senior Associate Deb Adler, who noted:

Studies show that the more quickly a consumer can access an appointment from the point of deciding to seek treatment, the more likely the consumer will engage in treatment. Research shows that “no show” rates rose from 12% when the appointment was delivered the same day, to 26% when the appointment was available the second day. No show rates rose up to 44% when the service was delayed for 13 days.

This has resulted in payers implementing rapid access or quick access networks as a means to improve the consumer experience and promoting engagement and positive outcomes. For example, Optum has an “express access” network-a narrow network of providers that offers appointments to members within five days of request compared to the industry standard of 10 days. These fast access providers are transparently displayed to consumers with a “stopwatch” symbol to help guide members to this option. More information is available on their provider portal—ProviderExpress.com—including the ability to apply to this program, sign the require addendum, and other frequently asked questions.

The question I have for any service delivery system—what is the wait time for an appointment at your organization? And, with an appointment, how long do consumers wait for services? The answers to these questions are important for being a “preferred provider”—both with consumers and their health plans.

For more on speeding access to care and access issues, check out these resources from the PsychU Resource Library:

  1. Health Insurance Coverage Vs. Access To Care—The Gap Between Them
  2. If There Are Enough Psychiatrists, Why Is Access Such A Problem?
  3. Is 2019 The Year Of The Telehealth Tipping Point?
  4. Network Adequacy Doesn’t Equal Consumer Access

Everything needs to be updated from time to time. Over the past few years, I’ve bought a newer model smartphone and modernized my kitchen. In health care, we’ve seen updates to quality measures from the NCQA, updates to regulations around telehealth, updates to electronic health record technology, and more. But one thing I never really fathomed being updated was the Current Procedural Terminology (CPT) codes. However, CPT® codes need to be modernized like everything else. In early November, there was a formal announcement in the Federal Register about changes to the way psychological and neuropsychological testing codes will operate for consumers starting in January 1, 2019.

When I first heard the news, it brought back memories of the massive code changes that occurred in 2013 that resulted in implementing the Evaluation and Management codes for psychiatrists and nurses with prescriptive authority. It also included significant changes to the behavioral health therapy codes impacting all behavioral health provider organizations. Visions of coding crosswalks—documents that map the old codes to the new codes—danced in my head.

My initial reaction to the most recent coding news was that this can’t be as challenging as the major code changes that occurred in 2013, could it? However, according to Neil Pliskin, Ph.D.—current American Psychological Association (APA) Advisor to the American Medical Association (AMA) CPT Health Care Professionals Advisory Committee and the lone psychologist on this committee—this is going to be an even more significant change for psychologists and neuropsychologists. Dr. Pliskin, along with Antonio E. Puente Ph.D., who was the first psychologist to hold this post on the AMA/CPT Health Care Professionals Advisory Committee and who was Past President of the American Psychological Association (APA), have been actively educating clinical professionals about these code changes, noting that these changes are aimed at resolving some current pain points in the existing code set.

Changes will include the creation of new codes with clear distinctions about types of services delivered within each code; examples of what activities are included in each service; and the introduction of new “base” and “add-on” codes.

With any coding changes, health plans must update their claims payment systems to assure timely and accurate payment and educate customer service and network staff to respond to questions from psychologists and neuropsychologists. Given that these two disciplines can represent 20 to 30% of the health plan’s network panel, thoroughly understanding these changes is critical to assuring a smooth launch on January 1. Changes in coding also affect a health plan’s authorization protocols and reimbursement, which then affect internal workflows and contracting by the health plan.

Provider organizations must make similar changes to assure their practice management software and/or billers are aware of the new coding protocols. How to do this? Provider organizations can avail themselves of free training and resources available through the American Psychological Association (APA).

Given the Federal Register announced these changes this month, health plans and provider organization managers will have to respond quickly to be ready to accommodate the new codes for dates of service January 1 onward. To assist payers in getting ready for these code change, the APA with the aid of the National Academy of Neuropsychology (NAN) and other national psychology organizations are offering a free web briefing, “What Insurers Need to Know about the New Psychological & Neuropsychological Testing Codes,” on November 28 from 1-1:45 p.m. EST.

“Everyone wants change, but no one wants TO BE changed. Part of user adoption is connecting this full circle and getting people to use the technology.” – Matthew Chamberlain, Chief Operating Officer, Welligent

For any health and human service organization holding “strategic discussions” about investing in technology, the numbers can look daunting. There are the upfront cost of selection, the technology, process reengineering, retraining, and more (see Structuring (& Budgeting For) Analytics).

But what every executive team is banking on is that they can get a return on investment (ROI) that makes the technology is not just an expense, but really a strategic investment. Calculating the ROI is the easy part—For Telehealth, The ROI Is Where You Plan For It. But getting the ROI that is projected is the challenge.

That challenge was the focus of the session, A Progressive Approach to User Adoption: Transitioning From Paper To Digital In An I/DD Setting, led by Mr. Chamberlain and Embassy Management executives Kendra Ellis, Executive Director, and Michael M. Hailye, Chief Information Officer. Mr. Chamberlain said, “We all have something we spend money on and we intend to get value out of it. But if you aren’t using the new tech efficiently, you aren’t going to get that value.” He recommended a few key steps to optimize the value of new technology—a framework for implementation that establishes clear and concrete goals for technology adoption; buy-in from key leadership and staff members; a progressive staff training program; continuous process improvement; and measurement of system performance.

Ms. Ellis and Mr. Hailye provided a great case study of how these core elements can result in a successful implementation of a new electronic health record (EHR). Embassy Management is a large, multi-state family of companies that provides home- and community-based services to adults and children with intellectual/developmental disabilities (I/DD) in Washington, Idaho, California, and Oregon. Their broad service lines and geographic areas presented some unique technology implementation challenges.

Conducting a pilot program to test the implementation model

After selecting Welligent as their EHR partner, Embassy Management built a strategy for adoption that focused on getting buy-in from staff to move the implementation forward. Part of that plan was conducting a pilot program at 24 sites with supported living programs for adults across three states to work on enhancing the EHR software for optimal support of the program. The pilot focused on the user interface design, reporting dashboards, and integrated data systems to support ease of navigation and use by staff.

Threnhauser, S.C. (2018). Training is key to getting tech ROI [PowerPoint slides]. Retrieved from OpenMinds.com.


Taking the technology to scale and getting buy-in from staff

The pilot created an ongoing feedback loop with staff and enabled continuous improvement and enhancements to the system. For example, Embassy used laptops and partnered with Welligent to build an auditor portal, so that auditors could come in and see different areas. This in turn promoted greater commitment to the use of the EHR from the staff, and support scale across the system. Besides implementation training, there is deep dive training for program supers and above, before it was scaled out to direct support professional training.

Ms. Ellis explained, “We addressed the challenges we identified early. We wanted to get buy in and commitment. And we wanted to convince the staff that it would improve their jobs. We also wanted to build a return-on-investment (ROI) over time and identify the things to measure to show that ROI both in quality services and cost.”

Team adoption of the new technology and continuous training

Staff training also plays a big role in gaining widespread technology adoption across an organization. Embassy Management’s system for staff training included: training new hires on day one of employment; with initial training taking place all in-person and monthly “refresher” training thereafter. In addition, they hired Subject Matter Experts (SME) in each city/program to help staff with on-going questions, as well as creating a “Quality Improvement” team who can help guide correct documentation methods and compliance. Mr. Hailye explained, “The message is, you aren’t done after the initial training. There is additional training, retraining, new hire training. Subject matter experts have been helpful to see who isn’t using the system the way it needs to be used. This feedback loop is great for understanding whether the system is working or not.”

Threnhauser, S.C. (2018). Training is key to getting tech ROI [PowerPoint slides]. Retrieved from OpenMinds.com.

For more on the role of staff adoption and training on technology ROI, check out these resources from the PsychU Resource Library:

  1. Do You Have A Leadership Strategy For Tech ROI?
  2. More Tools For Tech ROI
  3. Your Digital Tech Integration Checklist

Over the past couple of years accountable care organizations (ACOs) have become an increasingly important part of the evolution of health care delivery and financing. While the concept started with the Patient Protection and Affordable Care Act (PPACA) and Medicare, there are now more beneficiaries in commercial ACOs than in Medicare ACOs (more than 17.2 million in commercial ACOs versus 14.6 million in Medicare ACOs). And, in some states—Oregon, Massachusetts, and Colorado, among others—Medicaid ACOs are changing the landscape.

The question we’ve been contemplating is how do ACOs address the needs of complex consumers? I had a chance to learn more about this at the recent 2018 OPEN MINDS Executive Leadership Retreat, during the keynote address by William Lopez, M.D., CPE, Senior Medical Director for Behavioral Health at Cigna, “Key Issues Shaping The Market For Complex Consumers: A Health Plan Perspective On What Executives Need To Know To Succeed.”

He talked about Cigna’s version of ACOs, the Cigna Accountable Care (CAC) model, and specifically the latest pilot program which encourages behavioral health integration for the management of complex customers. Cigna originally launched its CAC program in 2008. Thus far, over 200 provider organizations have participated in some fashion, taking on financial risk and/or gainsharing related to total medical cost and quality. The behavioral integration pilot began in February 2018 after the Centers for Medicare & Medicaid Services (CMS) approved the new Collaborative Care Model (CoCM) codes the prior year. The purpose of the pilot is to demonstrate the value of the CoCM in a commercial book of business. The model has four key components that affect consumer care in general, and consumers with complex needs in particular.

Care coordination support – In order to assist provider organizations in transforming care to a population-based approach, Cigna funds at least one embedded care coordinator (ECC) in each CAC. The number of ECCs in each CAC depends on the size of the aligned population. Additionally, those organizations participating in the behavioral health integration pilot have an additional care coordinator to support the ECC. These care coordinators assist in managing care for consumers and connect them to outside programs in order to serve the whole person.

Clinical consultation – Cigna supports organizations participating in the CAC by acting as a clinical partner. Cigna provides organizations with clinical best practice resources, offers a learning collaborative, and a behavioral health toll-free hotline. The hotline is staffed by a masters-level behavioral health specialist who can assist with referrals, help providers to better evaluate the best clinical course, connect the consumer with Cigna’s coaching programs, and provide clinicians access to Cigna’s behavioral health medical directors for direct consultation.

Lopez, W. (2018). Key issues shaping the market for complex consumers: A health plan perspective on what executives need to know to succeed [PowerPoint slides]. Retrieved from OpenMinds.com.

Data sharing – As part of the CAC, provider organizations receive extensive reports from Cigna with the information needed to maintain a value-based arrangement. Organizations participating in the behavioral health integration pilot also receive a predictive report that identifies members with chronic conditions who may also have a co-occurring behavioral health disorder. This report can be used by the provider organization to reach out to the consumer and help get them needed services. It also allows them to identify individuals who may have higher than usual medical spend.

Gainsharing – The model supports a full spectrum of value-based payments from gainsharing to capitation. The risk arrangement is tailored to the provider organization’s current capabilities with the goal of slowly increasing risk acceptance over time. Cigna supports the provider organization in this process and will help them move between different risk arrangements as needed. Payments are tied to cost and quality. Cost is based on the total medical cost of the aligned population compared to the non-CAC population in the market. The program also tracks true reduction in care consumption such as a reduction in emergency department visits and improvements in quality of care, such as well-child screenings.

For executives of provider organizations, I think there is one major takeaway from Dr Lopez’s talk. Health plans like Cigna are tackling consumer needs mostly from the primary care side and behavioral health provider organizations are going to have to develop partnerships with these organizations in order to be successful.

On November 8, 2018, the U.S. Department of Health and Human Services (HHS) announced a number of priorities to spur value-based transformation of the U.S. health care system, including the intent to launch new mandatory bundled payment models for Medicare. The intent is that bundled payment models will be mandatory, rather than voluntary. Currently, CMS operates the voluntary Medicare Bundled Payments for Care Improvement Advanced (BPCI Advanced) model for 32 clinical 90-day episodes, paid fee-for-service.

HHS Secretary Alex M. Azar II, made the announcement during his “Remarks on Primary Care and Value-Based Transformation.” He said that the Centers for Medicare & Medicaid Services (CMS) will revisit some of the episodic cardiac models that it canceled in November 2017. CMS is actively exploring new and improved episode-based models in other areas, including radiation oncology. As of November 26, 2018, no further details have been released.

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 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.

In the announcement, Mr. Azar named Adam Boehler, director of the Center for Medicare and Medicaid Innovation to oversee the HHS effort to implement value-based transformation. Mr. Boeher has identified four primary objectives for the model: empowering consumers, holding provider organizations accountable for navigating the health system, paying for outcomes, and preventing disease before it occurs or progresses.

The full text of Secretary Azar’s “Remarks on Primary Care and Value-Based Transformation” was published November 8, 2018, by HHS. A copy is available online at HHS.gov.

PsychU reported on the latest voluntary model in “New Medicare Bundled Payment Model Has 1,299 Participating Provider Organizations,” which published on November 19, 2018.

For more information, contact: Press Office, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, District of Columbia 20201; 202-690-6343; Email: media@hhs.gov.

Low-income adults, whether uninsured, covered by Medicaid, or covered by private health insurance, generally reported better access to health care in states that expanded Medicaid. In this context, low-income is defined as annual income less than or equal to 138% of the federal poverty level, which is $16,753 for a single adult or $33,885 for a household of four. Compared to low-income adults in states that did not expand Medicaid, those living in states that did expand reported fewer unmet medical needs overall and fewer financial barriers to needed medical care overall. More people in expansion states reported having a “usual place of care” to access primary care services.

Comparison Of Insurance Types & Unmet Medical Need, 2016

Insurance Type % In Expansion States % In Non-Expansion Sates
All 26% 40%
Medicaid Insurance 27% 34%
Private Health Insurance 18% 25%
Uninsured 50% 63%

These findings were reported in “Medicaid: Access to Health Care for Low-Income Adults in States with and without Expanded Eligibility” by the Government Accountability Office (GAO). Researchers for the GAO obtained estimates from 2016 National Health Interview Survey from the National Center for Health Statistics (NCHS) regarding demographic characteristics of low-income adult respondents, and their access to health care services based on their insurance status: uninsured, Medicaid, or private insurance.  This population is estimated to include 24.5 million low-income adults aged 19 through 64, with 14.9 million in expansion states (including 5.6 million uninsured people), and 9.6 million in non-expansion states (including 3.7 million uninsured people). The goal was to determine trends in access to medical care for this population based on whether their states had or had not implemented Medicaid expansion.

As of December 2017, 31 states and the District of Columbia had expanded Medicaid. The non-expansion states include Alabama, Florida, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.

The 2016 NHIS estimates indicate that those living in expansion states were less likely to report financial barriers, even among the uninsured. However, uninsured adults were much more likely to report financial barriers to care than those covered by Medicaid or private insurance.

Comparison Of Insurance Types & The Percentage Reporting Financial Barriers To Needed Medical Care, 2016

Insurance Type % In Expansion States % In Non-Expansion States
All 9% 20%
Medicaid Insurance 8% 12%
Private Health Insurance 6% 10%
Uninsured 27% 37%

The 2016 NHIS estimates showed that low-income adults in expansion states were more likely to report having a usual place of care and more likely to report receiving selected health care services compared with those in non-expansion states. Compared to those who were uninsured, those who were insured were more likely report having a usual place of care and generally more likely to report receiving selected health care services. In expansion and non-expansion states, the share of the uninsured with a usual place of care was similar.

Comparison Of Insurance Types & The Percentage Reporting Having A Usual Place Of Care, 2016

Insurance Type % In Expansion States % In Non-Expansion States
All 82% 68%
Medicaid Insurance 88% 83%
Private Health Insurance 86% 78%
Uninsured 45% 46%

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; 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.

The ratios of actual to expected readmissions at for-profit hospitals range from 1.007 to 1.019 for people diagnosed with acute myocardial infarction (AMI), heart failure (HF), coronary artery bypass graft (CABG), pneumonia (PN), chronic obstructive pulmonary disease (COPD), and total hip arthroplasty or total knee arthroplasty (THA/TKA). The readmission ratios at for-profit hospitals are higher than at government-run or non-profit hospitals. At government-run hospitals, the ratios range from 0.995 to 1.012. At non-profit hospitals, the ratios range from 0.996 to 1.001. A readmission ratio of 1.0 or higher indicates that the hospital has unnecessary/preventable readmissions; a ratio below 1.0 indicates that the hospital is preventing unnecessary readmissions. The six conditions are those measured by the federal Hospital Readmission Reduction Program (HRRP).

These findings were reported in “Proprietary management and higher readmission rates: A correlation” by Manish Mittal, Chih-Hsiung E. Wang, Abigail H. Goben, and Andrew D. Boyd. The researchers analyzed 2012 to 2015 data from the Centers for Medicare & Medicaid Services (CMS) HRRP to determine readmission rates for the six conditions, in the context of hospital ownership. They calculated readmission ratios for each condition for each hospital type. Then, the researchers grouped the individual hospitals by readmission ratio into one of four readmission ratio cutoff groups: less than 0.8, 0.8 to 0.99, 1.0 to 1.2 and greater than 1.2. For each condition and each governance structure, the researchers calculated the percentage of hospitals in each cutoff group.

Mean Readmission Ratio By Hospital Type, Six HRRP Conditions, 2012 To 2015

Condition Government Non-Profit For-Profit
AMI 0.997 1.000 1.014
CABG 1.006 0.998 1.012
COPD 0.995 1.001 1.007
HF 1.001 0.996 1.018
THA/TKA 1.012 1.001 1.019
PN 1.000 0.999 1.014

The percentage of hospitals in each of the four cutoff groups varied by condition and by the hospital governance structure. More than half of for-profit hospitals had mean readmission ratios higher than 1.0 for the six HRRP conditions. Less than half of non-profit and government hospitals had readmission ratios higher than 1.0%. For each condition, the percentage of for-profit hospitals had mean readmission ratios of 1.2 or higher was greater than the percentage of non-profit or government hospitals with a 1.2 or higher readmission ratio.

Percentage Of Hospitals In Each Readmission Ratio Group, By Hospital Type For Six HRRP Conditions, 2012 To 2015

Condition Hospital Type Number Of Hospitals Reporting Percentage With Readmission Ratio Of <0.8 Percentage With Readmission Ratio Of 0.8 to 0.99 Percentage With Readmission Ratio Of 1.0 to 1.2 Percentage With Readmission Ratio Of <1.2
AMI
Government 257 0.4% 52.5% 47.1% 0.0%
For-Profit 421 0.0% 43.9% 55.3% 0.7%
Non-Profit 1,441 0.4% 50.7% 48.7% 0.2%
CABG
Government 112 0.0% 51.8% 47.3% 0.9%
For-Profit 197 0.5% 45.7% 51.8% 2.0%
Non-Profit 715 0.6% 52.5% 45.4% 1.5%
COPD
Government 469 0.0% 54.2% 45.6% 0.2%
For-Profit 572 0.0% 48.4% 51.1% 0.5%
Non-Profit 1,827 0.0% 52.2% 47.2% 0.6%
HF
Government 464 0.2% 51.3% 47.6% 0.9%
For-Profit 573 0.2% 42.2% 56.5% 1.1%
Non-Profit 1,837 0.4% 53.1% 45.6% 0.9%
THA/TKA
Government 321 3.7% 47.7% 40.5% 8.1%
For-Profit 517 4.5% 41.6% 45.6% 8.3%
Non-Profit 1,623 5.6% 46.6% 40.8% 7.1%
PN
Government 505 0.6% 53.5% 44.5% 1.4%
For-Profit 591 0.7% 44.8% 51.6% 2.9%
Non-Profit 1,865 0.9% 52.2% 44.6% 2.4%

The full text of “Proprietary management and higher readmission rates: A correlation” was published September 14, 2018 by PLOS One. A copy is available online at Journals.POLS.org

PsychU reported on hospital readmission rates in “30-Day Readmission Rate Declines About 2 Percentage Points At Safety-Net Hospitals,” which published on November 9, 2016.

For more information, contact: Jacqueline Carey, Communications, Office of Public & Government Affairs, University of Illinois at Chicago, 1919 W Taylor Street, 227 AHSB, Mail Code 530, Chicago, Illinois 60607; 312-996-8277; Email: jmcarey@uic.edu.

On October 19, 2018, the Disability Law Center (DLC) of Alaska issued a complaint against the state for placing people under civil commitment in jails while waiting for mental health competency evaluation and treatment. The complaint names the Alaska Department of Health and Social Services (DHSS), the Division of Behavioral Health, and the Alaska Psychiatric Institute (API). No hearing date has been set.

On October 6, 2018, API notified its external partners that it was at capacity and could not accept psychiatric referrals at that time due to high resident acuity, workforce shortage, and increased staff injury rates. On October 9, 2018, the Alaska Department of Corrections (DOC) sent a memo to announce that due to API’s issues, DOC would house people ordered to competency evaluation in jails while waiting for an open bed at API. The memo said the API bed reduction will remain in effect until API can be adequately staffed.

DLC said it has “grave concerns for the liberty of these patients” and for the lack of public information surrounding the decision to house people under a mental health hold in jail. The complaint alleges that housing individuals under civil commitment in jails violates the individuals’ rights to timely competency evaluation in appropriate evaluation facilities. Additionally the state failed to inform individuals under a psychiatric evaluation hold of their rights. DLC also filed a temporary restraining order to force the state to refrain from housing such individuals in jails, and immediately deliver those taken into custody to designated evaluation facility. If an immediate placement is unavailable, the individual must be released. The DLC requested that the state stop placing individuals in correctional facilities and start ensuring proper transportation of patients to appropriate facilities and that API stop refusing placements altogether. The DLC also requested that their attorney’s fees be covered.

The decision to reduce API capacity was due to staffing shortages. The workforce issues were the topic of an investigation earlier in the year; the findings were reported to the state Attorney General released in September 2018. The report presents the findings of an investigation of API’s working conditions; the author interviewed 46 people associated with API between March 26 and June 19, 2018. The author found that the facility had unsafe working conditions. The unsafe conditions were linked to insufficient staffing, ineffective scheduling practices, use of on-call personnel, lack of programming, and lack of consequences for violent individuals being treated at the facility. Additionally, the facility staff and administrators have a cultural divide over the use of restraints and seclusion, and their role in supporting staff and resident safety. The investigator found no evidence of organized retaliation or a hostile work environment.

In response to the API capacity issues, a rise in hospital emergency rooms holding psychiatric patients, and public safety concerns, DHSS Commissioner Davidson activated the DHSS Emergency Operations Center (EOC) on October 13, 2018. Governor Bill Walker and staff were briefed on October 14, 2018 by DHSS Commissioner Davidson, Dr. Jay Butler, and the Incident Management Team. The Incident Management Team contacted and briefed stakeholders on EOC activation. On October 23, 2018, DHSS announced that the state had created “Tactics Groups” to develop and implement strategies, tactics, and plans to address high patient acuity across the system, API workforce shortages, and a recent increase in API staff injury rates. The groups are focused on the following:

  • Crisis Stabilization Center: Contract with a vendor to stand up and manage a Crisis Stabilization Center in Anchorage, which would serve as a pre-triage location allowing individuals to receive immediate attention and be quickly referred to the appropriate level of care. This would help reduce the pressure on hospital emergency departments and allow time for individuals to be evaluated and determine the best resources needed to support them. A DHSS spokesperson said that as of November 9, 2018, this strategy has been deemed unbelievable due to vendor timelines.As a result the Crisis Stabilization Center work will be transitioned to the 1115 Behavioral Health Demonstration Project Waiver workgroup to be completed.
  • North Star Behavioral Health System: Explore North Star’s proposal to help alleviate emergency department overflow issues attributed to the wait list at API. The group is in the process of reviewing information from North Star to determine the best path forward. The DHSS spokesperson said that as of November 9, 2018, these negotiations are ongoing.
  • Access to Patient Care Plans in Emergency Departments: Determine how to share limited API patient care plans with hospital emergency departments to best support the psychiatric patients and reduce redundant services. Group is in the process of identifying available resources and IT requirements to make this happen.
  • Substance Use Disorder (SUD) Services Expansion Proposal: Expedite review of the Substance Use Disorder grant RFP proposals. The deadline for proposals was October 19. Evaluation is underway and DHSS plans to award the grants in early November.
  • Medicaid Emergency Room Boarding Coverage: Resolve coding issues to allow hospitals to bill Medicaid for eligible individuals after 23 hours of care in the emergency room. As of October 20, this issue was resolved.
  • Disproportionate Share Hospitals (DSH) Funds Distribution: Distribute funding to hospitals that qualify under federal and state regulations. Analyze other options to distribute funding to impacted hospitals. Group is in the process of identifying legal parameters for DSH funds in order to determine a path forward that best meets the needs of affected hospitals.

For more information about the DLC complaint, contact: Joanna Cahoon, Staff Attorney, Disability Law Center of Alaska, 3330 Arctic Boulevard, Suite 103, Anchorage, Alaska 99503; 907-565-1002; Email: jcahoon@dlcak.org;

To send questions or feedback about the EOC response effort, contact: Psychiatric Care Capacity Response, Office of the Commissioner, Alaska Department of Health and Social Services, 3601 C Street, Suite 902, Anchorage, Alaska 99503; Email: dhsseoc@alaska.gov.

Most health care provider organizations don’t think about consumers paying cash directly for services—for good reason. The U.S. has long had a health care financing system that relies on third-party payment. Forty-nine percent of the population is covered by employer-sponsored health plans, 14% by Medicare, and 19% by Medicaid. And, U.S. consumers have been trained to select health plans and services where they pay the least out-of-pocket (OOP). Analysis of consumer buying behavior for health plans has found that in many cases, consumers are willing to trade “choice” for cost reductions.

But lack of focus on how consumers choose health care services and what they want in health care services has left many provider organization management teams with a big blind spot. Many managers in provider organizations don’t know how to think about “what consumers want”—and turn that knowledge into service line redesign. The on-the-ground reality is that the “consumer experience” in health care hasn’t changed much—the appointment-making process is clunky, the consumer-facing communication is often unintelligible, and net promoter scores are hard to find. The rationale that I hear from my executive friends continues to be the reliance on referral relationships with health plans and the “shortage” of service delivery professionals.

But the exercise of thinking about what services a provider organization offers that consumers would pay for directly is useful for every executive team. It is the ultimate “value” discussion. What is the price point in a private pay market (see Doing The Private Pay Math)? And a related but equally pertinent question—what “amenities” do consumers expect and what are they willing to pay for them (see How Much Are ‘Amenities’ Worth To Your Consumers?)

While this may sound academic, I think there are a couple market developments that make this new thinking essential. First, consumers are covering more and more of their health care expenses. Second, “consumer reported” performance is playing a bigger role in health plan evaluations—which means it will play a bigger role in how health plans select provider organizations.

Consumer spending on health care

Last year it was reported that the average annual deductible for single adults with employer-sponsored health insurance was $1,077 (see The Challenges Of Rising Consumer Spending On Health Care), and OOP payments clocked in at $656 (see Out-Of-Pocket Health Care Costs – Down For Most, Up For Some). Additionally, about 14% of all families had OOP health care expenses exceeding $2,500 in 2015 (see 14% Of Families Had Out-Of-Pocket Health Care Expenses Exceeding $2,500 In 2015). A Kaiser Family Foundation study puts half of consumers with employer-sponsored coverage with a deductible of at least $1,000.

In 2018, the OOP limit for a marketplace plan is $7,350 for an individual plan and $14,700 for a family plan. This is up from 2017, when the OOP limit for a marketplace plan was $7,150 for an individual plan and $14,300 for a family plan.

Even with Medicare, retirees in the United States spent 34.3% of their Social Security benefits on OOP medical costs; and OOP health care costs for a couple entering retirement in 2016 were estimated at $260,000 over the course of their lifetime, about 6% higher than estimated retirement health costs of $245,000 in 2015. This does not include long-term care costs.

The strategic implication of this shift is that insured consumers paying more of the bill for health care will likely start to act like consumers paying all the bill. New rules from the Center for Medicare and Medicaid Services (CMS) about hospital price transparency (see Get Your Price List Ready!) and new pharmaceutical cost transparency legislation are going to speed up this transition. So will the many organizations that are promoting packaged pricing for services directly to consumers.

Health plan evaluations increasingly consumer-centric

Another development is that payers are increasingly evaluating health plans using consumer experience and patient-reported outcomes measures (PROM)—and that will make health plans more sensitive to consumer experience. For example, the National Committee for Quality Assurance has partnered with four health plans to identify approaches to collect PROMs. And the Centers for Medicare & Medicaid Service’s STARS program is using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) to evaluate hospitals—awarding 10% of hospitals in the United States a five-star consumer rating last year (see Under New CMS Hospital Care Rating Methodology, More Hospitals Earn Highest & Lowest Ratings). CMS is extending these consumer-focused ratings to the physician and health home rating programs.

This focus on consumerism and the consumer experience is increasingly important—and will require a new perspective on service line development (see Get Your Price List Ready!). For our latest on how to do this, check out these resources from the PsychU Library:

  1. Integration, Interoperability & Consumer Engagement
  2. You Say Subscription-Based Health Care, I Hear Customer Service
  3. The Next Wave Of Consumer Price Shopping For Health Care
  4. Make Change Or Be Changed
  5. The Big Rewards Of Health Care Through The Consumer Lens
  6. Answering The Question – Who Can Afford Their Health Services?

Medicare beneficiaries in Hawaii, Alaska, and Oregon had access to the highest quality care at the lowest cost in 2016, according to a nationwide comparison of health care value by state. Nationally, standardized annual per-beneficiary costs in 2016 were $9,533. Nationwide, per-person costs ranged from $5,920 in Hawaii to $11,142 in Louisiana.

States With Lowest & Highest Mean Per-Person Medicare Costs (National Mean Is $9,533)

Five Lowest Cost States, Mean Cost (% Lower Than National Mean) Five Highest Cost States, Mean Cost (% Lower Than National Mean)
State Mean Cost % Below National Mean State Mean Cost % Above National Mean
Hawaii $5,920 -34% Louisiana $11,142 +25%
Alaska $6,457 -28% Florida $10,814 +21%
Oregon $7,107 -21% Texas $10,743 +20%
Montana $7,301 -18% Mississippi $10,530 +18%
Colorado $7,910 -12% Oklahoma $10,133 +13%

The rankings were developed The Commonwealth Fund and presented in “Health Care Quality-Spending Interactive.” The presentation is an interactive map that shows how health care spending per beneficiary compares to quality state-by-state. The spending estimates are based on 2016 data for Medicare fee-for-service beneficiaries and exclude Medicare Part D spending. The data source is the Medicare Geographic Variation Public Use File for data year 2016. The Commonwealth Fund did not describe the source for the quality scores. Medicare requires its Medicare Advantage plans and accountable care organizations to submit data for numerous quality measures.

A scatterplot based on the interactive map data shows an inverse relationship between quality and cost. States with overall higher quality scores had lower mean costs. States with lower quality scores had higher costs. In total, 21 states were grouped as high quality and low cost, and 20 were grouped as low quality and high cost.

States with Highest & Lowest Medicare Quality Scores

Five States With Highest Quality Ranking, % Above The National Average, Mean Annual Per-Person Cost Five States With Lowest Quality Ranking, % Below The National Average, Mean Annual Per-Person Cost
State % Above National Mean Mean Cost State % Below National Mean Mean Cost
Hawaii +47% $5,920 Mississippi -14% $10,530
Alaska +21% $6,457 Louisiana -13% $11,142
Colorado +20% $7,910 Kentucky -11% $9,605
Minnesota +18% $8,134 Oklahoma -10% $10,133
Utah +18% $8,384 Arkansas -8% $9,376

The Commonwealth Fund posted its Health Care Quality-Spending Interactive rankings at CommonwealthFund.org.

The Centers for Medicare & Medicaid Services Office of Enterprise Data and Analytics developed a State: Geographic Variation Dashboard. The interactive dashboard is posted at CMS.gov.

For more information, contact: Mary Mahon, Vice President, Public Information, The Commonwealth Fund, 1 East 75th Street, New York, New York 10021; 212-606-3853; Email: mm@cmwf.org.

On October 16, 2018, a coalition of behavioral health advocacy organizations recommended that Medicare ensure that accountable care organizations (ACOs) have the capacity to address beneficiary mental health problems, addiction disorder, and suicide risk. The coalition—representing peer support organizations and trade organizations for behavioral health professionals—based their request on the one available ACO performance measure related to behavioral health.

Based on ACO performance on the sole behavioral health beneficiary-reported performance measure, Depression Remission at 12 Months, the behavioral health advocacy organizations believe ACOs may have widespread gaps in post-screening follow-up. Among ACOs reporting on that measure (and excluding ACOs that reported a score of zero), the median rate of depression remission at 12 months was 9%. However, an analysis of many studies found that about 53% of untreated people with depression experience remission at 12 months. The advocacy organizations noted that the ACOs’ poor performance on the depression remission measure may have been because the ACOs were not able to re-screen beneficiaries to determine if remission was achieved. The advocacy organizations believe that the post-screening follow-up problems indicated by poor ACO performance on the Depression Remission at 12 Months measure are likely to extend to follow-up for addiction treatment or services for those at risk of suicide.

They recommended home screening as a solution and recommended that Medicare explore ways to enhance data collection for “Patient-Reported Outcome” (PRO) performance measures. The advocacy organizations recommended that the Centers for Medicare & Medicaid Services (CMS) provide ACOs with technical assistance, quality improvement, and learning collaborative infrastructures, as well as financial incentives, to implement effective mental health and substance use interventions that work in their practice context. The letter mentioned the following interventions: the Collaborative Care Model or other forms of evidence-based behavioral health integration using the newly created billing codes, certified peer support specialists and/or other forms of recovery support services, tele-behavioral health, and/or digital health interventions.

Further, the advocacy organizations recommended that CMS consider making additional investment in mental health and substance use services, supports, and infrastructure, which may help build new capacities and catalyze further ACO innovation. To ensure cost-neutrality, new payments could be linked to projected future savings. Research indicates that depression remission likely predicts savings over several years due to lower total health care spending. CMS could develop a methodology to share some of these predicted future savings with ACOs as they achieve specified behavioral health outcomes. However, the advocacy organizations said it would be necessary to prevent ACOs from cherry-picking beneficiaries. The advocacy organizations said the methods could be similar to those being used in the Outcomes-Based Credits in the recently approved Maryland Total Cost of Care Model.

The organizations submitted their recommendations to the Centers for Medicare & Medicaid Services (CMS) in response to the proposed rule “Accountable Care Organizations‑‑Pathways to Success” (CMS-1701-P) to overhaul the ACO program. In addition to Mental Health America, the signatory organizations are American Foundation For Suicide Prevention; Depression and Bipolar Support Alliance; Facing Addiction with The National Council on Alcoholism and Drug Dependence (NCADD); The National Alliance on Mental Illness; The National Council for Behavioral Health; Patient-Centered Primary Care Collaborative; and Shatterproof.

CMS released the proposed rule on August 9, 2018. CMS received 471 responses to the proposed rule by the October 16, 2018 deadline. Via Pathways to Success, CMS proposes reducing the amount of time that an ACO can remain in the program without taking on risk down to, at most, two years. CMS developed Pathways to Success based on a comprehensive analysis of the performance of ACOs to date. Data on ACO performance to date has shown that ACOs that are not at risk for cost increases end up increasing Medicare spending in aggregate; and 82% of ACOs are not at risk for costs. Pathways to Success is designed to move in a new direction and advance five goals: accountability, competition, engagement, integrity, and quality.

For more information, contact: Nathaniel Z. Counts, J.D., Senior Policy Director, Mental Health America, 500 Montgomery Street, Suite 820, Alexandria, Virginia 22314; 703-684-7722; Fax: 703-684-5968; Email: ncounts@mentalhealthamerica.net.

Most specialty provider organization executive teams are looking at the twin challenges of retooling their services lines for success in a market moving toward integrated care coordination and value-based reimbursement. The question is what does this mean for the technology infrastructure of these organizations?

That was the focus of the town hall session, Building An Infrastructure For Integrated Care: A Town Hall Discussion On Interoperability, Technology & Innovation. The panel featured executives from two provider organizations that are the midst of this evolution in technology – Katy Beveridge, Vice President of Operations at LifeWorks NW and Brandon Ward, Psy.D., Director of Enterprise Applications at Mental Health Center of Denver. The panel was rounded out by A.J. Peterson, Vice President, Interoperability at Netsmart and Monica E. Oss, Chief Executive Officer at OPEN MINDS.

Both organizations have extensive experience with the new market model. LifeWorks NW is a Portland, Oregon-based $44 million behavioral health organization. They are a designated certified community behavioral health center (CCBHC) providing integrated care. And, LifeWorks NW is paid a case rate for mental health services (what Ms. Beveridge calls, “fee-for-service on steroids”) and fee-for-service for addiction treatment services. Oregon is currently in the process of gearing up for its next Medicaid managed care procurement cycle and its expected that the state will include value-based reimbursement (VBR) requirements.

Mental Health Center of Denver is a $98.5 million behavioral health organization in the city of Denver, with a long track record in providing behavioral health services under a capitated financial model. It also provides supportive housing and has opened up an innovative community center at its Dahlia Campus that includes an urban farm, dental care, early childhood education, health services, and community spaces.

The panel had a wide-ranging discussion of the issues, but there were a few technology “must haves” that I took away from the discussion.

Real-time platform facilitating care management – In managing consumer care, less than real-time information is costly. Not knowing a consumer’s history and current status makes care coordination less effective—increasing costs while compromising outcomes.

Ability to share data with both other provider organizations and with payers – Crucial to managing performance is the ability to receive and share information about consumers with other health care organizations. To participate in this type of data collaborations, provider organizations need both an EHR capable of sharing data and a health information exchange protocol with other providers or payers.

Care team “alerts” about changes in consumer health status – To improve care management and performance, its important to have a system that alerts your team to when a consumer visits the emergency room or is admitted to the hospital. Alerts make these events top of mind and bring them to your attention, often months before claims or other data becomes available.

Combining financial and clinical data to facilitate metrics-informed contract management – The ability to aggregate disparate data within your organization—from your EHR, HR information system, general ledger, and more—is essential for successfully managing payer contracts. Managing clinical outcomes or financial performance in silos doesn’t work in this new environment. Ms. Beveridge gave a great example. LifeWorks NW developed a data warehouse where they collect data from multiple systems in near real-time and use that data to make management decisions for each payer contract. They are just starting to use the data to move beyond managing the current system to developing predictive indicators.

If your organization is on the front end of this evolution in tech functionality, how do you get started? Both Ms. Beveridge and Dr. Ward shared some key pieces of advice. First, they said that it is important to start with simple metrics like demographic data and diagnostic data and then move on to more complicated performance measures. Second, its important to train your team on the new systems and using the new information – and build their trust.

To build that trust, Dr. Ward and Ms. Beveridge talked about not only listening to team feedback, but also acting on this feedback. By doing this, team members are more likely to use the tech platform and its information, which can result in better organizational performance. Dr. Ward explained that in order to build trust and improve adoption of new technology solutions, his team focuses on providing a two week turn around in order to implement some of the critical feedback provided by technology users. While not every project can be implemented in this manner, for those where this type of methodology is applicable, they have the benefit of improving technology in near real-time.

For more on the technology capabilities your organization needs to be successful in a value-based market, check out these resources from the PsychU library:

  1. The ‘Best Practice’ Challenge
  2. Using Data Can Make Care Coordination More Efficient (& Effective)
  3. Preparing For The Very Glacial VBR Rollout In Some Markets
  4. HIE 3.0?
  5. The Primary Care Reinvention

The Centers for Medicare & Medicaid Services (CMS) has awarded seven contracts to develop performance measures for the Medicare Quality Payment Program (QPP). The new QPP measure development focuses on seven specialty gap areas—orthopedic surgery, pathology, radiology, mental health and substance use, oncology, palliative medicine, and emergency medicine.

The seven awardees are working on four types of measure structures: outcome measures such as consumer-reported outcome and functional status measures; consumer experience measures; care coordination measures; and measures of appropriate use of services. The awardees, and their gap focus, are as follows:

  1. The Brigham and Women’s Hospital, Inc. – Six orthopedics measures, with two related to appropriate use of opioids during hospitalization for orthopedic procedures. One is focused on use of opioids at high dosages in people without cancer; the other monitors hospital-level risk-standardized medication side effect rates of opioid respiratory depression or extended use among people who had elective hip or knee replacement surgery.
  2. American Society for Clinical Pathology – Seven pathology measures focused on timely notifications to ordering professionals.
  3. The Regents of the University of California, San Francisco – One radiology measure focused on composite radiation dose and quality.
  4. American Psychiatric Association – Twelve behavioral health measures, with two focused on treatment for people with opioid use disorder.
  5. University of Southern California – One behavioral health measure focused on continuity of pharmacotherapy for opioid use.
  6. Pacific Business Group on Health – Two oncology measures, with one focused on self-reported pain following chemotherapy and the other focused on quality of life after chemotherapy.
  7. American Academy of Hospice and Palliative Medicine Inc. – Two palliative care measures, with one focused on the share of consumers who report that they received help for their symptoms, and the other focused on communication between professionals and family caregivers

CMS established the QPP to implement certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The QPP consists of two participation pathways for physicians and other clinical professionals—the Merit-based Incentive Payment System or MIPS and Advanced Alternative Payment Models (A-APMs) in which clinical professionals may earn an incentive payment through sufficient participation in risk-based payment models. Eligible clinical professionals must participate in an A-APM or MIPS. Non-exempt eligible clinical professionals who fail to participate in an A-APM or MIPS are subject to a 4% cut to Medicare reimbursements for 2019.

CMS believes measures for the seven specialty gap areas are underrepresented based on the findings of the “2018 CMS Quality Measure Development Plan Environmental Scan & Gap Analysis Report.” As a result, clinical professionals are limited on the number of relevant measures available to report that are also strong indicators of the quality of care. To address the QPP measure gaps, on March 2, 2018, CMS published the “Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity: Measure Development for the Quality Payment Program.”

Of the seven organizations awarded QPP cooperative measure development agreements two, the American Psychiatric Association and University of Southern California, are developing quality measures for mental health and addiction disorder treatment. The American Psychiatric Association is developing 12, the measures are as follows:

  1. Initial assessment for all consumers seen for mental health and substance use care; this is a process measure.
  2. Monitoring of symptoms, functioning, and recovery for all consumers seen for mental health and substance use care; this is a process measure.
  3. Treatment adjustment for all consumers seen for mental health and substance use care; this is a process measure.
  4. Improvement or maintenance of symptoms for consumers with psychosis; this is an outcome measure.
  5. Improvement or maintenance of symptoms for consumers with suicide risk; this is an outcome measure.
  6. Improvement or maintenance of symptoms for consumers with opioid misuse; this is an outcome measure.
  7. Improvement or maintenance of functioning for all consumers seen for mental health and substance use care; this is an outcome measure.
  8. Recovery for all consumers seen for mental health and substance use care; this is an outcome measure.
  9. Safety plan for individuals with suicide risk; this is an evidence-based treatment process measure.
  10. Initiation of antipsychotic treatment among individuals with first-episode psychosis (FEP); this is an evidence-based treatment process measure.
  11. Initiation of medication-assisted treatment (MAT) among individuals with opioid use disorder (OUD); this is an evidence-based treatment process measure.
  12. Patient experience of care for all consumers seen with mental health and substance use care; this is a consumer experience of care outcome measure.

In the awards announcement, CMS said that during 2018, it has removed or proposed to eliminate reporting requirements for 105 measures across the agency’s programs. Some of the changes were included in the “Medicare Final Rule: Hospital Inpatient Prospective Payment Systems For Acute Care Hospitals & The Long Term Care Hospital Prospective Payment System & Policy Changes & Fiscal Year 2019 Rates.” In the rule, CMS deleted 18 performance measures from four performance measurement programs. The four programs affected are the Inpatient Quality Reporting (IQR), Value-Based Purchasing (VBP), Hospital-Acquired Conditions (HAC) Reduction, and Hospital Readmissions Reduction Programs (HRRP). According to CMS, the goal is to use a smaller set of more meaningful measures, focusing on consumer-centered outcome measures, and considering opportunities to reduce paperwork and reporting burden on provider organizations. More than 400 measures remain across these programs, and CMS remains committed to patient safety and quality. The next phase of Meaningful Measures is identifying a set of measures that minimizes provider time spent collecting and submitting data to CMS, while assessing those core issues that are the most critical to providing high-quality care.

PsychU reported on this topic in “CMS Deletes 18 Performance Measures From Quality & Value-Based Purchasing Programs,” which published on September 17, 2018.

For more information, contact: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; Email: MACRA-Measure-Funding@cms.hhs.gov.

There is general agreement that health and human service delivery should be guided by measurement-based treatment protocols and standardized evidence-informed best. From there, the agreement ends.

I got a better sense of why clinical practice protocols and decision support tools for service delivery are slow in coming to programs focused on consumers with complex needs during a recent session, “Can There Be Best Practices In Complex Care? A Town Hall Discussion”. I was the moderator of an all-star panel – Clayton Chau, M.D., Ph.D., Regional Executive Medical Director, St Joseph Hoag Health/Providence St Joseph Health Southern CA Region; Mario San Bartolomé, M.D., M.B.A., M.R.O., FASAM, National Medical Director, Substance Use Disorders, Molina Healthcare, Inc.; and Scott Zeiter, Executive Vice President, Chief Operating Officer, Grafton Integrated Health Network.

Our discussion uncovered two issues—clearly defining who are “complex consumers” and identifying and using evidence-based practices (EBP). The first was relatively simple to answer. Dr. San Bartolomé, whose work focuses on addiction treatment services, explained that a “complex care consumer” is someone where transitions of care can go wrong. He said, “They have multiple inputs, so there is an excess of opportunity to mess it up. Each of those worlds are multi-factorial.” I would expand upon that definition and add from my experience in the field that complex consumers are recognized as those with mental health issues woven with multidimensional challenges such as social determinants like poverty, food instability, housing instability, and chronic medical issues.

Our discussion on EBPs was a little more complicated. Stakeholders often have different treatment intentions and take different treatment approaches depending on where they are at in the value chain. This contributes to the lack of use of EBPs.

Dr. Chau explained that most organizations are focused on answering the question, how do we manage care? This often means there isn’t the time or money to pursue EBPs—they are expensive. He said, “It’s not cheap to pursue EBPs that aren’t medication related. If you don’t have the resources, and high staff turnover, and your consumers are hard to deal with, and school doesn’t focus on EBP training, it doesn’t happen.”

Mr. Zeiter added that complicating the issue is that the clinical leadership of most provider organizations probably couldn’t agree on a treatment plan, which means there are seldom set protocols. He said, “Physical health would follow a treatment protocol, and we don’t do that. And some people interpret person-centered planning as hostile to the idea of protocols. There are disciplines that are better at this than other disciplines.”

One of the most important comments I heard on the day came from Dr. Chau who noted that it’s important that payers prioritize and incentivize paying for outcomes based on use of EBP, rather than “submitting to pay” for them. He said, “How do you see and provide incentives based on more than just a CBT code? Would you pay more for someone who got better in a short session versus paying for someone sitting with a counselor for three years? There is the cost of EBP, but there is also the cost of inefficient care.”

Dr. San Bartolomé added, “In some cases it could be the metrics that help payers satisfy their own quality that they have to support. For people in managed care, even in clinical hats, there are ROIs [return-on-investments] attached to outcomes, but there are also ROIs for the part that is financial.”

I found the perspectives good, but I left with a concern that we are a long way off of any “true measures of functioning.” Is the tail wagging the dog, or are health plans driving the treatment? Should provider organizations or consumers bypass the health plans and simply “drive the boat”? I posed a similar question at the close of the day, and Dr. San Bartolomé noted, “I don’t think you need to pick. I think that the best of class is going to come out. There is a role for all of them, and they have different redundancies. The question is how we integrate them.”

For more on clinical best practices and decision support, check out these resources on PsychU:

  1. What Will Mental Health Treatment Look Like In The Years Ahead?
  2. HIE 3.0?
  3. Preparing For The Very Glacial VBR Rollout In Some Markets
  4. Why Do Only A Third Of Consumers With SMI Receive Evidence-Based Treatment?

On October 1, 2018, New Jersey finished moving the Division of Mental Health and Addiction Services (DMHAS) from the Department of Health (DOH) back to the Department of Human Services (DHS). Before August 2017, DMHAS had been entirely housed within DHS. However, on August 28, 2017, former Governor Chris Christie transferred DMHAS from DHS to DOH to create a new system of integrated care intended to treat the “whole person,” by simultaneously addressing physical, mental and behavioral health care in the same primary care setting; a key focus was addiction treatment.

DOH is the state’s public health agency, responsible for the oversight, licensure, and inspection of health care facilities, integration of specialized services, such as behavioral diagnoses, into primary care and administration of traditional public health programs. Currently, DOH is in the process of creating a single license for such integrated care models.

On June 21, 2018, current Governor Philip D. Murphy issued a reorganization plan to return most DMHAS functions back to DHS. The goal is to ensure that the state is delivering behavioral health services in the most efficient, effective manner possible by connecting behavioral health services with critical community-based supports that are also administered by DHS. A secondary goal is to advance integrated licensing efforts for physical and behavioral health care.

Governor Murphy’s reorganization plan said that last year, when it located DMHAS within DOH, the state failed to consider the role of vital wrap-around services administered by DHS that support the treatment, recovery, and long-term well-being of individuals struggling with substance use and mental health diagnoses. Additionally, by locating DMHAS within DOH, the state failed to consider “the fiscal reality of Medicaid’s significant role as the primary payor for mental health and substance use treatment services in the State, as it is the insurance provider for approximately 1.7 million residents.”

After he was elected in 2017, Governor Murphy’s transition team convened experts and stakeholders to issue reports and recommendations. One of those reports, from the Human and Children Services Advisory Committee, recommended that DMHAS be moved back to DHS and proposed that DOH retain licensing functions related to behavioral health programs and facilities. The benefits of this recommendation were cited as follows:

  • DOH has long-standing expertise in licensing health care providers, including the primary care programs and sites with which behavioral services are becoming clinically and administratively integrated.
  • Potential delays and challenges in timely and accurate Medicaid payments are reduced by reconnecting community-based service delivery system through DMHAS with the payor, Medicaid. Additionally, access to care is enhanced when service delivery and payment methods are closely linked.
  • The success of prevention, treatment, and long-term recovery efforts are greatly enhanced when social risk factors are concurrently addressed. Assistance with food security, housing, employment, child care, and transportation impact health outcomes and DHS, through local, county, and statewide service delivery networks, is best equipped to maintain and increase community-based clinical services with critical community-based social supports.
  • The state’s ability to expand care options for individuals diagnosed with behavioral health and developmental disability is enhanced when the systems are coordinated. DHS administers services and supports for individuals with developmental disabilities through its Division of Developmental Disabilities (DDD); rejoining DMHAS with DHS will boost the ongoing collaboration and coordination needed for multi-disciplinary program design and development

The new reorganization shifted DMHAS and most of its former responsibilities back to DHS, but left oversight and operation of the four state hospitals – Ancora Psychiatric Hospital, Greystone Park Psychiatric Hospital, Trenton Psychiatric Hospital, and the Ann Klein Forensic Center –with DOH. DOH will also continue to oversee the civil commitment process.

Investigation of claims of abuse and neglect and other acts of wrongdoing or misconduct within community-based DMHAS-funded programs are transferred to DHS. The functions, powers, and duties related to background checks of staff members at the psychiatric hospitals and DMHAS licensees are transferred to DHS.

PsychU reported on this topic in “New Jersey Governor Proposes Moving Division Of Mental Health & Addiction Services To Health Department,” which published on September 8, 2017.

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.

The health and human service world is changing and it’s changing fast. New technology, new and different competitors, and new financing models (see The ‘Melting’ Value Chain) are reshaping the market for provider organizations, forcing executive teams to build a new strategy to keep their organization sustainable and to reassess their organizational, technical, and cultural competencies. To be sustainable in a value-based market, organizations need scale and they need partners. Connecting with the right partner in a time of change and consolidation is essential to long-term sustainability—and the right technology investments are critical ingredients in partnership development.

At a recent institute, Matthew M. Dorman, Founder & Chief Executive Officer at Credible Behavioral Health Software stated that to convince potential Partners and payers that you are ready to compete in the VBR environment, you need to build a case for your organization. To do that, Mr. Dorman discussed two investment theories—the “Firm Foundation Theory” and the “Castles in the Air Theory”—in his session, How Your EHR And IT Optimize A Merger, Sale, Or Acquisition.

The Firm Foundation Theory is based on the idea that any asset has an intrinsic value, and while the market value of the asset may fluctuate, investors can base investments on past data. The Castles in the Air Theory, on the other hand, is based more on investor behavior and predicting probable price rises. How do these investment theories relate to building partnerships in the health and human service market? Mr. Dorman suggested that provider organization executives should play to both of those theories of investment to demonstrate their organization’s value to potential partners.

In other words, potential Partners are looking to determine your organization’s value, so you should focus on building both the intrinsic and fundamental market value of your organization to create more partnerships opportunities across the market.

Figure 1. Dorman, M. How Your EHR And IT Optimize A Merger, Sale, Or Acquisition. [PowerPoint Slides]. Retrieved from www.openminds.com

Firm Foundation Theory—Build your intrinsic value. For provider organizations, this means ensuring that you have the data you need to demonstrate your organization’s value proposition for different consumer populations and services. But this will only happen if you make the effort to identify and collect those metrics that will show your organization and service lines as a solid investment. Ensure that you have core measures, including number of consumers served, until costs, payer mix, staffing models, treatment outcomes, etc. When you show this information to potential Partners, you are showing them the business model, and how successfully the organization fits into the market.

The key—put in the work to identify, track, and store the metrics. Your organization should be able to show financial performance and clinical treatment outcomes, and then be able to tie that information to your long-term goals and strategic decisions. This is where you can demonstrate to health plans, accountable care organizations (ACOs), and other potential Partners how your organization is positioned in the market and what you bring to the table.

Castle in the Air Theory—Build your potential for value before someone else does. Provider organizations need to use data from their EHR to demonstrate the “secret sauce” that can address the pain points Partners have today, and how that will bring increasing value in coming years. Building these relationships now, before someone else offers a different solution will be more lucrative in the long run.

The key—simply having data is valuable but analyzing that data so that it gives you usable knowledge about complex, high-cost consumer populations is more valuable, by far. Use your current strategy and performance outcomes as evidence to demonstrate how you will be able to address the “pain points” of potential Partners through new programs and treatment models.

The main takeaway from the day is that no matter what, it is fundamental to any organization to show what they have that the competition doesn’t—be that a better long-term business model, or a unique service line that is uniquely capable of addressing payer, health system, or Partner needs. Your performance data will help to create a clear picture of your organization’s past, present, and future.

For more on how to position your organization for success in a data-driven, value-based market, check out these resources on PsychU:

  1. Tech Management As Executive Competency
  2. Getting That Return On Your Tech Investment
  3. EHR Implementations: What Could Possibly Go Wrong?
  4. For Successful ‘Integration’, It Takes Interoperability & Patience
  5. Is Your EHR Up To The Challenge Of Value-Based Reimbursement?
  6. The Change Iceberg

The Connecticut Department of Developmental Services (DDS) is changing its regulations for applied behavior analysis (ABA), requiring therapists without a license to work under the supervision of a licensed behavior analyst. In July 2018 Connecticut became the 30th state in the country to require the license. The behavior analyst licenses are issued by the Connecticut Department of Public Health. The initial fee is $350 and the yearly renewal is $175.

DDS has historically been the entity that qualified any professionals seeking to offer Clinical Behavioral Supports, which covers a broad range of behavioral supports, including ABA. Board Certified Behavior Analysts have been among the professionals qualified to provide Clinical Behavioral Supports. Consistent with the statutory language, DDS will now require professionals calling themselves Behavior Analysts to furnish proof of licensure as part of the qualification process. No one may use the title “behavior analyst” unless such person is licensed by the Connecticut Department of Public Health.

DDS is currently in the process of reviewing professional credentials and revising the professional qualification process for Clinical Behavioral Supports, to ensure clarity and consistency with the statutory language for clinical professionals delivering ABA. DDS will formally notify professionals delivering Clinical Behavioral Supports of the process changes in the coming weeks. When the review is completed, DDS intends to post further information on its website.

For more information, contact:

  • Katie Rock-Burns, Chief of Staff, Connecticut Department of Developmental Services, 460 Capitol Avenue, Hartford, Connecticut 06106; 860-418-8762; Email: Kathryn.Rock-Burns@ct.gov
  • Connecticut Department of Public Health, 410 Capitol Avenue, Hartford Connecticut 06134; 860-509-8000; Email: communications@ct.gov

California is implementing a suite of legislation to improve screening and treatment for maternal mental health disorders. Two key bills were signed on September 27, 2018. The first, which focuses on the role of screening provided by office-based obstetricians, goes into effect on July 1, 2019. The other, which focuses on the role of hospitals, goes into effect on January 1, 2020.

The first bill, Assembly Bill (AB) 2193, Maternal Mental Health Screening and Support, requires obstetric providers confirm that screening for maternal depression has occurred, or to screen women directly, at least once during pregnancy or the postpartum period. By July 1, 2019, private and public health plans and insurers must develop a maternal mental health program designed to promote quality and cost-effective outcomes. The program shall be developed consistent with sound clinical principles and processes. The program guidelines and criteria shall be made available upon request to medical providers, including a contracting obstetric provider.

The second bill, AB 3032, Hospital Maternal Mental Health, requires hospitals to educate women and families about the signs and symptoms of maternal mental health disorders as well as any local treatment options. By January 1, 2020, a general acute care hospital or special hospital that has a perinatal unit shall develop and implement a program to provide education and information to appropriate health care professionals and patients about maternal mental health conditions.

The laws define screening and treatment for maternal mental health disorders as a core component of the delivery of quality maternity care. They were developed to address the findings of “California Task Force On The Status Of Maternal Mental Health Care Report,” which was released in April 2017. The task force found that health care professionals and provider organizations lack guidelines, referral pathways, capacity, and support to screen and treat pregnant and post-partum women for depression. Medical and mental health insurance and health delivery systems are not integrated. Depression screenings by obstetricians/gynecologists are not measured or reported. As a result, women are not provided with adequate maternal mental health support and education. Additionally, stakeholders lack a framework for making coordinated changes.

A third related third bill, AB 1893, Maternal Mental Health Federal Funding, was signed on July 20, 2018. It requires the California Department of Public Health to apply for federal funding provided through the Bringing Postpartum Depression Out of the Shadows Act, which was part of the 21st Century Cures Act.

For more information, contact: Press Office, California Department of Public Health, Post Office Box 997377, MS 0500, Sacramento, California 95899-7377; 916-440-7259; Email: CDPHpress@cdph.ca.gov.

Medicare Advantage health plans overturned 75% of their denials during preauthorization and payment denial appeals during 2014 through 2016. This equals approximately 216,000 denials overturned each year (about 649,000 for all three years) of about 863,000 total denials for this time period.

A review by the Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services found that Medicare Advantage plans overturned denials for two reasons. Either the appeals review may determine the original decision was incorrect, or the review may determine that the initial denial decision was correct based on information available at the time, but additional information changed the situation.

The OIG reported its findings in “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials.” The OIG collected data on denials, appeals, and appeal outcomes at each level of the Medicare Advantage appeals process for 2014 to 2016. A primary goal was to determine the rates of appeals and overturns of denied services and payments by Medicare Advantage health plans. Additional findings include:

  • 70% of appeals were fully successful, 5% were partially successful, and 25% were not successful.
  • 82% of overturned denials occurred after the services were provided to the beneficiary and resulted in a payment to the provider organization.
  • The median rate of overturned denials was 77%. Across 320 Medicare Advantage health plans, the contract specific denial overturn rates ranged from 0% to 100%. Seven contracts overturned more than 98% of the denials.

The Centers for Medicare & Medicaid Services (CMS) audited 140 Medicare Advantage health plan contracts and issued citations in 2015. Additional details are as follows:

  • CMS cited 79 of the 140 audited Medicare Advantage health plan contracts (56%) for two types of violations related to inappropriately denying requests for preauthorization of services and/or payment. CMS found that some of these contracts made the wrong clinical decision based on the information submitted by the provider organization or beneficiary, and some did not conduct appropriate outreach to obtain all needed information before making clinical decisions.
  • CMS cited 63 of the 140 audited Medicare Advantage health plan contracts (45%) for sending denial letters that did not contain important required information. CMS found that some denial letters did not clearly explain why a request was denied, contained incorrect or incomplete information, did not use approved language, and/or were written in a manner not easily understandable to beneficiaries.
  • CMS suspended new enrollment for two Medicare Advantage health plans due to serious threats to the health and safety of their beneficiaries. One of these Medicare Advantage health plans had a history of noncompliance. These Medicare Advantage health plans represented 22 contracts and nearly 500,000 beneficiaries.
  • CMS issued $1.9 million in civil money penalties to nine Medicare Advantage health plans for violations related to processing requests for services and payment, appeals, and grievances.
  • The plan violations did not impact Medicare Advantage health plan star ratings until an average of two years later.

According to the OIG, high overturn rates of appealed denials and continued performance problems identified by CMS audits, raises concerns that some beneficiaries and provider organizations may not be receiving required services and payment from the Medicare Advantage health plans. The OIG recommended that CMS enhance its oversight of Medicare Advantage health plan contracts, address problems related to inappropriate denials and inadequate denial letters in Medicare Advantage, and provide beneficiaries with information about serious violations by Medicare Advantage health plans. CMS concurred with all three recommendations.

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 3-500, San Francisco, California 94103; 415-437-7982; Fax: 415-437-8060; Email: Donald.white@oig.hhs.gov.

Medicaid beneficiaries enrolled in the CareMore Health (CareMore) comprehensive primary care model had fewer hospital admissions, fewer hospital days, fewer emergency room visits, and fewer specialist visits than other Medicaid beneficiaries. From May 2017 to April 2018, CareMore tested its primary care delivery model in Memphis, Tennessee; and Des Moines, Iowa; serving 8,000 to 10,000 members in each market. The enrolled beneficiaries included those enrolled in Temporary Assistance for Needy Families (TANF) and those considered aged, blind, and disabled (ABD).  In Tennessee, CareMore members had 10% to 17% fewer days in the hospital, 21% to 22% fewer emergency room visits, and 23% to 28% fewer specialist visits than other Medicaid managed care beneficiaries. In Iowa, the impact was similar.

The combined outcomes for CareMore’s Memphis and Des Moines members from May 2017 through April 2018, compared to other Medicaid managed care members, were as follows:

  • 9.5% fewer hospital days for CareMore members, with 1,378 days per year per 1,000 CareMore members and 1,523 days per year per 1,000 other Medicaid managed care members.
  • 17.4 fewer hospital admissions for CareMore members compared to other Medicaid managed care groups, with 199 admissions for CareMore members; and 241 admissions for other groups.
  • 21.7% fewer emergency room visits for CareMore members compared to other Medicaid managed care groups, with 1,196 emergency room visits for CareMore members; and 1,528 visits for other groups.
  • 27.9% fewer medical specialists visits by CareMore members compared to other Medicaid managed care groups, with 3,767 visits for CareMore members; and 5,222 visits for other groups.

The CareMore integrated care delivery system provides access to a team of physicians, nurse practitioners, community health workers, clinical pharmacists, and behavioral health specialists. The team works in unison to develop customized care plans that are initially based on the results of welcome visit health assessments. Standard primary care physicians and nurse practitioners are not able to provide a team approach that includes access to community health workers, clinical pharmacists, and behavioral health specialists.

These findings were reported in “Rethinking How Medicaid Patients Receive Care” by Vivek Garg, Amberly Molosky, Sandeep Palakodeti, and Sachin H. Jain of CareMore Health. The authors analyzed May 2017 to April 2018 data from CareMore Health and Amerigroup analysis of claims data for CareMore Health’s members in the test locations. The goal was to determine whether the program has delivered improved outcomes for its members in these locations, and whether the program should be expanded to other locations.

CareMore Outcomes Per 1,000 Members Per Year Compared To Other Groups (Per 1,000 Per Year), For May 2017 To April 2018

Hospital Admissions Hospital Days Emergency Room Visits Specialist Visits

Tennessee

ABD

CareMore 199 1,378 1,332 8,331
Other Groups 241 1,523 1,685 10,866
Performance Difference For CareMore Members 17.4% fewer 9.5% fewer 21.0% fewer 23.3% fewer

TANF

CareMore 46.2 158 1,196 3,767
Other Groups 46.6 190 1,528 5,222
Performance Difference For CareMore Members 0.9% fewer 16.8% fewer 21.7% fewer 27.9% fewer

Iowa

ABD

CareMore 142 1,315 1,152 8,343
Other Groups 192 1,027 1,491 9,567
Performance Difference For CareMore Members 26.0% fewer 28.0% more 22.8% fewer 12.8% fewer

TANF

CareMore 39 143 843 6,053
Other Groups 49 182 1,186 7,292
Performance Difference For CareMore Members 20.4% fewer 21.4% fewer 28.9% fewer 17.0% fewer

The researchers concluded that the results in these two states supported expansion of the CareMore Medicaid care-delivery program to other sites. The model was scaled to launch in the District of Columbia, Texas, and New York. CareMore is a physician-founded, physician-led integrated care delivery system that serves Medicare and Medicaid beneficiaries, and those dually eligible for both Medicare and Medicaid. It currently has operations in 10 states: Arizona, California, Connecticut, Georgia, Iowa, Nevada, Tennessee, Texas, Virginia, and the District of Columbia.

The full text of “Rethinking How Medicaid Patients Receive Care” was published on October 5, 2018, by Harvard Business Review. An abstract is available online at HBR.org.

For more information, contact: Sachin H. Jain, President and Chief Executive Officer, CareMore Health Plan, 2412 Church Avenue, Brooklyn, New York 11226; 914-336-7126.

Every meeting of health and human service managers ends up, at some point, talking about “the workforce problem”—the shortage of psychiatrists, the shortage of nurse practitioners, the shortage of direct support professionals, and the shortage of home care workers. (We’ve covered these issues recently in Staff Vacancies Just Got A Little More Important & Complicated, Workforce Shortages As A Strategy Issue, and Where Have All The Psychiatrists Gone?)

There are many reasons. Topping the list—demographics, professional choices, and the gap between reimbursement rates and compensation rates. On the demographic side of the issue, the aging population is creating a sharp increase in the demand for more direct care workers. Currently, about 50% of the population over age 65 need some form of long-term services and supports, and the population over 65 is predicted to double between now and 2050. With that growth, the Bureau of Labor Statistics predicts that we will need one million more direct care workers by 2024. Additionally, women make up about 90% of the home health and nursing assistant workforce, but the pool of women between the ages of 25 and 64 will grow by less than one percent during that time frame, creating a further gap in the available workforce.

And the gap between reimbursement rates and compensation rates has turned into a struggle, as low reimbursement rates prevent organizations from increasing pay for much of the workforce. Rates for units of service are likely not going up and reducing wages to hire more staff is likely not possible. In 2017, the average annual wage for home health aides was $23,210, and $23,100 for personal care aides; this is up about 16% for both positions, which made $20,000 in 2010 (see Will Clinical Professional Compensation Drive Task Shifting?). Hourly, personal care aides earn an average of $10.92/hour, while home care workers earn $11.03/hour. Low wage rates lead to high turnover rates—one in every two direct care workers leave their job within the first 12 months of employment, with most citing low wages as the cause. Nearly 20% of home care workers do not have health insurance; about 39% rely on public health care coverage; about 19% live below the federal poverty level; and about 51% receive some sort of public assistance, including food and nutrition assistance (30%), Medicaid (30%), and receive cash assistance (3%). Unsurprisingly, turnover rates among the direct support professionals are around 45% (see High Turnover, The Other Staffing Issue).

One observation I have about the workforce issue conversations that there is rarely a discussion of how to use technology to address the issue—a strategy that is common in other fields. A recent article in The Harvard Business Review, “AI Will Change Health Care Jobs for the Better,” provided a framework for thinking about how to apply “smart machines” to this problem solving. The authors provided a framework for the three types of functionality that applied technologies provide to extend our staffing:

Amplifying staff—What health care staff are capable of can dramatically increase with smart technologies. I think of two types of technology in this category. First, there are the technologies that remove the need for consumers and professionals to be physically together or even communicate at the same time. For example, asynchronous “store-and-forward” diagnostic services are becoming more common, allowing recorded diagnostic interviews of consumers, consumer brain scans, and other consumer “images” to be assessed by clinical professionals at a more convenient time. Then there is the continued adoption of augmented intelligence to assist with decisionmaking in the use of decision support tools. This does not replace professional insight, but rather provides professionals and consumers with the most recent research to inform diagnoses, treatment planning, and on-going care management.

Interacting with consumers—Another category of technologies to address the workforce issue is to leverage technology to interact with consumers, such as using technology to remind consumers to take medication or participate in physical and cognitive exercises. The recent Humana/Fitbit collaboration is just one example. And then there is technology-driven mental health therapy, a huge tech bucket that can include remote monitoring, web portals, robots, smartphones, machine learning tools, and much more. For example, Mindstrong Health uses a smartphone app to provide real-time measurement and support for consumers through messaging and telehealth from Mindstrong’s licensed provider care team. Tech that uses artificial intelligence can also be equipped to recognize voice, emotion, or gestures to further improve its precision and accuracy. For example, Canary Speech is a software algorithm that analyzes speech patterns and uses machine learning to help diagnose conditions such as Alzheimer’s disease, dementia, and Parkinson’s disease.The program can be used with voice-actived devices, such as the Amazon Echo system. That isn’t the only way voice-actived “virtual assistant” devices are being used.

I’ve been surprised at the adoption of the Amazon Alexa in serving consumers with autism and consumers in need of assistance with daily living. For consumers with autism, voice commands can be used to provide consumers with autism with reminders, such as when to eat or use the restroom, and can help consumers to practice language and social skills by engaging in conversations with the virtual assistant. For older consumers in need of assistance, Alexa can be used as an extender for home health care staff by using the system to remind older consumers when to take their medication or to manage the household by turning on lights or changing the thermostat. The devices can also be used to call for help in case of an emergency or to send messages to loved ones.

Embodying caregivers—Another way that smart machines can assist staff is to augment their physical performance. Yes, this is robots: “physically embodied systems capable of enacting physical change in the world” or “a machine resembling a human being and able to replicate certain human movements and functions automatically”. This is the use of augmented intelligence in a physical form. The U.S. has emerging adoption of robotics in health care and personal support (other countries are further ahead).

There are robots in facilities that can transport medications, linens, and lab specimens—like Tugs by Aethon or North American RoboCourier. Or Xenex, a robot that uses high-intensity ultraviolet light to disinfect facilities. And, robots like Robotic IV Automation, or RIVA, that can automate functions in pharmacies. There are robots capable of lifting a consumer from standing position or from the floor, transferring a consumer to a wheelchair, carrying a consumer, and turning consumers in bed—like RIBA and ROBEAR. There are personal health care companions for a physical presence to assist in care management, like Mabu and Baymax. And, there are companion robots—like Paro, Pepper, and Dinsow—designed to provide consumer interaction and monitoring functions.

The prospect of strategic initiatives to create hybrid human/technology service delivery systems may seem daunting. The challenge for health and human service organizations isn’t the lack of technology to augment the workforce and address some key workforce issues. The challenge is the disconnect between the developers of new technologies and the management practices of health and human service organizations. But the key is to have an overarching plan, proceed at a slow but steady pace, use metrics-based management to guide the process, and realize the plan will change with experience, new competition, and new technologies. In a field where 90%+ of operating expenses are people, creating a tech-enabled workforce is a competitive advantage. The executive team that can overcome that disconnect will be the executive team with the winning solution.

For more, on a tech-enabled workforce, see these resources in the PsychU Library:

  1. Staff Vacancies Just Got A Little More Important & Complicated
  2. Workforce Shortages As A Strategy Issue
  3. Will Clinical Professional Compensation Drive Task Shifting?
  4. The Innovation Conundrum
  5. Task Shifting To Bend The Cost Curve
  6. Would This List Bend The Cost Curve?
  7. Can A Virtual Assistant Make A Dent In Your Workload?

Reducing the use of restraints and eliminating seclusion at a behavioral health care facility that serves at-risk and high-risk clients with intellectual/developmental disability (I/DD), and psychiatric disabilities resulted in reducing staff injuries. The lower injury rate resulted in lower lost-time expenses, lower turnover cost, and lower workers compensation policy costs. Between 2003 and 2016, the facility decreased use of restraints by 99%. During the same period, staff injuries due to a restraint declined by 97%, and client-induced staff injury declined by 64%. At the same time, consumer goal mastery increased by 133%.

These findings were reported in “Evaluation of a Program Model for Minimizing Restraint and Seclusion” by Jason H. Craig and Kimberly L. Sanders. The researchers presented findings about an initiative implemented by Grafton Integrated Health Network, a developmental disability provider organization in Virginia that serves at-risk and high-risk children and adults with I/DD and psychiatric disorders. Both researchers are affiliated with Grafton. Grafton provides services in residential, educational, home, and community settings. The change effort focused on implementing trauma-informed, less restrictive treatment methods. The goal was to provide safer treatment for both consumers and staff, and increase mastery of individualized goals.

The initiative focused on training employees to reassure consumers, ask questions instead of making assumptions, be flexible, and treat others with kindness and respect. The goal was to replace restraint or seclusion with non-coercive, caring intervention from a person focused on peaceful conflict resolution who was willing and able to spend time with the upset or angry individual.

Key findings about the reductions were as follows:

  • Use of restraint dropped by 99%, and seclusion ended completely. In 2003 organization-wide, there were 6,646 uses of restraint, with 2,788 in community-based settings and 3,858 in residential treatment facility settings. Residential treatment facilities had 253 instances of seclusion. By 2016, organization-wide, there were 53 uses of restraint, with 3 in community-based settings, and 50 in residential treatment facility settings. Residential treatment facilities had no seclusion instances in 2015 or 2016.
  • The staff injury rate due to a restraint dropped by 97%. Organization wide, in 2004 there were 110 restraint-related staff injuries, with 63 in community-based settings and 43 in residential treatment facilities. By 2016, organization-wide, there were 3 staff injuries; all 3 occurred in a residential treatment facility.
  • The number of client-induced staff injuries dropped by 64%. Organization wide, in 2004 there were 360 such injuries, with 220 in community-based settings and 111 in residential treatment facilities. By 2016, the number had dropped to 126 organization-wide, with 73 in community-based settings and 44 in residential treatment facilities.
  • Consumer goal mastery increased from 34% in 2005 to 80% in 2016. This initiative focused on improving teaching and outcomes.

The researchers reported that because the staff injury rate declined, Grafton saved more than $16 million over 10 years. These lower costs were due to cost reductions in lost-time expenses, workers compensation premiums, and staff turnover costs.

  • The cost of lost-time expenses organization-wide decreased 75%, from $473,340 in 2004 to $120,339 in 2016. In community-based settings, the costs dropped by 79%, from $330,256 in 2004 to $70,407 in 2016. In residential treatment facility settings, the costs dropped by 63%, from $129,019 in 2004 to $47,417 in 2016.
  • Workers compensation policy costs dropped by 27%, from about $1.60 million in 2004 to $1.17 million in 2015.
  • The 2007 baseline cost of turnover was calculated at $2.17 million. The baseline included hiring costs, training, and lost quality and efficiency while a position is vacant. Each subsequent year, turnover costs were lower, such that between 2007 and 2016 cumulative savings totaled $6.6 million.

The full text of “Evaluation of a Program Model for Minimizing Restraint and Seclusion” was published August 13, 2018, by Advances in Neurodevelopmental Disorders. An abstract is available online at LinkSpringer.com.

For more information, contact: Kimberly L. Sanders, President Ukeru Systems, and Executive Vice President and Chief Operating Officer of Staffing and Training, Grafton Integrated Health Network, Post Office Box 2500, Winchester, Virginia 22604; 540-542-0200, ext. 6412; Fax: 540-542-1721; Email: ksanders@grafton.org.

An analysis of Medicaid home- and community-based services (HCBS) programs in five states (Arizona, Florida, Mississippi, Montana, and Oregon) found that the states and managed care organizations (MCOs) reported challenges recruiting and training direct care workers, due in part to low wages. The states also faced challenges due to the complexity of consumer care needs and state funding limitations.

Officials from all five states and three of the four MCOs interviewed as part of the analysis cited challenges recruiting and retaining HCBS direct care workers, particularly given the low wages these professionals typically receive. Officials from Montana and Oregon noted that direct care workers can typically earn more working at a fast food restaurant. Officials from Montana and Mississippi and officials from three of the MCOs said the workforce shortages are often worse in rural or remote areas, where travel across long distances is common. The officials said it can be hard to find a provider willing to drive a long distance each way to work for only a few hours.

Officials from four of the five selected states and all four MCOs described challenges serving beneficiaries with complex medical and behavioral health needs, including individuals who display aggressive or other challenging behaviors. The officials said complex medical conditions can be hard to accommodate in HCBS settings. Officials from Mississippi and one MCO mentioned difficulties finding appropriate placements for individuals requiring ventilator services. State and MCO officials also reported that complex conditions that affect beneficiaries’ behavior, such as co-occurring developmental disabilities and behavioral health conditions, dementia, and traumatic brain injury can also create challenges for providing HCBS, particularly when beneficiaries display aggressive or other challenging behaviors.

Officials from four selected states and officials from one of the MCOs in the fifth state said that limits on funding for HCBS programs were a challenge, particularly in the context of the growing number of individuals with long-term service and support (LTSS) needs.

  • In Mississippi, state officials were unable to enroll the maximum number in certain HCBS waivers, and that over the past three years, only a limited number of beneficiaries had been added to these programs.
  • Officials from an MCO in Arizona said that state budget constraints had led to past reductions in the amount of certain HCBS, such as respite care.
  • State officials in Oregon said that the increase in federal funding for implementing its 1915(k) Community First Choice state plan program failed to fully cover the increased cost of serving all eligible beneficiaries, which led to budget problems.
  • Florida officials said that the state has experienced rapid growth in the population with LTSS needs and that this growth, combined with medical advances that prolong life and reduce attrition from waiver programs, had contributed to a growing waiting list for HCBS.
  • Officials from one MCO said that the state’s limit on HCBS waiver spending per beneficiary was a challenge for beneficiaries with high needs because HCBS costs cannot exceed the cost of institutional care. If beneficiaries’ costs exceed 100% for more than a six-month period, the beneficiary can choose to move to an institutional setting, or to continue to receive more limited HCBS that do not exceed the cost of care in an institution. To choose the latter, the beneficiary and family/guardians are required to sign a form acknowledging the safety risks.

These findings were reported in “Medicaid HCBS: Selected States’ Program Structures and Challenges Providing Services” by the Government Accountability Office (GAO). The review encompassed 26 HCBS programs that provide long-term services and supports (LTSS) in Arizona, Florida, Mississippi, Montana, and Oregon. The analysis reported that the programs reflect state decisions on the population covered, whether to limit eligibility or enrollment, and use of managed care. Additionally, the analysis focused on state-level challenges related to providing HCBS, and actions states reported taking to respond to the challenges.

  • Populations: Four of the five states (Florida, Mississippi, Montana, and Oregon) had multiple HCBS programs (21 in total) that targeted specific populations. For example, Mississippi had separate HCBS programs for aged or physically disabled individuals and individuals with intellectual/developmental disabilities (I/DD). The fifth state, Arizona, had one program that targeted both the aged and disabled population and those with I/DD. The remaining four programs were not targeted to specific populations.
  • Eligibility: All five states had at least one HCBS program that limited eligibility to beneficiaries whose needs would otherwise require care in a nursing home or other institutional setting.
  • Enrollment: Four of the five states (Florida, Mississippi, Montana, and Oregon) limited enrollment in one or more of their HCBS programs; 19 of the 26 programs had enrollment caps, and 12 of these programs maintained a waiting list.
  • Managed care: Two of the five states (Arizona and Florida) used managed LTSS for one HCBS program.

The GAO reported state and MCO officials’ efforts to respond to the three key challenges to providing HCBS: workforce, consumer complexity, and funding. Their broad responses were as follows:

  • HCBS workforce: To make direct care worker salaries more competitive, officials from Mississippi, Montana, and two of the MCOs reported offering higher payment rates. Officials from Arizona and Montana and one MCO also mentioned that Medicaid’s participant-directed options—which allow beneficiaries to choose paid caregivers from among their family members, friends, and neighbors—had helped to address HCBS workforce shortages.
  • Consumer complexity: To respond to the challenge of serving HCBS beneficiaries with complex medical or behavioral health needs, the state officials and MCOs reported using the following strategies: supporting the development of locations in the community to serve individuals with specific complex needs, training provider organizations and direct care professionals, and increasing care coordination.
  • HCBS funding: State officials who said HCBS funding was a challenge said they responded to these challenges by, among other things, providing information to their legislatures on the projected need for HCBS to inform future funding decisions. The information included population growth, projected demand for Medicaid, the cost of providing HCBS, and cost avoidance achieved by keeping people out of nursing homes. They also leveraged other available resources, such as federal grants; these alternative funding sources include the Money Follows the Person grant program.

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; 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.

The need to standardize service delivery has become increasingly critical for better consumer experience, for better outcomes, and for consistent pricing and performance in value-based arrangements. This was the focus of my closing keynote, “Reinventing Your Organization: Key Management Best Practices For A Value-Based World”.

One key element of service standardization is the routine use of “best practice” service delivery—whether evidence-based practices (EBP) or practice-based evidence. Health and human service organizations should have models that identify the “best services and approaches” for consumers with specific characteristics and needs, increase the likelihood of a good outcome, provide a great consumer experience, and come with a predictable cost.

But in the sectors of the health and human service field, standardized treatment approaches are the exception rather than the rule. First there is the overarching problem of slow adoption of scientifically validated processes. The typical “new development” takes 15 to 20 years to get most consumers. Then there is the lack of consistency in delivery of the current models—or even lack of models. This situation is illustrated by recent research that found that in 2016, of the 10 million adults in the United States who were living with serious mental illness (SMI), only 32% received medication management and only 19% received support for illness self-management. Of the seven million children and youth who experienced a serious emotional disturbance (SED) less than 5% received multi-systemic therapy or therapeutic foster care, and about 7% received functional family therapy (see Why Do Only A Third Of Consumers With SMI Receive Evidence-Based Treatment).

This situation in the complex consumer market and the use of technology to address the current problems of decision support and service delivery consistency was the focus of the remarks of Carol Reynolds, Executive Vice President, Client Experience of Netsmart in her session, “Evidence-Based Practice & Practice-Based Evidence: How Technology Should Support The Former & Produce The Latter”.

Figure 1. Reynolds, C.J. (2018). Evidence-based practice & practice-based evidence: How technology should support the former & produce the latter. [PowerPoint slides]. Retrieved from openminds.com.

Her primary message—using and extending the use of your electronic health record (EHR) can provide health and human service organizations with the technology platform to push evidence-based practices by creating a “learning system” that proactively manages the health of populations. Collecting data through an EHR can enable organizations to share data, analyze population health, and implement clinical decision support tools.


Figure 2. Reynolds, C.J. (2018). Evidence-based practice & practice-based evidence: How technology should support the former & produce the latter. [PowerPoint slides]. Retrieved from openminds.com.

But what are the impediments to standardization of service delivery in general—and use of EBPs in particular? The American Nurses Association found that the biggest barriers to EBP implementation included a lack of educational opportunities, knowledgeable mentors, resources, and tools needed. Additionally, implementing EBPs can demand a large initial investment to design the program, train and hire new staff, and building an operational structure to document and measure the program’s outcomes—which can present big challenges for many organizations. Adding to these challenges, we are seeing systematic stigma from health care professionals and poor reimbursement for all elements of the EBP (see Behavioral Health Evidence-Based Practices As Population Health Management Tools). All of these factors add up to big challenges that have halted the progress of EBP implementation across the complex consumer market.

During the institute session, there was a great exchange with Greg Loop, Chief Executive Officer of Family Services of Northwest Pennsylvania. He pointed out one challenge of EBP adoption—the misinterpretation of EBP as “cookie cutter” and not individualized treatment. This was a perception of both clinical staff and of auditors. After the session, we touched base with Mr. Loop, who further explained:

We come into the field with what are now EBP, where we know assessments and interventions need to be presented in a certain order to be the most effective. Whether that’s multi-systemic therapy, functional family therapy, trauma-focused cognitive behavioral therapy, or any of the therapies that have gone through the rigor to be recognized as truly evidenced based. You really have phases, or prescriptions where you do A first, then B, then C. Then reviewers are coming in and seeing treatment plans that look similar because they are using an evidenced based approach. The individualized aspect of service is truly the assessment and diagnostic phase. The application of the intervention is in fact standardized. This is what makes it effective and an evidenced based approach. Important to note, that the EBPs have risen in use and are touted, because their outcomes are better than typical practice-say 20% or 30% more effective for the population being referred.

From my perspective, those reviewers want to see that the treatment is “highly individualized” and not just appropriately applied because of an individualized assessment. By comparison, if I went to a physician with my daughter and she had a diagnosis of an ear infection, he’d likely be recommending something in the amoxicillin family of antibiotics. And he’d know how many grams how many times a day. The individuation would be based on his assessment and diagnosis. And he would individuate that recommendation based on whether there was an allergy as well. But because amoxicillin is the intervention of choice, he wouldn’t further individuate it, just so it doesn’t look “cookie cutter.”

But that is the paradigm we find ourselves in when reviewers say our treatment plans look similar. We respond that’s because they are both for depression. We are using an appropriate intervention that is structured for depression and for this population. Then yes, they should look similar. I think our reviewers have been focused on making sure that everything must be “individual” but don’t understand the relationship with clinical best practice. Then, our clinicians start to feel pushed not to use the same kind of prescription for similar presenting consumers, for fear they won’t be individualizing the treatment plan.

The reality is, as provider organizations, we must work within our field, with our colleagues across agencies to define successful treatment. We need to find the appropriate entry and exit points for a course of treatment. We must develop a model for what a course of treatment should look like.  

I think this issue is just one example of a fundamental confusion about “best practice” treatment models. Providing consumer with “best practice treatment” is the best case of personalized medicine and individualized care. This doesn’t happen without the consumer voice in terms of preferences—but it requires sharing with consumers (in language they understand) that “why” behind those models.

This summary was developed utilizing the full recorded presentation of this webinar. You can access the full sourcing, polling results, recording, or presentation slides here: https://www.psychu.org/tackling-behavioral-health-provider-shortages-health-plan-strategies-access-engagement/.

Health plans are challenged to assure timely access to behavioral health care. A misconception is that this problem only occurs in rural markets, but many urban areas are also feeling the pinch with all types of clinical professionals. On November 7, 2018, William Wood, MD, PhD and Deb Adler, MS, CPHQ, conducted a webinar to discuss the growing demand for and shrinking availability of behavioral health clinical professionals – both psychiatrists and allied providers such as social workers and psychologists.

Dr. William Wood is a psychiatric physician executive with 34 years of extensive senior leadership experience in public and private behavioral health care. Before joining OPEN MINDS as a Senior Associate, he served as Managing Medical Director for Medicare & Medicaid Anthem/Amerigroup. He has also had experience as a psychiatric executive in community mental health and psychiatric hospital environments. Dr. Wood received his Doctor of Medicine from Baylor College. He also earned a PhD in Biochemistry from the University of North Carolina at Chapel Hill School of Medicine.

Ms. 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 clinical professionals and providers organizations. Currently she serves as a Senior Associate at OPEN MINDS. Ms. Adler received her Master’s Degree in Educational Psychology & Evaluation from Catholic University of America, and is a Certified Professional in Health Care Quality.

The presentation had the following educational objectives:

  1. Discuss where behavioral health access challenges are the greatest
  2. Investigate strategies to address behavioral health professional shortages to mitigate access challenges
  3. Explore potential best practices to improve behavioral health access and consumer engagement

The webinar began with a poll of the attendees, to learn what types of organizations were being represented within the attendee population. Results are presented in Figure 1.

Ms. Adler started the webinar with a discussion of monitoring and evaluating access and availability of behavioral health services. She reviewed the traditional methodology for measuring availability from the health plan perspective, including:

  1. Geographic Distance & Proximity: Using geoaccess reports to determine the distance from the consumer to the provider. In this methodology, the definition of distance evolves to reflect different areas (urban, rural and frontier).
  2. Timeliness Of Services: In particular, Ms. Adler spoke about timeliness in regards to outpatient services. For example, measuring the length of time between when a consumer first contacts a provider organization for their first appointment. Ms. Adler stated that typical industry standards are: 10 days from the consumer first requesting services to receiving service for a routine outpatient visit; 48 hours for urgent care; and 6 hours or immediately for emergencies.

Ms. Adler also mentioned other important measures of access, including: effectiveness (e.g. is the service evidence-based); convenience (e.g. can services be accessed at times that fit with the consumer’s work schedule); and whether or not care is consumer-centered. She then covered ways that payers can assess access to services, including: structural measures (e.g. what percent of a population is covered by insurance); utilization measures (e.g. penetration rate, which can range from 2%-4% for a commercially insured population, to 12-14% for a managed Medicaid population); and density (e.g. the ratio of providers to consumers for a given population or geographic region). Dr. Wood added to the discussion by stating that payers and providers are taking a more consumer-centered approach by answering new questions related to social determinants, like figuring out if consumers have access to transportation.

Moving on, Ms. Adler turned her focus to the current access and availability challenges in the behavioral health system. She began by presenting statistics from Centripetal’s Trends In Behavioral Health: A Reference Guide On The U.S. Behavioral Health Financing & Delivery System report, related to psychiatric bed supply and licensed psychiatrist shortages. Ms. Adler pointed out that the Treatment Advocacy Center recommends a standard of 40-60 available beds per 100,000 people, while findings from the Trends Report suggested that availability is closer to 30 beds per 100,000, with even less availability in rural and frontier areas. She mentioned that the supply of beds is even more challenging for Medicare and Medicaid consumers as opposed to consumers with commercial insurance, due to lower reimbursement rates within each payment system. Ms. Adler indicated that these current challenges with access to inpatient care may change over time as payers continue to look for alternatives for inpatient care.

Both Ms. Adler and Dr. Wood pointed out the national shortage of psychiatrists, which also varies by geographic region, with less availability within rural or frontier areas. They stated that a shortage of psychiatrists is likely to be a continual issue for some time, as demand continues to increase and supply continues to shrink. Speakers mentioned that dwindling rates of psychiatrists are due to an aging population of professionals heading toward retirement age, and fewer medical students choosing psychiatry as a specialty. Lastly, Ms. Adler mentioned that many private practitioners, including psychiatrists, have been moving towards “cash only” payment systems, which restricts access to those consumers who cannot afford to pay out of pocket for services.

At this point in the presentation, the audience participated in another poll, this time focused on the greatest challenges to access or availability within their current practice environment. Results are presented in Figure 2.

After the polling, Dr. Wood shared his professional experience during his time at Anthem. He stated that their largest issue was finding quick access to a psychiatrist for their commercial members. He mentioned that sometimes it was actually easier to find access for their Medicaid consumers, as many community mental health centers had psychiatrists on staff.

Ms. Adler moved on to a discussion of solutions to the challenges previously presented. The following potential solutions were explored:

  • Tackling The Psychiatric Bed Shortage: by encouraging partnerships and funding of new approaches; monitoring practices, collecting necessary data, and standardizing terminology; removing barriers to access
  • Changing Care Delivery: by utilizing advanced practice providers where appropriate and allowed within their prescriptive authority – including nurses with prescriptive authority, prescribing psychologists, physician assistants with psychiatric certifications, and board-certified psychiatric pharmacists; and offering virtual psychiatric services within state regulatory confines over HIPAA-secure technology to increase access to care
  • Delivering Collaborative Care: which is a person-centered model that rewards primary care providers and multi-disciplinary teams when they screen for anxiety or depression, allows access to psychiatrists in person or through a virtual consultation, and embeds a care manager in the team to coordinate care and update data as necessary
  • Exploring The Use Of Telehealth / Telepsychiatry: since around 15 million Americans are already receiving some medical care through telehealth, and it allows providers to increase productivity and eliminate travel time to increase convenience to the consumer
  • Addressing Reimbursement Issues: through increased rates, alternative models, other financial and non-financial perks, and equality between in-person and virtual visits

The audience was asked a third and final question to explore their organizations’ attempts to tackle access challenges. Results are presented in Figure 3.

Dr. Wood and Ms. Adler then discussed the critical link between access and engagement – the quicker the access, the better the engagement. They also mentioned that increased engagement may improve outcomes overall, including potentially lowering no-show rates, raising consumer satisfaction, and increasing medication adherence. Dr. Wood stressed the importance of an overall consumer-centered approach, including setting up a follow-up plan before individuals are discharged from a hospitalization, offering greater flexibility and availability of walk-in appointments, providing evening and weekend appointment times, and offering the consumer a choice of provider and location. He stressed that when consumers are given choices, they can be much more invested in health care outcomes.

The webinar concluded with a question and answer period in which the following questions were asked:

What are the best ways to work with primary care to support consumer engagement?

Ms. Adler cited the effectiveness of collaborative care models. Dr. Woods also pointed out the ability to do “warm handoffs” within collaborative care models – where the primary care professional introduces the consumer to the behavioral health professional as a part of the consumer’s care team – which can help with transition and engagement in care.

How can using clinical professionals to the top of their level of licensure help with workforce issues?

According to Dr. Wood, allowing professionals to practice at the top of their licensure increases access to necessary services. One potential issue often encountered is that psychiatrists are not traditionally or typically trained to work as a part of a larger interdisciplinary team. Dr. Wood stated that when behavioral health professionals work together as a team, each clinical professional is able to perform the tasks and duties that are most appropriate for their level of licensure. In turn, this can increase efficiency, and create more capacity to see consumers.

Are current reimbursement policies potential barriers to telehealth?

Ms. Adler expressed her opinion on the issue as a difficulty of awareness rather than reimbursement. She stated that many payers do pay the same rate for telehealth as face-to-face appointment time, however, consumers and providers may not be aware that telehealth is an equivalent option financially.

What role can peer specialists / peer providers play to help with these issues?

Dr. Woods stated his belief that peer specialists are an underused resource within the field, and that they could play a critical in role in consumer engagement and serve as a critical member of the provider team. Ms. Adler agreed, and stated her opinion that payers could ensure reimbursement for their services, which in turn would reflect the importance of these services and the peer specialists within the treatment team and behavioral health system.

On August 27, 2018, Medicare included 2,599 hospitals — or over half the total U.S. hospitals — in a list of those facing reimbursement penalties throughout fiscal year 2019 through Medicare’s Hospital Readmissions Reduction Program (HRRP). The penalties are imposed if the hospital’s 30-day readmission rate exceeds the hospital’s benchmark. The HRRP penalties do not apply to psychiatric hospitals.

For 2018, 47 hospitals received the maximum penalty, a 3% reimbursement reduction during fiscal year 2019. The average penalty cut reimbursements by 0.7%, which is about the same amount as last year. The reimbursement reductions are estimated at $566 million. The 47 hospitals that received the 3% reimbursement reduction include:

  1. Arizona Specialty Hospital, Chandler, AZ
  2. Arnot Ogden Medical Center, Elmira, NY
  3. Baylor Medical Center at Frisco, Frisco, TX
  4. Baylor Scott and White Surgical Hospital at Sherman, Sherman, TX
  5. Bertrand Chaffee Hospital, Springville, NY
  6. Canyon Vista Medical Center, Sierra Vista, AZ
  7. Centerpoint Medical Center, Independence, MO
  8. Charleston Surgical Hospital, Charleston, WV
  9. Chestatee Regional Hospital, Dahlonega, GA
  10. Christus Lake Area Hospital, Lake Charles, LA
  11. Crestwood Medical Center, Huntsville, AL
  12. Doctors Hospital at Deer Creek L L C, Leesville, LA
  13. El Paso Specialty Hospital, El Paso, TX
  14. Harlan ARH Hospital, Harlan, KY
  15. Hazard ARH Regional Medical Center, Hazard, KY
  16. Henry County Medical Center, Paris, TN
  17. Hilton Head Regional Medical Center, Hilton Head Island, SC
  18. Houston Physicians’ Hospital, Webster, TX
  19. Kentuckiana Medical Center LLC, Clarksville, IN
  20. Lafayette General Surgical Hospital, Lafayette, LA
  21. Lake Huron Medical Center, Port Huron, MI
  22. Lakeland Regional Medical Center, Lakeland, FL
  23. Lee’s Summit Medical Center, Lees Summit, MO
  24. Memorial Hermann Surgical Hospital Kingwood, Kingwood, TX
  25. Methodist McKinney Hospital, McKinney, TX
  26. Northwest Specialty Hospital, Post Falls, ID
  27. Northwestern Lake Forest Hospital, Lake Forest, IL
  28. Oklahoma Center For Orthopaedic & Multi-Sp, Oklahoma City, OK
  29. Oroville Hospital, Oroville, CA
  30. Physicians Centre, The, Bryan, TX
  31. Pine Creek Medical Center LLP, Dallas, TX
  32. Providence Medical Center, Kansas City, KS
  33. Reston Hospital Center, Reston, VA
  34. Southcoast Hospital Group, Inc., Fall River, MA
  35. St John Broken Arrow, Inc., Broken Arrow, OK
  36. St Lucie Medical Center, Port Saint Lucie, FL
  37. St Mary’s Medical Center, Blue Springs, MO
  38. Sugar Land Surgical Hospital LLP, Sugar Land, TX
  39. Surgical Specialty Center at Coordinated Health, Allentown, PA
  40. The Hospital at Westlake Medical Center, Austin, TX
  41. Tristar Greenview Regional Hospital, Bowling Green, KY
  42. Tug Valley ARH Regional Medical Center, South Williamson, KY
  43. Unity Point Health Trinity, Bettendorf, IA
  44. USMD Hospital at Fort Worth LP, Fort Worth, TX
  45. Webster General Hospital/ Swing Bed, Eupora, MS
  46. WellSpan Surgery and Rehabilitation Hospital, York, PA
  47. Wheeling Hospital, Wheeling, WV

The Centers for Medicare & Medicaid Services (CMS) evaluation method for 2018 includes a significant change. Prior evaluations judged each hospital against all others. The new method assigns hospitals to five peer groups containing facilities with similar proportions of low-income consumers. Medicare then compared each hospital’s readmission rates from July 2014 through June 2017 against the readmission rates of its peer group during those three years to determine if a penalty was warranted, and how much that penalty should be. An analysis by Kaiser Health News found that the new method reduced penalties against safety-net hospitals by an average of 25% compared to last year.

According to the Medicare Payment Advisory Commission (MedPAC) June 2018 report to Congress, the penalties from previous years successfully pressured hospitals to reduce readmissions, which has saved Medicare about $2 billion a year. The commission found that between 2010 and 2016 readmission rates fell by 3.6 percentage points for heart attacks, 3 percentage points for heart failure and 2.3 percentage points for pneumonia. At the same time, readmissions caused by conditions that do not factor into the penalties fell on average 1.4 percentage points, indicating hospitals were focusing on lowering unnecessary readmissions that could hurt them financially.

Hospitals that were exempt from the program include those with too few cases, veterans’ hospitals, children’s hospitals, critical access hospitals, and psychiatric hospitals. Hospitals in Maryland also were exempt because the state has a federal waiver related to how it distributes Medicare funding.

The full text of “Mandated Report: the Effects of the Hospital Readmissions Reduction Program” was published in June, 2018 by MEDPAC. A copy is available online at MEDPAC.gov.

The “Medicare Readmission Penalties By Hospital, Year 7” data was published September 26, 2018 by Kaiser Health News. The data is available at KHN.org.

Additional information about Medicare’s Hospital Readmissions Reduction Program can be found at the CMS website at CMS.gov.

For more information, contact: James Poyer, Division Director for Value Incentives and Quality Reporting, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: james.poyer@cms.hhs.gov.

Of the 1,040 health plans rated by the National Committee for Quality Assurance (NCQA) in 2018, 12 health plans earned the top 5.0 rating, and 71 received a rating of 4.5. The ratings are based on consumer satisfaction with the plan, the plan’s provision of preventive services, and how well the plan’s network professionals provide evidence-based treatment. Most plans received a ranking of 2.5 to 4.0. About 8% (85 plans) received a top rating of 4.5 or 5.0 out of the maximum of 5.0. About 2% (25 plans) received the lowest ratings of less than 2.0. Of the plans that earned the top 5.0 rating, two are commercial health plans, four are Medicaid managed care organization (MCO) plans, and eight are Medicare Advantage plans.

For the 2018 Health Insurance Plan Ratings, NCQA researchers studied nearly 1,500 health plans and rated 1,040: 445 private (commercial) plans, 418 Medicare Advantage plans, and 177 Medicaid managed care plans. The goal of the ratings is to provide consumers with a way to compare health plan quality. Data for the rating for each health plan is from the plan’s combined scores on the Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and NCQA Accreditation standards scores as of June 30, 2018.

The two top-performing (rating of 5.0) commercial plans and their scores for consumer satisfaction, prevention, and evidence-based treatment are as follows:

  • Group Health Cooperative of South-Central Wisconsin, 3.5, 4.5, 4.5
  • Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 2.5, 5.0, 4.5

The four top performing (rating of 5.0) Medicaid MCO plans and their scores for consumer satisfaction, prevention, and evidence-based treatment are as follows:

  • Blue Plus (HMO Minnesota dba Blue Plus) 5.0, blank, 4.5
  • Jai Medical Systems Managed Care Organization, Inc., (Maryland) 4.0, 5.0, 4.0
  • Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Maryland) 3.0, 5.0, 4.5
  • Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Virginia) blank, 5.0, 4.5

The eight top-performing (rating of 5.0) Medicare Advantage plans and their scores for consumer satisfaction, prevention, and evidence-based treatment are as follows:

  • Group Health Plan, Inc. (serving Minnesota and Wisconsin) 4.5, 5.0, 4.0
  • Kaiser Foundation Health Plan, Inc.- Southern California 4.0, 5.0, 4.5
  • Kaiser Foundation Health Plan of Colorado 3.5, 5.0, 4.5
  • Kaiser Foundation Health Plan Of the Mid-Atlantic States, (serving the District of Columbia, Maryland, and Virginia) 3.5, 5.0, 4.5
  • Kaiser Foundation Health Plan of the Northwest, Inc (serving Oregon and Washington) 3.5, 5.0, 4.5
  • Kaiser Foundation Health Plan, Inc. – Hawaii 4.5, 5.0, 4.5
  • Kaiser Foundation Health Plan, Inc.- Northern California 4.0, 5.0, 4.5
  • Medical Associates Health Plan, Inc. 5.0, 4.5, blank

Over the last three years, the 10 states with the highest number of top-rated health plans (at 4.5 and 5.0) have remained similar. The only movement was in 2016 when Iowa entered the top 10 and in 2017 when Hawaii entered the top 10. In 2015 Iowa was ranked 12th and Hawaii was ranked 11th. The 10 states with the highest-rated health plans (rated at a 4.5 or 5.0) for the past three-year average are as follows:

  1. Massachusetts
  2. Rhode Island
  3. Maine
  4. Wisconsin
  5. Minnesota
  6. New Hampshire
  7. Hawaii
  8. Vermont
  9. New York
  10. Iowa

NCQA posted the plan ratings online in a searchable database, which can be accessed at HealthInsuranceRatings.NCQA.org.

For more information, contact: Matt Brock, Director of Communications, National Committee for Quality Assurance, 1100 13th Street NW, 3rd Floor, Washington, District of Columbia 20005; 202-955-1739; Fax: 202-955-3599; Email: Brock@ncqa.org.

In this series of interviews, Sloan Manning, MD, discusses a variety of screening tools that may be used in primary care (or mental health) settings to screen for mental health symptoms and associated risks, and measure response and reduction of symptoms over time.

For this installment, Dr. Manning discusses the World Health Organization’s (WHO) Compositive International Diagnostic Interview Shortened Screener (CIDI-3.0): its measures and scoring mechanisms, and models the way he might utilize the tool with a fictional patient.

Dr. Manning is the Medical Director and Adjunct Associate Professor, School Of Medicine, as well as the Co-Director of the Mood Disorder Clinic at Novant Health Urgent Care & Occupational Medicine at the University Of North Carolina.

Check out the other videos in this series:

What will mental health treatment look like from the consumer perspective in the years ahead? That was the question I addressed at the Cohen Veterans Care Summit yesterday in my session, The Future Mental Health Care Landscape & Its Likely Effect On Veterans & Families. I always find it a bit daunting to make predictions. But as a subscriber to the John Naisbitt philosophy of trend analysis—”The most reliable way to forecast the future is to understand the present”—I think the present does provide some clues to what we are likely to see ahead.

So, what do current trends tell us about the likely future of consumer treatment of mental health disorders? I think consumer services will continue to change in four important ways:

  1. An individual consumer’s access to treatment and the treatment system will be determined by the health care coverage, their health plan choice, and their personal income. A consumer’s health insurance status; their type of coverage (Medicaid, Medicare, other government insurance, or commercial insurance); and which state they live in will be the determining factors in their access to treatment. The current uninsured rate among working-age adults ages 19 to 64 is 15.5%, an increase of 12.7% since June 2017 (see 2018 Adult Uninsured Rate Is 5%, Up From 12.7% In 2017)—with a high of 26.4% in Texas and a low of 5.4% in Massachusetts. If a consumer has Medicaid for coverage, what state they live in will be a big variable. And, personal income will be a growing factor in treatment access. Consumer cost sharing is significant and growing, along with the income gap. About 50% of Americans make less than $30,000. About 30% of Americans make less than $15,000. These are demographic factors that shape access.
  2. Mental health treatment will happen within integrated systems of care. Payers (whether Medicare, Medicaid, or employers) are encouraging integration and coordination. New integrated delivery systems, like accountable care organizations, medical homes, health homes, and other new models of financing, are reducing the use of specialists outside the system of care. This leaves mental health treatment integrated with primary care as part of a new coordinated care system.
  3. Consumers will have more limited choices of treatment—of provider organizations, professionals, and treatment models. The move to value-based reimbursement and integrated systems of care is driving the emergence of “curated networks”, making it increasingly “inconvenient” for consumers to access treatment outside the networks (see The Future Has Arrived For VBR). In addition, as we see more risk at the provider organization level, we’ll see more use of decision support to assist professionals and consumers in selecting the “best” treatment While consumers will have full choice of professionals and treatment models on paper, these changes will effectively limit treatment choices.
  4. Tech-enabled treatment will be the rule, rather than the exception. While we have imperfect data about the comparative effectiveness of tech-enabled treatment (telehealth, text, store-and-forward, wearables, virtual automated therapies, ) to traditional face-to-face services, tech-enabled treatment will continue to gain traction and market share. It’s convenient, it solves part of the access issue, and it is less expensive—all drivers of use even without “perfect” information.

Figure 1 Oss, M. (2018) What Will Mental Health Treatment Look Like In The Years Ahead? [PowerPoint slides]. Retrieved from http://www.openminds.com

As I remarked to the audience at the Cohen Veterans Care Summit, you may or may not like this forecast of the future of treatment. After all, I’m not saying this is an optimal future for treatment—just a likely future scenario. What could or would change this trajectory? I think there are four possible intervening variables:

Coverage and its rules—The single most important decisions about access to mental health treatment will be made in Washington D.C. over the next year. What are the coverage rules? Will we have coverage for all Americans or not? Will the rules assure coverage of pre-existing condition limitations? Will we keep the rules with no annual and lifetime limits to coverage? Will medical loss ratio remain the same (see With The Future Of The PPACA, The Past May Be Prologue)? And, will coverage include parity for treatment of mental health and addictive disorders?

The slow progress on parity enforcement—Enforcement of mental health parity has been weak and progress has been slow. And we’re seeing further erosion of parity with the dismantling of pre-existing condition coverage guarantees and the removal of the essential health benefit requirements from short-term insurance plans (see The Beginning Of The End Of Parity and The Thousand Right Things). This trend likely won’t be reversed any time soon, as just last week the Senate Democrats missed on an attempt to overturn the expansion of short-term, limited-duration health plans that do not require parity and allow exclusion of pre-existing conditions.

Addressing the science-to-service lag—The delay between the validation of new treatment practices and getting them to most consumers is somewhere between 15 and 20 years. How to address this? Our political leaders and policymakers can try to make decisions based on data and ignore parochial stakeholder interests that are not in the best interests of consumers. Organizations promoting new treatment models or technology can invest in more formal proof of concept demonstration pilots. Provider organizations can adopt “best practice” models using implementation of science to speed adoption of innovation. One note: assuming you can avoid the “bleeding edge” of losses by being early to market, there is a “first mover” advantage by being the organization to bring new science to scale.

The operational definition of value in mental health—Across the health care field, we don’t have an operational definition of the value of mental health (and addiction) treatment services. I was struck by a recent session where the discussion turned to why it is so difficult to measure the “success” of addiction treatment across systems of care. And, my recent discussion with health plan executives was a case in point—they are looking for the professional associations to unify around standard definitions and outcome measures. As we move to a health system focused on value-based reimbursement, the organizations defining “value” will shape the treatment system.

Data-informed decisionmaking by all stakeholders—Last but not least, we need more data, but not just any data. We need more digested and actionable data designed to enable stakeholder decisionmaking. And while we need more data- informed decision making in politics and policymaking, I will leave that for another day. What needs to be addressed in the short term, for both health care professionals and consumers, is the provision of better decision support platforms. We already have the data to drive treatment planning on an individual level (see Preparing For Your ‘Augmented’ Workforce and Consumer Satisfaction, Consumer Engagement & Shared Decisionmaking). We’re just not using it.

How do you prepare for value-based reimbursement when you’re in a market with a payer mix that isn’t quite there yet? That was the focus of a great presentation Building A New Value Proposition: Strategy & Positioning For Sustainability, delivered by Kent Dunlap, Chief Executive Officer of Stars Behavioral Health Group this past August.

I thought that Mr. Dunlap’s prescription for preparing for VBR sustainability was focused on the key areas that every executive team should be looking at, regardless of their market. Mr. Dunlap explained that Stars has been in the VBR “prep mode” for a few years and their journey began by codifying the best practices needed for success in their 2016 five- year strategic plan. Their goal for the current time is developing a “culture of value.” His guardrails for preparation for a value-based environment? Better business analytics, strengthening outcome measures, and proactive selection of evidence-based practices.

The focus of their business analytics development is two-fold—systems for staff to use data to manage care at the program and individual consumers levels, and to improve performance using metrics to identify staff in need of performance development support. The Stars team developed a set of key performance indicators by tying together the data in their Ceridian (HRIS), myEvolve (EHR), and SAGE (financial) systems.

Figure 1 Dunlap, K. (2018) Building A New Value Proposition: Strategy & Positioning For Sustainability [PowerPoint Slides] Retrieved from https://www.openminds.com.

On the outcomes side of the equation, The Stars team is focusing on treat-to-target dashboards, expanding the use of collaborative documentation, and advocacy training for clients. Their approach is focused on benchmarking their clinical performance, which the Stars team is doing by comparing programs from different counties and looking at outcomes from different models. He noted that they have the ability to compare and contrast like programs from different counties, and to

look at outcomes from those different models; explaining that the counties in California want to be able to differentiate between the provider organizations. This means that they have to go forward with their own approach to benchmarking that includes contextual information about when that benchmark is applicable.

The business analytics and outcomes benchmarking are key ingredients in selecting evidence-based practices. In California, Mr. Dunlap explained, there is an added challenge in that each county had a different approach that needed to be catalogued and evaluated. Stars has been evaluating 14 different EBPs—by costs, clinical staff reactions, and the outcomes for the programs.

But like most markets, the Stars executive team is struggling with the timing of the transition to value in the California behavioral health market. The current financing of public behavioral health services is largely cost-based reimbursement—and payers have a “use it or lose it” attitude toward savings and surpluses. And, looking ahead, the politics are uncertain. There are a myriad of outcome and performance measures—and the payers have little experience in value-based contracting.

Mr. Dunlap’s assessment of the California behavioral health market is not unlike other public mental health markets. Movement to value-based contracting is slow—by payers, by health plans, and by the dominant provider organizations. But I think of it as glacial. Glaciers move slowly, but they are massive forces that inexorably sculpt the face of every landscape they touch. For more, check out these resources in the PsychU 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. The Hospital Perspective On ‘Owning’ Value-Based Reimbursement
  8. Building A Workforce For Value-Based Reimbursement = Advice From Four Executives

In this series of interviews, Sloan Manning, MD, discusses a variety of screening tools that may be used in primary care (or mental health) settings to screen for mental health symptoms and associated risks, and measure response and reduction of symptoms over time.

For this installment, Dr. Manning discusses the World Health Organization’s Well-Being Index (WHO-5): its measures and scoring mechanisms, and his professional experience of the tool’s practical application within a clinical setting.

Dr. Manning is the Medical Director and Adjunct Associate Professor, School Of Medicine, as well as the Co-Director of the Mood Disorder Clinic at Novant Health Urgent Care & Occupational Medicine at the University Of North Carolina.

Check out the other videos in this series:

In this series of interviews, Sloan Manning, MD, discusses a variety of screening tools that may be used in primary care (or mental health) settings to screen for mental health symptoms and associated risks, and measure response and change in symptoms over time.

For this installment, Dr. Manning discusses the clinician-rated, Young Mania Rating Scale (YMRS): its measures and scoring mechanisms, and his professional experience of the tool’s practical application within a clinical setting.

Dr. Manning is the Medical Director and Adjunct Associate Professor, School Of Medicine, as well as the Co-Director of the Mood Disorder Clinic at Novant Health Urgent Care & Occupational Medicine at the University Of North Carolina.

Check out the other videos in this series:

In this series of interviews, Sloan Manning, MD, discusses a variety of screening tools that may be used in primary care (or mental health) settings to screen for mental health symptoms and associated risks, and measure response and change in symptoms over time.

For this installment, Dr. Manning discusses the Montgomery-Åsberg Depression Rating Scale (MADRS): its measures and scoring mechanisms, and his professional experience of the tool’s practical application within a clinical setting.

Dr. Manning is the Medical Director and Adjunct Associate Professor, School Of Medicine, as well as the Co-Director of the Mood Disorder Clinic at Novant Health Urgent Care & Occupational Medicine at the University Of North Carolina.

Check out the other videos in this series:

In this series of interviews, Sloan Manning, MD, discusses a variety of screening tools that may be used in primary care (or mental health) settings to screen for mental health symptoms and associated risks, and measure response and reduction of symptoms over time.

For this installment, Dr. Manning discusses the Patient Health Questionnaire 9 (PHQ-9): its measures and scoring mechanisms, and his professional experience of the tool’s practical application within a clinical setting.

You can download a copy of the PHQ-9 through the PsychU Psychiatric Rating Scales Collection, here. Questionnaires and scales are provided for PsychU members’ screening and educational purposes only and are not to be used as diagnostic tools.

Dr. Manning is the Medical Director and Adjunct Associate Professor, School Of Medicine, as well as the Co-Director of the Mood Disorder Clinic at Novant Health Urgent Care & Occupational Medicine at the University Of North Carolina.

Check out the other videos in this series:

In this series of interviews, Sloan Manning, MD, discusses a variety of screening tools that may be used in primary care (or mental health) settings to screen for mental health symptoms and associated risks, and measure response and change in symptoms over time.

In this installment, Dr. Manning discusses the Generalized Anxiety Disorder 7 (GAD-7): its measures and scoring mechanisms, and his professional experience of the tool’s practical application within a clinical setting.

You can download a copy of the GAD-7 through the PsychU Psychiatric Rating Scales Collection, here. Questionnaires and scales are provided for PsychU members’ screening and educational purposes only and are not to be used as diagnostic tools.

Dr. Manning is the Medical Director and Adjunct Associate Professor, School Of Medicine, as well as the Co-Director of the Mood Disorder Clinic at Novant Health Urgent Care & Occupational Medicine at the University Of North Carolina.

Check out the other videos in this series:

An audit by Milwaukee County auditors found persistent health staffing issues by Armor Correctional Health Services, Inc., the medical services contractor at the Milwaukee County Jail and the Milwaukee County House of Correction (HOC). Armor provided an average of 89% of its staffing requirements for these facilities from November 2015 to August 2017. The contract set a 95% threshold for full payment for staffing. During this time, several people died while in custody at the jail.

These findings were reported in “Improved Staffing Levels From Armor, Assignment Of A Contract Manager With Clinical Expertise Along With Contract Revisions Would Improve Inmate Medical Services” by the Milwaukee County Comptroller’s Office. Milwaukee County has contracted with Armor Correctional Health Facilities since 2013. The review focused on health services staffing patterns at the Milwaukee County Jail and the HOC during a 22-month period from November 2015 through August 2017, including full-time Armor employee hours, pool employee hours, agency employee hours, and paid time-off hours. The goal of the review was to determine if Armor’s staffing levels complied with the contract.

Additional findings include:

  • In 2017, the two facilities housed more than 2,100 inmates and the county paid Armor Correctional Health Facilities — which has been under contract since May 2013 — $16 million to provide health services. This is almost 20% of the total cost to run the facilities.
  • Some of the positions that were understaffed include psychologist, registered nurse, and psychiatrist.
  • Armor’s total paid work hours increased from 19,342 hours in November of 2015 to 20,868 hours in August It was also noted that the use of agency hours increased from 518 hours or 2.7% of total hours paid in November of 2015 to 3,700 hours or 17.7% of total hours paid in August of 2017. Meanwhile, full-time Armor and pool staff hours decreased during that time by 1,656 hours.

Along with the findings, auditors made several recommendations, including:

  • The HOC should explore the retention of a contract manager with clinical expertise to ensure compliance with all contract requirements and allow for a detailed continuous review of the provision of care at both facilities.
  • Revise the Medical Services Contract to clarify responsibility and expectation of Armor and its provision of services. Specifically, that Armor provide access to all records and employees who support the agreed-upon services, without limitations; and that a mandatory staffing level for intake be specified.
  • Require Armor to submit segregated invoices for pharmacy, specialty services, and general medical This would allow better tracking of services rendered and assist the contract manager in reviews.

PsychU reported on this topic in “Armor Correctional Health Services Barred From New York Jails For 3 Years,” which published on November 4, 2016.

For more information, contact: Scott Manske, Comptroller, Milwaukee County Comptroller, 901 N 9th Street, Room 301, Milwaukee, Wisconsin 53233; 414-278-3001; Email: Scott.Manske@Milwaukeecountywi.gov

On August 28, 2018, the Illinois Department of Healthcare and Family Services (HFS) announced the selection of 18 quality performance measures for its new Medicaid integrated health home (IHH) program that will formally launch in January 2019. The first quarterly reports will take place in April 2019. A year-end assessment will determine a bonus level based-on performance outcomes, or corrective action plans as needed. IHHs will be able to qualify for one of three bonus levels: Bronze, Silver, or Gold.

The IHHs contract with Medicaid MCOs for MCO members, and the IHHs contract with HFS to serve Medicaid fee-for- service (FFS) members. For the MCO members, the Medicaid MCO will receive a higher capitation rate to account for payments to the IHHs. For the FFS members, the IHHs will be paid directly by the state. The IHH provider organizations will receive a per-member per-month (PMPM) payment from the MCO to coordinate MCO member care or will receive a payment from the state for FFS populations. The rates range from $48 to $240, varying across three age levels and three levels of member complexity. The IHHs are for Medicaid beneficiaries with chronic physical and behavioral health problems.

Eligible IHH provider types include primary care practices, clinical practices/clinical group practices, rural health clinics, physicians and physicians’ groups employed by hospitals, community mental health centers, home health agencies, community/behavioral health agencies, and federally qualified health centers. In addition to these providers or practice types, all other Medicaid enrolled provider/practice types that meet the IHH eligibility standards will be potentially eligible for the program. IHH provider organizations can be either a single practice with physical and behavioral health (including addiction treatment) capabilities housed under a single roof; or a lead practice, with one of the capabilities that establishes formal collaboration agreements with other provider organizations to provide the other capabilities. To participate, the IHH provider organizations will form agreements with collaborating provider organizations, such as a primary care provider and a behavioral health clinic. The state intends to approve provider organizations that meet the IHH criteria. After gaining the state approval, IHH provider organizations will then join Illinois Medicaid managed care organization (MCO) networks to provide health home services.

Then the IHH provider organization will apply for enrollment and specify which tier of members it can accept (tiers A, B, and C). The tiers and rates reflect underlying levels of physical and behavioral health needs, with further sub- segmentation based on age group.

  • Tier A is for members with both high physical health needs and high behavioral health needs.
  • Tier B is for members with low physical health needs, but high behavioral health needs.
  • Tier C is for members with low behavioral health needs, but high physical health needs.

The MCOs and/or state will passively assign members to the IHH provider organizations. An IHH must have at least 500 continuous members for six months to qualify for bonus payment.

According to “Integrated Health Homes Quality Indicators, Incentive Payments & Reporting” the IHHs will report eight quality measures that are not linked to incentive payments and 10 that are linked. To be eligible for outcomes-based payments, IHH must report on all 18 quality measures, and must meet a specific performance level for any single measure once all 18 measures are reported on.

The criteria and bonus levels are as follows:

  • Bronze criteria: Average 40th percentile, with no individual measure lower than 20th The bonus will be 10% of total amount of IHH’s care coordination per-member per-year (PMPY) payment
  • Silver criteria: Average 60th percentile, with no individual measure lower than 40th The bonus will be 25% of total amount of IHH’s care coordination PMPY payment
  • Gold criteria: Average 80th percentile, with no individual measure lower than 50th percentile. The bonus will be the Silver-level bonus and share of cost of care savings provider has achieved as determined via proxies for total cost of care

The eight measures for reporting only are as follows:

  1. Plan all-cause readmission rate
  2. Follow-up after hospitalization for mental illness
  3. Controlling high blood pressure
  4. Metabolic monitoring for children and adolescents on antipsychotics
  5. Prenatal and postpartum care
  6. Medication management for people with asthma
  7. Potentially preventable readmission for behavioral health
  8. Behavioral health related emergency department visits per 1,000

The 10 measures affecting outcomes-based payments are as follows:

  1. Initiation and engagement of alcohol and other drug dependence treatment
  2. Screening for clinical depression and follow-up plan
  3. Chronic condition hospital admission composite – PQI
  4. Adult body mass index assessment
  5. Follow-up after hospitalization
  6. Emergency department visits per 1,000
  7. Immunization combo 3 (This measure concerns the number of child members who by their second birthday have had four diphtheria, tetanus, and acellular pertussis (DTaP) vaccinations; three polio (IPV) vaccinations; one measles, mumps, and rubella (MMR) vaccination; three haemophilus influenza type B (HiB) vaccinations; three hepatitis B (HepB) vaccinations; one chicken pox (VZV) vaccination; four pneumococcal conjugate (PCV) vaccinations; one hepatitis A (HepA) vaccination; two or three rotavirus (RV) vaccinations; and two influenza vaccinations.)
  8. Breast cancer screening
  9. Diabetes management (hb1ac testing)
  10. Antidepressant medication management

PsychU reported on this topic in “Illinois Medicaid To Launch Integrated Health Home Program In October 2018,” which published on September 4, 2018.

For more information, contact: John K. Hoffman, Director of Communications, Illinois Department of Healthcare and Family Services, 401 South Clinton, Chicago, Illinois 60607; 312-793-4792; Email: John.K.Hoffman@illinois.gov.

The Wisconsin Medicaid program intends to make the first bonus payments in 2019 on its pay-for-performance initiative for Family Care managed physical, mental, and long-term services and supports (MLTSS) plans. The initiative launched in 2018. The state Department of Health Services (DHS) intends to require the Family Care and Family Care Partnership Medicaid managed care organizations (MCOs) to implement and complete a pay-for-performance initiative based on results of a member satisfaction survey to be administered during the third quarter of 2018. Over the next several years, DHS intends to add more pay-for-performance initiatives for the Family Care and Family Care Partnership plans.

Family Care is a capitated Medicaid managed care program for the delivery of all Medicaid long-term care services. Members enrolled in Family Care may be eligible at a Wisconsin Medicaid nursing home-certifiable level of care or at a non-nursing home level of care. One of these functional levels of care is required as a condition of eligibility.

Family Care Partnership is a capitated integrated Medicaid and Medicare managed care program that, in addition to the Family Care long-term care benefits, provides managed health care benefits, and all applicable Medicare Advantage Special Needs Plan and Medicare Part D prescription drug benefits. All members enrolled in Partnership have a Wisconsin Medicaid nursing home-certifiable level of care, which is required as a condition of eligibility. As a fully integrated program, all supports and services – whether Medicare or Medicaid benefits – are delivered through the Partnership model design identified in this contract.

According to the 2018 Wisconsin Family Care DHS-MCO Contract last updated in July 2018, all MCOs will have 0.5% of their calendar year 2018 capitation rate withheld to be returned based on the MCO’s performance on the member satisfaction survey. The aggregate value of this withhold is estimated at $10 million. The Family Care pay-for-performance initiative began on January 1, 2018. In the third quarter of 2018, DHS sent the member satisfaction survey to a sample of each MCO’s members. The pay-for-performance criteria will be based on four questions that are part of the survey. The questions assess the following:

  1. Member access to services
  2. Member participation in the care planning process
  3. Member satisfaction with care plan/team
  4. Member satisfaction with services

Benchmarks have been set for 2018. The MCO contract document did not mention the name of the entity that conducted the survey. DHS will notify the MCOs about the benchmarks before the survey is distributed. The evaluation will be complete in the 4th quarter of 2018.

The MCO will receive one fourth of the 0.5% withheld from the capitation rate for each survey question in which they meet the minimum performance standard set by the Department. MCOs that meet the minimum performance standards for all four questions will earn back all of the 0.5% withheld from the rate and will earn a 0.125% performance enhancement to their rate for each targeted performance benchmark they meet. Payments under this section will be made by December 31, 2019.

For more information, contact:

  • Wisconsin Department of Health Services, Post Office Box 7850, Madison, Wisconsin 53707-7850; 608-266- 1683; Email: DHSMedia@dhs.wisconsin.gov
  • Annette Cruz, Vice President of Public Policy & Advocacy, Leading Age Wisconsin, 204 South Hamilton Street, Madison, Wisconsin 53703; 608-255-7060; Fax: 608-255-7064; Email: info@LeadingAgeWI.org

You can’t go to a health and human service meeting where the topic of workforce doesn’t come up. Common topics include retention of direct service professionals, the shortage of psychiatrists, tech-enabled task shifting, and paying for productivity and performance.

Payers have discovered the importance of the right team and the right number of team members too. Case in point—in July, the Centers for Medicare & Medicaid Services (CMS) released updated Nursing Home Compare Star Ratings. And for the first time, those ratings used payroll-based journal (PBJ) staffing data to substantiate nurse staffing ratios.

The result was that 8.9% of facilities (1,387) had their star rating for direct care staffing downgraded to one star (out of a possible five). And for about half of those skilled nursing facilities, their overall star rating also dropped. Perhaps even more interestingly, consumers and their families can also view the average number of residents per day and the average number of hours certain staff members (i.e., physical therapists, registered nurses, and nurse’s aides) spend with consumers compared to the national and state averages.

We did write last week that consumers don’t always pay attention to quality ratings. But, I would argue that ratings will grow in importance with consumers, and that payer and health plan managers do pay attention to these rankings and ratings. And as data aggregation becomes easier, I suspect that transparency in areas like staffing will become expected, and required, across the board.

While transparency in staffing and ratings incorporating staffing functions are increasing, staffing challenges for health and human service provider organizations continue to grow. These big challenges include high turnover rates, the cost of staff vacancies, the impact of addictions on personnel, and the reductions to the foreign labor pool.

Turnover—The turnover rate among health care workers is both high, and of high concern. It rose from 15.6% in 2010 to 20.6% in 2017, and in some cases reaches a rate of 50% (for my recent breakdown of that turnover, check out High Turnover, The Other Staffing Issue).

Cost of vacancies—The cost of recruiting, training, and paying of interim staff can add up to 16-20% of annual compensation for each position that needs replaced (see The High Costs Of Paraprofessional Employee Turnover – Sizing Up The Challenge).

The impact of addictions on personnel costs—Substance abuse and addiction reduce the available labor pool and increase personnel costs. Recent reports have referenced the challenges of finding a workforce that can pass drug tests, and the impact of addictions on skill sets, presenteeism, and absenteeism. And, substance use disorders can cost employers from $2,600 to $13,000 per employee annually, from absenteeism, impaired or decreased job performance, on-the-job injuries, and increased health care utilization.

Reduced foreign labor pool—There will be an as-yet-unknown impact of President Trump’s “Buy American, Hire American” executive order, issued last year, on the ability for skilled foreign workers to attain H-1B visas needed to work in the U.S. According to numbers put out by the Paraprofessional Healthcare Institute (PHI), one in four direct care workers, which includes nursing assistants, personal care aides, and home health aides-are immigrants; and 25% of physicians practicing in the U.S. were born in another country, up from 16% in 2010. Leading Age has released a series of reports recommending foreign-born workers as possible solution to long-term care staffing crisis. How feasible these recommendations are in the current environment is a question.

To prepare for a new health and human service environment that is focused on outcomes, performance, and consumer engagement, new roles and new skills for clinical and service team members are essential. But that leads to the question:

How are executive teams going to find all these tech-savvy, evidence-based practice-embracing, team-oriented, flexible community-based team members? The competition for talent is on. Executives in the health and human service field are faced with challenges from an unusual combination of demographics, national policy, the growth of the “gig” economy, and competition from other industries. Creativity will certainly be required to address the issues at hand. And, for more on staff retention, check out these resources from PsychU:

  1. 75% Of Your Management Team Was Offered Another Job This Year
  2. 4 Ways To Retain & Grow Millennial Employees
  3. Reducing Paraprofessional Employee Turnover
  4. The High Costs Of Paraprofessional Employee Turnover – Sizing Up The Challenge

In 2017, about 2.5% of all Medicare beneficiaries surveyed and 4.4% of all privately insured consumers reported problems accessing a new PCP. About 10% of consumers surveyed were seeking a new primary care physician (PCP).

Within the group of Medicaid beneficiaries seeking a new PCP, about 27% reported problems finding a new PCP, with 14% reporting a “a big problem” and 13% reporting “a small problem.” Within the group of privately insured consumers seeking a new PCP, 40% reported problems, with 22% reporting “a big problem” and 18% reporting “a small problem.”

These findings were presented in “Mandated Report: Clinician Payment in Medicare,” by Kate Bloniarz, a senior analyst with the Medicare Payment Advisory Commission (MedPAC). For this report, MedPAC staff conducted an annual survey with a sample of Medicare beneficiaries and privately insured consumers. The goal was to determine whether health care consumers have issues when trying to see a physician.

Between 2006 and 2017, the share of Medicare beneficiaries reporting small or large problems accessing a new PCP has fluctuated between 20% in 2010 and 35% in 2011 and 2016. For privately insured consumers, the share reporting problems accessing a new PCP has gradually increased, from 25% in 2006 to 40% in 2017.

Additional findings included the following:

  • The number of clinical professionals billing Medicare has steadily increased since 2009, from about 790,000 in 2009 to about 950,000 in 2016.
  • The number of primary care physicians billing Medicare increased by about 2% per year from 2009 through 2016.
  • The number of other specialty physicians billing Medicare increased by about 1.5% per year from 2009 through 2016.
  • Direct Medicare billing by advance practice registered nurses and physician assistants averaged 10% per year from 2009 through 2016.

The analysts concluded that Medicare access is comparable to, or better than, access for the privately-insured. This is despite the finding that private insurance payment rates are considerably higher than Medicare’s payment rates, and that private insurance coverage has grown significantly faster in the past 10 years.

PsychU last reported on this topic in “CMS Expanding Population-Based Provider Reimbursement Models In Medicare & Medicaid,” which published on June 23, 2018.

For more information, contact: Medicare Payment Advisory Commission, 425 I Street NW, Suite 701, Washington, District of Columbia 20001; 202-220-3700.

Approximately 8% of U.S. hospitals are at risk for closure. Another 10% show weak performance. Four key factors were associated with hospitals with weak financial performance and risk for closure: lower-than average capital expenditures, another hospital located within 10 miles, low efficiency-adjusted operating cash flow, and for-profit status. The weak hospitals had at least three of the following four factors: occupancy below 40%, net patient revenue growth negative over the last three years, earnings growth below 10% over the past three years, or earnings margin below 8%. The highest concentrations of at-risk hospitals are located in Texas, Oklahoma, Louisiana, Kansas, Tennessee, and Pennsylvania.

These findings were reported in “Hospital X-Ray: Fractured Foot(print),” by Vikram Malhotra, Zack Sopcak, Mark T. Schmidt, Kevin Egan, Moses Mutoko, and Leigh Pressman, C.F.A for Morgan Stanley Research. The researchers worked with AlphaWise to analyze Centers for Medicare & Medicaid Services’ (CMS’) Medicare Cost Reports for hospitals to match more than 6,000 hospitals to systems using American Hospital Association directory information. The researchers then separated the facilities by tax category and cross-referenced them to a proprietary list of 150 hospital closures over the past five years. The goal was to determine the financial and security status of hospitals, based on the following risk factors:

  1. Location in a non-Medicaid expansion state.
  2. Higher exposure to government reimbursements.
  3. Average case-complexity level.
  4. Low per-bed capital expenditures.
  5. Classification in a smaller market or submarket.
  6. Below-average household income among the 10-mile population.
  7. Bed capacity in a 10-mile radius.
  8. Low efficiency-adjusted operating cash flow (OCF).
  9. Miscellaneous factors, including star ratings, population density and growth, number of beds, rural versus urban location, case mix of competitors within 3 and 10 miles, and health care worker wage growth.

Key findings about the differences between average hospital performance and the performance of weak and at-risk hospitals were as follows:

  • The average hospital in the United States spent $43,000 per bed during each of the last five years. Average capital expenditures among the weak hospitals were 29% less, and averaged 41% less among the closed hospitals.
  • Bed capacity per 1,000 people within a 10-mile radius of a hospital averaged 2.9 for all hospitals, but averaged 3.1 at the weak hospitals and 3.3 at the closed hospitals.
  • Hospital efficiency-adjusted operating cash flow (OCF) averages 0.28 for all hospitals, but averages negative 10 at weak hospitals and negative 0.24 at closed hospitals. Efficiency-adjusted OCF indicates the hospital’s ability to earn profits on government reimbursements. The metric was developed by the Morgan Stanley Muni team.
  • Hospitals that are owned by for-profit entities are at higher risk of closure than those owned by non-profit entities because the owners are less likely to continue to operate an unprofitable facility. A non-profit owner is more likely to continue to operate an unprofitable hospital if doing so aligns with the organization’s non-profit mission.

The researchers believe that of the more than 6,000 hospitals in the analysis, the metrics indicate that 16.6% (1,000 hospitals) have weak performance (600 hospitals) or are at-risk of closure (450 hospitals). The researchers believe that during the next 18 months hospital closures will increasingly drive the debate on health care disruption. They noted that the share of hospitals at-risk of closure, 8%, is higher than the 2.5% rate over the past five years.

The full text of ” Hospital X-Ray: Fractured Foot(print)” was published August 15, 2018 by Morgan Stanley. A copy can be requested the publisher.

For more information, contact: Samantha Kreloff, Corporate Communications, Morgan Stanley, 1585 Broadway, 23rd Floor, New York, New York 10036; 212-761-2448; Email: mediainquiries@morganstanley.com.

I had a chance to talk to William Lopez, M.D., CPE, Senior Medical Director for Behavioral Health at Cigna last week— and learned a lot about Cigna’s strategies to better serve customers with the most complex needs. My takeaway? Success with managing “complexity” is less about expertise with specific conditions and more about a care delivery model. His response to my question about the issue:

I think traditionally the most complicated medical conditions are those for which customers need the most support. In general, that is diabetes, hypertension, coronary heart disease, especially when there is a co-morbid psychiatric condition present. That being said, when managing complex cases we don’t focus on addressing specific conditions. We look at the care delivery model, the use of evidence-based practices and making sure that health care professionals are addressing customers in a holistic way. In other words, we don’t focus on a specific number of conditions, but instead, we are trying to be more comprehensive about the whole care of each customer. The goal for our value-based relationships is to improve the quality overall, which lowers medical costs, and improves the customer’s health and satisfaction.

And, performance evaluation of programs to manage consumers with complex needs is straightforward. He said, “In general, we are looking at emergency room use, readmissions, total medical cost, and at areas where the customers’ care can be improved.”

One program Cigna is evaluating is the Advancing Integrated Mental Health Solutions (AIMS) model, that was developed at the University of Washington AIMS Center. It is a model of behavioral health integration that enhances “usual” primary care by adding two key services: care management support for patients receiving behavioral health treatment; and regular psychiatric inter-specialty consultation to the primary care team, particularly regarding patients whose conditions are not improving.

One specific program we are piloting based on the AIMS model is the Psychiatric Collaborative Care Model (CoCM) rolled out by CMS. Cigna is enabling provider organizations to have behavioral health services in office to target customers with chronic conditions and comorbid mental health diagnosis. The goal is to find the customers with the highest need for medical and behavioral health. We are basing reimbursement on the CPT codes CMS released last year to support the CoCM model (see Medicare To Reimburse For Integrated Behavioral Health Services In 2017). Currently, Cigna is not reimbursing these codes across the board because there are specific activities related to the code, and we are trying to figure out how to attest those activities. We are testing them with a selected number of Cigna’s collaborative care partner practices (ACO) and helping the health care providers build the structure required around the codes. In addition to that, we are looking at population health analytics and helping providers target those customers that are at the highest risk.

But for executives of specialty provider organizations, the interview with Dr. Lopez left me thinking there are new market threats and market opportunities in this approach. The opportunity is for specialist provider organizations to move beyond “traditional” consumer segments with “whole person” care coordination. There is room for innovation. Dr. Lopez said, “Determining what health plans want isn’t strictly a known quantity, and there is room to innovate as long as that innovation can be attached to a delivery care model that offers an integrated, holistic approach to services.”

At the same time, the threat is that acute care and primary care organizations will develop and perfect those same models. Want to know how prepared your organization is for developing and delivering a value-based care coordination model? Check out these resources from the PsychU Library:

  1. Getting That ‘Preferred’ Role With Health Plans
  2. Tackling The Thorny Issue Of Behavioral Health ‘Value’
  3. The Value Challenge, Again
  4. The Value Train Has Left The Station
  5. Value-Based Reimbursement: 3 Steps To Go From Idea To Action

Shorter wait times for an initial behavioral health appointment following a referral from primary care were associated with higher attendance rates by adult primary care consumers. Whether or not the consumer had a “warm handoff” from the primary care professional to the behavioral health professional had no significant impact on attendance rates for the behavioral health appointment. In a “warm handoff” the primary care professional introduces the consumer to the behavioral health professional who then meets with the consumer and schedules an intake behavioral health appointment.

In a retrospective analysis of an integrated primary care and behavioral health program launched by Boston Medical Center in 2014, about 40% of those scheduled for a behavioral health appointment and 40% of those with a warm handoff kept the appointment. Whether or not there was a warm handoff, the odds of keeping the behavioral health appointments were 1.7 times higher for consumers whose appointments were scheduled within 30 days of the referral. The odds were 11.6 times higher when the behavioral health appointment was scheduled to take place the same day as the referral.

These findings were reported in “Warm Handoffs and Attendance at Initial Integrated Behavioral Health Appointments” by Christine A. Pace, M.D., MSc; Katherine Gergen-Barnett, M.D.; Alysa Veidis, RN, MSN, NP-BC; Joanna D’Afflitti, M.D., MPH; Jason Worcester, M.D.; Pedro Fernandez, M.D.; and Karen E. Lasser, M.D., MPH. The researchers conducted a retrospective analysis of clinical and scheduling data from new referrals to an integrated behavioral health program at Boston Medical Center from July 1, 2015, to December 31, 2016.

Boston Medical Center is an urban safety-net hospital. In 2014, the hospital-based general internal medicine and family medicine clinics began a program of integrated behavioral health in which mental health clinical professionals (primarily social workers) offer evaluation, short-course therapy, and substance use counseling to patients. Primary care professionals could refer consumers to a behavioral health services using either warm handoffs in which the behavioral health professional meets with the consumer and schedules an intake encounter, or by having front desk staff schedule an initial appointment. The mental health clinical professionals noted a warm handoff in the electronic health record (EHR). The primary outcome was whether the patient attended their initial program appointment.

During the study period, 2,690 consumers were scheduled for initial appointments with the behavioral health professionals, and 1,087 (40%) subsequently kept the appointment. For 21% of the consumers (542 people), the primary care professionals used a warm handoff. The remaining 2,148 were scheduled for the appointment using usual processes. Of the 542 scheduled following a warm handoff, 221 kept the appointment. Of the 2,148 scheduled using usual processes, 866 kept the appointment.

The researchers noted that the primary care professionals may have preferentially performed warm handoffs for those consumers they perceived as the least likely to keep an appointment. Such consumers could include those with severe mental health conditions, addiction disorder, low health literacy, reluctance to engage with behavioral health services, disorganization, social barriers, or other factors. The researchers also noted that in the real-world setting, it is possible that the behavioral health professionals were not able to deliver all aspects of a warm handoff. Ideally, during warm handoffs, behavioral health professionals establish rapport with consumers, deliver brief supportive counseling or a brief intervention, and educate consumers about the integrated behavioral health program.

The full text of “Warm Handoffs and Attendance at Initial Integrated Behavioral Health Appointments” was published in the July/August 2018 issue of Annals of Family Medicine. An abstract is available online at www.AnnFamMed.org.

For more information, contact: Christine Pace, M.D., M.Sc., Clinical Addiction Research & Education (CARE) Unit Faculty and Assistant Professor of Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, Massachusetts 02117; 617-414-6962; Email: Christine.pace@bmc.org.

For the most part, executives of health and human service organizations haven’t viewed electronic health records (EHR) as a tool for improving staff satisfaction or consumer engagement.

Most of the coverage about clinical professionals’ views of EHRs are pretty negative. And, even though consumer engagement is more important than ever to improve self-care and improve outcomes, consumers’ satisfaction with their ability to access their own health data is mixed. Recent surveys show that, in 2014, nearly 4 in 10 Americans were offered electronic access to their medical record—and only half of those individuals their record at least once within the year. The research also shows that some vulnerable populations—especially Medicaid beneficiaries, low-income individuals, the uninsured, Spanish speakers, and family caregiver—are “health information-compromised.”

As health care becomes more information-intensive, the most vulnerable consumers risk poorer care access, potentially higher costs, and a greater burden of disease. What consumers want in health information is straightforward—easier access to clinical professionals, financial transparency, improved communication, and mobile-friendly formats. All of this presents a challenge for managers, who are trying to bridge the consumer information and engagement gap with EHRs they aren’t satisfied with (see Less Consumer Education Demands More Consumer Engagement and From Consumer Engagement To Consumer Activation).

But there are EHR deployment practices that can improve both staff satisfaction and consumer engagement. That was the message in the session, Increasing Client & Staff Engagement Through Creative Use Of Technology, featuring Matt Chamberlain, Chief Operating Officer, Welligent; Heather Rudolph, President, RCI; Gaston Nguyen, Ph.D., Director of Electronic Health Information Management Department, Pacific Clinics; and Yamile Arriola, Project Manager, Pacific Clinics. They identified five key criteria for data—accessible, actionable, timely, engaging, and reusable—to make this happen.

Accessible—Data must be available “on-demand”, when it is needed, regardless of consumer or staff location. Whether in the “office”, or in the field, consumers and staff need access to information in order to make decisions.

Actionable—The system must “interpret” the data and prompt staff and consumers to act. These reminders assure that consumers don’t need to be reminded about remaining engaged or that staff don’t forget important clinical information.

Timely—These “action insights” need to be delivered to consumers and staff at the right time, allowing quick response.

Engaging— EHRs have traditionally been designed to meet specific business needs and functional requirements. Platforms developed for staff and consumers must be easy to access, easy to use, and help to “interpret” information and prompt interaction and action. Some examples of engaging features in these platforms include mapping appointment location; online surveys; real-time access to health records; access to medication lists; access to educational materials; and enhanced communication between members of care teams and consumers and caregivers.

Reusable—To make the return on investment on any of these initiatives work, consumer and staff platforms need to be based on using existing EHR data, and factor in on-going labor costs associated with recruiting consumers and maintaining consumer involvement.

Pacific Clinics in Los Angeles is a great example of how to leverage EHR data for better consumer and staff engagement. They serve 22,500 consumers each year by providing mental health, substance use treatment, housing, and employment services, across four counties. Pacific Clinics recently launched an online consumer portal to allow consumers to have real-time access to their health care records, as well as medication lists, educational materials, appointment location mapping, and customer satisfaction surveys. To get consumers engaged and using the portal, they started by targeting a specific group for participation: consumers that were receiving medication services—with the goal of getting 5% of consumers to use their portals. Ms. Yamile explained, “Our support staff was trained at a central location to the point that they felt comfortable enough to go back to their own sites. Our department tracked the enrollment status because we wanted to make sure we were on track for the minimum five percent. Some hit up to 32%.”

Dr. Nguyen explained that with a project this size, the communication and support is critical, as is the buy in from staff throughout the organization. Educating the consumer and the staff is critical, as is the ability to customize the platform to make it as user-friendly as possible; e.g., what do you want the consumer to see, how will they enroll or disenroll, how will that be managed? Dr. Nguyen explained, “We had to change our intake process, with new agreements and consent forms. Decide how you will manage the workflow when things go wrong. We then thought about the promotion part. How we get it out to the consumers, and the training they need to use it. We spent months on the promotion part to get the excitement up about the coming tool.”

 For all of the recent focus on performance and quality measures, a recent headline caught my attention: Medicare Beneficiaries Seldom Choose The Highest Quality Provider During Hospital Discharge Planning.

A recent MedPAC report found that following a hospital discharge, Medicare beneficiaries seldom choose the provider organization in their area with the highest quality ratings. For home health services, 94% selected a home health service with lower quality scores on the Medicare’s Home Health Compare. When selecting a skilled nursing facility, 85.3% selected a facility with lower quality scores in on Medicare’s Nursing Home Compare.

So, what gives? Obviously, Medicare’s Nursing Home Compare and Home Health Compare data has minimal impact in helping beneficiaries to choose providers with the highest clinical quality. But is this true across the board? Do consumers generally ignore comparative quality data and select provider organizations based on other factors? Unfortunately, the answer is “yes.” A recent panel for a segment on The Business of Healthcare on Wharton’s Business Radio discussed their findings that consumers “choices are being made by word of mouth and by who you know – despite this plethora of information available”.

This situation has big implications for consumer marketing by provider organizations. Quality scores are important, but it’s clear that consumers are making decisions on other factors. The research, and our experience, find that these factors include insurance coverage, brand awareness, positive brand perception, access and convenience, and consumer experience.

Insurance coverage—When it comes to health care, consumers are very price sensitive. While consumers don’t always select health coverage based on “choice”, they often select provider organizations based on network coverage. About 72% of consumers note that they chose their physician based on whether they accepted their insurance. It’s important for provider organization websites to be clear about what insurance coverage they accept—and (in the very near future) what their rates are.

Brand awareness and positive brand perception—Consumers make decisions based on what they know and who they recognize. If they don’t know that you are the top-rated provider organization in your area (or that you exist), this won’t factor into their decision. To make sure your targeted consumers are finding you, start with a digital customer journey map. This is a flowchart that shows all the different stages your target customers go through as they experience your brand online—from awareness to consideration to decision. For more on building your brand, check out these resources:

  1. Succeeding In The Online Ratings Game – First, Know The Score
  2. How Effective Is Your Online Marketing Strategy?

Access and convenience—There is always the chance that the consumer knows about your organization and your services, but simply finds it inconvenient to work with your organization. Can they get immediate service? Are the office hours convenient? Are the locations easy to access? Does your staff answer the phone promptly every time it rings? Do you have a system for answering calls outside of normal business hours? For more on access issue, check out:

  1. Will Good, Cheap & Easy Win the Day?

Customer experience—While access and convenience are a big part of the consumer experience, it is still only a part. There is a lot more that goes into making the experience with your organization, its services, and your service team a positive one. For many consumers (and their families) their interaction with the health and human service field is under stressful conditions. Having staff that are trained in best practices for managing these interactions is key. There is some push back from health care professionals about the use of consumer experience in provider organization evaluation selection—but recent research finds that organizations with the best consumer experience are most often organizations with above average clinical quality. For more on consumer experience, check out these resources:

  1. Making Consumer-Centricity A Reality For Medicaid Consumers With Complex Needs
  2. You Say Subscription-Based Health Care, I Hear Customer Service

As the competition for consumers gets more intense, understanding how consumers choose health care provider organizations is critical. It’s not enough to just be open.

From 2005 to 2015, the percentage of part-time workers covered by employer-sponsored health insurance (ESI) decreased from 64.1% to 54.0%. During this same period, the percentage of part-time workers covered by public health insurance, such as Medicaid, increased from 10.3% to 21.6%.

These findings were presented in “Medical Expenditure Panel Survey Statistical Brief #511: Differences in Health Insurance Coverage between Part-Time and Full-Time Private-Sector Workers, 2005 and 2015,” by William A. Carroll, M.A; and G. Edward Miller, Ph.D., for the Agency for Healthcare Research and Quality (AHRQ). The researchers analyzed data from the 2005 and 2015 MEPS Full Year Consolidated Data Files and the 2000-2013 Employment Variables File. The goal was to determine the differences in health insurance coverage for part-time (under 30 hours per week) and full-time (30 or more hours per week) workers in the private sector.

Additional findings include:

  • In 2015, non-elderly private-sector workers working full time were policyholders of employer-sponsored insurance provided through their current main job 66.9% of the time, compared to 15.1% of those working part-time.
  • In 2015, 38.9% of part-time workers had ESI through, a family member’s job, or another source than their current employer. This compares to 14.5% of full time workers.
  • From 2005 to 2015, full-time workers had a decline in the percentage of those uninsured: from 12.6% to 9.6%.
  • From 2005 to 2015, part-time workers had a decline in the percentage of those uninsured: from 19.3% to 12.7%.

For more information, contact: Lorin Smith, Media Contact, Office of Communications, Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, Maryland 20857; 301-427-1864; Email: lorin.smith@ahrq.hhs.gov

For executives of specialist organizations trying to stake out a place in an integrated market, understanding and packaging the “value” of unique expertise is key. Monica E. Oss spoke to the emerging opportunities for specialist organizations as falling in two categories—specialty care coordination and crisis management/diversion programs for consumers with special needs—in her keynote, Reinventing Your Organization: Key Management Best Practices For A Value-Based World. Success in either of these roles requires specialist organizations to be recognized by health plan managers as “uniquely qualified”—or a “center of excellence” (COE) for that specific consumer population. But that is not the traditional use of the term.

Figure 1 Mandros, A. (2018). What Does ‘Center Of Excellence’ Mean Now?. Retrieved from openminds.com

There is not a clear definition of COEs. Traditionally, a “center of excellence” has been defined as a research center focused on promoting best practices related to a certain health care condition or topic. Medicaid plans use COEs in either the traditional sense, or to designate organizations as providing high quality care. But health plans are taking a slightly different approach to the term COE. Generally, most health plan managers now define a COE as “a tertiary or quaternary health care provider organization that is identified as the most expert and cost efficient and produces the best outcomes”. What this means of course, varies in practice. Each health plan identifies what constitutes expert, cost efficient, and best outcomes for their programs. They also determine how a provider organization would qualify. For provider organizations, there are some clear benefits of COE recognition. Often it means enhanced rates, additional referrals, special status in the provider directory, or additional consultative help from the health plan.

What are some examples of the center of excellence concept in the current health care market? Walmart implemented their center of excellence program for employees in 1996, which pays a bundled rate to designated provider organizations for providing certain surgeries. For selecting these high quality organizations, employees have reduced out-of-pocket costs, and Walmart pays travel and expenses. At the local level, a Texas health plan made the news when it designated a center of excellence for providing children’s therapy services and in Arizona, one of the state’s health plans has designated centers of excellence for autism services.

OPEN MINDS Senior Associate Deb Adler weighed in:

Health plans are just beginning to “dip their toe” into the COE waters for behavioral health. Much of the pressure to expand COEs to the behavioral health and addiction space are tied to employer pressure. Employers have seen improvement in quality outcomes and significant health care cost savings for their employees and dependents in many of the early medical model COEs (e.g., transplant COEs). Employers see the COE model as an effective approach that could easily translate to behavioral health and substance use disorder and be used to drive new benefit designs and health care savings. Consensus around the member outcome measures is still evolving, albeit savings is typically measured in behavioral health care savings with total cost of care (inclusive of medical) a future goal of most plans.

I recently completed a market scan of the largest health insurers and their current COE initiatives. At this time, most of COE initiatives among the largest plans are focused on medical procedures related to complex physical health treatment such as bariatric surgery and transplants. Most health and human services related COEs are found at the local Medicaid plan level or are through behavioral health organizations (BHO). Both Optum and Beacon Health Options, two of the largest BHOs, offer programs focused on clinical excellence for behavioral health provider organizations

Medicaid expansion under the Patient Protection & Affordable Care Act (PPACA) has been linked to fewer stays in the intensive care unit (ICU) for conditions that can be managed through outpatient ambulatory care. In a five-state analysis, between January 2012 and December 2014, Medicaid or uninsured ICU admissions dropped by 3.7% in the two Medicaid expansion states (New Jersey and Washington) compared to no change in the non-expansion states (Nebraska, North Carolina, and Wisconsin). The conditions that can be managed through outpatient ambulatory care include obstructive lung diseases, congestive heart failure, pneumonia, and urinary tract infections.

These findings were reported in “The Effects of Medicaid Expansion on Rates of Ambulatory Care-Sensitive ICU Admission” by A.J. Admon; M.W. Sjoding; S.M. Lyon; T.J. Iwashyna; and C.R. Cooke in a presentation at the American Thoracic Society 2018 Conference. The researchers analyzed acute care hospital discharges for adults ages 18 to 64 from five states (Nebraska, New Jersey, North Carolina, Washington, and Wisconsin) between 2012 and 2014. Across the five states, there were nearly 5.07 million hospital admissions; the analysis focused on the 11.2% (567,160 admissions) for ambulatory-care sensitive conditions. New Jersey and Washington expanded Medicaid; the other three did not. The goal was to determine connections between Medicaid expansion, ICU stays, and the likelihood of enrolling in health care insurance following PPACA implementation.

The researchers conducted a difference-in-difference analysis to evaluate the effects of Medicaid expansion in ICU admission rates as a proportion of all hospital admissions for ambulatory care sensitive conditions.

  • The overall ICU admission rate as a proportion of all hospital admissions was 12.1%.
  • The ICU admission rate for people with one of the ambulatory care-sensitive conditions was 20.9%.

Additional findings about change in the share of admissions for uninsured consumers and those covered by Medicaid were as follows:

  • In expansion states, the percentage of uninsured hospitalized consumers fell from 7% to 4.5%. In expansion states, the rate of Medicaid coverage rose from 19.0% to 26.6%.
  • In non-expansion states, the rate of uninsured hospitalized consumers remained relatively unchanged, at 8% in 2012 and 7.5% in 2014. The rate of Medicaid coverage declined slightly from 25.0% in 2012 to 24.7% in 2014.

The presentation abstract of “The Effects of Medicaid Expansion on Rates of Ambulatory Care-Sensitive ICU Admission” was published in May 2018 by the American Thoracic Society. A copy is available online.

PsychU reported on this topic in “14.7 Million Working Americans Gained Health Coverage Under The Patient Protection & Affordable Care Act,” which published on September 1, 2017.

For more information, contact: Andrew Admon, M.D., MPH, Fellow, Division of Pulmonary and Critical Care Medicine and at the Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, North Campus Research Complex (NCRC), Building 16, Ann Arbor, Michigan 48109; 734-763-5880; Email: ajadmon@umich.edu.

During 2016, the 18 organizations participating in the Medicare Next Generation accountable care organization (NextGen ACO) model generated net savings to Medicare of $62 million, representing a 1.1% reduction in the projected cost of care for the 477,197 aligned fee-for-service beneficiaries in 2016. Gross savings generated by the NextGen ACOs totaled about $100 million. As a group, the NextGen ACOs received shared savings payments of $38 million.

In total, 14 of the 18 NextGen ACOs generated per beneficiary per month (PBPM) savings, and 4 had increased PBPM costs. On average, the estimated cost reduction in Medicare spending was $18.20 PBPM. Across the ACOs, the PBPM changes ranged from a reduction of $79.4 PBPM to an increase of $38.8 PBPM. Over half (57%) of the model’s cost and utilization decline was generated by four of the 18 NextGen ACOs.

Compared to projected utilization for the 477,197 beneficiaries aligned to a NextGen ACO, their actual utilization of acute care hospital days and monthly non-hospital evaluation and management visits were lower. They had 1.7 fewer acute care hospital days per 1,000, representing a drop of 1.3%. They had 15.6 fewer visits per 1,000 for non-hospital evaluation and management visits per month, representing a drop of 1.5%. The number of annual wellness visits per 1,000 NextGen ACO beneficiaries rose by 20.4 visits, an increase of 11.9%. The savings were largely associated with reductions in hospital and skilled nursing facility (SNF) associated costs. Acute care hospital costs were 1.0% lower. SNF costs were 3.1% lower.

The NextGen ACO model launched in January 2016. The participating organizations have nearly complete financial risk sharing, at 80% to 100%, and they must accept risk of loss, unlike previous ACO models that limited risk exposure. The NextGen ACO model has no minimum savings or loss requirements; to balance the risk, the participating ACOs are able to implement features that give them a greater ability to manage their attributed beneficiaries. These features include prospective setting of financial benchmarks and prospective alignment of beneficiaries. The participating ACOs can also offer three optional benefit enhancements that waive certain Medicare requirements around SNF admissions, telehealth visits, and post-discharge home visits; and provisions for beneficiaries to voluntarily align with an NextGen ACO and to receive an incentive for an annual wellness visit from a NextGen ACO-affiliated provider organization.

These findings were reported to the Centers for Medicare & Medicaid Services (CMS) in “First Annual Report Next Generation Accountable Care Organization Model Evaluation” by researchers with NORC at the University of Chicago. The report presents initial and descriptive and analytic findings for the 18 NextGen ACOs that launched in 2016, were active for at least one quarter, and were financially responsible during the first program year. The researchers measured impact using Medicare claims a difference-in-differences evaluation design. The evaluation is organized around questions in four domains: model features and approaches, model impact, variations in impact and replicability of model effects; and implementation experience

Of the 18 NextGen ACOs, 15 had prior ACO experience, and 11 were integrated delivery systems, comprised of primary and specialty physicians and hospitals under a common ownership structure. Ten of the ACOs implemented the SNF three-day waiver in 2016. That waiver allowed the ACO to bill for costs of SNF admission for an attributed beneficiary who had not met the usual Medicare coverage requirement of a three-day hospital admission prior to SNF admission.

Most of the 2016 NextGen ACOs selected the 80% shared risk option and the traditional fee-for-service payment mechanism. Most of the ACOs had prior experience with risk sharing.

Next Generation Accountable Care Organizations, 2016

ACO Name Location Prior ACO Experience Risk Percentage & Payment Mechanism Attributed Beneficiaries Estimated Aggregate Impact (in millions) Estimated Change In Per Beneficiary Per Month Estimated Reduction In PBPM Relative To Expected PBPM
Accountable Care Coalition of Southeast Texas Inc. Houston, Texas Medicare Shared Savings Program (MSSP) 80%, fee-for- service (FFS) 13,391 -$0.5 million -$3.0 -0.3%
Baroma Accountable Care, LLC Miami, Florida MSSP 80%,

population- based payment (PBP)

27,449 -$1.3 million -$4.1 -0.3%
Beacon Health, LLC Brewer, Maine Pioneer 80%, FFS +

monthly infrastructure payment (MIP)

14,714 +$6.6

million

+$38.8 +4.3%
Bellin Health DBA Physician Partners, Ltd. Green Bay, Wisconsin Pioneer 80%, FFS 8,286 +$3.3

million

+$35.0 +4.5%
Cornerstone Health Enablement Strategic Solutions, LLC High Point, North Carolina MSSP 100%, FFS + MIP 13,281 -$4.6 million -$30.3 -3.4%
Deaconess Care Integration Evansville, Indiana MSSP 80%, FFS 31,442 -$15.3

million

-$42.4 -4.1%
Henry Ford Physician Accountable Care Organization Detroit, Michigan N/A 80%, FFS+ MIP 20,988 -$5.2 million -$22.1 -1.8%
MemorialCare Regional ACO, LLC Fountain Valley, California N/A 80%, FFS 19,453 -$12.6

million

-$57.4 -4.3%
Lifeprint (Optum) Accountable Care Organization, LLC Phoenix, Arizona N/A 100%, FFS 29,671 -$11.9

million

-$34.7 -3.6%
OSF HealthCare System Peoria, Illinois Pioneer 80%, FFS 36,668 +$1.0

million

+$2.3 +0.3%
Park Nicollet Health Services St. Louis Park, Minnesota Pioneer 80%, FFS 14,428 -$5.0 million -$30.3 -3.1%
Pioneer Valley Accountable Care, LLC Springfield, Massachusetts MSSP 80%, FFS + MIP 33,903 -$2.2 million -$5.6 -0.5%
Prospect ACO CA, LLC Los Angeles, California MSSP 80%, FFS + MIP 13,799 -$8.6 million -$55.1 -3.2%
Steward Integrated Care Network, Inc. Boston, Massachusetts Pioneer 80%, FFS 36,436 +$2.2

million

+$5.1 +0.4%
ThedaCare ACO LLC Appleton, Wisconsin Pioneer 80%, FFS 15,857 -$7.8 million -$43.2 -5.2%
Triad HealthCare Network, LLC Greensboro, North Carolina MSSP 100%, FFS 29,035 -$26.5

million

-$79.4 -8.4%
Trinity Health ACO Inc. Wilmington, Delaware MSSP 80%, FFS + MIP 52,882 -$9.7 million -$15.9 -1.6%
Iowa (UnityPoint) Health Accountable Care West Des Moines, Iowa Pioneer, MSSP 80%, FFS 65,487 -$1.8 million -$2.4 -0.3%

The NextGen ACO model is currently scheduled to run for a five-year period ending on December 31, 2020. In 2016, the NextGen ACOs had 477,197 beneficiaries aligned to one of the 31,070 NextGen ACO participating provider organizations. The NextGen ACOs had from 8,286 to 65,487 aligned beneficiaries; the average was 26,511 aligned beneficiaries per NextGen ACO. Two additional NextGen ACO cohorts began in 2017 and 2018.

PsychU reported on this topic in “17 Additional ACOs To Participate In The Medicare Next Generation ACO Program,” which published on March 16, 2018.

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.

After peaking in 2011 through 2012, the proportion of people filling any opioid prescription for populations covered by either commercial health insurance or Medicare Advantage plans, has remained nearly unchanged. Over the study period 2007 to 2016, annual opioid use prevalence was 14% for commercial beneficiaries, 26% for Medicare Advantage members age 65 and older, and 52% for Medicare Advantage members with disabilities under age 65.

These findings were reported in “Trends In Opioid Use In Commercially Insured And Medicare Advantage Populations In 2007-16: Retrospective Cohort Study,” by Molly Moore Jeffery, W. Michael Hooten, Henry J. Henk, M. Fernanda Bellolio, Erik P Hess, Ellen Meara, Joseph S Ross, and Nilay D Shah. The researchers analyzed data from the OptumLabs Data Warehouse, a database of claims for healthcare services, insurance enrollment, and demographic information of medical and pharmacy claims. The study included approximately 48 million commercially insured people, disabled Medicare Advantage members aged 65 and under, and Medicare Advantage members age 65 and older in the United States. All included in the study had medical and pharmacy coverage for any period of time between January 1, 2007 and December 31, 2016. The goal was to determine trends in the rate and dosage of opioids for these populations.

Additional findings include:

  • Opioid use prevalence was 14% for commercial beneficiaries, 26% for aged Medicare Advantage members, and 52% for disabled Medicare Advantage members, calculated across all years of the study.
  • Since 2011, the average daily dose of 17 milligram morphine equivalents (MME) remained unchanged in the commercial beneficiary group.
  • For the commercial beneficiary group, quarterly prevalence of opioid use also remained unchanged, starting and ending the study period at 6%.
  • For aged Medicare beneficiaries, quarterly use prevalence remained largely unchanged, ranging from 11% at the beginning of the study period to 14% at the end.
  • Disabled Medicare beneficiaries had the highest rates of opioid use, with quarterly use rates rising from 26% in 2007 to 39% in 2016. The average rate of opioid use during the study period for commercial beneficiaries was about 7%, and about 14% for aged Medicare beneficiaries.
  • Disabled Medicare beneficiaries had the largest average daily doses.

The authors concluded that, despite increased awareness of opioid abuse and risks, opioid use and average daily dose have not substantially declined. They recommend evaluation of the success of opioids between consumers and their health care professionals, and to consider alternative treatments to supplement or replace opioid use if no benefit is perceived.

The full text of “Trends In Opioid Use In Commercially Insured And Medicare Advantage Populations In 2007-16: Retrospective Cohort Study” was published August 1, 2018, by BMJ. An abstract is available online at BMJ.com.

PsychU reported on this topic in “BCBS Reports Decrease In Member Opioid Prescriptions,” which published on August 15, 2018 and “U.S. Opioid Prescriptions Drop 2.5%,” which published on August 29, 2017.

For more information, contact: Adam Harringa, Public Affairs, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905; 507-284-5005; Email: newsbureau@mayo.edu.

The Centers for Medicare & Medicaid Services (CMS) has deleted 18 performance measures from four performance measurement programs. The four programs affected are the Inpatient Quality Reporting (IQR), Value-Based Purchasing (VBP), Hospital-Acquired Conditions (HAC) Reduction, and Hospital Readmissions Reduction Programs (HRRP). According to CMS, the goal is to use a smaller set of more meaningful measures, focusing on consumer-centered outcome measures, and taking into account opportunities to reduce paperwork and reporting burden on provider organizations.

The change to the measure sets was included in the “Medicare Final Rule: Hospital Inpatient Prospective Payment Systems For Acute Care Hospitals & The Long Term Care Hospital Prospective Payment System & Policy Changes & Fiscal Year 2019 Rates.” This final rule is effective on October 1, 2018; it applies to about 3,300 acute care hospitals and 420 long-term care hospitals.

Changes to the Hospital Inpatient Quality Reporting (IQR) Program are as follows:

  1. Adopt one additional factor to consider when evaluating measures for removal from the Hospital IQR Program measure set: “The costs associated with a measure outweigh the benefit of its continued use in the program.”
  2. Remove 18 previously adopted measures that are “topped out,” do not result in better patient outcomes, or have associated costs that outweigh the benefit of its continued use in the program.
  3. De-duplicate 21 measures to simplify and streamline measures across These measures will remain in one of the other four hospital quality programs.
  4. The six health care-associated infection (HAI) patient safety measures that are being de-duplicated will be removed for calendar year 2020, which is one year later than originally CMS will use the additional time to ensure consistency in collection and reporting of these data while working to HAI data collection policies for the Hospital Value-Based Purchasing (VBP) Program. Additionally, this will help create a seamless transition of the quarterly public reporting on the Hospital Compare website to the HAC Reduction Program and the Hospital VBP Program.

Changes to the Hospital Value-Based Purchasing (VBP) Program will de-duplicate four measures, as follows:

  1. De-duplicate one measure from the Safety domain that is also in the Hospital IQR Program.
  2. De-duplicate three condition-specific payment measures from the Efficiency and Cost Reduction domain that are also in the Hospital IQ