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Metrics, Oversight, Politics, & Treatment Decisions: Studying The Interrelation Between Risk & Protective Factors For Burnout Among VHA PTSD Specialty Clinic Teams

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 IQR Program.

CMS finalized three changes to the Hospital-Acquired Conditions (HAC) Reduction Program. The HAC Reduction Program establishes an incentive for hospitals to reduce hospital-acquired conditions by requiring CMS to reduce applicable IPPS payment by 1% to hospitals that rank in the worst-performing 25% of all eligible hospitals. In the fiscal year (FY) 2019 IPPS/LTCH PPS final rule, CMS finalized three changes to existing HAC Reduction Program policies. Measures under the HAC Reduction Program will stay the same. The changes are as follows:

  1. Specify the dates of the time period used to calculate hospital performance for the FY 2021 HAC Reduction Program.
  2. Adopt administrative processes to receive and validate National Healthcare Safety Network (NHSN) Healthcare- associated Infection (HAI) data that is submitted by hospitals to the Centers for Disease Control and Prevention (CDC) beginning calendar year (CY) 2020.
  3. Adopt a new scoring methodology, which will equally weight all measures used in a hospital’s program score.

The Hospital Readmissions Reduction Program (HRRP) provides an incentive for hospitals to provide high-quality patient care by reducing applicable IPPS hospital payments by up to 3% for excess readmissions within hospital peer groups in six clinical areas. In the FY 2019 IPPS/LTCH PPS final rule, CMS said measures under the HRRP will stay the same. CMS finalized proposals to:

  1. Establish the applicable period for the FY 2019, FY 2020, and FY 2021 program years.
  2. Codify previously finalized definitions of dual-eligible patients, proportion of dual-eligibles, and applicable period for dual-eligibility.

Additional changes were finalized for the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program. The PCHQR Program collects and publishes data from 11 PPS-exempt cancer hospitals on an announced set of quality measures. In the FY 2019 IPPS/LTCH PPS final rule, CMS finalizes the adoption of a new measure, the removal of four previously adopted measures, and the adoption of a new measure removal factor. These policies are consistent with CMS’ commitment to using a smaller set of more meaningful measures, focusing on patient-centered outcome measures, and taking into account opportunities to reduce paperwork and reporting burden on providers. Specifically, in this final rule, CMS finalized the following proposals:

  1. Adoption of one new claims-based outcome measure beginning with the CY 2019 reporting period, Proportion of 30-Day Unplanned Readmissions for Cancer Patients measure (NQF #3188).
  2. Removal of four measures based on measure performance, because measure performance is “topped out.” The removal begins with the CY 2019 reporting The measures are: Oncology: Radiation Dose Limits to Normal Tissues; Oncology: Medical and Radiation – Pain Intensity Quantified; Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients; and Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients.
  3. Adoption of one additional factor to consider when evaluating potential measures for removal from the PCHQR Program measure set, “The cost associated with the measure outweighs the benefit of its continued use in the program.”

Some of the deleted measures were deleted because they were determined to be duplicative. CMS determined that others showed no meaningful distinction in performance because the overwhelming majority of hospitals are performing highly on them. Still others were determined to be overly costly to maintain and report when compared with the benefit of retaining them in a program. In addition to provisions that reduce the number of measures that acute care hospitals are required to report across the four quality and value-based purchasing programs, CMS is easing documentation requirements and providing flexibility in several areas, while still intending to maintain important patient and program integrity protections.

PsychU reported on provisions in the 2019 Hospital IPPS in “CMS Finalizes ‘Promoting Interoperability’ Rule For Hospitals” on September 4, 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

On June 21, 2018, Illinois Governor Bruce Rauner announced that the Centers for Medicare & Medicaid Services (CMS) approved the state’s updated Medicaid funding model known as the Hospital Assessment Program. The new model will use an updated data baseline and ensure that more reimbursements are based on the actual services hospitals provide. The previous model provided supplemental payments to hospitals based on a static dataset. The program requires hospitals to pay a tax to the state that is then matched by the federal government; it raises about $3.5 billion annually to fund the Illinois Medicaid program. The new program went into effect on July 1, 2018.

Medicaid health care-related taxes, often called provider taxes, fees, or assessments, are allowed as a Medicaid funding mechanism under federal rules if at least 85% of the tax burden falls on health care provider organizations. States use these taxes to establish supplemental Medicaid payments for the classes of provider organizations that pay the tax; increase or avert reductions in Medicaid rates; or to finance other areas of the Medicaid program. States are permitted to use the provider tax revenues for the state share of Medicaid spending if the tax is broad-based, uniformly imposed, and no provider organizations are held harmless from the tax burden. During fiscal year 2016, all states except Alaska imposed a Medicaid tax on provider organizations, and 34 of the states (including Illinois) imposed three or more provider taxes. Many of the states tax inpatient hospital services, nursing facility beds, or intermediate care facilities for intellectual/developmental disability.

The plan was created by Senate Bill 1773, which was signed in March 2018. It updates the dataset the state uses to reimburse hospitals for Medicaid services; under the previous model, some data was from 2005. The legislation dedicated more than $263 million to help hospitals transform their operations by offering more urgent care and outpatient services to better meet the needs of their communities. The bill also creates a Hospital Transformation Committee that will help reconfigure the state’s health care system. A sunset provision in the bill requires the state legislature to evaluate the program’s effectiveness and a vote to renew the program in 2020. If the 2020 legislature fails to renew the program, rates will return to those that were in place prior to July 1, 2018.

According to a fact sheet developed in February 2018 by the Illinois Health and Hospital Association, the redesigned Hospital Assessment Program includes the following:

  • Update utilization data used as the basis for the assessment.
  • Preserve and rationalize the $850 million in Patient Protection and Affordable Care Act (PPACA) funds that the state has secured and maximized for the past four years.
  • Transition more than $600 million from static supplemental payments to dynamic claims-based payments by moving 18% of the plan’s funding into “live rates.” After two years (assuming the legislature renews the program), the live rate allocation will increase to 35%, and after six years, increase to 50%.
  • Increase hospital outpatient rates by 23%.
  • Increase hospital inpatient rates by 10%.

The full text of “Fact Sheet: Senate Bill 1773 & Senate Bill 1573 Hospital Assessment Program: Preserve Access To Care, Modernize The Payment System, Preserve Federal Medicaid Funding, Enhance Medicaid MCO Performance Transparency” was published in February 2018 by the Illinois Health & Hospital Association. A copy is available online at team-iha.org.

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

Background

A report published April 9, 2018 by the journal Addiction Science and Clinical Practice cites evidence that alcohol and substance use are among the top ten causes of preventable deaths in the U.S.; but while primary care providers routinely screen for alcohol abuse, they rarely assess or screen for substance use. Because of this disparity, a group of researchers conducted a multi-phase study to understand what types of substance use screening practices are in use, to identify barriers to implementing these screenings, and to gather recommendations for implementing screenings for substance abuse into primary care clinics. In general, participants agreed that screening for substance use is a valuable aspect of medical care. They also identified individual and system-wide barriers to implementation and suggested that patients would benefit from becoming aware of the goals of screening programs and efforts to counteract stigma associated with substance use. Staff concerns encompassed issues with time to implement substance use screenings, workflow, education and resources needed to implement program in primary care settings.

The comprehensive report, “Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: qualitative study of patients, providers, and staff”, was written by Jennifer McNeely, Pritika C. Kumar, Traci Rieckmann, Erica Sedlander, Sarah Farkas, Christine Chollak, Joseph L. Kannry, Aida Vega, Eva A. Waite, Lauren A. Peccoralo, Richard N. Rosenthal, Dennis McCarty, and John Rotrosen. Details of the report are included in the summary below.

North Carolina Medicaid beneficiaries diagnosed with schizophrenia who failed to take antipsychotic medications as directed had 60% more emergency department visits for medical concerns than beneficiaries with schizophrenia who took antipsychotics as directed. The relationship between adherence and psychiatric emergency department use was small and not statistically significant.

These findings were reported in “Antipsychotic Adherence And Emergency Department Utilization Among Patients With Schizophrenia” by Morgan Hardy, Carlos Jackson, and Jennie Byrne. The researchers conducted a retrospective cohort study with claims and pharmacy data from 7,851 adult North Carolina Medicaid beneficiaries diagnosed with schizophrenia who were enrolled in Community Care of North Carolina (CCNC) from January to December 2015. The participants’ medication adherence was approximated using the medication possession ratio (MPR). The researchers estimated the effect of antipsychotic adherence on rates of medical and psychiatric emergency department visits. CCNC is an enhanced primary care case management program for North Carolina Medicaid beneficiaries. The study population included beneficiaries diagnosed with schizophrenia on at least two Medicaid claims prior to the study period, and who had one oral antipsychotic fill in the six months prior to the study period and at least one fill during the study period. People receiving long-acting injected antipsychotics were excluded from the analysis. The researchers created five MPR categories: less than 0.20 (non-adherent); 0.20 to less than 0.40; 0.40 to less than 0.60; 0.60 to less than 0.80; and more than 0.80 (fully adherent).

During the study year, about 75% of the study population had visited a primary care professional, 12.8% had at least one medical hospitalization, and 8.2% had at least one psychiatric hospitalization. Key findings were as follows:

  • The mean MPR across all in the study population was 0.73, and 56% had an MPR of 0.80 or higher.
  • Non-and partially adherent people had 1.61 times more medical emergency department visits than fully adherent people. Non- adherent people (less than 0.20 MPR) had 2.18 times as many medical emergency department visits as fully adherent people and 1.12 times as many psychiatric emergency department visits.
  • The adjusted rate ratio of medical emergency department visits dropped as MPR There was no observed trend in the adjusted rate of psychiatric emergency department visits.
  • The most common diagnostic categories of medical emergency department visits were injuries and poisonings (16%), ill-defined symptoms (14%), and musculoskeletal conditions (12%).
  • Only about 3.9% of emergency department visits were for mental health-related complaints.

The researchers concluded that beneficiaries with an antipsychotic MPR below 0.80 had higher medical emergency department utilization than those who had an antipsychotic MPR of 0.80 or higher. They noted that due to the observational study design, it was not possible to establish a clear causal relationship between antipsychotic adherence and emergency department use.

Antipsychotic Adherence and Emergency Department Utilization Among Patients with Schizophrenia” was published in Schizophrenia Research. An abstract is available online at SCHRES-journal.com.

For more information, contact: Jennie Byrne, M.D., Ph.D., Deputy Chief Medical Officer, Behavioral Health Integration, Community Care of North Carolina, 2300 Rexwoods Drive, Suite 100, Raleigh, North Carolina 27607; 919-745-2350; Email: jbyrne@communitycarenc.org.

Bishop Rehabilitation and Nursing Center in Syracuse, New York and Service Employees International Union (SEIU) local 1199 recently agreed on a wage incentive program to pay staff bonuses when the facility meets quality of care measures. SEIU represents the facility’s direct care staff. On July 18, 2018, the two organizations ratified an agreement where the facility said it will provide lump-sum increases concurrent to meeting quality of care benchmarks, such as the reduction of pressure ulcers, falls with injury, re-hospitalizations, and other quality indicators.

In the collective bargaining agreement, SEIU 1199 and Bishop Rehabilitation agreed to create a quality assurance and performance improvement (QAPI) committee of certified nurse’s aide (CNAs). The committee is tasked with improving resident care. Bishop Rehabilitation also agreed to provide tuition reimbursement for employees seeking to further their nursing education. SEIU 1199, United Healthcare Workers East, represents 6,500 health care workers in Central New York and over 400,000 total members throughout the East Coast.

Bishop Rehabilitation and Nursing is a 440-bed skilled nursing and rehabilitation facility currently operated by Vestracare. The facility was formerly known as James Square Health and Rehab and owned by River Meadows LLC. The New York State Attorney General’s Office had been investigating the former owner over poor care, and staffing shortages. Vestracare purchased the facility in December 2017 for $45 million and renamed it Bishop Rehabilitation and Nursing. It provides short term sub-acute care as well as long term placement.

Vestracare operates four nursing facilities in New York State: Bishop Rehabilitation & Nursing in Syracuse; Chautauqua Nursing & Rehabilitation in Dunkirk; Golden Hill Nursing & Rehabilitation Center in Kingston; and Susquehanna Nursing & Rehabilitation Center in Johnson City. The Vestracare website says a fifth, Roscoe Nursing & Rehabilitation Center, is opening soon.

For more information, contact:

  • Bishop Rehabilitation and Nursing Center, 918 James Street, #2503, Syracuse, New York 13203; 315-766-2477; Email: info@bishopcare.com; or Edward Farbenblum, Chief Executive Officer, Vestracare, 230 Hilton Avenue, Hempstead, New York 11550; 516-350-5551; Fax: 888-959-9402; Email: info@vestracare.com.
  • Allison Krause, Media Contact, 1199 SEIU United Healthcare Workers East, 250 S Clinton Street, Suite 200, Syracuse, New York 13202; 315-679-6032; Email: krause@1199.org; Mindy Berman, Media Contact for 1199 SEIU New York State, 518-229-0486; Email: mindyb@1199.org.

This week, I’ve heard a lot of conversations about value-based reimbursement (VBR) that have ranged from, “We don’t have the ability to track, let alone report, these types of performance measures”, to “we’re as ready as we are ever going to be.” But the big question is what should executive teams be doing now to ensure that their organization is positioned and prepared for VBR, even if they don’t have risk-based contracts yet. OPEN MINDS advisory board member Ken Carr answered that question at a recent institute in his seminar, “How To Prepare For & Succeed With Value-Based Reimbursement.” Mr. Carr shared three steps to keep the momentum moving forward in preparation for value-based payment.

First, he suggested that provider organization executive teams need to ensure that their strategic plan includes initiatives that will move the enterprise toward value-based reimbursement readiness. If you’re doing scenario-based planning, this is likely already part of your planned scenarios for the future. In particular, this means focusing on three aspects of readiness:

  1. Strengthening relationships with payers and health plans—Build trust with payers by delivering results in fee-for- service (FFS) contracts and pilot projects is an important way to develop working relationships that will be needed later to tackle larger opportunities together.
  2. Improve revenue cycle effectiveness—With one foot still in FFS and the other stepping toward VBR, revenue cycle management is Organizations need to show they can do FFS well before adding value-dependent payments to the equation.
  3. Implement the state-of-the art technology needed to create a data-driven culture—Gathering relevant data, analyzing that data, and adapting services based on the data to achieve outcome goals is essential to sustainability with VBR.

Second, Mr. Carr recommended that executive teams need to focus on assessing the talents and culture of their team. All staff must understand and embrace their role in delivering quality services with the most efficient use of resources. Talent, or the lack of talent, is what sets one organization apart from another. It is a key ingredient of organizational brand management and competitiveness and comes down to two essential components:

  1. Insure you have the right staff, and that your staff have the right skills—The skills necessary under a value-based reimbursement business model are different from a FFS model. Focus on customer service, engagement and activation, motivation to achieve outcomes, and tech skills to understand and use data are all important skill sets to master.
  2. Attract the best talent—Inbound marketing (based on online marketing reputation) will assist in the process of attracting, engaging, converting, and tracking a talent pool of potential staff.

And finally, Mr. Carr outlined the need for strategy execution, which puts the strategic alignment decisions and talent together to actually move the organization to readiness. Executing your plan to move VBR forward has three key components:

  1. Educate all staff on the role of value-based reimbursement—It is essential for staff to understand the relationship between customer service and financial results; and how their role within the organization helps to create value for consumers, payers, and the organization. It also ensures ongoing focus on the move to VBR and prevents staff from straying away to other perceived priorities.
  2. Ground all project planning “in reality”—A plan without implementation details is a plan that will A strong plan should identify what resources will be needed, where those resources will be obtained, and how they will be managed.
  3. Construct dashboards around the project plan—Continuous monitoring of key metrics will enable the organization to monitor whether it is achieving the key readiness initiatives on anticipated timeline. Variations identified in the dashboards will provide opportunity to adapt activities before losing momentum.

Mr. Carr summed up the challenge of moving to value-based reimbursement care, saying, “Moving to a place of readiness for value-based purchasing is a complex process that involves multiple changes in the organization—culture, staffing, workflows, and processes. Taking time to integrate the plan into strategy, assess and onboard the right talent, and stay focused on execution will be necessary to move the organization to readiness.”

For more on the recent developments in value-based reimbursement, check out our coverage:

  1. Pennsylvania Medicaid Moving To Value-Based Reimbursement For Behavioral Health
  2. 46% Of Health Care Leaders Expect Value-Based Reimbursement To Increase Profitability
  3. Massachusetts Medicaid Proposes Changes To One Care Duals Demo Program

During the hospital discharge planning process, Medicare beneficiaries seldom choose the provider organization with the highest quality ratings. About 94% of Medicare fee-for-service (FFS) beneficiaries who used home health services in 2015 had at least one provider organization within a 15-mile radius of their homes that had a higher quality score than the one from which they received services. Among FFS beneficiaries who used a skilled nursing facility (SNF) in 2015, 85.3% had at least one better quality provider organization within a 15-mile radius.

Recent data found that in addition to the 94% of beneficiaries using home health services who selected a provider organization with lower quality scores, about 70% of those who chose a lower quality home health provider organization had five or more provider organizations within a 15-mile radius that had better quality scores. With regard to SNF selection, about, half of FFS SNF users had five or more provider organizations within a 15-mile radius that had better quality scores. However, among beneficiaries in rural areas, only 9.9% had five or more SNFs in a 15-mile radius.

These findings were reported in the Medicare Advisory Payment Commission (MedPAC) in its June 2018 report to Congress on Medicare payment policy. Section 5 of the report is focused on issues related to helping beneficiaries select high quality post-acute care provider organizations. Eligibility for SNF services is limited to beneficiaries discharged after a three-night hospitalization. Home health services can be accessed without a hospitalization. In 2015, about 1.8 million FFS beneficiaries were referred to a SNF following a hospitalization and about 2.2 million beneficiaries were referred to a home health provider organization following a hospitalization.

Number Of Nearby Higher Quality Post-Acute Care Options Available To Medicare Beneficiaries In 2015 Within A 15 Mile Radius Of The Beneficiary’s Home

Share Of Beneficiaries With Higher Quality Options Nearby
Post-Acute Care Type 0 Higher Quality Options 1 2 3 4 5 Or More
Home health (n=2.2 million) 5.5% 5.7% 6.0% 5.9% 7.4% 69.5%
Skilled nursing facility (n=1.8 million) 14.7% 12.2% 9.8% 8.3% 8.2% 46.8%

The MedPAC report said the evidence suggests that Medicare’s Nursing Home Compare and Home Health Compare data have minimal impact in motivating beneficiaries to choose higher quality providers. The limited impact could indicate that beneficiaries are unaware of the data, or that they have limited or no access to online services while hospitalized. Additionally, hospitalized beneficiaries may not have the ability (due to distraction or illness) to conduct detailed research about their post-acute care options. Their family members or other caregivers may also have difficulty finding the Medicare quality data, and if they find it may have difficulty using the information.

The report also said that although hospital discharge planners might be perceived as a source of post-acute care recommendations, Medicare discharge planning rules prohibit them from recommending specific provider organizations. Further, discharge planners may also have limited knowledge about the post-acute care quality data or how to use it to guide beneficiaries.

For more information, contact: Medicare Payment Advisory Commission, 425 I Street NW, Suite 701, Washington, District of Columbia 20001; 202-220-3727.

Associated costs for public services in Los Angeles decreased 59.7% following implementation of the county’s permanent supportive housing (PSH) program. The average public service utilization cost per participant for the year prior to housing totaled $38,146; in the year after receiving housing, it totaled $15,358. The PSH program model provides long-term housing with case management services for ill people experiencing chronic homelessness. The cost reductions more than covered the year’s worth of supportive housing costs, and generated net cost savings of 20%.

The public service costs included in the analysis focused on inpatient and emergency department services provided by the county Department of Health Services, the Department of Mental Health (DMH), addiction treatment services provided by the Department of Public Health (DPH); general relief assistance provided by the Department of Public Social Services (DPSS), and shelter services provided by the Los Angeles Homeless Services Authority (LAHSA). The analysis also included costs for law enforcement encounters with the housing participants by the Sheriff’s and Probation departments. The goal of the PSH program is to reduce homelessness, reduce inappropriate use of emergency department and inpatient health services, and improve the health of the population experiencing homelessness.

Comparison Of Mean Per-Person Public Service Costs Of Participants In Los Angeles Housing For Health Permanent Supportive Housing (PSH)

Service Type Mean Per-Person Cost Pre-PSH Mean Per-Person Cost Post-PSH Percent Change
DHS Emergency Services $2,468 $832 -66.3%
DHS Inpatient $25,213 $6,102 -75.8%
DHS Outpatient $7,065 $5,454 -22.8%
DMH Inpatient $2,640 $271 +4.3%
DMH Crisis Stabilization $63 $26 -59.2%
DMH Outpatient $1,436 $1,093 -23.9%
DPH Addiction Treatment $132 $87 -34.1%
General Relief $1,072 $889 -17.1%
Jail Services $258 $468 +81.5%
Probation Services $165 $118 -28.5%
Subtotal County Services $38,146 $15,170 -59.7
PSH Housing $0 $15,288 N/A
Total Service Costs $38,146 $30,458 -20.2%

These findings were reported in “Evaluation of Housing for Health Permanent Supportive Housing Program,” by Sarah B. Hunter, Melody Harvey, Brian Briscombe, and Matthew Cefalu of RAND Corporation. The researchers examined data on service use and costs from several county departments for 890 890 individuals placed in PSH during the first 2.5 years of the program, up to June 30, 2015. The analysis compared the participants’ costs during the year before entering PSH, to their costs in the year after entering PSH. The analysis included data for January 2010 through June 2016. The goal was to evaluate the program structure, program goals, and the effects of the Los Angeles County DHS Housing for Health (HFH) division’s PSH program.

To qualify for the PSH program when it began in 2012, the individual had to be homeless, have at least two inpatient hospitalizations or one emergency department visit during the past year, and be a county resident with income of 30% or less of the median area income (in 2016 the median area income was $18,250 for a household of one). In 2015, the county also allowed referrals based on utilization of DHS outpatient services in addition to referrals based on hospital and emergency department utilization.

Of the individuals studied, 83% were experiencing chronic homelessness when they entered PSH. The remainder were at risk of becoming homeless. About 88% had co-occurring medical and behavioral health conditions. Additional findings of note include:

  • The average time from initial application to receipt of PSH was 7.2 months.
  • The average time from initial application to receipt of case management was 3.6 months.
  • More than 96% of HFH PSH recipients were stably housed for at least one year.
  • PSH clients’ use of medical and mental health services, including emergency room visits and inpatient care, dropped substantially: participants made an average of 1.6 fewer emergency room visits per year, and the length of inpatient hospital stays decreased by an average of four days.
  • PSH recipients’ time receiving General Relief declined by an average of 1.38 months.
  • Although the number of individuals arrested and the number of jailed arrests decreased during the year after receiving housing, the number of jail days increased following PSH entry by an average of 2.76 days.

While the benefits of the DHS PSH seem positive, the researchers caution that cost results measured only services associated with six county departments over a two-year period, and are not a full accounting of all potential costs and benefits from the HFH PSH program. However, the researchers said their initial findings suggest that DHS succeeded in implementing the HFH PSH program.

The full text of “Evaluation of Housing for Health Permanent Supportive Housing Program” was published November 22, 2017 by Rand Corporation. A free abstract is available online at RAND.org.

For more information, contact: 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.

Health plans are continually working to measure quality, and reshaping behavioral health care delivery through initiatives aimed at improving outcomes, such as integrated care. However, implementing quality measures across different types of payers (commercial vs. public) can raise challenges – some behavioral health measures see performance gains in one context while they see declining performance within others. Addressing this discrepancy requires that health plan quality experts take a tailored and practical approach to implementing and improving quality measures like those in the NCQA© HEDIS® and CMS Stars sets across their markets.

In this webinar, hear from Deb Adler, MS, CPHQ, Former Senior Vice President of Network Strategy for Optum and current Senior Associate at OPEN MINDS; Kimber Bishop, RN, BSN, CPHQ, LSSGB, Director of Corporate Quality Management at New Directions Behavioral Health; and Kristen Kidwell, BS, Director of Behavioral Health Quality Program Management at Anthem, Inc. Speakers discuss how their organizations are striving to improve outcome measurement across all members and markets, and strategies that include policy changes toward more integrated care, and population health management programs driven by data based on quality measures.

Check out the Q&A with the speakers here:

On June 15, 2018, the New Hampshire Insurance Department (NHID) announced that the legislature had approved new health insurance network adequacy rules for commercial health plans that include provisions to strengthen parity access to mental health and addiction treatment services. The new rules go into effect on August 1, 2018. They apply only to individual and group commercial health plans, but not to self-insured employer plans or the state Medicaid managed care organizations.

Previously, network adequacy rules had applied to primary and specialty care services, but not behavioral health services. The new rules were developed because the state’s previous network adequacy rules, drafted more than 20 years ago, were set to expire at the end of July 2018.

Under the new rules, NHID will use all-payer claims data to support a network adequacy approach that allows for greater transparency and accountability in its review of health insurers’ provider networks. The reviews will be conducted annually, or when a carrier introduces a new product.

NHID believes the all-payer claims approach recognizes that many health care services are available from a range of health care provider organizations and professionals offering treatment in both traditional and non-traditional settings. This approach is also intended to ensure that state residents have local access to commonly used services, such as primary care, behavioral health care, and urgent care.

The network adequacy standards apply to primary and specialty care services and must include standards for access to behavioral health services. Primary and acute care services are designated as “core” and “common”. Most behavioral health services are classified as “core” services; however, alcohol/drug acute detoxification is classified as a “specialized service. Across metro, micro, and rural areas, “Core” services must be available within a closer distance than “common” or “specialized” services.

Under the basic access requirement:

  • Each health carrier offering a network plan shall maintain a network of primary care providers, dental providers, specialists, institutional providers, and other ancillary health care personnel that is sufficient in numbers and types of provider organizations to ensure that all covered health care services are accessible to covered persons without unreasonable delay.
  • The evaluation of network adequacy shall be based on the most recent United States census data for populations under 65 years of age.
  • The basic access requirement must be met in each county in which the health carrier is actively marketing a health benefit plan. In this context, actively marketing means advertising in publications published within the county or initiating contact with a potential policyholder in person, by phone, or by mail.
  • In a multi-tiered provider health benefit plan carrier networks, except for services identified as “core,” access shall be evaluated based on the tier of participating providers associated with the highest level of cost sharing for the consumer. However, for “core” services, carriers shall meet access requirements based on the network tier of participating providers that is associated with the lowest level of, cost sharing for the consumer.
  • In any county in which compliance is required and in which a health carrier’s network is insufficient to meet one of the access standards, and the carrier has not been granted an exception, the health carrier shall cover services provided by a non-participating provider located within the applicable geographic area at no greater cost to the covered person than if the services were obtained from a participating provider organization. This provision does not require a health carrier to provide coverage for services provided by a non-participating provider who has been excluded from the health carrier’s network for failing to meet any applicable credentialing standards.
  • A health carrier shall not actively solicit new policyholders in any county in which it does not meet the required access standards unless the health carrier has been granted an exception.

Core services include behavioral health screening and assessment services, community-based behavioral health services, half-way house services, peer services, partial hospitalization, short-term residential, ambulance services, chiropractic, dental services, diagnostic physical therapy evaluations, mammograms, preventive and routine acute care for adults and children, routine immunizations and injections, pharmacy, routine EKGs, stitches, urgent care, and blood samples. Geographic access requirements for “Core,” “Common,” or “Specialized” services vary across Metro, Micro, and Rural counties, as follows:

  • In Metro areas (Strafford, Hillsborough, and Rockingham counties), Core services must be available within 10 miles or 15 minutes driving time; Common services must be available within 20 miles or 30 minutes driving time; and Specialized services must be available within 40 miles or one hour driving time.
  • In Micro areas (Belknap, Cheshire, Carroll, Grafton, Merrimack, and Sullivan counties), Core services must be available within 20 miles or 40 minutes driving time; Common services must be available within 40 miles or 80 minutes driving time; and Specialized services must be available within 70 miles or two hours driving time.
  • In Rural (Coos County), Core services must be available within 30 miles or 60 minutes driving time; Common services must be available within 80 miles or two hours driving time; and Specialized services must be available within 125 miles or 2.5 hours driving time.

The standards for waiting times for appointments and access to after-hours care vary between behavioral health and other urgent care services. The behavioral health standards require carriers to ensure that members are able to obtain an initial appointment with an in-network provider within six hours for a non-life-threatening emergency, within 48 hours for urgent care, and within 10 days for an initial visit. For other services, the carrier must ensure that members can obtain an initial in-network appointment within one day for urgent care and within 30 days for other routine care, including initial visits.

PsychU reported on the proposed rules in “New Hampshire Insurance Department Proposes New Network Adequacy Standards For Behavioral Health Access,” which published on April 11, 2018.

For more information, contact: Eireann Aspell, Outreach Coordinator, Communications Office, New Hampshire Insurance Department, 21 South Fruit Street, Suite 14, Concord, New Hampshire 03301; 603-271-3781; Email: Eireann.Aspell@ins.nh.gov.

The National Committee for Quality Assurance (NCQA) maintains its focus on behavioral health quality measures by continually updating and improving its performance measurement tool known as the Healthcare Effectiveness Data and Information Set (HEDIS). During this webinar, experts from NCQA – Junqing Liu, PhD, MSW, Research Scientist; Lauren Niles, MPH, Senior Health Care Analyst; and Nora Fritz, BA, Health Care Analyst – present a brief background on measure development, performance of current HEDIS behavioral health measures, future work around treatment for substance use disorders and pain management, and identifications of gaps in care and challenges related to HEDIS behavioral health measures (e.g. unhealthy alcohol use screening and follow-up, depression screening and followup).

In July 2018 we asked the PsychU Community, “Does your workplace currently utilize systematic assessment to inform measurement-based care / treatment planning?” A small, dedicated proportion of our membership responded to this poll, by email, Twitter, or through the Community Insights webpage on PsychU. Results were split between individuals who work at organizations that utilize standardized assessment for all disease states and those who do not utilize them at all. Further results are detailed in Table 1 and Figure 1 below.

Assessing what this means for our community as a whole is difficult given the small sample size for this poll. However, what we do know is that standardized implementation of measurement-based care screens and instruments can help to guide patient treatment over time. It can also help clinicians to adhere to prescribed treatment practices and guidelines for care. For more on a variety of assessments / scales / screeners, check out the PsychU Psychiatric Scales Collection here.

As always, make sure to participate in PsychU polling each month (through your email, the @PsychUCommunity Twitter feed, or through our website) to make your voice heard. You can also browse results of our previous polls on the Community Insights page on PsychU.org.

Rating scales included in the PsychU Psychiatric Scales Collection are provided for PsychU member’s screening and educational purposes only and are not to be used as diagnostic tools.

Last month, my colleague Monica E. Oss, took a look at a proposed initiative by the Centers for Medicare and Medicaid Services (CMS) for direct value-based reimbursement of provider organizations, describing it as “another step in moving health care provider reimbursement from volume to value” (see VBR Jumping From Hospital-Centric ACOs To Community-Based Players). What caught my interest was the focus on consumer-centricity: “The proposed model touts a consumer-centric model, by giving consumers greater control in selecting their primary care practice through beneficiary engagement tools to empower beneficiaries, their families, and their caregivers to take ownership of the beneficiary’s health.”

Start a discussion about the benefits of consumer-centric health care at your local coffee shop and you likely won’t find anyone who disagrees with the idea. We live in a crowd sourced, “everything ratable” society—think Yelp, Uber, Glassdoor, etc. We all want five-star service, and if we don’t get things the way we want, we expect the vendor of our service (be that Grubhub delivery or our primary care doctor) to make it right.

There are consumer-centric strategies and models on the drawing board all around the field. Or, as Geisinger Health System’s Chief Informatics Officer Alistair Erskine was quoted as saying in a Forbes article last October, “Everyone talks about putting the patient first and that’s great, but to make it actually happen we needed to take a big step that would force us to change”. Geisinger’s “big step” was to offer refunds on copayments in 2015 as part of its ProvenExperience program. Geisinger now provides copayment refunds on certain types of services to consumers who are unsatisfied with their care (see Would You Give A Refund To Dissatisfied Consumers?). In 2016, ProvenExperience refunded $320,141; in 2017, it refunded $411,325; and as of March of 2018, it has refunded $266,340.

More recently, I had the chance to hear Charles Gross, Ph.D., Vice President, Behavioral Health, Anthem, Inc. share Anthem’s value-based reimbursement model for contracting specialty care during his opening plenary address, Going Beyond Innovation-Developing Partnerships With Health Plans. He was quick to point out that a core element of Anthem’s VBR strategy was a great consumer experience. This perspective isn’t limited to Anthem. We’ve seen similar focus on consumer experience as an element of “value” by Wellcare; Optum; and Magellan.

But the sad reality is that even with these health plan preferences for a great consumer experience, most of the consumers needing more complex care and support don’t really have selection preference, nor family members that can help them guide their choices. My experience is that Medicaid consumers typically end up with whomever the direct support professional (DSP) chooses. While these DSP choices are based on good intentions and consumer convenience, this situation actually defeats the idea of consumer-centricity.

What I’ve seen in practice in the field is that Medicaid consumers are not routinely asked what services they want, nor how they would like to receive them. Be it good intentions, staff shortages, limits in coverage, or a host of other reasons, these consumers typically get what they are given, not what they necessarily want nor need.

What does it take to have a “consumer centric” system? How do managers of provider organizations improve this situation in real time? How do they perform better on value-based contracts? I think it has to start from the bottom up. Unfortunately, the DSPs who spend the most time with consumers—particularly consumers with complex needs—are proving harder to keep on the job. The average turnover rate among all health care workers was 20.6% in 2017, up dramatically from 15.6% in 2010 (see High Turnover, The Other Staffing Issue). In this kind of high-turnover environment, executive teams need to ask:

  1. How skilled are the DSPs?
  2. Are staff trained to see the nuances in the consumers to whom they provide care?
  3. Is there consistency in staffing to allow for rapport and relationship building with consumers?

If we flipped the script and began to give complex consumers more choice and control of their care, I imagine we’d find less friction with direct care staff, which would likely translate to a happier work environment and reduced turnover (not to mention better health care outcomes).

The overarching issue, specifically for consumers with behavioral health conditions, is the blurred line between “primary care concerns” and “psychiatric concerns.” Care coordinators often visit consumers who have symptoms that could fit in any bucket—for example, are the stomach pains a side effect of a new depression medication, an effect of a poor diet, or symptoms of an ulcer? To make matters more complex, it’s not uncommon for the symptom to be the psychosocial result of loneliness. Isolation and loneliness are common for consumers in the complex care space (see Is Loneliness The Overlooked Social Determinant?). The current trend toward a more “whole person” approach to care coordination is positive. However, if you leave primary care and behavioral health treatment fragmented, you are missing the interconnection between body, mind, and social determinants.

I think the big question is how to develop—and retain—the DSP workforce, and how to provide that workforce with the care coordination tools they need. All roads in health and human services are leading to an integrated, community-based service system, but we need the talent to get us there.

The recent Journal of the American Medical Association (JAMA) study, Health Care Spending in the United States and Other High-Income Countries, is a confirmation of what U.S. health policymakers know—we spend more on health care than other countries and have consistently poorer outcomes. The new data comparing the U.S. to ten other high-income countries on medical care (Canada, Germany, Australia, the U.K. Japan, Sweden, France, the Netherlands, Switzerland, and Denmark) found:

  1. About 18% of the S. gross domestic product was spent on health care, much higher than the other countries (ranging from 9.6% in Australia to 12.4% in Switzerland).
  2. About 90% in the U.S. population has health care insurance—lower than the other countries, where insurance coverage ranges from 99% to 100%.
  3. The S. has the lowest life expectancy at 78.8 years; while other countries range between 80.7 and 83.9 years. The mean life expectancy of the other 11 countries studied at 81.7 years.
  4. The S. has the highest infant mortality at 5.8 deaths per 1,000 live births; compared to 3.6 per 1000 for other countries.
  5. About 8% of U.S. spending on health care goes to administrative costs related to planning, regulating, and managing health systems and services—while other counties spend between 1% to 3% on administrative costs.
  6. Per capita spending on pharmaceuticals was $1,443 in the S., compared to a range of $466 to $939 per capita in other countries.
  7. Salaries of physicians and nurses are higher in the U.S. (i.e., in the U.S., physician generalist salaries averaged $218,173, compared to a range of $86,607 to $154,126 in the other countries).

Everyone agrees these metrics need to change, but the agreement ends there. There is a lot of disagreement about what strategies to use to improve the performance of the U.S. health system. In part, this is due to a disagreement about what causes the U.S. health care cost and outcomes numbers to lag.

There is the waste in the system. Merrill Goozner, in the Modern Healthcare editorial, Waste Isn’t The Cause Of High Healthcare Costs, thinks that there isn’t enough waste to turn the corner on these metrics, writing:

Proponents of the waste theory blame providers. There are too many specialists ordering too many tests and procedures. There aren’t enough primary-care physicians emphasizing prevention and care coordination. Hospitals staff too many beds that need to be filled. In short, the supply side creates its own demand.

 

Then, there is the price issue. Dr. Ashish Jha, a professor of global health at Harvard, was quoted as saying, “We completely have a price problem. MRIs cost twice as much in Kansas as in London, and that makes no sense” in Why Does The U.S. Spend So Much More On Healthcare? It’s The Prices. And, a look at the comparative metrics show out-sized spending on pharmaceuticals and administrative costs. Eight percent of U.S. health care spending went to administrative costs incurred by private and public insurers, but that figure doesn’t include billing and insurance-related activities by hospitals and physician Including those costs would boost the actual administrative burden in U.S. health care to 14%, according to Dr. Steffie Woolhandler, author of a 2013 Health Affairsstudy, A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far.

Then there is the social determinants issue. The U.S. has higher rates of poverty, and related incidences of obesity, diabetes, and other chronic health conditions (see Social Determinants Today, Social Determinants Tomorrow)—all contributing to higher health care costs. At the same time, the U.S. spends far less than Western European countries on social services, which results in poorer health and health outcomes—and higher costs.

At this moment, I would say that we have made the decision to use consumer market forces (like high deductible plans and health savings accounts) and value-based reimbursement as the strategies to improve system performance. Whether or not those strategies will work is a most important question and one that needs constant research and evaluation. In particular, how these strategies affect specific portions of the population—low-income consumers, high-needs consumers, consumers of color, etc.—is an important question to answer sooner rather than later

For more on the issues around “bending the cost curve” in the U.S. health and human service system, check out:

  1. Will Clinical Professional Compensation Drive Task Shifting?
  2. The Innovation Conundrum
  3. Behavioral Health Evidence-Based Practices As Population Health Management Tools
  4. Task Shifting To Bend The Cost Curve
  5. Bend The Cost Curve? We Need Behaviorally-Led Health Systems
  6. ‘Person-Centered’ Health Care Records Take Center Stage

Over the last eight years, the use of social impact bonds (SIB) for funding human services has grown. Thirty-two SIBs launched worldwide in 2017, bringing the global total to 108, with an estimated $300 million total investments.

If you’re unfamiliar with the SIB concept, the model is based on leveraging private funding for human services. A provider organization uses loans from private investors to fund the management of a specific service, with while government agencies agree to pay for the program only if performance targets are met (see Social Impact Bonds – Moving From Experimental To Scale and Social Impact Bonds: Small Model, Big Implications For Value-Based Reimbursement).

The question that has hovered over all coverage of SIBs is simple: Are they working? It’s still too early to give a global “thumbs up” to SIBs, but some of the early results are showing positive outcomes.

In Colorado, the first year of the City of Denver’s supportive housing SIB initiative, the outcomes met benchmarks to trigger the first success payment of $188,349 to project investors. In 2016, Denver and eight private investors invested $8.6 million to fund the program to house 250 people over five years. The city anticipates that it will save $3 million to $15 million over the five-year project (see Denver Supportive Housing Social Impact Bond Initiative Earns The First ‘Success Payment’ For Project Investors).

Last year, the very first SIB ever enacted in the United Kingdom reported that investors in the Peterborough SIB at Peterborough Prison were repaid in full with a return of 3%. As part of that SIB, seven service provider organizations delivered substance abuse and mental health services for ex-prisoners—reporting that rates of re-offense were cut by 9%.

On the other hand, in the U.S., the first social impact bond at Rikers Island did not meet its target, but still had positive outcomes—87% of the target population attended at least one intervention session, and 44% reached a program milestone found in other studies to be associated with positive outcomes.

While the evaluation of social impact bonds is still thin, there is enthusiasm for the model and expectations that they will continue. Last year Senator Todd Young (R-IN) introduced the Social Impact Partnerships to Pay for Results Act (SIPPRA), which would provide a $92 million fund through the Department of Treasury and would allow the Treasury to enter into agreements with state and local governments for SIB partnership projects. SIPPRA was passed in February as part of the Bipartisan Budget Act of 2018.

Included in the legislation was plans to release requests for proposals (RFPs) from state and local governments for projects related to reducing utilization of emergency room services for consumers with chronic conditions; reducing the number of children in foster care living in group homes and institutions; reducing homelessness among vulnerable populations; improving the health and well-being of consumers with mental health issues; and more. The programs will require applicants to meet the following criteria:

  1. Outcome goals for the proposed program should be met within a time period of up to 10 years.
  2. No more than 15% of awarded funds for the proposed program can be used to evaluate the implementation and outcomes of the project.
  3. Applications must include a plan to develop and deploy projects that produce measurable outcomes that result in social benefit, as well as federal, state, or local savings.
  4. Applications need to provide outcome goals, intervention, evaluation, target population, expected social benefits, projected costs, and projected savings.

The Office of Management and Budget will implement the legislation over the next year, and the RFPs are expected to be released in February of 2019. Though it appears that the federal RFPs will be intended for state and local governments, these institutions will need experienced partners with demonstrated results to be part of their proposal for funds. The legislation notes that funding applications must include description of the expertise of each service provider organization that will administer the intervention, including their past experience with similar programs. This means the field is still wide open for provider organizations with innovative programs and demonstrated outcomes.

Will this become the next face of value-based care? Payers and stakeholders want to know that quality care is being provided and that dollars are being put to the best use—what the final face of outcomes-based funding looks like is still clearly up for grabs.

Between 2011 and 2017, CareFirst BlueCross BlueShield members participating in a patient-centered medical home (PCMH) have had 21.3% fewer hospital admissions compared to non-PCMH members. The PCMH members also had 22.5% fewer emergency department visits and spent 7.8% fewer days in the hospital. In 2017, the PCMH members had 7% fewer hospital admissions, 3% fewer readmissions to the hospital, and 3% fewer emergency department visits; they spent 4% fewer days in the hospital.

Nearly 90% of all primary care professionals (representing nearly 4,400 physicians and nurse practitioners) in the CareFirst mid-Atlantic service area (Maryland, the District of Columbia, and Northern Virginia) participate in the PCMH program. About three-quarters of participating primary care professionals have been with the program since 2011. The participating professionals in a PCMH form panels that are responsible for coordinating care for the PCMH members. CareFirst provides financial incentives, clinical supports, and data analytics to the primary care professionals to help them achieve high levels of quality care and a lower total cost of care targets. Those that meet the targets are eligible for financial incentives.

CareFirst reported these findings in “Patient-Centered Medical Home 2017 Program Performance Report.” The CareFirst PCMH program launched in 2011 and serves over one million CareFirst members. The report presents trends over time and factors that CareFirst has identified as key to the program outcomes.

Across the CareFirst in-service area book of business, excluding Medicare Primary, since 2011, admissions per 1,000 members have dropped from 63.9 to 53.7 in 2017. Total annual hospital admissions dropped from 120,593 in 2011 to 89,980 in 2017. Emergency department visits have dropped from the high of 244.5 per 1,000 in 2012 to 207.0 per 1,000 in 2017. Total annual emergency department visits dropped from the high of 462,953 in 2012 to 351,350 in 2017.

Before the PCMH program started on January 1, 2011, CareFirst per member per month costs had been increasing by an annual average of 7.5%. The annual increases over the preceding decade had ranged from 6% to 9%. From 2012 through 2017, the compound annual growth rate has been 3.5%.

After the PCMH program launched in 2011, CareFirst’s average PMPM was $336. By 2017, it rose 30.6%, to $439 PMPM. However, during that period, the share of the PMPM for primary care increased, and the share for specialists and inpatient care decreased. The share for outpatient care remained the same. The share for pharmacy increased.

Changes To CareFirst PMPM By Service Type, 2011 & 2017

2011 2017
Service Type Share Of PMPM $ Value Share Of PMPM $ Value PMPM Increase 2011 To 2017
Pharmacy 29.6% $86.38 PMPM 32.3% $130.75 PMPM 51.3%
Specialists& Others 27.6% $115.38 PMPM 25.2% $137.86 PMPM 19.4%
Inpatient 20.3% $84.60 PMPM 17.9% $97.92 PMPM 15.7%
Outpatient 18.4% $76.68 PMPM 18.7% $102.30 PMPM 33.4%
Primary Care Physician 4.1% $17.09 PMPM 6.0% $32.82 PMPM 92.2%

Between 2013 and 2018, the share of PCMH members rating their satisfaction with the experience of care at a 4 or above on a five point scale has increased from 71% in the first quarter of 2013 to 91% in the first quarter of 2018. Over 4,800 members (87%) completed the survey in the first quarter of 2018; the average overall score was 4.5.

The full text of “Patient-Centered Medical Home 2017 Program Performance Report” was published in June 2018 by CareFirst BlueCross BlueShield.

For more information, contact: CareFirst BlueCross BlueShield, 1501 South Clinton Street, Baltimore, Maryland 21224; 410-581-3000; Email: mediarelations@carefirst.com.

Value-based care (VBC) can fail to account for differences in health needs among underserved populations—particularly in areas such as clinical guidelines, evaluation metrics, and risk adjustment. To assure equity in VBC arrangements for people of color, low-income populations, and rural populations, there six design domains that should be addressed in the development of VBC programs—payment systems, delivery system investments, community partnerships, inclusiveness of the evidence-base, equity-focused metrics, and workforce diversity. These are the findings and recommendations of researchers at Families USA.

The findings and recommendations were reported in “A Health Equity and Value Framework for Action: Delivery and Payment Transformation Policy Options to Reduce Health Disparities” by Sinsi Hernández-Cancio, Ellen Albritton, Eliot Fishman, Sophia Tripoli, and Andrea Callow. The researchers sought to identify the most critical elements for building an efficient, effective, high-quality, and equitable health care system. They reviewed existing academic research and analysis on the topic.

The report discusses each of the six domains and provides a set of potential policy options for federal decisionmakers, state policymakers, the private sector, and potentially Congress. For each policy domain, the researchers made recommendations for health equity-focused transformation.

Payment systems must sustain and reward high quality, equitable health care. Reducing inequity must be a primary goal, coupled with increasing quality and reducing costs. Promising models for meeting this goal include accountable care organizations, all-payer hospital global budgets, and connecting health care and social services through accountable communities. The researchers recommended three key policy options, as follows:

  1. Reform new Medicare, private insurance, and Medicaid payment models so that the programs have a fundamental framing and day to day operational focus on health outcomes and equity. Incorporate robust risk adjustment for social risk factors into all or some risk-based payment programs so that provider organizations are not penalized for caring for people with more complex health or social needs. Avoid overemphasizing cost reduction; incentivize or require that payment model quality and cost incentives explicitly include equity measures, both in Medicare and in Medicaid. Encourage the spread of All-Payer Hospital Global Budget models, with strong incentives for health equity.
  2. Build improvements to care delivery into new payment models by incentivizing or requiring that payment models include a minimum mandatory set of equity-focused care delivery reforms, when appropriate, such as requiring that federal and state programs: implement or improve clinical-community linkages; use community health workers and similar community care team members; implement some or all patient-centered medical home criteria.
  3. Incentivize needed care within fee-for-service to better remove barriers to and prioritize preventive care, primary care, care coordination, and connections with social and community services.

In delivery system reform, investments are needed to support safety net and small community-based provider organizations that are often an essential source of culturally, geographically, and language-accessible care. These provider types face barriers to implementing value-based payment models because many models require significant upfront investments that the provider organizations may not have the resources to make. The researchers believe that providing upfront funding to safety net and small community providers can help overcome these barriers. They said funding could come through the Center for Medicare and Medicaid Innovation (CMMI); Medicare MACRA-related funding; or state Medicaid funding. The researchers recommended four key policy options, as follows

  1. Continue Medicaid Delivery System Reform Incentive Payments (DSRIP) with safety net and small community provider organization requirements
  2. Establish a targeted Medicaid waiver to support safety net and small community provider organizations
  3. Establish a new CMMI program to support safety net and small community provider organizations
  4. Expand Medicare MACRA implementation support for small, underserved, and rural practices

Robust and well-resourced community partnerships must be created to enable people to improve their health. Provider organizations seeking to improve health outcomes should partner with and invest in community-based organizations trusted by disadvantaged populations. Such partnerships can address socio-economic factors and community context in shaping health. The researchers recommended four key policy options, as follows:

  1. Focus payment and delivery reform models and Medicaid waivers on incentivizing community CMMI should prioritize models specifically designed to minimize the health impacts of negative social determinants of health and models that prioritize community partnerships as a key feature of the model, such as the Accountable Health Communities model’s “Alignment Track.” ACOs should seek out and include representation from communities of color. Medicaid managed care organizations (MCOs) should be required to contract with community-based organizations to provide social services and outreach, engagement, assessment, and follow- up.
  2. Strengthen and expand non-profit community benefit requirements for non-profit hospitals and health plans, including Medicaid MCOs. Community benefit programs could be a condition for receiving state Medicaid disproportionate share hospital Non-profit hospitals could be required to meet a minimum budget percentage for community benefit, or the total dollars that must be targeted at reducing health disparities by addressing root causes.
  3. Incentivize/resource infrastructure required to enable seamless coordination between health systems and provider organizations and community-based resources. This could be accomplished by building on the Beacon Communities, Community Interoperability, and Health Information Exchange grants. Regional information technology hubs could be set up to connect community-based organizations with few resources grants could fund installation and deployment. Incentives should reward leveraging existing community infrastructure: community- based organizations, faith-based organizations, schools, and recreation centers.
  4. Incentivize/require health care provider organizations to recruit actively from their communities and contract with businesses in their communities to provide needed services and These initiatives could take the form of local business contracting programs, local outreach/recruiting programs for hiring, or workforce development partnerships with schools, community colleges, or provider organizations that manage affordable housing.

Improve the evidence base so that it reflects population diversity. Avoid implicit bias in clinical guidelines based on incomplete medical research. Transparency about the data limitations of treatment guidelines is needed so that consumers, physicians, and payers can make better care decision. The researchers recommended four key policy options, as follows:

  1. Mandate improved reporting and analysis of demographic characteristics in clinical and delivery systems research and evaluation; policymakers, payers, provider organizations, and consumers need accurate information about the demographic characteristics of research and evaluation participants of studies that inform clinical guidelines, treatment recommendations, and reimbursement decisions.
  2. Support the generation of more community-specific health system and delivery research.
  3. Improve the translation and dissemination of evidence to decision makers, practitioners, and communities by requiring federally funded research on health topics relevant to communities of color and other disparity groups to create dissemination plans and plain-language summaries of the results.
  4. Ensure appropriate use of evidence in treatment guidelines and reimbursement across private and public payers, the U.S. Preventive Services Task Force, and other bodies that develop and disseminate clinical practice guidelines. They should consider potential differential impacts of specific treatments on diverse individuals based on sex, age group, race, ethnicity, and disability. Clinical guidelines should clearly indicate when the evidence base indicates significant variation in outcomes based on demographic Payers should incorporate exceptions or evidence-based alternatives into their medical necessity determinations.

Use equity-focused metrics to accelerate reduction in health inequity. Health system transformation should incorporate equity-sensitive metrics into payment models. The researchers recommended four key policy options, as follows:

  1. Require health care organizations to report performance data stratified by race, ethnicity, language, socioeconomic status, sex, gender identity, sexual orientation, disability, and other demographic factors. Provide financial incentives for those organizations that collect and report stratified measures. Provide upfront financial support and technical assistance to help provider organizations build capacity to collect and report stratified data.
  2. Require and incentivize collection and reporting of social and behavioral risk factor data in electronic health records (EHRs). Include social and behavioral risk factor data in electronic health information exchanges, and support sharing the information with other public assistance programs to support comprehensive person-centered services.
  3. Prioritize the development and use of disparities-sensitive and health equity measures by increasing the number of disparity-sensitive and health equity measures that can be reported in accreditation programs, value-based program, and core measure sets used by public and private initiatives. Require provider organizations participating in all or a subset of Medicare and Medicaid value-based programs to report on a certain number of these measures. Further, the measures should be used to evaluate the success of demonstration projects.
  4. Directly incentivize provider organizations to reduce disparities in performance measures by rewarding them for achieving decreases in health disparity or improving their performance toward health disparities.

To drive equity and value, the health care workforce must be more ethnically and racially diverse, better distributed geographically, and inclusive of a broader array of jobs. The researchers recommended three key policy options, as follows:

  1. Increase the diversity of health care providers and health system leaders
  2. Promote the sustainable use and integration of community health Workers (CHWs) and similar community care team members
  3. Promote the use and integration of mid-level health care professionals

The researchers said the six domains fit together as components of a person-, family-, and community-centered health system. Underserved communities and populations must be included throughout the decision-making process, in terms of defining priorities, policy development and adoption, and implementation and evaluation. For a successful VBC initiative, financing for health reform must be focused on the goal of reducing health and health care inequities, in addition to goals of increasing health care quality and reducing costs. Resourcing and rewarding equity across populations must be a clear priority.

The full text of “A Health Equity and Value Framework for Action: Delivery and Payment Transformation Policy Options to Reduce Health Disparities” was published in June 2018 by Families USA.

For more information, contact: Annette Raveneau, Media Director, Families USA, 1225 New York Avenue NW, Suite 800, Washington, District of Columbia 20005; 202-626-0611; Email: press@familiesusa.org.

Performance measurement, and the management of that performance, may be the defining factor for successful relationships between provider organizations and health plans, but with each passing year the level of measurement fatigue and exhaustion that I’m seeing in executive teams is increasing. The main reason for this is simple—performance measurement in health and human services is an evolving, growing science.

And a great example of this is the 2019 updates to the Healthcare Effectiveness Data and Information Set (HEDIS), from The National Committee for Quality Assurance (NCQA). Earlier this month, NCQA released its updates to HEDIS, which included four additional measures, and changes to four existing measures. The new measures include:

Hospitalization Following Discharge From a Skilled Nursing Facility—This measure will track the percentage of skilled nursing facility discharges to the community that result in an unplanned hospitalization within 30 days and 60 days, and will be used to assess the coordination of provider organizations and services to support a successful transition to the community from a skilled level of care across Medicare Advantage plans.

Risk of Continued Opioid Use—A pair of measures will assess members with a new episode of opioid use who are dispensed opioids for a period of time that puts them at an increased risk of continued use, using two rates:

  1. The percentage of members whose new episode of opioid use lasts at least 15 days in a 30-day period.
  2. The percentage of members whose new episode of opioid use lasts at least 31 days in a 62-day period.

Prenatal Immunization Status—This measure assesses receipt of important prenatal vaccines, tracking the percentage of deliveries on or after 37 gestational weeks in which women received influenza and diphtheria and pertussis (Tdap) vaccines.

Adult Immunization Status—This measure assesses routine vaccination against influenza, tetanus, diphtheria and pertussis for all adults 19 years and older, and vaccination against herpes zoster and pneumococcal disease for older adults 19 years and older.

Also new in the world of measurements are recent updates from the National Quality Forum (NQF), which in May announced four new measures in its Behavioral Health and Substance Use Fall 2017 project (see NQF Endorses Four Behavioral Health Measures). The new measures address continuity of care for adult Medicaid beneficiaries admitted to detoxification, follow-up care for adult Medicaid beneficiaries newly prescribed an antipsychotic, timely medication reconciliations for people newly admitted to inpatient settings, and provision of psychosocial screening during well-child pediatric visits.

Continuity of Care for Medicaid Beneficiaries after Detoxification (Detox) From Alcohol and/or Drugs—This measure is focused on adult Medicaid beneficiaries ages 18 to 64 who are discharged from a detoxification episode. The measure tracks the percentage of these discharges that are followed within 7 or 14 days by a treatment service for addiction disorder.

Follow-Up Care for Adult Medicaid Beneficiaries Who are Newly Prescribed an Antipsychotic Medication—This measure tracks the percentage of new antipsychotic prescriptions for beneficiaries in the target population who have completed a follow-up visit with a clinical professional with prescribing authority within four weeks (28 days) of prescription of an antipsychotic medication.

Psychosocial Screening Using the Pediatric Symptom Checklist-Tool (PSC-Tool) —This measure tracks the percentage of children whose pediatric well-child visit includes administration of a Pediatric Symptom Checklist (PSC) Tool as a visit component.Medication Reconciliation on Admission—This measure tracks the percentage of newly admitted people for whom a designated Prior to Admission (PTA) medication list was generated by referencing one or more external sources of medications and for which all PTA medications have a documented reconciliation action by the end of Day 2 of the hospitalization when the admission date is Day 0.

The reaction of many of my colleagues who are executives of provider organizations has been—”more measures?” The solution is to invest in technology that makes reporting different measures to different health plans as painless and inexpensive as possible. As we have reported before, all payers are moving to more focus on performance and value (see Crawl, Walk, Run To VBR and Why Your Performance Reporting Should Include ‘Episodes Of Care’). And, our recent analysis found that more health care dollars are being managed by health plans (see Value = ‘Whole Person’ Approach)—health plans that see good performance on the NCQA/HEDIS and NQF measures as critical to their sustainability. They are going to be looking for provider organization partners that can deliver on these measures.

How to approach this hydra-like market situation? If you’re just getting started on metrics-based performance management for payer contracts, develop an incremental plan. First, identify the payers/health plans with the greatest effect on your revenue. Secondly, what are their most important performance measures? Finally, develop an incremental plan to measure your organization’s performance relative to those measures (whether it the actual measure or a proxy measure). These performance metrics provide your organization with a competitive advantage, no matter how limited or elemental they seem. (One of my favorite expressions come to mind—“In the land of the blind, the one-eyed man is king.”)

For more on keeping ahead of the measurement tidal wave, check out these resources in the PsychU Library:

  1. Are You Suffering From Measurement Fatigue?
  2. A Few More Drops In The Performance Measurement Bucket
  3. When It Comes To Performance Measurement, The “Work” Is Never Done
  4. Moving To ‘Healthy Days’ As A Measure Of Success
  5. The Five-Step Process To Demonstrate Your “Performance” To Health Plans
  6. Is One Set Of Performance Measures Possible?

Suicide rates in the U.S. increased 30% between 2000 and 2016——from 10.4 to 13.5 suicides per 100,000 population. Suicide rates increased an average of about 1% per year from 2000 through 2006, and by about 2% per year from 2006 to 2016.

Males are at least three times more likely to commit suicide than females. For males, the age group most likely to commit suicide remained the same in 2016 as in 2000: those aged 75 years and over (42.4 per 100,000 population in 2000, and 39.2 per 100,000 population in 2016). For this group, firearms were the most frequent cause of suicide, followed by suffocation. For females, the age group most likely to commit suicide remained the same in 2016 as in 2000: those aged 45 to 60 years (6.2 per 100,000 population in 2000, and 9.9 deaths per 100,000 population in 2016). For this group, poisoning was the most frequent cause of suicide, followed by firearms.

These findings were presented in “Data Brief #309: Suicide Rates In the United States Continue To Increase,” by Holly Hedegaard, M.D.; Sally C. Curtin, M.A; and Margaret Warner, Ph.D. of the National Center for Health Statistics at the U.S. Centers for Disease Control and Prevention. The researchers analyzed data from the National Vital Statistics System to identify suicide deaths according to the International Classification of Diseases, 10th Revision. The goal was to update trends in suicide mortality from 2000 through 2016; and to describe differences by sex, age group, and means of suicide.

A link to the full text of “Data Brief #309: Suicide Rates In the United States Continue To Increase” may be found online.

For more information, contact: National Center for Health Statistics, U.S. Centers for Disease Control and Prevention, 3311 Toledo Road, Hyattsville, Maryland 20782; 800-232-4636; Email: paoquery@cdc.gov

Key Messages

  • There has been a well-documented shortage of physicians in some specialties, including Neurology and Psychiatry.
  • Osteopathic medical students demonstrated a greater interest compared to allopathic medical students in Neurology and Psychiatry.
  • Required rotations did not correlate with applications or matches.

Measurement-based care (MBC) can be an important component in effectively treating an individual with behavioral health needs by systematically measuring symptoms and responses to treatment. In this webinar, two experts in the field of behavioral health explain the concepts of MBC, its role in pay-for-value, and how MBC may raise quality in psychiatry. James Greer, MD, Clinical Director of Child & Family Services at The Providence Center, provides the clinician’s perspective; Charlotte Ostman, BA, MSW, Chief Executive Officer at The Mental Health Association of Westchester Inc. explains the importance of MBC from an organizational administrative perspective.

“At the heart of the subscription economy is the idea that customers are happier subscribing to the outcomes they want, when they want them, rather than purchasing a product with the burden of ownership.” Tien Tzuo, Zuora

This was a quote shared with the audience by Ravi Ganesan, the Chief Executive Officer of Core Solutions, in his session, Digital Healthcare In A Subscription-Based Economy. The subscription economy concept has been around a long time (think newspapers) but has gained new life as the internet has offered a platform for companies to sell just about anything by subscriptions—from information, to music, to movies, to dog treats, to cars. And this subscription market is growing, increasing over 100% a year over the past five years. The largest organizations in this subscription market segment are upward of $2.6 billion in sales.

Mr. Ganesan shared several examples of a growing subscription market in health care. His first was the growing number of tech-enabled health services available by subscription. He gave the example of Boston-based Iora Health where consumers pay a flat fee-between $60 and $200 per month for a health coach. Another example is TalkSpace, which provides different plans (with different levels of service) based on a weekly subscription (the base plan starts at $49 per week and includes unlimited messaging therapy).

His second example of a subscription-based approach was the changing primary care market. New direct primary care (DPC) models provide consumers with access to primary care services for a flat fee. Gold Standard Pediatrics, in South Carolina, is an example of this model directed at serving children for monthly membership fees of $70 (birth to two years), $45 (2 to 12 years), and $35 (12 to 18 years).

If you are an executive at a specialty provider organization, you may be asking yourself, should my organization consider offering a subscription-based service? And, if so, should that service be focused on-the direct-to-consumer market or the payer/health plan market? The subscription-based approach addresses a number of trends in the health and human service market; whether a direct-to-consumer or payer-based model, subscription services provide a transparent value proposition for consumers with the service provider organization accepting the financial risk for the volume of utilization. And, increasingly, the value proposition is focused on the consumer-both reducing out-of-pocket payments and improving the consumer experience in terms of access and convenience (see What ‘Performance’ Should Your Team Care About? Look At Your Health Plan’s Contract).

From Mr. Ganesan’s perspective, the future of subscription-based services is tied to the concept of “on-demand fulfillment” – a convenient, anytime, anywhere model of service. (For a look at some of the big disruptors proliferating this approach in health care, see Invaders At The Gate and Don’t Let The Big Disruptors Out Of Your Sight.) And, to make the subscription model and the desired consumer experience happen, the service provider organization needs to invest in technologies that provide a superior consumer experience-including consumer self-service technologies and technologies that streamline administrative functions (and reduce their costs).

My take? Whether an executive team opts to offer a “subscription model” or not, the expectations for “on demand” services can’t help but spill over. Those next generation technologies-for streamlined administrative process and consumer self-service-will soon move from “nice to have”, to “must have” functionality.

Managing a team of clinical professionals in the community is different than managing a team in at a fixed location. And the differences—in culture, technology, and process—are increasingly “must have” skills for health and human service provider organizations. Across all market segments, but particularly with the consumers with the most complex support needs, we’re seeing the growth of the volume of care outside the institutional and clinic settings. Consumer preference, cost pressures, performance requirements, and value-based reimbursement are all contributing to the increase in community-based care.

This leads to the question—are your staff (and your managers) prepared to serve consumers where they are? This was the focus of the session, How To Manage A Community-Based Workforce, featuring Boris Vilgorin, Healthcare Strategy Officer, NYU McSilver Institute; and Chris Copeland, Chief Operating Officer, The Institute for Community Living (ICL).

Mr. Vilgorin and Mr. Copeland’s advice? Pay particularly close attention to four key areas—attract the staff suitable for working in the field, develop new business practice for community-based settings, leverage mobile technology, and address the unique safety issues of community-based work.

Attracting The Right Staff—Staff that are based in the community are often working with the toughest consumers in the toughest communities. They are physically disconnected from their organization and operate with the kind of freedom and self-direction that facility-based staff don’t have. This demands different skill sets—staff in the community need to show more independent initiative, have strong engagement skills, be culturally responsive, and be better communicators with the ability to consistently share information through different channels.

OPEN MINDS Senior Associate, Annie Medina noted that, “Because community-based employees need to be able to operate capably without immediate and direct oversight, they should be comfortable with a fair amount of autonomy and ambiguity. They should also be highly self-aware and know their own limitations and when they need to consult with someone else. The ‘right’ staff are able to operate successfully as part of a team, even if they don’t necessarily see their team members on a daily basis.”

Developing New Business Practices—Building a community-based service model means determining the geography you will need to cover, including all the budgeting, transportation, mobile tech, and “home base” location needed to serve the territory. Key to succeeding is understanding that some things are the same (the infrastructure it will take, such as human resources, compliance/quality, IT, billing), and some things are different depending on the state and location you are working in (labor laws, compliance, insurance).

According to Ms. Medina, “policies and procedures may need to be adjusted. One of our speakers specifically pointed out long-standing policies about needing to clock-in and clock-out for shifts. This makes sense when you have an on-site work force. However, it’s not a reasonable expectation to make community-based employees—who may be covering areas 90 minutes away from the home office—come in simply to comply with dogma. Evaluate which practices need to be adjusted in order to support off-site employees.”

Leveraging Mobile Technology—Best practice community-based work requires mobile technology. Key mobile technology functions needed in the field include the ability to connect, as well as supply the necessary security compliance for HIPAA and the security of protected health information. A field-based mobile tech strategy means thinking through who has access to the tech, tracking who is in possession of the tech, and deciding how best to keep the staff and equipment safe. Ms. Medina expanded on the additional mobile tech considerations, noting the importance of “consistently having access in remote areas, and planning for the inevitable loss of access.” She also advised that, “some technology may label your work force as ‘outsiders’, such as a new iPhone when they are serving consumers in a largely impoverished area. Make sure that technology use policies include ‘safeties’, such as location tracking and communicating location ahead of the service, so that if your staff is unable to get to their technology, a plan is in place to check on them.”

Addressing Safety Issues— Organizations need to build a culture of safety, as well as the community connections to address safety concerns. This includes routines that promote safety (information sharing, pre-visit planning, fully charged phone, checking in at end of day), and de-escalation strategies. It also demands greater communication and collaboration with law enforcement/police, hospitals, landlords, and community groups. Ms. Medina explained:

“Staff perceive that safety may be an issue because they are outside of the four walls of a facility. In reality, it may not be. There is inherent risk in going into someone else’s home, regardless of who the other person is. However, there is also risk in serving consumers in clinics and hospitals. The best way to help mitigate the perceived heightened risk of being outside of the facility is to build that culture of safety. Have procedures and check-ins in place, follow through with them, assign teams, etc. One of the wonderful things about the health and human services field is that the work force is typically driven by a need to serve the consumer. In community-based services, we need to be sure that this drive doesn’t overshadow better judgment. Part of the culture of safety is making it clear that the employee can walk away from providing the service if he or she feels unsafe, and never has to face any situation alone.”

On May 10, 2018, J.D. Powers released their rankings of member satisfaction in commercial health plans in 22 regions. In 10 of these regions, BlueCross BlueShield plans took the top ranking; Kaiser Foundation Health Plan took the top ranking in six other regions. The survey also discovered that just 47% of members completely understand how their plan works.

These findings were presented in “J.D. Power 2018 Commercial Member Health Plan Study,” by J.D. Power. The Commercial Member Health Plan Study examined satisfaction among 33,342 members of 163 health plans in 22 regions throughout the U.S. J.D. Power ranked satisfaction by six measures: coverage and benefits; provider choice; information and communication; claims processing; cost; and customer service. Rankings were based on a 1,000-point scale. The average of the satisfaction scores was 712 out of 1,000.

Winners in the 22 health plan regions included (score in parenthesis):

  1. California: Kaiser Foundation Health Plan (780)
  2. Colorado: Kaiser Foundation Health Plan (734)
  3. Delaware/West Virginia/Washington D.C.: Cigna (730)
  4. East South Central: BlueCross BlueShield of Alabama (743)
  5. Florida: AvMed (759)
  6. Heartland: BlueCross BlueShield of Kansas (716)
  7. Illinois-Indiana: Health Alliance Medical Plans (734)
  8. Maryland: Kaiser Foundation Health Plan (807)
  9. Massachusetts: BlueCross BlueShield of Massachusetts (727)
  10. Michigan: BlueCross BlueShield of Michigan (729)
  11. Minnesota-Wisconsin: HealthPartners (724)
  12. Mountain: Regence BlueCross BlueShield of Utah (726)
  13. New Jersey: Horizon BlueCross BlueShield (729)
  14. New York: Capital District Physicians Health Plan (777)
  15. Northeast: Anthem BlueCross BlueShield of Connecticut (708)
  16. Northwest: Kaiser Foundation Health Plan (746)
  17. Ohio: Anthem BlueCross BlueShield of Ohio (724)
  18. Pennsylvania: UPMC Health Plan (748)
  19. South Atlantic: Kaiser Foundation Health Plan (773)
  20. Southwest: Anthem BlueCross BlueShield of Nevada (715)
  21. Texas: BlueCross BlueShield of Texas (723)
  22. Virginia: Kaiser Foundation Health Plan (785)

PsychU reported on this topic in “Medicaid Managed Care Insurance Plans Score Higher than Commercial Health Insurance Plans In Customer Satisfaction,” which published on September 25, 2017.

For more information, contact: Media Relations, J.D. Power, 3200 Park Center Drive, 13th Floor, Costa Mesa, California 92626; 714-621-6200; Fax: 714-621-6297; Email: media.relations@jdpa.com; or Robert Elfinger, Media Contact, Blue Cross Blue Shield, 225 North Michigan Avenue, Chicago, Illinois 60601; 312-297-5899; Email: press@bcbsa.com.

In 2016, hospital admission rates were highest in the District of Columbia, and lowest in Alaska. The rate of admission per 1,000 in population in the District of Columbia was 186, while the rate was 69 per 1,000 in population in Alaska.

The statistics were presented in “Hospital Admissions per 1,000 Population by Ownership Type, for 2016” by Kaiser Family Foundation (KFF). Researchers for KFF analyzed the 1999-2016 AHA Annual Survey, by Health Forum, LLC; and Population data from Annual Population Estimates by State, U.S. Census Bureau. The goal was to determine the most recent data related to community hospital admissions across the U.S for state and local government, non-profit, and for- profit facilities. Federal hospitals, long term care hospitals, psychiatric hospitals, institutions for the mentally retarded, and alcoholism and other chemical dependency hospitals were not included in the analysis.

Additional findings include:

  • After the District of Columbia, the next states with the highest rate of hospital admissions per 1,000 population were: West Virginia (138), Alabama (130), Mississippi (127), and both Kentucky and Missouri (126 for both).
  • For state and local government-owned hospital admissions only, Alabama (64), Mississippi (51), Wyoming (48), North Carolina (29), and South Carolina (28) had the highest admission rates per 1,000 Pennsylvania and Wisconsin had no admissions in this category.
  • For non-profit hospital admissions only, District of Columbia (153), North Dakota (118), West Virginia (114), Pennsylvania (109), and South Dakota (108) had the highest admission rates per 1,000 Wyoming had the least at 17 admissions per 1,000 population.
  • For for-profit hospital admissions only, Nevada (55), Florida (45), Alabama (38), Tennessee (36) and Texas (34) had the highest admission rates per 1,000 population. Delaware and Maryland had no admissions in this category.

The full text of “Hospital Admissions per 1,000 Population by Ownership Type, for 2016” was published by Kaiser Family Foundation.

For more information, contact: Rakesh Singh, Vice President of Communications, Kaiser Family Foundation, 1330 G Street, NW, Washington, District of Columbia 20005; 202-347-5270; Fax: 202-647-5274; Email: rsingh@kff.org.

Medicare fee-for-service beneficiaries who received services through a hospital-at-home (HAH) program bundled with a 30-day post acute transitional care episode had better outcomes, compared with people who remained hospitalized. HAH programs provide acute hospital-level care in a consumer’s home as a substitute for traditional inpatient care. Compared to a control group who remained hospitalized, Medicare beneficiaries who received HAH services had a shorter hospital length-of-stay, lower hospital readmission rates, fewer emergency department visits, and fewer admissions to a skilled nursing facility (SNF).

These findings were reported in “Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences” by Alex D. Federman, M.D., MPH; Tacara Soones, M.D., MPH; Linda V. DeCherrie, M.D.; Bruce Leff, M.D.; and Albert L. Siu, M.D., MSPH. The researchers sought to determine how an HAH program bundled with a 30-day episode of post-acute transitional care affected clinical outcomes compared to traditional inpatient care. The study compared outcomes of 507 adult hospital inpatients recruited in New York City from November 18, 2014, to August 31, 2017. The participants were 18 years or older with fee-for-service Medicare and acute medical illness requiring inpatient-level care. There were 295 in the HAH group and 212 control group members, who met HAH eligibility but refused participation or were seen in the emergency department when a HAH admission could not be initiated. The average age, across both groups was 74.6 years; 68% of the participants were women. The HAH participants were older than those in the control group and were more likely to have a pre-acute functional impairment.

Key findings were as follows:

  • Inpatient length of stay: HAH participants stayed 2.3 days compared to 5.5 days for the control group.
  • Readmission rates: 8.6% of HAH participants were readmitted compared to 15.6% of the control group.
  • Emergency department revisits: 8% of HAH participants revisited the emergency department compared to 11.7% of the control group.
  • Skilled nursing facility (SNF) admissions: 7% of the HAH participants were admitted to a SNF compared to 10.4% of the control group.
  • There were no differences in referrals to certified home health agencies.
  • There were no differences in the rates of adverse events.

In addition to having lower hospital and emergency department utilization, the HAH participants were more likely to rate their hospital care highly. About 68.8% of the HAH group and 45.3% of the control group gave the hospital high rankings. The researchers concluded that HAH bundled with a 30-day episode of post-acute transitional care may be a safe and effective alternative to inpatient care.

The full text of “Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences” was published June 25, 2018, by JAMA Internal Medicine.

For more information, contact: Albert Siu, M.D., Internal Medicine, Mount Sinai Hospital, 1468 Madison Avenue, Annenberg Building Floor 10, New York, New York 10029; 212-241-4290; Email: albert.siu@mountsinai.org.

“I can’t think of a recent conversation at Anthem that didn’t include value-based care. But, we can’t do value-based payment on an island. All insurance companies are interested in discussing a village concept of value-based care with consumer-centric provider organizations that have the infrastructure to do that. There are relationships all along that pathway, and while most organizations can’t be the whole village, they can be a significant piece of it.”

These remarks—made by Charles Gross, Ph.D., Vice President, Behavioral Health, Anthem, Inc., during his opening plenary address, “Going Beyond Innovation-Developing Partnerships With Health Plans” earlier this month—are words to the wise for any provider organization executive team developing strategy for the years ahead (assuming they are planning on health plan revenue as part of their income stream).

From the health plan perspective, there are some major hurdles to overcome. Dr. Gross discussed three key concerns— each of which have implications for provider organization strategy:

  1. Achieving network adequacy. Getting access to care, particularly access to psychiatrists and other high-demand specialists is an issue, and “better” (read: more attractive) payment models (see The Value-Based Reimbursement Steeplechase).
  2. Finding provider organization with the scale and capabilities to manage value-based contracts. There are some specific organizational capabilities needed to manage value-based arrangements and some requirements in terms of financial stability. For this reason, larger and resource-rich specialty provider organizations are more attractive to health plans.
  3. Developing a medical/behavioral health integration model. Many current VBR models have focused gainsharing on the primary care side of the equation—and a new model is needed that extends that gainsharing to behavioral health partners (see The Strategic Challenges On The Road To Value-Based Reimbursement).

Where is Anthem in a transformation to value-based reimbursement? Last year, Anthem Blue Cross executives announced that nearly 60% of its health plan spending during the first quarter of 2017 was through value-based care arrangements, including accountable care organizations (ACO) and patient-centered medical homes (PCMH) (see Anthem Blue Cross Nears 60% Value-Based Care Spending). Anthem is also focused on moving forward with VBR models for specialty provider organizations through several new programs.

The first of these programs that grabbed my attention is their new medical behavioral integration program (BHMIP)—what I see as curated partnerships matching behavioral health providers and primary care practices (PCP) in gainsharing arrangements. Launched in 2017, BHMIP pilots are operating in multiple states and utilize the standard outpatient quality and utilization metrics, while including additional focus on care coordination with PCP partners through care compact adoption and joint accountability for key physical health quality measures with behavioral health influences.

In addition, Anthem launched a gainsharing program for addiction treatment facility partners in 2017. The program is focused on promoting successful transitions out of inpatient/residential care with prevention of readmission back into a facility setting.

Dr. Gross also shared Anthem’s future plans for new models for contracting with specialists – calling the ACO and PCMH models unrealistic in their current engagement of specialty care. To address this, Anthem is working on specialty services (included behavioral) with new contracting models-acute and chronic bundles; payment for chronic management and e- consults; and a value-based fee-for-service (FFS) framework.

Gross, C. (2018). Behavioral health – value-based care evolution [Presentation Slides]. OPEN MINDS Strategy & Innovation Institute. Retrieved from https://www.openminds.com/market-intelligence/resources/060618_openingkeynote/.

The future Anthem VBR model for contracting for specialty care presented by Dr. Gross is a roadmap to a more consumer-centric health care system—and it is also a roadmap for provider organization strategy (see What’s The Window To Value-Based Care? and Crawl, Walk, Run To VBR). And these efforts to find a health care financing system that facilitates both better consumer outcomes and a new “partnership” model with provider organizations is not limited to Anthem (see Getting Past The Bumps In The Road To Value-Based Reimbursement). But, this shift in the specialist landscape also changes the competitive landscape and the model for organizational sustainability. The big strategy question for specialist organization management teams is a plan to weather the transition.

Mental health and addiction disorder-related medical conditions accounted for about 4.7% of total health spending in 2014. Behavioral health spending totaled about $101.5 billion in 2014; total health care spending that year was $2,047 billion. Of the total $101.5 billion spending for behavioral health-related spending, 2.3% was for alcohol use disorder treatment, and 4.75% was for substance use disorder treatment other than alcohol. The remaining 93% was for mental health treatment services.

The 2014 spending on mental illness was a 13.4% increase from the $89.54 billion spent in 2013. In 2013, mental health spending represented 4.05% of the total $2,208 billion health spend that year.

These findings were offered within the U.S. Bureau of Economic Analysis’ (BEA) Health Care Satellite Account. Researchers at BEA analyzed spending figures on more than 260 medical conditions categorized into 18 aggregate classifications between the years 2000 through 2014. These classifications, in order of spending, include: symptoms/ill- defined conditions, circulatory conditions, musculoskeletal conditions, respiratory conditions, endocrinological conditions, nervous system/sense organ conditions, neoplasms, injury/poisoning, genitourinary conditions, digestive conditions, mental illness and addiction disorder conditions, infectious diseases, skin/subcutaneous conditions, pregnancy/birth complications, blood and blood-forming organs conditions, perinatal conditions, congenital anomalies, and residual codes. The goals of the analysis were to identify the trends in spending over time and the key drivers of spending growth.

Additional findings from the BEA Health Care Satellite Account data for 2014 were as follows:

  • The five mental health conditions with the greatest share of spending in the category include mood disorders (31.9%); attention deficit, conduct and disruptive behavior disorders (14.1%); anxiety disorders (13.9%); delirium, dementia, amnestic and other cognitive disorders (10.8%); and schizophrenia and other psychotic disorders (9.1%).
  • Overall, mental illness spending was outspent by 10 other condition categories.

The full study of “Health Care Satellite Account” was published June 4, 2018 by the Bureau of Economic Analysis in the Journal of Health Affairs. A free summary is available online.

PsychU reported on this topic in “Spending For Consumers With Comorbid Medical & Behavioral Conditions At 34% Of Total U.S. Health Care Spending,” which published on March 22, 2018.

PsychU reported on the last BEA estimates in “Cost Of Treating Mental Illness Rose To $282 Per Capita In 2013, Up 1.5% From 2012,” which published on January 11, 2017.

For more information, contact: Thomas Dail, Media Contact, Bureau of Economic Alliance, 4600 Silver Hill Road, Washington, District of Columbia 20233; 202-606-2649; Email: thomas.dail@bea.gov.

Of 100 sampled claims for Medicare distant site telehealth services provided during 2014 and 2015 that did not have a corresponding originating site claim, 31 (31%) did not meet Medicare’s telehealth requirements. The Office of the Inspector General (OIG) estimates that Medicare could have saved about $3.7 million during this time by avoiding paying these and similar claims for services that failed to meet Medicare’s telehealth requirements.

Medicare telehealth payments include a professional fee, paid to the clinical professional performing the service at a distant site, and an originating-site fee, paid to the facility where the beneficiary receives the service. Conditions for payment include compliance with telehealth site location criteria, compliance with criteria for the professional delivering the services, the communication method criteria, and provided service eligibility.

These findings were presented in “CMS Paid Practitioners For Telehealth Services That Did Not Meet Medicare Requirements,” by Gloria L. Jarmon, deputy inspector general for audit services at the OIG. Auditors at the OIG reviewed 191,118 Medicare paid distant-site telehealth claims that did not have corresponding originating site claims, and performed a detailed analysis of a stratified random sample of 100 of these claims. The objective was to determine whether these services were allowable in accordance with Medicare requirements.

Of the 100 paid claims analyzed, 31 had did not meet Medicare telehealth requirements. Some had more than one disqualifying problem, as follows:

  • 24 claims were unallowable because the beneficiaries received services at non-rural originating sites.
  • 7 claims were billed by ineligible institutional provider organizations.
  • 3 claims were for services provided to beneficiaries at unauthorized originating sites.
  • 2 claims were for services provided by an unallowable means of communication.
  • 1 claim was for a non-covered service.
  • 1 claim was for services provided by a physician located outside the United States.

The OIG recommended that the Centers for Medicare & Medicaid Services (CMS) conduct periodic reviews of paid Medicare claims to find errors for which telehealth claim edits cannot be implemented. CMS should work with its Medicaid contractors to implement all telehealth claims edits listed in the Medicare Claims Processing Manual. Training and education should also be offered to those providing health care services regarding Medicare telehealth requirements.

PsychU last reported on telehealth issues in “VA Finalizes Telehealth Rule Allowing Health Care Professionals To Practice Across State Lines,” which published on June 21, 2018.

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.

Yesterday during the Aspen Spotlight Health Conference sessions, “Algorithms, Big Data, and Your Health” and “The Science Of Delivering Health Care” the big discussion was about the potential of “augmented intelligence” and “assistive technologies” to change the price point of health and human service delivery. What was interesting to me is that the presenters focused on “task shifting” as the primary way to harness technology in cost reduction-focusing on the idea that work done by specialists can be done by primary care professionals; that work done by primary care professionals can be done by other health workers; and that many services can be tech-enabled and directed by consumers themselves.

Toyin Ajayi, Chief Health Officer of Cityblock Health, spoke about task shifting as a key strategy to address inequities in access to health care—essentially augmenting and extending scarce clinical professionals’ time. She developed this perspective as part of the work of her organization in developing health systems for underserved urban populations. Lizzie Dorfman, Technical Program Manager with Google Brain gave a great example of task shifting—the work of her team at Google developing big data models to interpret diagnostic tests, reading scans, and reading biological laboratory samples. A diagnostic tool that will allow non-specialists to manage the diagnostic process. And not only can technology be a tool for creating the “tech-enabled professional”, Jay Komarneni, the founder of the Human Diagnosis Project, spoke of using technology for the competency testing that would allow clinical professionals to move “beyond their license” in delivering care with new technology.

This approach is not without its challenges. All the panelists spoke about the “resistance”—financial, cultural, regulatory, and more—to adopting clinical treatment technologies in the United States. Kelller Rinaudo, the Chief Executive Officer of Zipline, a company that delivers medical supplies of all types by drone, spoke about their growing business outside the United States—and their challenges getting scale in the U.S. market. But, I think that cost pressures in fee-for-service rates, and in the move to value-based reimbursement, may hasten the transition to tech-enabled professionals and consumers.

Our team has covered the changes in compensation in the positions that deliver the great volume of care to consumers with complex needs. What we see are steady increases in compensation at a time when service rates have remained flat.

Psychiatrists-The median compensation for psychiatrists rose more than any other specialty between 2017 and 2018, up 16% from $235,000 to $273,000. Foreign-trained psychiatrists earn slightly more at $308,000 vs. $256,000; as do men, at $285,000 vs. $250,000 (see Medscape’s “Psychiatrist Compensation Report 2018”).

Primary Care Physicians-Median compensation for primary care physicians in 2017 was $257,000, up 10.6% since 2013, when median compensation was $233,000. Within the primary care specialty, family medicine physician median compensation rose 12% between 2013 and 2017, but their median number of work relative value units (wRVUs) rose less than 1%. In two states, median compensation for primary care physicians declined: Alabama was down by 9%, and New York was down by 3%. It increased in five states: Wyoming (41%), Maryland (29%), Louisiana (27%), Missouri (24%) and Mississippi (21%).

Physician Assistants-Over the last five years, the average certified physician assistant (PA) salary increased 12.7%, from approximately $95,500 in 2012, to $107,700 in 2017. This price tag ranges from a high of $120,000 (pathology), to a low of $85,000 (adolescent medicine, gynecology, and pediatrics).

Nurse practitioners-From 2013 to 2017, median compensation for nurse practitioners rose by 7.9% (from $98,250, to $106,043), and the median compensation for non-physician clinical professionals rose by 8.4%, from $102,000 to $110,612.

Social Workers-The median annual wage for all social workers was $47,980 in 2017; there are wide ranging differences in specialties including health care ($54,870); child, family, and school ($44,380); and mental health and substance abuse ($43,250). Differences in setting included hospitals ($58,490); local government ($52,900); ambulatory health care ($48,340); state government ($46,120); and individual and family services ($40,800). The average salary for all social workers has risen 9.7% since 2010, when it was $43,700.

Applied Behavior Analysts-Salaries for ABAs as a specialty are not as readily available, but the Sage Colleges report that ABA therapists with a Bachelor of Science in Applied Behavior Analysis earn an average of $47,281 annually. Entry- level salaries range from $25,528 to $50,862 annually, and staff with a Master of Science degree in ABA earn $55,402 on average, with the highest earners collecting $80,287 annually.

Direct Support Staff-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. The lowest 10% of health home aides earned less than $18,450, and the highest 10% earned more than $31,260. For personal care aides, the lowest 10% earned less than $18,160, and the highest 10% earned more than $30,750. And, in 2016, the average rate of direct support personnel (DSP) turnover was 45.5%.

Peer Support Staff-Average peer specialist compensation was $15.42 in 2015. Compensation varied by type of employer, including Consumer/Peer Run Organization ($13.73), Community Behavioral Health Organization ($14.18), Health Care Provider Organization ($17.23), Psychiatric inpatient Facility ($15.85), and Health Plan/Managed Care Organization ($17.96). And, Medicaid fee-for-service reimbursement rates for selective states found a wide variation in reimbursement for peer support: group rates for a 15-minute period ranged from less than $2.00, to over $5.00 and individual rates ranged from $6.50 to $24.36 per 15 minutes; comparatively, average peer specialist compensation was $15.42 in 2015 (see Does Peer Support Pay?).

In the end, it may be that the market forces that are opposed to redefinition of professional roles may fall to the market forces looking to expand access and reduce costs through the leverage of technology in service delivery. In the meantime, provider organization executive teams should look for ways to leverage their clinical talent-from technology for consumer self-service to service process reengineering to performance-based compensation-these are continuous improvements needed to maintain margins in a time of increasing costs of talent and competitive rates.

For more, check out these resources from our senior team in the PsychU Library:

  1. How To Tackle Performance-Based Compensation
  2. The Value-Based Reimbursement Steeplechase
  3. From Consumer Engagement To Consumer Activation
  4. Task Shifting To Bend The Cost Curve
  5. Planning For The Digital Reinvention Of Your Market

For organizations delivering health and human services, there is the often-discussed behavioral health workforce shortage. Health plan managers are continuously looking for expanded capacity for psychiatric services. Provider organization executives often have recruiting and retention at the top of their list of strategic issues.

The subject of clinical capacity and consumer access to care are the subject of a wide range of recent studies and reporting. A new study found that by 2028, California will have 41% fewer psychiatrists than are needed to meet demand (see California Faces Major Shortage Of Behavioral Health Professionals). A state-level analysis showed that Nebraska is currently far below the national average when it comes to psychiatrist-to-population ratios (see Nebraska’s Psychiatrist- To-Population Ratio At 8.8 Per 100,000 Is 41% Below National Average Of 12.4 Per 100,000). And, the National Council Medical Director Institute reported last year that psychiatric services have been deemed “in crisis” and that “the pool of psychiatrists working with public sector and insured populations declined by 10% from 2003-2013”.

The behavioral health workforce is so “top of mind” in health care that it was the focus of a recent special issue of the American Journal of Preventive Medicine–“The Behavioral Health Workforce: Planning, Practice, and Preparation.” The edition opens with an overview, “The Future of the Behavioral Health Workforce: Optimism and Opportunity,” which explains the landscape facing the field–44 million American adults and counting have a diagnosable mental health condition, but the number of professionals who will choose behavioral health as a profession is predicted to be 250,000 “workers” short by 2025.

The issue also summarized the geographic variations in service capacity by types of clinical professionals—see “Geographic Variation in the Supply of Selected Behavioral Health Providers.” The analysis found that the percentage of counties that lack a psychiatrist ranged from a low of 6% in the New England Census Division to a high of 69% in the North Central Census Division. New England metropolitan areas have the highest proportion of mental health professionals per 100,000 population with 36.0 psychiatrists, 55.6 psychologists, and 5.8 psychiatric nurse practitioners (NP) per 100,000 population. The lowest proportion is in the West South Central metropolitan areas with 11.1 psychologists, 16.4 psychologists, and 1.4 psychiatric NPs per 100,000.

Another big topic of the workforce issue is the possible future roles of peers in the system. As of 2014, there were 36 states where mental health peer support services are a Medicaid billable service, and at least 11 states peer support for substance use disorders or co-occurring conditions is a billable service. In addition, the role of peers is expanding to become an integral part of care teams and consumer recovery efforts. While there are issues that need to be addressed in regards to wages, stigma, training and funding, peer support specialists represent an important workforce that can help connect consumers to resources and alleviate some of the current workforce shortages.

But, how to address these behavioral health workforce issues? There appear to be no easy solutions. I wrote earlier this week about the opportunities that technology presents for task shifting. One of the key problems identified is that there is no national data about the actual size of the behavioral health workforce, as discussed in the American Journal of Preventive Medicine article, “Improving Data for Behavioral Health Workforce Planning: Development of a Minimum Data Set,” which makes planning difficult. The authors note that despite 27 national data sources that collect workforce data, “no combination of data sources provides adequate data across the field of behavioral health to construct a national behavioral health workforce monitoring.” The solution presented by the authors is to create a minimum data set (MDS) that encompasses five elements: demographics; licensure and certification; education and training; occupation and area of practice; and practice characteristics and settings. This would be a great area of focus for SAMHSA but is unlikely to happen.

For more, I reached out to OPEN MINDS Senior Associate Sharon Hicks, who noted the need to rethink the roles of service professionals in the service delivery system:

For years, the non-medical, sometime called ancillary, professions in health care have been underpaid and undervalued as professional parts of the team. At the same time, people with Master’s degrees in clinical fields began to be replaced by bachelor-level staff. Salaries were driven down, while the responsibility for the safety of the people on one’s caseload went up.

I think that we have to re-professionalize the roles of people who do direct service, especially those who are doing so in community and other non-supervised settings – and allow all service professionals to work at the top of their license. A great start would be to develop standard definitions for activities and the skills required for each.

In many other Organization for Economic Co-operation and Development (OECD) countries, human service workers are coupled with health care service staff so that things like homelessness and poverty don’t have to be a barrier to effective care for chronic illness. But until we respect those who provide human services, compensate them at a reasonable level, require them to have advanced education and treat them as an important, and integral, part of the treatment team, the system in the United States won’t get there.

On May 22, 2018, the National Quality Forum (NQF) announced it had endorsed four new measures in its Behavioral Health and Substance Use Fall 2017 project. The new measures address continuity of care for adult Medicaid beneficiaries admitted to detoxification, follow-up care for adult Medicaid beneficiaries newly prescribed an antipsychotic, timely medication reconciliations for people newly admitted to inpatient settings, and provision of psychosocial screening during well-child pediatric visits.

The measures endorsed from the Fall 2017 project have been added to NQF’s Behavioral Health and Substance Use Portfolio, which includes measures endorsed during three previous project phases. After a measure is endorsed, it is ready for use by any entity that wants to adopt it as a quality measurement. The four newly endorsed behavioral health measures are as follows:

  • NQF# 3312: Continuity of Care for Medicaid Beneficiaries after Detoxification (Detox) From Alcohol and/or Drugs. The measure steward is the Centers for Medicare & Medicaid Services, Centers for Medicaid & CHIP Services (CMS). The measure is focused on adult Medicaid beneficiaries ages 18 to 64 who are discharged from a detoxification episode. The measure tracks the percentage of these discharges that are followed within 7 or 14 days by a treatment service for addiction disorder. The treatment services include the prescription or receipt of a medication to treat an addiction disorder. This measure will be reported across all detoxification settings for all adult Medicaid beneficiary discharges from detoxification from January 1 to December 15 of the measurement year. Data for this measure will be gathered from claims. The measure can be used at the population level.
  • NQF# 3313: Follow-Up Care for Adult Medicaid Beneficiaries Who are Newly Prescribed an Antipsychotic Medication. The measure steward is CMS. The measure is focused on adult Medicaid beneficiaries age 18 years and older. The measure tracks the percentage of new antipsychotic prescriptions for beneficiaries in the target population who have completed a follow-up visit with a clinical professional with prescribing authority within four weeks (28 days) of prescription of an antipsychotic medication. The measure will not include beneficiaries in the target population who have an acute inpatient admission during the four-week follow-up period after prescription of an antipsychotic medication, or beneficiaries who died within four weeks of the date of a new antipsychotic prescription. Data for this measure will be gathered from claims. The measure can be used at the population level.
  • NQF# 3317: Medication Reconciliation on Admission. The measure steward is CMS. The measure is focused on all people admitted to an inpatient facility from home or a non-acute setting. The measure tracks the percentage of newly admitted people for whom a designated Prior to Admission (PTA) medication list was generated by referencing one or more external sources of medications and for which all PTA medications have a documented reconciliation action by the end of Day 2 of the hospitalization when the admission date is Day 0. The measure allows for two exclusion criteria for people transferred from an acute care setting, and people whose length of stay is no longer than 2 days. Data for this measure will be gathered from electronic health records and paper medical records. The measure can be used at the facility level.
  • NQF# 3332: Psychosocial Screening Using the Pediatric Symptom Checklist-Tool (PSC-Tool). The measure steward is Massachusetts General Hospital. The measure is focused on children age 3 through 17 years seen for a pediatric well-child visit. The measure tracks the percentage of children whose pediatric well-child visit includes administration of a Pediatric Symptom Checklist (PSC) Tool as a visit component. Data for this measure will be gathered from claims, electronic health records, and paper medical records. The measure can be used at the clinician and population levels.

NQF is an independent, non-profit, multi-stakeholder membership organization whose mission is to improve health care quality. It brings together health care stakeholders to recommend quality measures and improvement strategies that improve consumer outcomes and reduce costs. Its primary activities include setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs.

The Behavioral Health and Substance Use Portfolio Standing Committee oversees NQF’s portfolio of behavioral health measures. Measures in this portfolio address tobacco, alcohol, and substance use; depression, major depressive disorders (MDD), schizophrenia, and bipolar disorders; health screening and assessment for those with serious mental illness; attention deficit hyperactivity disorder (ADHD); safe and appropriate inpatient psychiatric care; and follow-up after hospitalization.

PsychU reported on NQF activities in “National Quality Forum Recommends Measuring Telehealth Quality In Four Areas Of Impact,” which published on October 16, 2017.

For more information, contact: Behavioral Health and Substance Abuse Portfolio, National Quality Forum, 1030 15th Street NW, Suite 800, Washington, District of Columbia 20005; Email: behavioralhealth@qualityforum.org; or Sofia Kosmetatos, Director, 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.

The four-year Medicare Comprehensive Primary Care (CPC) initiative reduced the rate of emergency department use and hospitalization. CPC slowed growth in emergency department visits by 2% relative to the comparison group; and also slowed growth in hospitalizations by 2% relative to the comparison group, though this finding was statistically significant only at the 10% level.

These findings were reported in Evaluation of the Comprehensive Primary Care Initiative: Fourth Annual Report” by researchers with Mathematica. The researchers conducted a five-year evaluation which included implementation, impact, and synthesis studies from a number of data sources. The goal was to determine how CPC practices changed the way they delivered care through work on specific milestones.

The CPC was launched in October 2012 and ran through December 2016. The goal of CPC was to improve primary care delivery, health care quality, and patient experience, and lower costs; and also improve clinicians’ and staff members’ experience. CPC required practices to transform across five key care delivery functions: access and continuity, planned care for chronic conditions and preventive care, risk-stratified care management, consumer and caregiver engagement, and coordination of care across the medical neighborhood.

Additional findings include:

  • CPC practices reported improved primary care delivery, in terms of measures for care management for high-risk consumers, enhanced access, and improved coordination after care transitions.
  • Medicare expenditures grew more slowly for the CPC group than for the comparison group; however this change in Medicare expenditures was not enough to offset the initiative’s care management fees.
  • CPC did not noticeably improve or worsen physician or consumer experience or practice performance on a limited set of Medicare claims-based quality measures.

The full text of “Evaluation of the Comprehensive Primary Care Initiative: Fourth Annual Report” was issued May 3, 2018 by Mathematica. A free copy is available online.

PsychU reported on the Comprehensive Primary Care initiative in “Evaluation Of Comprehensive Primary Care Initiative Finds Hospital Admissions Down 2% & ER Visits Down 3%,” which published on April 9, 2015.

For more information, contact: Deborah Peikes, Senior Fellow, Mathematica Policy Research, Post Office Box 2393, Princeton, New Jersey 08543-2393; 609-750-2005; Fax: 609-799-0005; Email: dpeikes@mathematica-mpr.com.

Medicare Part D costs for brand name drugs rose by 77%, from $58 billion in 2011 to $102 billion in 2015. During the same period, the number of prescriptions for a brand name drug dropped by 17%, from 229 million prescriptions in 2011 to 191 million in 2015. After accounting for manufacturer rebates, reimbursement for brand name drugs in Part D still increased 62% from $49 billion in 2011 to $80 billion in 2015.

The rise in Part D costs for brand name drugs raised beneficiary out-of-pocket costs by 40% from 2011 to 2015. Across the five-year period, beneficiaries without third-party cost assistance paid $29 billion out-of-pocket for copayments and co- insurance for Part D brand name drugs. In 2011, about 3.7% of beneficiaries had out-of-pocket costs of $2,000 per year or more. By 2015, about 7.3% had out-of-pocket costs above $2,000 or more for brand name drugs.

These findings were reported in “Increases in Reimbursement for Brand-Name Drugs in Part D” by the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS). In the analysis, “brand name drug” was defined as any medication covered by Medicare Part D that has a national drug code (NDC) classified as an innovator product by the First Databank compendium and listed as a brand name product in the Red Book compendium. An NDC is an 11-digit identifier that provides information about the drug’s manufacturer, product, and package size. The OIG analyzed prescription drug event records from 2011 through 2015 for reimbursement amounts and utilization changes for brand name drugs covered by Medicare Part D, including the number of prescriptions and average unit costs. Further, the OIG evaluated beneficiary out-of-pocket costs for brand name drugs in Part D from 2011 to 2015.

Additional findings about brand name drugs and reimbursement include:

  1. Over the five-year span, Medicare Part D paid $382 billion for brand name drugs.
  2. From 2011 to 2015, the average unit cost for brand name drugs with Part D reimbursement in all five years increased 29%.
  3. From 2011 to 2015, the number of brand name drugs increased by 51%, from 3,637 drugs in 2011 to 5,492 in 2015.
  4. Of the 3,578 brand name drugs that were reimbursed by Part D in every year from 2011 to 2015, 89% had unit cost increases across the 5-year span. The average cost increase was 29%, and ranged from $115 in 2011 to $148 in 2015. For 12% of drugs, the unit costs at least doubled from 2011 to 2015.
  5. The increase in average unit cost was nearly 6 times greater than the 5% increase in the consumer price index (CPI) measure of inflation. Part D unit costs outpaced inflation for 85% of the brand name drugs the OIG reviewed.

The study also analyzed the utilization of specific brand name drugs with findings that include:

  1. In 2015, the 200 most used brand name drugs accounted for 85% of prescriptions and 71% of total Part D reimbursement for the brand name drugs the OIG reviewed. Part D reimbursement for these same 200 brand name drugs was $26 billion higher in 2015 than in 2011. The OIG believes that this indicates that manufacturers may have raised prices for brand name drugs with high Part D prescription volume.
  2. Part D unit costs for brand name drugs with the most utilization increased at a significantly greater rate than all brand name drugs in Part D from 2011 to 2015. Average unit costs for the 200 brand name drugs with the most prescriptions in 2015 increased by 57%, about twice the 29% rate of increase for all Part D brand name drugs.
  3. Benchmark prices, which plan sponsors use to negotiate Part D reimbursement amounts increased by about 10% for branded drugs reimbursed by Part D in two consecutive years. Benchmark prices for brand-name drugs increased about 10% from year to year between 2011 and 2015.
  4. For nearly half of branded drugs, Part D unit costs increased by at least 50% from 2011 to 2015. Part D spent $12 billion more for these same drugs in 2015 than in 2011.
  5. The total value of manufacturer rebates increased by 155%, from $9 billion in 2011 to $23 billion in 2015.
  6. Manufacturers paid rebates for 72% of brand name drugs in 2011, 2,612 of 3,637 drugs. In 2015, manufacturers paid rebates for 61% of brand name drugs, 3,328 of 5,492 drugs.

The OIG concluded that despite lower prescription volume for brand name drugs, the cost increases led to greater overall Medicare Part D spending and higher beneficiary out-of-pocket costs for these drugs. Because the Medicare Part D plan sponsors base reimbursement on the manufacturers’ prices, if the manufacturers increased wholesale costs, then costs rose for the plan sponsors and for beneficiaries.

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.

New England metropolitan areas have the highest proportion of mental health professionals, per 100,000 population. The New England metropolitan areas have 36.0 psychiatrists per 100,000 population, and 55.6 psychologists and 5.8 psychiatric nurse practitioners (NP) per 100,000 population. Nationwide across all metropolitan counties, there are 17.5 psychiatrists per 100,000 population, and 33.2 psychologists and 2.2 psychiatric NPs per 100,000 population. The lowest proportion is in the West South Central metropolitan areas. This region has 11.1 psychologists per 100,000 population, and 16.4 psychologists and 1.4 psychiatric NPs per 100,000.

Overall, across the United States, there are 15.6 psychiatrists per 100,000 population, 30.0 psychologists, and 2.1 psychiatric NPs. About 51% of counties have no psychiatrist, 37% of counties have no psychologist, and 67% of counties have no psychiatric NPs. The distribution of each type of mental health professional varies across metropolitan areas, non-metropolitan areas, micropolitan areas, and non-core areas which have fewer than 10,000 people. Metropolitan areas have the highest concentrations of all three types of mental health professionals. Non-core areas have the lowest concentrations.

Mental Health Professional Per 100,000 Population & Percent Of Counties Without A Professional, By County Type

County Psychiatrists Psychologists Psychiatric NPs
Professionals per 100,000 population % of Counties without provider Professionals per 100,000 population % of Counties without provider Professionals per 100,000

population

% of Counties without provider
Overall U.S. 15.6 51 30.0 37 2.1 67
Metropolitan 17.5 27 33.2 19 2.2 42
Non- metropolitan 5.8 65 13.7 47 1.6 81
Micropolitan 7.5 35 16.8 19 2.1 60
Non-core 3.4 80 9.1 61 0.9 91

These findings were reported in “Geographic Variation in the Supply of Selected Behavioral Health Providers” by C. Holly A. Andrilla, MS; Davis Patterson, Ph.D.; Lisa A. Garberson, Ph.D.; Cynthia Coulthard, MPH; and Eric H. Larson, Ph.D. Researchers used 2015 National Provider Identifier data from The National Plan and Provider Enumeration System to assess the supply of psychiatrists, psychologists, and psychiatric nurse practitioners, across three geographic categories based on their practicing county (metropolitan, micropolitan, and non-core). The provider-to-population ratios for each provider type were estimated using Claritas 2014 U.S. population data.

The researchers found that there was a large difference in availability of mental health professionals between census divisions. The New England Census Division had the highest availability at 34.1 psychiatrists per 100,000 population compared to the lowest availability, 9.8, in the South Central Census Division. In the New England Census Division, 6% of counties lacked a psychiatrist compared with 69% of counties without a psychiatrist in the West North Central and the West South Central Census Divisions.

Mental Health Professionals Per 100,000 Population & Percent Of Counties Without A Professional, By U.S. Census Division

Census division Psychiatrists Psychologists Psychiatric NPs
Professionals per 100,000 population % of Counties without provider Professionals per 100,000

population

% of Counties without provider  

Professionals per 100,000 population

% of Counties without provider
New England Average 34.1 6 55.6 1 5.8 15
Metropolitan 36.0 3 57.1 3 5.7 9
Non- metropolitan 19.9 9 44.3 0 6.3 21
Micropolitan 24.6 6 49.5 0 7.4 19
Non-core 12.0 12 35.4 0 4.5 24
Middle Atlantic Average  

24.7

 

9

 

41.8

 

5

 

2.9

 

29

Metropolitan 25.8 4 43.9 2 3.0 15
Non- metropolitan 9.3 19 14.3 9 2.1 54
Micropolitan 9.4 0 15.6 0 2.4 40
Non-core 9.1 42 11.0 21 1.4 71
East North Central Average  

13.5

 

42

 

31.3

 

22

 

1.2

 

66

Metropolitan 15.4 22 35.3 12 1.3 42
Non- metropolitan 5.3 55 13.8 29 0.7 82
Micropolitan 6.4 33 16.2 17 0.9 69
Non-core 3.2 73 9.1 39 0.4 94
West North Central Average  

13.1

 

69

 

32.3

 

56

 

2.4

 

77

Metropolitan 16.6 40 39.4 33 2.5 55
Non- metropolitan 5.3 77 16.6 62 2.2 83
Micropolitan 7.7 37 23.9 25 3.3 52
Non-core 3.0 88 9.8 73 1.2 92
South Atlantic Average 14.3 42 25.0 27 1.6 67
Metropolitan 15.4 29 27.0 17 1.7 49
Non- metropolitan 5.9 58 10.2 38 0.7 87
Micropolitan 7.9 34 12.2 18 1.1 73
Non-core 3.5 69 7.7 48 0.3 95
East South Central Average  

10.1

 

57

 

16.9

 

46

 

3.2

 

65

Metropolitan 13.1 40 21.3 34 3.7 47
Non- metropolitan 3.7 65 7.7 52 2.1 74
Micropolitan 4.9 40 10.0 30 3.2 49
Non-core 2.3 78 5.3 63 1.0 87
West South Central Average  

9.8

 

64

 

14.9

 

49

 

1.3

 

80

Metropolitan 11.1 36 16.4 26 1.4 55
Non- metropolitan 3.2 77 7.2 61 0.6 92
Micropolitan 4.7 47 9.1 28 0.8 82
Non-core 1.3 89 4.9 74 0.4 96
Mountain Average 12.0 61 28.3 40 2.8 68
Metropolitan 13.3 28 30.7 18 3.0 29
Non- metropolitan 6.0 71 16.6 46 2.2 80
Micropolitan 7.6 40 19.2 12 2.5 54
Non-core 3.1 86 11.5 62 1.5 92
Pacific Average 16.9 34 36.1 22 1.8 49
Metropolitan 17.5 9 37.0 5 1.8 22
Non- metropolitan 6.8 56 19.6 37 2.5 72
Micropolitan 7.7 24 21.3 6 2.6 47
Non-core 4.3 75 15.1 55 2.1 88

The full text of “Geographic Variation in the Supply of Selected Behavioral Health Providers” was published in June 2018 in a Special Supplement on “The Behavioral Health Workforce: Planning, Practice, and Preparation” released by the American Journal of Preventive Medicine. The supplement is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services. A free copy is available online.

PsychU reported on this topic in “California Faces Major Shortage Of Behavioral Health Professionals,” which published on March 28, 2018.

PsychU also reported on this topic in “Nebraska’s Psychiatrist-To-Population Ratio At 8.8 Per 100,000 Is 41% Below National Average Of 12.4 Per 100,000,” which published on October 16, 2017.

For more information, contact: C. Holly A. Andrilla, MS, Research Scientist at the Washington, Wyoming, Alaska, Montana, Idaho Rural Health Research Center, Department of Family Medicine, University of Washington, Box 354982, Seattle, Washington 98195; 206-685-6680; Fax: 206-616-4768 Email: hollya@uw.edu.

From 2012 through 2014, American adults made more than 30 million physician office visits for mental health concerns, and 55% of those visits were to psychiatrists. For adults age 18 and older, the mental health-related office visit rate was 1,251 per 10,000 adults. The psychiatrist visit rate was 693 per 10,000 adults. The rate of primary care visits for a mental health concern was 397 per 10,000 adults. The rate of visits to other specialists for a mental health concern was 162 per 10,000 adults. Mental health office visits are defined as any visit with a primary diagnosis code indicating a mental health issue; inclusive of codes 100–1199 or 2300–2349.

Mental Health-Related Physician Office Visit Rates Per 10,000 For Adults Age 18 & Older, By Physician Specialty & Age Group, 2012-2014

Total Psychiatrist Primary Care Physician Other Specialist
All Ages 1,251 693 397 162
18 to 34 1,093 605 377 110
35 to 49 1,369 805 426 138
50 to 64 1,399 799 399 201
65+ 1,140 529 384 226

These findings were reported in “Data Brief, No. 311. Mental Health-related Physician Office Visits by Adults Aged 18 and Over: United States, 2012–2014” by Donald Cherry, M.S.; Michael Albert, M.D., M.P.H.; and Linda F. McCaig, M.P.H. There researchers analyzed data from the 2012–2014 National Ambulatory Medical Care Survey (NAMCS) to examine adult mental health-related physician office visits. The goal was to determine differences in visit patterns by specialty and selected consumer characteristics. The NAMCS collected data on 76,330 office visits in 2012, 54,873 office visits in 2013, and 45,710 office visits in 2014. For 2012–2014, a sample of 6,040 mental health-related visits was drawn from all visits made by patients aged 18 and over. The national data are weighted to produce national estimates of office visits.

For both men and women, the rate of mental health-related office visits to psychiatrists was higher compared with visits to primary care physicians. Men made 596 psychiatrist visits per 10,000 and 337 primary care visits per 10,000. Women made 782 psychiatrist visits per 10,000 and 452 primary care visits per 10,000.

Mental Health-Related Physician Office Visit Rates Per 10,000 For Adults Age 18 & Older, By Physician Specialty & Consumer Gender, 2012-2014

Total Psychiatrist Primary Care Physician Other Specialist
Male 1,111 596 337 178
Female 1,380 782 452 147

The percentage of mental health-related office visits to psychiatrists compared with primary care physicians was lower in rural areas, but higher in large metropolitan areas. In large metro areas, 63% of mental health visits were to psychiatrists, and 26% were to primary care physicians. In medium to small metropolitan areas, 37% of mental health visits were to psychiatrists and 37% were to primary care physicians; this difference could have been due to chance. In rural areas, 26% of mental health visits were to psychiatrists, and 54% were to primary care physicians.

Percentage Of Mental Health-Related Physician Office Visits By Physician Specialty, According To Urban-Rural Status Of Consumers, 2012-2014

Psychiatrist Primary Care Physician Other Specialist
Large Metropolitan Area 63% 26% 11%
Medium – Small Metropolitan Area 37% 44% 18%
Rural 29% 54% 17%

Privately insured people made a greater share of mental health visits to psychiatrists than primary care physicians, 54% to psychiatrists compared with 34% to primary care. The same pattern was true for people covered by Medicaid or the Children’s Health Insurance Program, at 56% to psychiatrists compared with 34% to primary care. The pattern was exaggerated for the uninsured; 78% of mental health visits were to a psychiatrist, and 14% were to a primary care physician. Among Medicare beneficiaries, 45% of mental health visits were to a psychiatrist, and 36% were to a primary care physician.

Percentage Of Mental Health-Related Physician Office Visits By Physician Specialty, According To Primary Expected Payer, 2012-2014

Psychiatrist Primary Care Physician Other Specialist
Private 54% 34% 12%
Medicare 45% 36% 19%
Medicaid/ CHIP 56% 34% 10%
Uninsured 78% 14% 8%

PsychU last reported on this topic in “Behavioral Health Utilization Increased Among Individuals With Private Insurance After Recession,” which published on February 4, 2016.

For more information, contact: Donald Cherry, MS, Ambulatory and Hospital Care Statistics Branch, Division of Health Care Statistics, CDC’s National Center for Health Statistics, Center for Disease Control and Prevention, 3311 Toledo Road, Room 3325, Hyattsville, Maryland 20782; 301-458-4800; Email: paoquery@cdc.gov.

Community-based care is the concept where health care and social services are delivered to the consumer wherever they are, outside of the traditional office setting. This may be in their home, daycare, community center, park, or group home. Over the past ten years, the use of community-based care has increased both due to consumer preference and to lower costs (see Over 50% Of Medicaid LTSS Expenditures For HCBS In 2013). And with the increase in value-based reimbursement, provider organizations have increasing flexibility on how and where services are delivered.

At a recent session, “Innovative Community-Based Care Models For Consumers With Complex Conditions,” led by Senior Associate Annie Medina, MBA, ACNP-BC, featured two models—the Healthy Together Care Partnership model operated by Banner University Health Plans, and the dual diagnosis treatment team operated by Merakey (formerly NHS)—presented by Kristin Cline, Clinical Lead Specialist, Merakey; Kevin Kumpf, Ph.D., Clinical Director, Merakey; and Nancy Wexler, Program Manager, Healthcare Innovation, Banner University Health Plan.

There is a wide range of community-based program models which vary in their enrollment of consumers, the clinical professionals included on the care team, the payer, the rate, etc. The models shared by Banner and Merakey varied significantly in their individual components, but both were focused on wrapping around the member, coordinating their care, and building the skills to manage their own care.

OPEN MINDS. (2018). Innovative community-based care models for consumers with complex conditions. Accessed online 20 June 2018 at https://www.openminds.com/market-intelligence/resources/sii18_medina_complexconditions_060618/.

The results from the HTCP program were impressive. In the initial year, the program resulted in $61 per member per month in savings, and a 10% decline in medical expenses for the population. Overall there was a 16% decline in emergency department visits and a 26% decline in inpatient admissions. Additional, population-specific analyses in 2016 showed that for consumers with a behavioral health diagnosis there was a 17% reduction in inpatient admissions, and a 29% decrease for those with diabetes. Additionally, 87% of consumers reported improved health status and 94% that they were better able to manage their condition.

OPEN MINDS. (2018). Innovative community-based care models for consumers with complex conditions. Accessed online 20 June 2018 at https://www.openminds.com/market-intelligence/resources/sii18_medina_complexconditions_060618/.

There were a couple of key points that both Merakey and Banner emphasized that are important to running community- based programs. The first is the staffing and culture of the program. Working in a community-based program is much different than working in an office-based setting. Staff have to be comfortable working in stressful situations and with a high degree of irregularity. If you spend 85% of your time in the community, every day can look different. Staff have to be comfortable with not knowing what is going to happen. Additionally, members of the team have to be careful about not becoming too attached to participants in the program. It is important that the team builds trust and can tell one another when it is time to take a step back.

The second key point, was that follow-up after treatment was crucial. While both programs phased down after 12-18 months, they continued to check in with consumers after the program ended. The idea was to reinforce behaviors learned and to make sure they don’t need additional assistance.

Finally, Nancy Wexler, Program Manager, Healthcare Innovation, Banner University Health Plan, emphasized the importance of evaluating your program and being able to report outcomes. Banner began funding the HCTP program via an internal grant in 2014. Over the next couple of years, the HTCP program was able to test enrolling different populations and tweak the model. The ability to not be locked into a set program was also crucial. Ultimately, the evaluation was shown to be successful through careful outcome reporting and the health plan agreed to continue the program using a pay-for-performance contract.

For her insight and takeaways on the session, I reached out to Ms. Medina, who noted:

Both of these programs highlight some of the best-practices that we know to be true in delivering home- and community- based services: collaborative, interdisciplinary teams; consumer-centric, personalized services; flexible service definitions and locations; and services designed to support integration and inclusion. The successes that Merakey and Banner shared really highlight the ability of innovative treatment models to meet the needs of some of our most complex and hard-to-reach consumers, while also showing a positive return on financial investment.

The care coordination program model (medical homes, specialty medical homes, and health homes) has gained traction over the past decade across all payers. In between 2014 and 2016, there was a 39% increase in the number of individuals in Medicaid care coordination initiatives. And in 2017, 88% of Medicaid health plans had adopted specialty care coordination initiatives and there was adoption of these models by commercial payers (see Trends In Behavioral Health: A Reference Guide On The U.S. Behavioral Health Financing & Delivery System and Think Health Homes Are Only For Medicaid?).

For Medicaid health plans, the use of health homes have increased over that period since their introduction in the PPACA. In 2014, a little over one million individuals throughout 18 states were served by health homes. In 2018, 1.3 million individuals throughout 22 states are served by health homes. Currently, there are new states planning to add health home programs in the summer of 2018, such as California (see California Medicaid Health Homes To Launch On-Time In San Francisco, Riverside & San Bernardino Counties).

One big consideration is whether Medicaid plans will continue their support of health homes. I think this depends on the performance of health homes for Medicaid plans, as well as some of the big policy issues in their implementation and on- going management. At the national level, the Centers for Medicare & Medicaid Services (CMS) has not released a quantitative evaluation of the health program; however, individual states have reported mixed results (see Suspension Of Iowa Medicaid Integrated Health Homes On Hold).

We got a firsthand look at these questions from the state perspective last week during a recent institute, when Alyssa Brown, Deputy Director, Planning Administration, Office of Health Care Financing, Maryland Department of Health shared outcomes and experiences from the Maryland health home program during the session “The Return On Investment On Medical and Health Homes.” As a little background, Maryland implemented their health home program in 2013 for individuals with serious mental illness or opioid substance use disorder, and who are at- risk for an additional chronic condition due to tobacco, alcohol, or non-opioid related addiction disorder. Services are delivered by the psychiatric rehabilitation programs (PRPs), mobile treatment services, and opiate treatment programs, which contract directly with the state. Rates are $100.85 for outreach and engagement, and $100.85 for services delivered each month thereafter.

Coming into its fifth year, Ms. Brown shared the results of the Maryland health home program. Currently, there are 83 approved health home provider organizations who have served approximately 6,800 enrollees. The majority of enrollees are served by the PRPs. On average, participants receive 5 to 6 health home services per quarter, with the greatest need being for comprehensive care coordination and care promotion. Annual costs for the program are about $6 million per year.

OPEN MINDS. (2018). The return on investment on medical and health homes. Accessed online 20 June 2018 at https://www.openminds.com/market- intelligence/resources/the-return-on-investment-on-medical-and-health-homes/.

 

Preliminary results from Maryland’s health home program found that the longer a consumer is engaged in health home services, the larger the decrease in emergency department utilization. Participants that were enrolled in the health home program for zero to six months had an average of 1.03 emergency department visits. For participants that were enrolled in the program for 37 to 42 months, there was an average of 0.29 emergency department visits per participant. The same held true for inpatient admissions. For participants enrolled zero to six months, 12.5% utilized inpatient services. Comparatively, only 5.3% of participants enrolled for 37 to 42 months utilized inpatient services.

OPEN MINDS. (2018). The return on investment on medical and health homes. Accessed online 20 June 2018 at https://www.openminds.com/market- intelligence/resources/the-return-on-investment-on-medical-and-health-homes/.

Based on the preliminary results, Maryland is continuing to delve deeper into the results. While results appear to improve the longer a person is enrolled, only a small percentage of health home participants actually remain in the program for 37 to 42 months. How to keep participants engaged is a major challenge, one for which Maryland does not yet have a prescription or solution. Then there is the issue of how long participants should be enrolled in the health home program. Is the goal to provide the tools for consumers to manage their own care, or should health homes be a program that the participant receives indefinitely?

Ms. Brown noted that—based on the promising data and Maryland’s goal to better integrate behavioral health and physical health services (Maryland has a behavioral health carve-out)—the state will continue to offer the health home program in the future. The state is looking to address some of the challenges with operating health homes, such as which provider types can participate, as well as questions pertaining to rates.

What implications do the results in Maryland have for provider organizations in other states? The first is the issue of improvement over the long-term. In Maryland, the state manages the health home program and pays for behavioral health services directly, meaning that long-term results are desirable. For states where the health plan manages the health home services and enrollees churn on and off the roles, short-term results may be more desirable than a program that takes momentum. The second is that organizations who can engage consumers initially—and keep them engaged over time— will be more successful than organizations who do not prioritize engagement.

Median compensation for primary care physicians in 2017 was $257,000, up 10.6% since 2013, when median compensation was $233,000. During the same period, median compensation for psychiatrists rose about 16% from $227,000 to $265,000. Compensation for this comparison includes total wages, bonuses, life insurance, 401K, and pre- taxed employee contributions. It does not include fringe benefits paid by the medical practice, expense reimbursements, flex spending accounts, health insurance, or employer contributions.

These statistics were provided by Medical Group Management Association (MGMA) from its 2018 “MGMA DataDive Provider Compensation” report. The report is based on comparative data from survey responses submitted by over 136,000 physicians and health care professionals in over 5,800 organizations. The survey represents a variety of practice types including physician-owned, hospital-owned, academic practices, as well as clinical professionals from across the nation at small and large practices. Additional findings were as follows:

The 10% increase in primary care physician median compensation was nearly double the median compensation increase of most other specialists. MGMA believes that the variation, combined with the rise in median compensation for non- physician clinical professionals indicates a worsening shortage of primary care physicians. MGMA is an association for professionals who lead medical practices. Its membership includes more than 40,000 medical practice administrators, executives, and leaders who represent more than 12,500 organizations.

The full text of the “2018 MGMA DataDive Provider Compensation” report was published in May 2018. The report can be purchased by MGMA members and non-members.

PsychU reported on this topic in “76% Of Physicians Satisfied With Their Current Position; Salary The Leading Source Of Dissatisfaction,” which published on May 14, 2018.

PsychU also reported on this topic in “Specialist Physician Median Compensation Nearly $123,000 Higher For Private Hospitals Compared To Teaching Hospitals,” which published on January 10, 2018.

For questions related to purchasing, contact: Data Sales Team, Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado 80112-5306; 877-275-6462, ext. 1801; Email: sales@mgma.com.

For data-specific questions, contact:, Data Solutions Team, Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado 80112-5306; 877-275-6462, ext. 1895; Email: survey@mgma.com.

Average certified physician assistant (PA) salaries increased 12.7%, from approximately $95,500 in 2012, to $107,700 in 2017. The highest median incomes for PAs in 2017 were for those working in pathology ($120,000), critical care medicine ($115,000), dermatology ($115,000), emergency medicine ($115,000), and surgical subspecialties ($115,000). The lowest median incomes for PAs were for those working in adolescent medicine, gynecology, and pediatrics, all with a median income of $85,000.

These findings were reported in “2017 Statistical Profile of Certified Physician Assistants” by the National Commission on Certification of Physician Assistants (NCCPA). Researchers for the organization analyzed responses from 112,485 PAs of the 123,089 PAs currently certified. The goal was to determine trends in the PA profession.

Additional findings include:

The full text of “2017 Statistical Profile of Certified Physician Assistants” was published in May 2018. A free abstract is available online.

PsychU last reported on this topic in “Nurse Practitioners May Represent 27% Of The Family Practice Workforce By 2025,” which published on May 23, 2018.

For more information, contact: Mary Rittle, Media Contact, National Commission on Certification of Physician Assistants, 12000 Findley Road, Suite 100, Johns Creek, Georgia 30097-1409; 678-417-8142; Email: maryr@nccpa.net.

Clinicians managing patients with behavioral health issues are presented with various diagnostic and treatment challenges, spanning the areas of neurobiology, adherence, safety, and medication tolerability. Currently available pharmacotherapeutic, psychotherapeutic, and combination therapies often provide inadequate or only partial responses, leaving patients with a host of residual symptoms. Neuromodulation techniques, including transcranial magnetic stimulation (TMS), deep brain stimulation (DBS) and others, have been gaining favor among experts as alternative options for addressing those experiencing inadequate response with more traditional treatment regimens.

In this webinar, Philip G. Janicak, MD, Adjunct Professor in the Department of Psychiatry and Behavioral Sciences at Northwestern University, Feinberg School of Medicine and Director of the Transcranial Magnetic Stimulation Center at Edward/Elmhurst Healthcare in Naperville, Illinois and Michael Thase, MD, Professor of Psychiatry and Director of the Mood and Anxiety Disorders Treatment and Research Program at University of Pennsylvania Perelman School of Medicine, discuss the state of the science in neuromodulation techniques. Speakers discuss their perspectives and the supporting evidence for various forms of neuromodulation in the treatment of mental health disorders, with a focus on depression.

Mental health self-direction for consumers with serious and persistent mental illness (SPMI) is associated with a modest increase in employment and housing independence outcomes. Self-direction allows a health care consumer to choose the combination of supports and services that fits their life and needs. Compared to consumers who did not participate in self- direction, those who did participate were 73% more likely to increase the number of days worked in the past 30 days, or to maintain the number of days worked at 20 or more during the past 30 days. Those participating in self-direction were twice as likely to attain or maintain independent residential status.

These findings were reported in “Housing and Employment Outcomes for Mental Health Self-Direction Participants” by Bevin Croft, M.P.P., Ph.D.; Nilüfer İsvan, Ph.D.; Susan L. Parish, Ph.D.; and Kevin J. Mahoney, Ph.D. The researchers collected data from 271 self-directing participants, and built a comparison group of 1,099 non-self-directing individuals, for a four-year study period. The data came from FloridaSDC, a large mental health self-direction effort for Florida residents 18 and older diagnosed with a serious and persistent mental illness. FloridaSDC participants must be legally competent to make financial decisions and may not be enrolled in assertive community treatment. The analysis was based outcomes of two study periods, one that ran from July 1, 2010, to April 30, 2015; and the other that ran from July 1, 2012, to June 22, 2015.

The FloridaSDC participants controlled a budget of funds that would traditionally have been spent only on mental health treatment services. The participants were able to decide how to use the funds to purchase a range of goods and services that would not typically be considered mental health treatment. Their purchases could include transportation, supports for housing, employment, or education, or even mental health treatment from a provider of the person’s choosing.

Employment and independent housing outcomes of the self-directing group were compared to those of the non-self- directing group. The comparison focused on the likelihood of achieving positive outcomes between the first and last assessments. The researchers calculated the number needed to treat (NNT) to obtain one more positive outcome.

A positive employment outcome was defined as increasing the number of days worked in the past 30 days from the first to last assessment, or maintaining the number of days worked at 20 or more during the past 30 days at both assessments. A positive housing outcome was defined as maintenance of independent housing status at the first and last assessments.

Additional findings include:

The full text of “Housing and Employment Outcomes for Mental Health Self-Direction Participants” was published May 15, 2018, by Psychiatric Services. A free abstract is available online.

For more information, contact: Bevin Croft, M.P.P., Ph.D., Research Associate, Human Services Research Institute, 2336 Massachusetts Avenue, Cambridge, Massachusetts 02140; 617-876-0426; Email: bcroft@hsri.org.

On May 10, 2018, the National Committee for Quality Assurance (NCQA) and Medical Home Network (MHN) launched a joint research project to study the effects of connections between Medicaid patient-centered medical homes (PCMH) and community-based organizations (CBO) that provide social services. For this project, a CBO is defined as any social service provider organization that serves an individual but is not responsible for providing “whole person care” in the same way that a PCMH or a hospital is held responsible.

The goal is to test a web-based system, MHNConnect, as a communication and care management health information exchange to connect the participating PCMHs with CBOs. The project will assess whether connecting hospitals and PCMHs with CBOs affects adult Medicaid beneficiaries’ subsequent use of hospital and emergency department services, and how the information sharing affects health outcomes among populations with social risk factors such as homelessness, unemployment, or food insecurity. The project is funded by the Robert Wood Johnson Foundation.

The project will take place in Cook County, Illinois, with MHN and the Cook County Health & Hospitals System (CCHHS). CCHHS has partnered with MHN since 2013 to help coordinate care for over 350,000 Medicaid beneficiaries enrolled in CountyCare, the CCHHS Medicaid managed care plan. For the project, up to 200 CountyCare participating PCMHs and 25 hospitals will use MHNConnect to share consumer information with a variety of CBOs within Cook County to address social risk factors for about 120,000 CountyCare members. The study will only analyze data for adults, but will tangentially consider children in that some CountyCare members are parents who use CBO services for needs that include their children. The study started in January 2018, and ends in December 2019. The outcomes during the study period will be compared to historical data collected by the county and MHN. In the analysis, NCQA will use Healthcare Effectiveness Data and Information Set (HEDIS) measures to monitor the quality of care provided to consumers.

Initially, 13 CBOs prioritized by CCHHS are participating, and one more is considering participating. The participants include 12 behavioral health provider organizations that are part of The Behavioral Health Consortium; and HRS Home Health, a home health provider organization. CCHHS prioritized these CBOs for participation after reviewing data about adult CountyCare members. One of the factors was to identify the CBOs that served the large share of CountyCare members. Over time, MHN intends to include all CBOs in the CountyCare network. There is no cost to the CBOs to use MHNConnect, nor is there a cost for training.

MHNConnect, is a secure, web-based health information exchange platform that shares real-time consumer health care activity alerts and clinical information between clinical professionals, hospitals, and clinics. In 2016, MHNConnect expanded to provide behavioral health utilization alerts. In January 2018, MHN added a module to facilitate communication between PCMHs and CBO social service provider organizations. The portal shares claims, condition history, care management history, prescriptions. It facilitates bilateral communications between the PCMH and the CBO.

For the project, the CBOs will also use MHNConnect to communicate with the PCMHs. The project press release noted that MHN believes MHNConnect will solve two barriers to information sharing: Most CBOs do not use electronic records that can easily communicate with PCMH electronic health records, and most PCMHs do not have adequate mechanisms for referring consumers to social services. CCHHS Chief Executive Officer Jay Shannon, M.D. said the project will help CCHHS learn where provider organizations, such as Cook County Health, can work more effectively with CBOs to improve consumer health status.

PsychU reported on MHNConnect in “Medical Home Network Expands Cook County Partnership To Include Mental Health Alerts,” which published on February 13, 2017.

For more information, contact:

On May 18, 2018, Kaiser Permanente, a large non-profit managed health care system, announced plans to invest $200 million through its Thriving Communities Fund to address housing stability and homelessness, among other community needs. This is one of the largest private-sector initiatives with a concentration on homelessness.

In the announcement, Bernard J. Tyson, Kaiser Permanente’s chairman and chief executive officer, said housing stability is a key factor in overall health and well-being, and that investing in housing stability ultimately serves Kaiser Permanente’s core health care business. The investment, classified as an “impact investing commitment,” will be made by 2021. Impact investments are made with the intention to generate both a measurable social benefit and a financial return.

The new investments will target areas in which Kaiser Permanente currently operates. These areas include Northern and Southern California, Washington State, Oregon, Hawaii, Colorado, Georgia, Maryland, Virginia, and the District of Columbia. Kaiser Permanente’s initial efforts will focus on the following: preventing displacement and homelessness in lower- and middle-income households in rapidly changing communities; ensuring access to supportive housing; and making affordable homes healthier and more environmentally sound.

Non-profit Kaiser Permanente provides health care services for more than 12.2 million members in eight states and the District of Columbia. Additional community health initiatives by the company include a number of healthy eating, active living, health education, and policy direction efforts for health improvement.

For more information, contact: Marc Brown, Manager, National Public Relations & Media Relations, Kaiser Permanente, One Kaiser Plaza, Oakland, California 94612; 510-271-5953; Email: national-media-relations@kp.org.

Background

The disparity in life expectancy between the general population and individuals with serious mental illness (SMI) can be attributed in part to preventable chronic conditions, exacerbated by behavioral risk factors and metabolic side effects from some antipsychotic medications.

Although individuals with SMI receive preventive care at rates similar to that of the general population, there is evidence that rates of screening among this population are suboptimal, particularly for individuals served by federally qualified health centers (FQHCs).

Comparison shopping, common in every other field, has been a long time coming to health care. But recent news from the Centers for Medicare & Medicaid Services (CMS) may signal a sea change in price transparency.

Last month, CMS issued a proposed rule that requires hospitals to post their standard charges online. If this sounds familiar, that’s because CMS already “requires” this, but currently allows hospitals an alternative. Hospital can elect to only show the charges by request, as long as the facility posts notices explaining this policy. If finalized, the new rule will eliminate the alternative and require the posting of standard charge list, online and publicly accessible.

CMS also recently released the responses to a request for information seeking comments about barriers that prevent provider organizations from informing consumers of their out of pocket costs; what changes are needed to support greater transparency around consumers obligations for their out of pocket costs; what can be done to better inform consumers of these obligations; and what role provider organizations should play in this initiative. The goal of this price transparency is to provide consumers with the tools to do “price shopping” when looking for health care services – and reduce the cost of health care.

Does price transparency decrease health care costs? We’re not exactly sure because there has been little research done on this topic—and very few organizations that are actually transparent about their costs. The studies that are out there suggest positive results. For example, an insurer-initiated price transparency program that focused on elective advanced imaging procedures resulted in reducing variation in prices for magnetic resonance imaging (MRI) by 30%. Other studies have found that prices have dropped by 15 to 17% for lab tests when consumers have access to pricing and some have found prices dropped by 1.6% – still a statistically significant amount. And the CalPERS program in California saved $7 million on colonoscopies and $2.8 million on joint replacement after the implementation of a reference price program.

But, the data is unclear whether consumers will actually check the price of health care services. There are a few resources out there that in theory allow consumers to access prices, but these take a lot of consumer effort. After the California state employee health plan launched a price transparency tool in 2014, only about 12% of covered employees used it to search for prices on lab tests, office visits, and advanced imaging services. And studies have found that as the number of procedures an individual searches and the complexity of those services increases, pricing tools are less likely to decrease cost.

This will likely all change in the next five years. I think that increasing popularity of high-deductible health plans will make consumers better shoppers. The number of consumers with high-deductible health plans increased from 26.3% in 2011 to 39.3% in 2016, and a report from Benefitfocus found that 70% of employers offered at least one high-deductible health plan (see “Consumer-Directed Care, High Deductibles Popular for Employees”).

What consumer-facing price information is available now? There are a small number. A couple of states such as Wisconsin and Maine have tools that allow consumers to compare prices across health plans and hospitals (e.g. “CompareMaine” and “Wisconsin PricePoint”). Then there are the health insurer specific tools that are only available to members (e.g. “UHC Cost Estimator” and “SelectHealth Medical Cost Estimator”). But, the “disruptors” in the field are publishing fee schedules – take a look at the fee schedules of CVS Minute Clinics and the Cleveland Clinic (e.g. “CVS Price List” and “Cleveland Clinic Patient Price Information List”).

But these are the exceptions. Most provider organizations do not have a public fee schedule and most do not have the ability to provide with point- of-service pricing. A 2016 survey for Navicure found only 33% of provider organizations have cost estimation tools. The questions for executives of provider organizations are: if a consumer (or a health plan) wants to know how much as service costs, can they find that out on your web site? Can they call your customer service number and get a fee schedule? These will likely become the new standard for consumerism.

Do you use crowdsourced consumer reviews? TripAdvisor has “collective” reviews of restaurants and tourist sites. Rotten Tomatoes brings us the collective wisdom of the crowds on movies. Yelp reviews just about any service you can buy— restaurants, medical care, a spa day, lawn care…

I’m not a big fan of crowdsourced reviews—personally, I prefer curated reviews that are based on specific criteria or expert opinions (I’m a Consumer Reports fan). But these days, TripAdvisor, Rotten Tomatoes, and Yelp move markets. That’s because millions (or possibly billions) of people use these crowdsourced sites each year.

So I wasn’t shocked when I read that 82% of health care consumers use online physician reviews for care decisions and treatment options; up from 25% in 2013. Of this group, 72% use online reviews as their first step in finding a new health care professional; 48% would use a health care professional outside of their insurance network coverage who had good reviews; and about 65% expect health care professionals to respond to negative reviews. Given that big leap in just five years, these numbers have a big implications for the strategy (and online presence) of health and human service organizations.

The question is, how does strategy change? I asked my colleague, OPEN MINDS Senior Associate Heidi Holman, about how provider organizations should read into the growing use of online reviews by consumers; and what those organizations can do about it. Here are some best practice tips:

Regularly audit websites that your organization could show up on. Ms. Holman explained, “If you don’t know where to look for reviews then you don’t know what your consumers are saying. Google, Yelp, Facebook (if you have a page), and Yellow Pages are great places to start. If you’re not sure where your ratings are showing up, begin with a simple Google search with ‘your organization’s name AND reviews.’ You can also go to some of the bigger review sites (see above) and use their search tools to find your organization. Bookmark the sites where your organization shows up and periodically visit the sites where your organization doesn’t currently have any reviews, just in case a consumer writes one in the future. Then note whether the existing reviews are negative or positive to find areas of improvement or enhancement.”

Respond to bad reviews with internal changes. Once the reviews are posted, there is not much that a provider organization can do about existing posts. HIPPA laws make it nearly impossible for provider organizations to respond directly to comments. There are actions you can take to mitigate these reviews, however. You can claim the page on which your organization is showing up, like Yelp or Yellow Pages, and then put a disclaimer that asks dissatisfied consumers to also follow up with your organization by phone or in-person. You should also work to fix the internal problems that were causing the poor review. Maybe you have faulty systems that lead to customers not being seen on time. Perhaps your billing department hasn’t been effectively trained on how to communicate that co-payments are due. If that all feels too passive, Ms. Holman said, “You can also ask your front desk team members to get in the habit of asking how the visit went. Doing so helps you get ahead of any concerns your consumer might have and you can turn it around before the review is permanently posted online.”

New positive reviews can help. Since you’ve already educated your office staff to ask how the client’s visit went, you have created an opportunity to turn around those old, negative reviews by increasing your positive scores. If the consumer had a great experience, ask them if they would be willing to fill out a review online. Ms. Holman recommended

“concentrating on a review site where you had the lowest ranking first to address that negative score. Once it has improved, move to the next one until you have raised all of your scores.”

For more on how to set up and strengthen your online reputation management program, check out these resources in the PsychU Library:

  1. Succeeding In The Online Ratings Game – First, Know The Score
  2. Consumer Star Ratings For Hospitals – It’s Only Going To Get Harder To Earn Those 5 Stars
  3. The Value Challenge, Again
  4. When It Comes To Performance Measurement, The “Work” Is Never Done
  5. Therapists & Online Reviews – Where Is The Ethical Line?
  6. Marketing Is Changing, Even In The Health & Human Service Space

Wake Forest Baptist Medical Center (WFBMC) found that its addiction-focused peer support pilot program reduces readmissions among consumers with conditions complicated by addiction disorders. Additionally, WFBMC reported in April 2018 that the peer support program was also linked to a reduction in the number of people who left the hospital against medical advice. The baseline and improvement statistics have not been released because the pilot is still under evaluation.

WFBMC launched the program in July 2017 by adding four peer support specialists (PSS) to its addiction counseling team, and embedding them in its emergency department and two medical units. For the peer support program, consumers in the hospital’s inpatient medical units receive specialized intervention services by clinical addiction specialists combined with certified PSS staff. The PSS staff help individuals identify issues, set recovery goals, learn coping strategies and self-help techniques, and access treatment services.

The hospital’s addiction counseling team is analyzing the early outcome data for the first three months following the initial implementation start up; further analyses will address the full year of services. The initial analysis reviewed those who had received, while inpatient, combined services of the PSS and addiction specialist counselors on the two medical units providing the intervention and support services. Their outcomes are being compared to consumers with similar addiction disorder complications who did not receive intervention or support services. The initial analysis also found positive benefit from education aimed at improving empathy provided to physicians, nurses, and care coordinators. The hospital anticipates expanding the program during 2018 to add five more PSS staff in two additional inpatient units and the emergency department, which will bring the number of certified PSS staff to nine.

The Hanley Family Foundation provided one year of start-up funding of $195,000 for the peer-support program, which the hospital augmented with $45,000 to provide program design, implementation, clinical support and supervision; and $20,000 for emergency department support. The primary goal of the grant is to reduce recurring emergency department visits and hospitalizations by consumers with addiction disorders, with a particular focus on alcohol. A secondary goal is to permanently establish peer support within the hospital’s workflows. The non-profit Hanley Family Foundation supports projects associated with chemical dependency, alcoholism, and addictive behavior.

WFBMC intends to continue to fund the two inpatient PSS positions currently funded through the Hanley Family Foundation grant. Part of a program expansion will be funded through a one-year grant awarded on May 9, 2018, by the North Carolina Healthcare Association (NCHA) and the North Carolina Department of Health and Human Services (DHHS) for a new pilot peer support program focused on opioid addiction. For the pilot, NCHA and DHHS selected a total of six hospital/health systems for one-year grants of $180,000 each funded through DHHS. In addition to WFBMC, the other pilot sites are Carolinas Healthcare System Northeast (part of Atrium Health), Cone Health, Novant Health Presbyterian Medical Center, Southeastern Regional Medical Center, and UNC Hospital. For the pilot, the hospitals will embed certified PSS staff in their emergency departments to connect consumers presenting with opioid overdose to treatment, recovery, and harm reduction supports. The hospitals committed to hire a minimum of two certified PSS, each of whom have been in recovery for at least three years, to act as liaisons between the emergency department and the community. With the NCHA grant, WFBMC intends to hire three to four more PSS staff, and another PSS position is being funded through an internal hospital grant. In addition to expanding its peer support program, for the grant, WFBMC will work with NCHA to provide technical assistance and training for the other pilot sites.

During the NCHA/DHHS grant year, WFBMC intends to develop options for sustaining the peer support program. Currently, North Carolina Medicaid only reimburses for PSS services provided in outpatient settings. It does not cover PSS provided in an inpatient or emergency department setting.

The peer specialists are certified by the state through the North Carolina Certified Peer Support Specialist Program. The certification is an acknowledgment that the peer specialist has completed a 40-hour training and met a set of requirements necessary to provide support to individuals with mental health or addiction disorder. The certificate must be renewed every two years, and the specialist must complete 20 hours of continuing education.

For more information, contact:

On April 26, 2018, Blue Cross Blue Shield Association (BCBS) announced that BCBS members served by physicians, hospitals, and clinical care teams participating in its Blue Distinction Total Care program had fewer emergency department visits, and fewer hospitalizations than BCBS members served by non-participating clinical professionals and hospitals. BCBS members with cardiovascular disease served by the Blue Distinction Total Care participating professionals and provider organizations had better adherence to medications than BCBS members with cardiovascular disease served by non-participating professionals and provider organizations.

The Blue Distinction Total Care program is part of the BCBS system’s Blue Distinction portfolio of value-based care programs, which includes three programs: Total Care, Specialty Care, and Flexible Network. The Total Care program includes accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). The Specialty Care program includes facilities designated as Centers of Excellence across 99 of the top 100 metropolitan statistical areas (MSAs) targeting seven high-cost specialty care areas. The Flexible Network program is a custom-tiered network of acute care hospitals and ambulatory surgical centers (ASCs). About one-third of BCBS network physicians and hospitals participate in the Total Care program and nearly 62 million BCBS members have access to those physicians and hospitals.

BCBS reported the national aggregate outcomes of its third Total Care program evaluation as of January 2018; the evaluation has not been publicly released. Since implementing the Blue Distinction Total Care program in 2015, emergency department visits decreased about 10% to about 275,000; and hospitalizations declined by 15% each year. Adherence to medications among members with cardiovascular disease increased 5%, and 7% of members with diabetes had better HbA1c testing rates. The BCBS professionals and provider organizations participating in the Total Care program decreased aggregate medical costs by 35% compared to BCBS non-Total Care professionals and provider organizations.

Information about the Total Care program is posted online by BlueCross BlueShield.

For more information, contact: Robert Elfinger, Media Contact, Blue Cross Blue Shield Association, 225 North Michigan Avenue, Chicago, Illinois 60601; 312-297-5899; Email: press@bcbsa.com.

The use of psychiatric drugs in California jails rose from 16% in March 2012, to 20% in February 2017. This is a 25% increase in the 45-county sample studied, from an average of 10,999 inmates in 2012-2013 to 13,776 inmates in 2016-2017.

These findings were reported in “How Many Incarcerated Individuals Received Psychotropic Medication in California Jails” by Konrad Franco, David Panush, and David-Maxwell-Jolly. The researchers analyzed data from the Board of State and Community Corrections (BSCC) to estimate the number of jail inmates who receive psychotropic medication and assess the relative representation of this group among the jail population. They reviewed data from 45 California counties that completed the BSCC Jail Profile Survey from March 2012 to February 2017. They used receipt of psychotropic medications as a proxy indicator for SMI. The goal was to estimate the number of jail inmates who receive psychotropic medication as a representation of the total jail population.

Key findings were as follows:

The full text of “How Many Incarcerated Individuals Received Psychotropic Medication in California Jails” was published in January 2018 by California Health Policy Strategies LLC. A free copy is available online.

PsychU reported on this topic in “One-Third Of New Orleans Jail Inmates On Behavioral Health Medications; Service Provision Uneven,” which published on July 18, 2017.

For more information, contact: David Panush, President, California Health Policy Strategies, LLC., 580 Rivergate Way, Sacramento, California 95831, 916-842-0715; Email: d.panush@calhps.com.

Eroding financial stability of traditional service lines, the arrival of new value-based payment models, a growing scarcity of resources, and the wave of competition trying to exploit these changes—these are the constant features of the landscape for health and human service provider organizations. They make “sustainability” a constant feature of strategy sessions.

But as the saying goes, knowing the path and walking the path are not the same thing. For more on walking the path, we recently sat down with Michael Griffin, president and chief executive officer of Daughters of Charity Services of New Orleans (DCSNO) and Marillac Community Health Centers, DBA Daughters of Charity Health Centers (DCHC). DCSNO is a $30 million operation—serving the greater New Orleans region. The organization is a member of Ascension Health, the largest Catholic non-profit health system in the United States. DCHC is Louisiana’s largest federally qualified health center.

DCSNO serves about 55,000 consumers each year—90% of which are at 200% of the federal poverty level or below. With the expansion of Medicaid in Louisiana, Medicaid became DCSNO’s largest payer with 70% of the DCSNO consumer population. Prior to the Medicaid expansion, about 27% of their consumer population was on Medicaid, while 35% of those served were uninsured. To serve this population, DCSNO operates ten fully-integrated health centers, providing physical, behavioral, dental, and pharmacy services through a patient-centered medical home approach. Prior to Hurricane Katrina in 2005, the organization operated only one health center.

How has Mr. Griffin been able to operate an innovative, sustainable organization that excels at the financial challenges, while fulfilling the mission that drives their work in the community? By balancing his organization’s mission with a focus on sustainability, diversifying service options, focusing on integrated whole-person health care, and building on innovation for the future.

Create Sustainable Programs

Mr. Griffin explained that when his organization considers the development of a new program or service, they think about both the community need and the long-term business model:

One of the things I always say is, we only go where we are asked by the community to work and to participate. We have good buy-in from consumers, the city, neighborhood associations, and other community partners. As we’ve recovered from Katrina, it’s been important for us to think strategically about the partners we work closely with in our rebuilding and recovery efforts.

It’s important to start with a needs assessment. Then, decide if the need correlates with the mission and build a business case around the need if it fits the mission. For example, if it’s a new health center, you first determine the consumer and payer base—and then do a three to five year financial assessment. You have to put pen to paper on the financials and make sure you have a solid business plan to support the focus.

But as Mr. Griffin discussed, sometimes, even when your organization cannot make the numbers add up to logically support the new program or service, your mission might supersede the financial considerations. That is where you need to consider other sources of revenue for long-term sustainability—fundraising, grants, partnerships with local government and neighborhood groups, and supplementing the losses in a program through other service lines with a strong margin.

Promote Program Diversification

Diversification is a strength that many provider organizations don’t leverage, instead building an unhealthy reliance on one payer, one consumer group, or a handful of service lines. Mr. Griffin noted that his organization’s more financially successful services help to support services that are needed, but not self-sustaining. For example, as an FQHC,

Daughters of Charity Health Centers is able to utilize 340b drug pricing, making pharmacy a service with a strong margin. Oral health services, on the other hand, have low Medicaid reimbursement rates and therefore operate at a loss. Yet dental services are a vital service for DCHC’s consumer population. Therefore, they look at margins in pharmacy services as a way to balance out the loss in oral health. Mr. Griffin noted that “As a non-profit organization, a major part of fulfilling your mission should be diversification of services and income streams. You really need a balancing act between billable services, philanthropy, and operational efficiencies all in one.”

Build Innovation For The Future

A key to sustainability is having an eye to the future. According to Mr. Griffin, this means stepping back and looking at the big picture—including both your future goals and understanding the consequences of the decisions that you make today.

His view is that the current trajectory of value-based reimbursement is going to make community-based provider organizations an essential player. A big part of this is making his organization data-driven:

As we start thinking about models that really increase value, the way you provide services must change. The bottom line is, it’s about having information at our finger tips, and getting it real time. It’s about being able to communicate with clinicians when the consumer needs care. We are working on systems for our community health workers to have real-time information. Our goal is that when the consumer enters a hospital, we can have a community health worker show up at that emergency room to see what the consumer needs. They may need that ER, or they may really need something else. This is also about empowering the consumer to get the service, whatever it is, that they need when they need it. That’s the future of health care delivery.

The other issue that Mr. Griffin sees in the future is the need for community-based organizations to address the social determinants of health:

The other part is taking a holistic approach to health care delivery…offering health care and assisting consumers in obtaining other social support services. Even though we are a health care provider organization, we need to assist people in getting all the things they need outside of health care as well. We want to be a total resource for those individuals to live a healthier and more productive life.

The challenge is timing. He explained that payment has always lagged behind innovation, but that organizations cannot afford to wait for payers and policymakers to act. This is the balancing act of today’s health and human service organizations – fulfilling the mission, while sustaining the margin.

During the first year of Denver’s supportive housing social impact bond (SIB) initiative, the outcomes met benchmarks to trigger the first success payment of $188,349 to project investors. From January 1, 2016 to June 30, 2017, 39 people in the target population of people frequently involved with the criminal justice system remained housed for at least 365 days without any episodes away from housing lasting more than 90 days or unplanned exit from housing. The participants remained housed for a total of 12,457 days; for each day housed, the investors were paid $15.12 per day.

In February 2016, the City of Denver and eight private investors closed on the bonds, an $8.6 million investment to fund the program to house 250 people over five years. The project’s fiscal intermediary is Denver PFS LLC (formed by Corporation for Supportive Housing and Enterprise Community Partners); the service provider organizations are the Colorado Coalition for the Homeless, which started the first year, and the Mental Health Center of Denver, which started the second. The project seeks to house people frequently involved with the city’s criminal justice system. The project goals are housing stability and decreased jail days. Over five years, the city will make outcome payments of $0 to $11.42 million. Compared to its current jail and social service costs for people frequently involved with the criminal justice system, the city anticipates that it will save $3 million and $15 million over the five year project.

These first year findings were reported in “Denver Supportive Housing Social Impact Bond Initiative: Housing Stability Outcomes; Report to the Governance Committee” by Sarah Gillespie, Devlin Hanson, Mary K. Cunningham, and Mike Pergamit of the Urban Institute. The Urban Institute is the project evaluator. This report details the first assessment of housing stability payment outcomes. 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. Starting with this brief, housing stability outcomes will be reported annually, with a final report on the impact of supportive housing on jail stays in early 2021. The Crime Prevention and Control Commission provided staff for the program referral process, and the Denver Police Department provided administrative data for the evaluation. The contract designated the first six months of the project as a pilot period.

The housing stability outcomes are based on a measure of total adjusted days in housing. The measure includes participants who remain in housing for at least 365 days without any episodes away from housing for greater than 90 days or who had a planned exit from housing at any point. The pilot period (the first six months) was not included in the total adjusted days in housing for the first payment, but it does count for determining if the participant achieved at least one year in housing. Days participants spent in jail were also subtracted from the total days in housing. The remaining total adjusted days in housing were multiplied by $15.12/day, as specified in the SIB contract, to calculate the first success payment from the city. Housing stability outcomes will be measured every two quarters for the next three and a half years and may change as more participants are engaged in the program.

During the first six quarters, from January 1, 2016 to June 30, 2017, 39 participants met the payment requirements, and 33 maintained the housing for 365 days. The remaining six died during the year, but in the analysis this is considered a planned exit event because many of the target participants have fragile health status. Among the 39 participants, there were 215 jail days. About 64% (25 people) of the 39 participants had no jail stays, and 14 had one or more jail stays. Of those who had a jail stay, the mean stay lasted 22 days and the median was 12 days. They spent an average of 100 days in housing before the first jail stay. Among the 33 who maintained housing for 365 or more days, 20 had no jail stays and 13 had one or more. Of those who had a jail stay, the mean stay lasted 22 days and the median was 10 days. They spent an average of 95 days in housing before the first jail stay.

The full text of “Denver Supportive Housing Social Impact Bond Initiative: Housing Stability Outcomes” was published October 30, 2017, by the Urban Institute. A free copy is available online.

For more information, contact:

Approximately 82% of health care consumers use online physician reviews for care decisions and treatment options. About 57% report using online reviews “often” or “sometimes”. In 2013, about 25% of health care consumers said they used online reviews.

These findings were presented in “How Patients Use Online Reviews,” by Gaby Loria of Software Advice, reporting on 2018 survey findings. The survey was completed by 2,409 U.S. health care consumers. The goal was to determine trends in how consumers use online reviews for health care services.

Additional findings include:

The analysts at Software Advice concluded that online reviews can greatly affect the success of a health care professional. Not only is it important for health care professionals to pay attention to existing online reviews, but it is also important to recruit more reviews from existing consumers.

The full text of “How Patients Use Online Reviews” was published March 29, 2018 by Software Advice. A free copy is available online.

For more information, contact: Lisa Hedges, Content Analyst, Digital Markets, Software Advice, Inc., 200 Academy Drive, Suite 120, Austin, Texas 78704; 512-640-0320; Email: Lisa@softwareadvice.com.

Background & Methodology

In the United States, emergency department (ED) visits due to mental health and substance abuse (MHSA) conditions have increased from an estimated 4-6% in 1992 to 12% of total ED visits in 2007. Many patients treated in the ED for MHSA-related issues make a quick return to acute care, a pattern that may represent avoidable health care utilization in some cases. To date, little is known regarding who presents in the ED for psychiatric care and which individuals are at increased risk for early return, knowledge that may assist both clinicians and policymakers alike.

In a recent article entitled “Predictors of Return Visits Among Insured Emergency Department Mental Health and Substance Abuse Patients, 2005-2013,” Sangil Lee and colleagues sought to provide answers using data from a national insurance-claims database (Optum Labs Data Warehouse) containing information for over 100 million enrollees in the United States.

The authors identified all ED visits for patients who presented with MHSA as the primary reason for seeking care between January 1, 2005 and November 30, 2013. ED visits that resulted in a hospital admission were excluded, as were visits for patients who had been seen for another MHSA-related ED visit within the prior 12 months (in order to accurately define the index visit). Covariates in analyses included age group, sex, number of chronic conditions, race/ethnicity, non-MHSA- related ED utilization within 12 months prior to the index visit, and MHSA as a primary diagnosis. The primary outcome was a return ED visit or inpatient admission within 3, 7, and 30 days of discharge.

Background & Purpose

Recent health reforms such as the Affordable Care Act (ACA / PPACA) and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), along with endorsements by health care bodies such as the Institute of Medicine (IOM), have brought increased resources and requirements for measuring and assessing health care quality. Within the field of behavioral health, however, questions remain regarding developing, validating, and using quality measures. In a recent article entitled “Quality Measures For Mental Health And Substance Use: Gaps, Opportunities, And Challenges,” Harold Alan Pincus and colleagues presented an overview of the state of quality measurement of behavioral health conditions, including identification of priorities and challenges, followed by recommendations to address gaps.

By 2025, about 27% of family practice/ primary care professionals will be nurse practitioners, up from about 18.5% of the workforce in 2010 and 2013, according to federal workforce projections. In 2010, nurse practitioners represented 18.5% of the 295,000 professionals in the primary care workforce; physicians represented 70.8%; and physician assistants represented 10.2% of the primary care workforce. In 2013, nurse practitioners represented 18.7% of the 307,300 professionals in the primary care workforce; physicians represented 70.5%, and physician assistants represented 10.9% of the primary care workforce. By 2025, the projected primary care workforce of 408,770 will include 110,540 nurse practitioners, 239,460 physicians, and 58,770 physician assistants.

Primary care workforce statistics and projections are monitored and developed by several federal entities including the Bureau of Labor Statistic (BLS), the Health Resources & Services Administration (HRSA), and the Agency for Healthcare Research and Quality (AHRQ). The dates and projection windows of the most recent projections do not align exactly, but each indicates that the size of the primary care workforce will increase.

The BLS Occupational Outlook Handbook indicates that the 2016 primary care workforce included 475,900 medical professionals and is projected to increase by 26.6% to reach 602,700 by 2026. Additional details are as follows:

The HRSA report indicates that the 2013 primary care workforce included 307,300 professionals, including 57,330 nurse practitioners, 33,390 physician assistants, and 216,580 physicians. The report presents population-based projected demand for full-time equivalent nurse practitioners, physician assistants, and physicians; and it projects the size of the workforce. The data is presented on a national and regional basis.

HRSA National Primary Care Workforce Estimates 2013 To 2025

Professional Nurse Practitioner Physician Assistant Physician Total Workforce
2013 Workforce 57330 33,390 216,580 307,300
2025 Projected Workforce 110,540 58,770 239,460 408,770
Percentage Change, 2013

To 2025

93% 76% 11% 33%
Projected Demand 2025 68,040 39,060 263,100 370,200
Percentage Change In Demand 2013

To 2025

19% 17% 17% 20%

The BLS projections can be viewed online.

For more information, contact:

Increased physician employment by hospitals between 2012 and 2015 raised Medicare costs by $3.1 billion because a greater share of services that could be provided in an office visit were provided in a hospital outpatient department (HOPD). The $3.1 billion increase represented about 4.3% of the total increase in Medicare spending from 2012 to 2015. During this period, physician employment by hospitals increased by 49%; surveys indicate that a major reason for independent physicians to sell their practices to hospitals is to cut required administrative work.

In 2012, Medicare spending was $534.9 billion, and by 2015, it rose to $607.1 billion. Of the $72.2 billion increase, about 4.3%, $3.1 billion, was attributed to higher costs for four cardiology services, orthopedic services, and gastroenterology services. During the 2012 to 2015 period, the share of these services delivered by hospital-employed physicians in HOPD settings increased, and the share delivered in office-based settings dropped.

A major reason for independent physicians to sell their practices to hospitals is to cut required administrative burden due to documentation, information technology system integration, and data capabilities to support contracting. Additional reasons for physicians to sell to hospitals include higher reimbursement for services performed under a hospital payment system, to focus more on medicine rather than running a business, to provide better service coordination for consumers, and better eligibility for the 340B federal program that offered discounts on outpatient drugs.

These findings were presented in “Implications of Hospital Employment of Physicians on Medicare & Benefits” by Physicians Advocacy Institute. The analysis was conducted by Avalere Health. The researchers analyzed practice patterns for hospital- employed physicians, and how the practice patterns compared to those of independent physicians in the same geographic area. The researchers analyzed how the difference in practice patterns for certain cardiology, orthopedic, and gastroenterology services affected the cost of care. Once the costs were determined, researchers calculated the difference in costs to Medicare and costs shared by the Medicare beneficiary.

Increased Cost to Medicare For Procedures Performed By Hospital-Employed Physicians

Colonoscopy Arthrocentesis Echocardiogram Diagnostic cardiac catheterization
Independent Physicians: Share Of Procedures Provided In HOPD 95% 3% 24% 92%
Employed Physicians: Share Of Procedures Provided In HOPD 98% 21% 70% 99%
Percentage Cost Increase To Medicare For Employed Physicians +14% +4% +27% +13%
Added Medicare Cost $233.2 million $25.6 million $2,083.5 million $369.3 million
Average Increase Per Episode $263 $33 $667 $994

Additional findings were as follows:

The full text of “Implications of Hospital Employment of Physicians on Medicare & Benefits” was published November 9, 2017 by Physicians Advocacy Institute. A free abstract is available online.

PsychU reported on this topic in “Hospitals Acquired 5,000 Physician Practices From July 2015 To July 2016,” which published on April 25, 2018.

For more information, email: Kelly Kenney, Executive Vice President, Physicians Advocacy Institute,312-543-7955; Email: K2strategiesllc@gmail.com

“Episodes of care” are an increasingly common form of value-based reimbursement.

The most widely known episode of care or bundled payment model is the Centers for Medicare & Medicaid Services (CMS) bundled rate initiative for Medicare, which pays for acute care hospital stays and related post-acute services through episodic payment mechanisms. Depending on the payment model, bundles include designated episode lengths of 30, 60, or 90 days related to a hospital stay.

Humana recently expanded the availability of its Medicare Advantage value-based care bundled payment model for joint replacement to a total of 13 states. The model provides a bundled payment to provider organizations to cover services from diagnosis to post-surgery recovery for consumers undergoing total hip or knee joint replacement surgery. The goal of the program is to reduce post-surgery hosptial admissions and complications by increasing care coordination at the provider organization-level. Just last month Humana also announced the launch of a maternity bundled payment program within their commercial plans. Initially, Humana will partner with five provider organizations to serve consumers with low-to-moderate risk pregnancies, with the episode of care covering prenatal services; labor and delivery; and post-delivery care.

Last summer, the Tennessee Health Care Innovation Initiative implemented new cross-payer episodes of care reimbursement for anxiety and non-emergency depression. An episode of care includes health care services delivered in association with a “trigger” diagnosis, or acute health care events such as a surgical procedure or an inpatient hospitalization. The model is retrospective, in that the procedures and services included in the episode have already occurred. The “episode window” is the entire duration of the episode (see TennCare Implements Episodes Of Care Reimbursement For Anxiety & Depression On July 1).

And, Optum is utilizing a bundled payment for medication assisted treatment (MAT) models for addiction treatment provider organizations – paying them for a group of services associated with an episode of care. For example, Optum and MAT provider organization CleanSlate developed a monthly bundled rate that includes a single payment for all services associated with MAT (lab costs, psychosocial supports, care coordination, and medication management) exclusive of pharmacy.

I think we can expect reimbursement for “episodes of care” to increase thanks to growing successes using this approach. The Medicare Comprehensive Care for Joint Replacement bundled payment model, which holds hospitals responsible for the costs from the time of the surgery through 90 days after hospital discharge, resulted in a 20% reduction in the total costs of care per episode. The Tennessee Health Care Innovation Initiative has shown promising results – reducing costs 3.4% for perinatal services, 8.8% for asthma exacerbation, and 6.7% for total joint replacement. And Horizon Blue Cross reported that its bundled joint replacement program has resulted in 100% fewer hospital readmissions for knee arthroscopy, 37% fewer hospital readmissions for hip replacement and 22% fewer hospital readmissions for knee replacement.

And, before you think that episode-based reimbursement might not be something you’ll see in your specialty, it’s important to note that episode-based reimbursement is relevant to almost 75% of health care costs. Episodic reimbursement is being applied to procedures, to acute care episodes, and chronic medical and specialty care. And, episode-based payment is being deployed within accountable care organizations or primary care capitation and shared savings arrangements—where specific groups (such as specialists) are rewarded for managing an episode of care effectively. For this reason, health and human service executives should consider including analytics about episodes of care in your standard performance measures.

The ability to track the cost per consumer for specific issues and conditions is the basis of episode-based reporting. In the example of a program with a $6,000 payment for a six-month episode of community-based medication assisted treatment, a management team would want a report that outlines for each consumer in that program all service utilization and associated costs during that six-month period. And, the management team would want to see those metrics across the entire group of consumers enrolled. Episode-based reporting often requires interoperability. If a provider organization is part of a larger bundle of services and performance payments are based on the performance (and utilization and costs) across all service provider organizations, having a reporting tool that aggregates that utilization/cost data for the specific consumer across a number of provider organizations is essential.

In addition to tracking costs for specific consumers against specific contracts, episode-based reporting has the opportunity to improve other areas of performance. Episode-based reporting can be used to determine which particular professionals and/or programs are “best” in treating particular types of consumer conditions. And, the data can also be used to select the best “partners” for specific contracts. That same data can be used in professional education, by highlighting variations in treatment patterns and understanding that variance. Episode-based reporting data also allows organizations to target case management, care coordination, and utilization management resources on the most critical and actionable consumers and professionals (see The Thousand Right Things). For an example of the proactive use of episode analytics, McKinsey analyzed Medicaid fee-for-service data, and found that for consumers receiving a spinal fusion procedure, of the 70% of the consumers at high risk for an opioid overdose were concentrated among 10% of primary providers. The perfect example of where episode analytics can direct the use of utilization review and case management resources.

The ability to report on (and manage) clinical utilization, cost, and performance by consumer and by episode will continue to grow in importance. Whether your organization is participating in value-based reimbursement arrangements that pay by episode, or not, the ability to report consumer costs in this way is an important element in population health management sophistication and in demonstrating value to payers.

Approximately 76% of physicians are satisfied with their current position regarding salary, benefits, quality of work, and quantity of work. Salary was the most commonly cited factor related to dissatisfaction among physicians.

Of the physicians satisfied with their current position, 23% said they are “very satisfied,” and 53% said they are “somewhat satisfied.” About 57% of physicians would recommend the medical profession to family or friends; 26% would recommend against becoming a physician.

Salary was the most commonly cited factor related to dissatisfaction among physicians: 25% of those surveyed named salary as the least satisfying part of their work. Additional factors relating to dissatisfaction are: working hours (17%); amount of time on call (16%); types of work (such as consumer management, administrative duties, teaching or research) other than practicing medicine (11%); and coworker/staff relationships (8%). About 15% of those who responded reported no dissatisfying factors related to their job.

These findings were presented in “Most doctors are satisfied with their jobs despite eroding respect, survey finds,” by John Murphy of MdLinx. Researchers from M3 Global Research surveyed both primary care physicians, and specialists, in August 2017 for the MdLinx study; in total, 1,150 physicians responded to the survey. The goal was to determine job satisfaction in the medical industry.

The full text of “Most doctors are satisfied with their jobs despite eroding respect, survey finds” was published February 23, 2018 by MdLinx. A free copy is available online.

For more information, contact: Roni DasGupta, President of Market Research, Americas, MDLinx, 501 Office Center Drive, Suite 410, Fort Washington, Pennsylvania 19034; 202-293-2288; Email: info@usa.m3.com

In 2016, illness or death due to non-optimized medication use, adverse medication interactions, and less than optimal consumer adherence with medication regimens results in costs of about $528.4 billion annually in the United States. These costs represent additional medical resources needed to resolve problems due to the initial diagnosis and subsequent use of prescription drugs, including additional needed medications, emergency department visits, hospitalizations, long-term care (LTC) stays, and health care visits. The costs do not include non-medical costs, such as transportation or caregiving costs; nor do they include costs related to lost productivity or disability. The costs account for 16% of the total $3.2 trillion in health care spending.

These findings were reported in “Cost of Prescription Drug-Related Morbidity and Mortality” by Jonathan H. Watanabe, Pharm.D. M.S., Ph.D.; Terry McInnis, M.D., MPH; and Jan D. Hirsch, Ph.D. The researchers used data from the Centers for Disease Control and Prevention (CDC), the American Hospital Association, and other published studies to analyze prescription-related cost-of-illness in the U.S. in 2016. These figures were then used to model resource use spending on treatment of medical problems related to prescription drugs. The goal was to estimate the cost of prescription drug–related health issues and deaths in the United States for that year.

Additional findings include:

The researchers conclude that an effective way to avoid the costs resulting from non-optimized medication regimens —whether it was the wrong medicine or dose, or the medicine caused new problems, or consumers skipped doses— is to expand comprehensive medication management programs. This would also improve health outcomes for consumers by enhancing their ability to reach their treatment goals. Methods for these programs include comprehensive medication management (CMM), and medication therapeutic management (MTM). CMM involves collaboration between care personnel and pharmacists that includes an evaluation of the health care consumer’s clinical status, and formulation of a treatment plan with follow-up assessments to meet specified treatment goals. CMM also seeks to improve adherence by reducing the number of medications when possible, and making the regimen more affordable. MTM also involves review of the medication regimen, however the pharmacist may not have access to the consumer’s complete medical record. Both CMM and TM focus on issues such as prescribing the lowest effective dose of a medication, and determining whether new symptoms are actual new symptoms, or an adverse drug reaction.

The full text of “Cost of Prescription Drug–Related Morbidity and Mortality” was published on March 26, 2018, in Annals of Pharmacotherapy. A free abstract is available online.

For more information, contact: Sandy Mau, Vice President, Communications, Health2 Resources, 344 Maple Avenue W, Suite 245, Vienna, Virginia 22180; 703-394-5398; Email: smau@health2resources.com; or Jonathan H. Watanabe, Pharm.D., M.S., Ph.D. BCGP, Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, 9500 Gilman Drive, MC 0764, La Jolla, California 92093-0764; Email: jhwatanabe@ucsd.edu

We can add a few more data points to the growing list of online ratings of health care provider organizations. As 2017 wrapped up, the Centers for Medicare & Medicaid Services (CMS) added 2016 Physician Quality Reporting System (PQRS) data and measure-level star ratings to their Physician Compare website. While PQRS data was available in the past, star ratings were added for physicians in December 2017.

CMS is implementing the star ratings based on the Achievable Benchmark of Care (ABC™) methodology to develop a benchmark. This means that CMS will rank-order physicians by highest to lowest performance score; create subset of the groups by selecting the best performers; and calculate the benchmark using the “performance” provided to the top 10% of consumers. CMS will then use the “equal ranges method”, based on the difference between the ABC™ benchmark and the lowest performance score for a given measure.

The measures themselves are from the 2016 Physician Quality Reporting System (PQRS) data, a voluntary CMS Quality Program. The program uses a combination of incentive payments and payment adjustments to promote reporting of quality information. The measures are derived from eight categories, including general health preventative screening, cancer screening preventative care, consumer safety, care planning, diabetes, heart disease, respiratory diseases, and behavioral health. All told, consumers who search the Physician Compare site will have access to this new data, plus 2016 data for the Shared Savings Program, Pioneer, and Next Generation Accountable Care Organizations (ACOs), and group ACO affiliations.

Given the recent statements from Secretary of Health and Human Services Alex Azar and CMS Administrator Seema Verma, it is likely that these initiatives will continue to expand. Secretary Azar and Administrator Verma have both been vocal about the need to improve transparency and access to data for consumers, with new programs designed to increase data sharing and give consumers more control over their health care decisions (see CMS Shifting Data Control To Consumers: Are You Ready To Share? ). As of today, there are ten ratings systems from CMS:

  1. Physician Compare
  2. Hospital Compare
  3. Home Health Compare
  4. Nursing Compare
  5. Dialysis Facility Compare
  6. Inpatient Rehabilitation Facility Compare
  7. Long-Term Care Hospital Compare
  8. Medicare Plan Finder
  9. Supplier Directory
  10. Hospice Compare

If your organization isn’t concerned about CMS measures because you’re not participating in Medicare or Medicaid—or your volume in those programs isn’t large—you might want to take note that consumers and referral sources search these sites whether they are in those programs or not. This means that the importance of these resources for either free marketing, or permanently available “bad press,” has also grown.

We’ve written before about the importance of online reputation management and this new development just increases that importance. For more on how to set up and strengthen your online reputation management program, check out these resources in the PsychU Library:

  1. Succeeding In The Online Ratings Game – First, Know The Score
  2. Consumer Star Ratings For Hospitals – It’s Only Going To Get Harder To Earn Those 5 Stars
  3. The Value Challenge, Again
  4. When It Comes To Performance Measurement, The “Work” Is Never Done
  5. Online Ratings Are All Wrong. Consumers Don’t
  6. Therapists & Online Reviews – Where Is The Ethical Line? 
  7. Marketing Is Changing, Even In The Health & Human Service Space

In February 2018, the Centers for Medicare & Medicaid Services (CMS) announced the process for Medicaid alternative payment models (APMs), such as an accountable care organization, to be certified as “Other Payer Advanced APMs” (A-APMs) under Medicare’s Quality Payment Program (QPP). This is a requirement for provider organizations to qualify for the QPP bonus payments.

Managed care organizations (MCOs) that want to submit models for certification as Other Payer A-APMs must do so through the state Medicaid agency. CMS created a document to assist states in collecting information from MCOs for this process.

It is voluntary for state Medicaid agencies to submit APMs for certification. In order to qualify as an Other Payer A-APM, a Medicaid APM must meet three criteria: require clinical professionals to use certified EHRs; tie payments to quality measures; and require eligible clinical professionals to bear nominal financial risk.

The QPP was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which restructured how Medicare pays clinical professionals. MACRA repealed the Medicare sustainable growth rate; established permanent statutory payment updates; created incentive for participants in A-APMs. Eligible professionals must participate in an A-APM or the merit- based incentive payment system (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.

For more information, contact: Mary Wallace, Deputy Director, Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov.

The Centers for Medicare & Medicaid Services (CMS) has added 2016 Physician Quality Reporting System (PQRS) data and measure-level star ratings to their Physician Compare website. PQRS is a voluntary CMS Quality Program to measure quality of care, and star ratings quickly communicate quality that CMS believes is both realistic and achievable for health care professionals. In addition, Physician Compare now includes 2016 data for the Shared Savings Program, Pioneer, and Next Generation Accountable Care Organizations (ACOs), and group ACO affiliations. By publishing this data, CMS seeks to continue providing transparency for health care consumers and encourage consumers to choose health care professionals committed to providing high quality care.

The Physician Compare website is an initiative that was originally designed to give health care consumers and their families a way to search for health care professionals who participate in Medicare. PQRS data has been provided by CMS on the website since 2014. Star ratings are new to the CMS website as of late 2017.

The PQRS measures are reported for groups and individual clinicians. The measures are derived from eight categories including general health preventative screening, cancer screening preventative care, consumer safety, care planning, diabetes, heart disease, respiratory diseases, and behavioral health.

Two access methods exist for the Physician Compare website. Physicians and consumers primarily access data through the public-facing interfacing profile pages. However, there are also CMS data that is intended for health care professionals’ use through downloadable databases.

Access to the Physician Compare quality data and additional information is posted online.

For more information, contact: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov

In its March 2018 report to Congress, the Medicare Payment Advisory Commission (MedPAC) recommended that the Medicare program eliminate the recently launched merit-based incentive payment system (MIPS). To replace MIPS, MedPAC recommended that Congress finalize and implement the Voluntary Value Program (VVP), a voluntary program centered on population-based outcomes.

MedPAC believes that the current MIPS structure, which has already launched the initial data collection phase, will not be able to differentiate which clinical professionals provide higher or lower value services to Medicare beneficiaries. MIPS allows health care professionals to report only those areas where they already have high quality, and therefore is unable to determine true performance. Additionally, about 40% of clinical professionals are exempt from participating in MIPS. MedPAC believes that MIPS replicates flaws from the payment systems it was meant to replace, and that it creates greater reporting burden for health care professionals.

The recommendation was presented in the “March 2018 MedPAC Report to the Congress: Medicare Payment Policy.” The Centers for Medicare & Medicaid Services (CMS) finalized rules for MIPS in 2017. MIPS is one of two payment tracks established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to restructure how Medicare pays clinical professionals. MACRA repealed the sustainable growth rate; established permanent statutory payment updates; created incentive for participants in Advanced Alternative Payment Models (A-APMs); and established MIPS as a value-based purchasing program for fee-for-service (FFS) Medicare. Under the final program rules, all MIPS-eligible professionals must either participate in an advanced alternative payment model (A-APM), such as an accountable care organization, or must participate in MIPS.

MIPS requires eligible clinical professionals to submit performance data on certain quality measures in four categories: quality, cost, practice improvement, and use of electronic health records. Performance on the four categories determines whether clinical professionals receive a bonus or penalty reduction on their Medicare fee-for-service payments. Three of the four categories allow the clinical professional to choose which measures to self-report.

In calendar years 2017 and 2018, MIPS-eligible professionals include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include clinical professionals who bill under Medicare Part B or Critical Access Hospital (CAH) Method II payments assigned to the CAH. 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.

Under the proposed Voluntary Value Program (VVP), 2% of a medical professional’s payment is withheld unless they join an A- APM or choose to be measured as part of a larger group. The non-A-APM large groups would be measured on population-based outcomes and allow others to collect and report individual health care professional performance. Under this system, CMS would make a value payment adjustment to all clinical professionals that participate.

MedPAC believes the VVP would simplify the program and limit subjective self-reports. The VVP would apply objective measures that could be calculated from claims or survey data.

Although the recommendation has been made, MedPAC lacks binding authority to make the proposed changes. The group was created to provide Congress and CMS with guidance and analysis relative to the Medicare program.

PsychU reported on this topic in “MedPAC Calls For Repeal, Replacement Of MIPS,” which published on December 5, 2017.

For more information, contact: Olivia Berci, Administration, Medicare Payment Advisory Commission, 425 I Street NW, Suite 701, Washington, District of Columbia 20001; 202-220-3727; Email: oberci@medpac.gov

On April 1, 2018, Medicare started covering a performance-based diabetes prevention program. The program is a structured behavioral intervention with the goal of preventing progression to type 2 diabetes in beneficiaries with an indication of prediabetes. The goal is that the participants will implement lifestyle changes and achieve at least 5% weight loss, which will reduce their risk of developing type 2 diabetes.

The clinical intervention for the Medicare Diabetes Prevention Program (MDPP) consists of a minimum of 16 intensive “core” sessions of a Centers for Disease Control and Prevention (CDC) approved curriculum furnished over six months in a group- based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. After the completing the core sessions, less intensive follow-up meetings furnished monthly help ensure that the participants maintain healthy behaviors. The total MDPP service period lasts for two years, consisting of one year of core and core maintenance sessions followed by up to one year of ongoing maintenance sessions. To maintain eligibility for ongoing maintenance sessions, the MDPP beneficiaries must obtain 5% weight loss.

The MDPP uses a performance-based payment structure that ties payment to performance goals based on attendance and weight loss. The MDPP is covered by Medicare Part B; beneficiaries enrolled in a Part C Medicare Advantage plan are also eligible for MDPP if their Medicare Advantage plan has contracted with an MDPP enrolled supplier.

The Part B fee-for-service reimbursement methodology gives beneficiary weight loss greater value than attendance because weight loss is a key indicator of reducing the risk of type 2 diabetes. Provider organizations will receive payment for beneficiaries who attend at least two out of three monthly sessions within a core or ongoing maintenance interval, given other payment requirements are satisfied.

Medicare Diabetes Prevention Program Performance-Based Payment Structure, Benchmarks With & Without Weight Loss & Corresponding Payments

Performance Goal Performance Payment Per Beneficiary (with the required minimum weight loss) Performance Payment Per Beneficiary (without the required minimum weight loss)
1st core session attended $25 $25
4 total core sessions attended $50 $50
9 total core sessions attended $90 $90
2 sessions attended in first core maintenance session interval (months 7-9 of the MDPP core services period) $60 (the required minimum weight loss from baseline must be achieved or maintained during the core or ongoing maintenance) $15
2 sessions attended in second core maintenance session interval (months 10-12 of the MDPP core services period) $60 (the required minimum weight loss from baseline must be achieved or maintained during the core or ongoing maintenance) $15
5% weight loss achieved $160 $0
9% weight loss achieved $25 $0
2 sessions attended in ongoing maintenance session interval (4 consecutive 3-month intervals over months 13-24 of the MDPP ongoing services period) $50 (the required minimum weight loss from baseline must be achieved or maintained during the core or ongoing maintenance) $0 (attendance requirements must be met, and minimum weight loss must be maintained during an ongoing maintenance session)
Total performance payment $670 $195

MDPP services are furnished in community and health care settings by coaches, such as trained community health workers or health professionals. To bill for MDPP services, MDPP provider organizations must have received MDPP Interim Preliminary Recognition from CMS by February 28, 2018, or after that date must receive recognition from the Centers for Disease Control and Prevention (CDC) 2018 Diabetes Prevention Recognition Program in order to enroll in Medicare as an MDPP supplier. Any organization that received MDPP Interim Preliminary Recognition will automatically qualify as having CDC Preliminary Recognition. Organizations that have MDPP Interim Preliminary Recognition will not have to take any action to apply for CDC Preliminary Recognition and should receive notification of their transitioned DPRP recognition status from the CDC on or after March 1, 2018. After March 1, organizations that apply for Medicare enrollment as an MDPP supplier should use their notification from CDC of achievement of CDC Preliminary Recognition for their MDPP enrollment application. The CDC will maintain a registry of recognized MDPP provider organizations.

In November 2017, the Centers for Medicare & Medicaid Services (CMS) finalized MDPP polices related to the set of MDPP services, including beneficiary eligibility criteria, the MDPP payment structure, and supplier enrollment requirements and compliance standards aimed to enhance program integrity. This information is published in the Calendar Year 2018 Physician Fee Schedule (PFS) final rule, published in November 2016. The final details were issued in the CY 2018 PFS final rule, and include the Healthcare Common Procedure Coding System (HCPCS) G-codes that MDPP suppliers will use to submit claims for payment when all the requirements for billing the codes have been met.

MDPP suppliers may only furnish the MDPP services to eligible beneficiaries. Eligibility is limited to beneficiaries enrolled in either Medicare Part B or Part C who have a Body Mass Index (BMI) of at least 25 (23 if self-identified as Asian) on the date of the first core session and have at least one clinical indicator of prediabetes, but no previous diagnosis of diabetes (except for gestational diabetes). The clinical indicators include a hemoglobin A1c test with a value between 5.7% and 6.4%, or a fasting plasma glucose of 110-125 mg/dL, or a 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test).

The CDC MDPP Registry is posted online.

For more information, contact: Help Desk, Medicare Diabetes Prevention Program, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 877-906-4940; Email: mdpp@cms.hhs.gov

There are an estimated 102,460 tax-exempt non-profit organizations providing health care services – including organizations providing services for addiction and substance abuse (8,578); diseases and disease research (18,667), health care facilities and programs (53,769), medical disciplines and specialty research (5,794), and mental health and crisis services (15,652). Among those non-profit organizations are 2,849 non-profit hospitals.

Importantly for these organizations, the standards required to keep tax-exempt status, specifically how uncompensated care is calculated, are shifting. Starting January 1, 2018, public and some non-profit health care provider organizations began using a new accounting standard that changes how they report revenue and bad debt. Under the new standard, bad debt expense is not reported as a separate line item. Instead, the amount reported as net revenue will reflect price concessions demanded by third- party payer contracts (and managed care organizations), and will reflect an “implicit” price concession for the amount of the bill that a consumer is considered unlikely to pay (see New 2018 Accounting Standard Limits What Health Care Provider Organizations Can Report As ‘Bad Debt’).

Bad debt is defined as any bill submitted for payment to a third-party payer or patient that is not paid in full. Currently, provider organizations report revenue as the amount billed for the service, less concessions to third-party payers, even if it does not expect to collect the full amount that is the consumer’s responsibility. Any gap between the amount billed and the amount the provider organization expects to collect from the consumer has previously been recorded as a “bad debt expense.” The current standard allows a provider organization to utilize the full gross charge to determine the bad debt amount for a service. Under the new standard, only the amount the hospital expects to reasonably collect from either the third party payer (insurance coverage) or the consumer can be used for determination of the revenue amount earned, and therefore the bad debt if not paid.

As an example, let’s assume that a provider organization has a gross charge of $1,000 for a service—and they have a contract with a health plan for $700 for that same service. For many organizations, previously, the revenue recognized would be $1,000— and any amount not paid (including the $300 “contractual allowance”) would be considered “bad debt” and included in the uncompensated care that is the community benefit. Under the new accounting standard, the amount of revenue allowed to be booked is the amount contractually agreed upon with that health insurance plan—$700. In essence, revenue and bad debt will now be determined on a contract-by-contract, service-by-service situation.

My colleague, James Stewart, Chief Executive Officer of Grafton Integrated Health Network explained the impact of this change in this way:

Historically, many provider organizations have calculated bad debt based on their “gross charge amount,” instead of their “expected reimbursement amount.” This means they have inflated their bad debt expense with an amount they never truly expected to collect. What the new standard does is make that practice against Generally Accepted Accounting Principles (GAAP). It says the first adjustment has to be from gross revenue, down to expected revenue, with that adjustment being a “contractual adjustment.” The bad debt is then calculated from the new expected amount.

This pronouncement will not in any way change actual revenues, just where the reduction is recognized. This means that many hospitals who used to use bad debt in their uncompensated care calculation will have greatly reduced uncompensated care amount that is recognized in the community.

These new standards present two key challenges for executive teams. First, financial operations will need to be changed to recognize revenue based on the contractual amount—which will vary by contract. The move to value-based reimbursement complicates the assumption of “contractual amount.”

The second challenge is that tax-exempt non-profit organizations will need to re-estimate the calculations of their uncompensated care and their community benefit.

To qualify for federal tax exempt status—501(c)(3) status—non-profit hospitals must provide documentation of their community benefit, which has historically been somewhat vaguely defined by the Internal Revenue Service (IRS) to include charity care, financial assistance, and subsidized services; participation in means-tested programs, like Medicaid; participation in education

and research programs; and community health improvement activities, donations to community programs, and community- building activities. States and local governments typically tie their tax exemptions to an organization’s federal 501(c)(3) status and have their own rules are regulations around community benefit. These new rules will change these calculations.

The full effects of this accounting change are still shaking out. What we know for sure is that as governments become more stressed for “revenue”, challenges to tax-exempt status will increase. For more on these issues, check out these resources from the PsychU Library:

  1. Will Charity Care Survive?
  2. The Kerfuffle About ‘Non-Profit’ Profits

Last month, I had a chance to touch base with Debbie Cagle-Wells, Chief Marketing Officer at Centerstone about their value- based health plan partnerships (see The Evolution Of Successful Value-Based Contracting). During that conversation, she noted the increased use of health plan incentive payments based on an interesting quality metric: consumer activation.

If you aren’t familiar with consumer activation, it is similar to consumer engagement with one important difference— consumer decision-making power. Consumer activation refers to a consumer’s knowledge, skills, ability, and willingness to manage his or her own health and care. The key is that consumers are making independent choices about managing their health care. In contrast, consumer engagement refers to work done by health care provider organizations to help lead consumers, ultimately, to activation. (For more consumer engagement, check out the work being done by Nicole Schechter, Psy.D., Rehabilitation Psychologist, Johns Hopkins School of Medicine-Is Consumer Engagement A Habit At Your Organization?).

So how do executive teams improve their consumer engagement and consumer activation skill set—an area where most service provider organizations have limited skills (see Making Consumer Engagement A Reality). The first step is measuring where the organization is at. For example, assessing the organization’s customer service.

Figure 1. Oss, M. The Transition To Value: Balancing The Strategic Challenges Of Performance Measurement, Talent & Capital [PDF Document]. Retrieved from https://www.openminds.com/

Another option is to track consumer activation using a measure similar to the Patient Activation Measure (PAM). The measure involves ranking consumers on a 0-to-100 scale in four categories: (1) believing the consumer role is important, (2) having the confidence and knowledge necessary to take action, (3) actually taking action to maintain and improve one’s health, and (4) staying the course even under stress. A meta-analysis in Health Affairs, that looked at results using PAM, found that a higher score led to: more positive care experiences; fewer complications from chronic diseases; better care coordination; and fewer hospitalizations and emergency department (ED) visits. Specifically, for every 10-point increase on the measure, the probability for an (ED) visit dropped one percentage point. And, activated consumers had better health outcomes in 9 of 13 measures.

How to bring consumer activation into your overall engagement strategies? A recent article in PatientEngagementHIT, 4 Patient Education Strategies that Drive Patient Activation, outlined four strategies:

  1. First, assess your consumer’s “health literacy”—Better-educated consumers are more active in managing their health care. Provider organizations should focus on categorizing consumers into groups based on levels of understanding and information needs, and then focus education strategies according to consumer need (see Less Consumer Education Demands More Consumer Engagement).
  2. Second, ensure consumers understand you—When you explain health care matters to consumers, do they understand you? This can be a particularly important step for complex consumers with comorbid mental and physical health issues. An important method for gauging this is to ask them to repeat back your instructions, in their own words, known as the “teach-back” method (see Consumers Don’t Know What They Don’t Know).
  3. Third, build consumer-driven educational plans—Work to meet consumers where they are, not where you are. Think about language and format choices to make sure that the information you are sharing with consumers is convenient to access, easy to understand, and designed from the consumer-perspective. Consumer activation is important, but it can’t be overly complex to explain, or consumers will tune out.
  4. Finally, utilize technology—A big key to convenience is technology options. Provider organizations need to adopt consumer-enabling tech options that can empower consumers to participate more fully in their care. This may mean making it easier for consumers to access to their own health data (see CMS Shifting Data Control To Consumers: Are You Ready To Share?), providing access to more tech-enabled treatment options (see Building Your Own Tech-Enabled Consumer Base), or updating service delivery models to enhance consumer convenience through digital platforms (see ‘Going Digital’ For A Better Consumer Experience).

Last year I had a chance to speak with James Schuster, M.D., Chief Medical Officer, Medicaid and Behavioral Services and Vice President, Behavioral Integration, UPMC Insurance Division, Community Care Behavioral Health Organization, about his work with consumer activation (see Looking For A Tech Strategy? Try Consumer Engagement). UPMC worked with several counties and the Pennsylvania Department of Human Services in a Patient-Centered Outcomes Research Institute (PCORI) funded comparative effectiveness study of two behavioral health home model approaches—self-directed and provider-supported—to improve the health status of consumers with serious mental illness by supporting consumer wellness, engagement, and self- management. The self-directed intervention used a secure web portal to support consumer access to personal health information, self-guided wellness interventions, and trackers for smoking cessation, weight management, and improved nutrition and sleep hygiene. The provider-supported intervention provided consumers with a full-time registered nurse at each community mental health provider organization to provide a wellness consultation.

Since then, Dr. Schuster and his colleagues have published this study on consumer activation. What they found was that the self- directed approach worked, but the provider-supported approach worked faster, noting in the study: “Provider-Supported participants experienced a more rapid initial [activation] increase that was then sustained over time…[but] findings show a nearly two-point increase in the Patient Activation Measure score for both approaches.” This suggests that organizations who can dedicate staff (even if it isn’t a full-time registered nurse) to help consumers actively manage their health care will be more likely to see better consumer outcomes over a shorter period of time.

For more on informing your consumer engagement strategies, check out these resources from the PsychU Library:

  1. Social Media Listening As Consumer Engagement Strategy
  2. Consumer Satisfaction, Consumer Engagement & Shared Decisionmaking
  3. Is Consumer Engagement A Habit At Your Organization?
  4. Consumer Engagement Is The Missing Piece In Population Health
  5. Looking For A Tech Strategy? Try Consumer Engagement
  6. The Dollars & Sense Of Consumer Experience
  7. The Big Rewards Of Health Care Through The Consumer Lens
  8. Will Your Consumers Miss You If You Are Gone?

On March 28, 2018, the health insurer Cigna announced that since implementing an initiative in 2016 to reduce member use of prescription opioid pain relievers, it has reduced the volume of opioids prescribed by 25%. When Cigna launched the initiative the goal was to reduce the volume by 25% over three years to bring utilization down to 2006 levels. In April 2017, Cigna reported that its members’ use of prescribed opioids had declined by nearly 12%.

For this initiative, Cigna measured the total volume of opioids being prescribed, taking into account the number of pills, the dosing of those pills, as well as the relative strengths of the different opioid medications. Cigna collaborated with more than 1.1 million prescribing clinical professionals, such as physicians and dentists. Cigna also collaborated with patient awareness and support organizations in local communities to identify immediate and longer-term approaches that increased safeguards in the opioid prescribing process, enhanced support and counseling, and made it easier to access treatments for substance use disorders.

Cigna analyzes claims data across pharmacy and medical benefits to detect opioid use patterns that suggest possible misuse by individuals. If patterns of potential misuse are identified for an individual member, Cigna notifies the member’s network health care professionals. Additionally, prescribers are alerted if their opioid prescribing patterns are not consistent with the Centers for Disease Control and Prevention’s (CDC) guidelines for opioid selection, dosage, and duration. To date, Cigna has engaged with more than 85,000 prescribers annually caring for consumers who have a concerning pattern of opioid prescription use to ensure that prescriptions are appropriate, medically necessary and safe for the consumer.

During the first year of the initiative, Cigna focused on its in-network provider organizations, especially those that participate in its Cigna Collaborative Care arrangements. As of April 2017, 161 medical groups participating in Cigna Collaborative Care, representing nearly 63,000 physicians had signed a pledge to reduce opioid prescribing and to treat opioid use disorder as a chronic condition. On July 1, 2017, Cigna implemented additional measures affecting use of long-acting opioids and quantities of short-acting opioids. A prior authorization is now required for any new prescriptions for long-acting opioids not used to treat pain due to cancer or sickle cell disease, or pain for people receiving hospice care. Most new prescriptions for a short-acting opioid are subject to quantity limits.

PsychU reported on this topic in “Cigna Reports Member Use Of Prescribed Opioids Down Nearly 12% Since May 2016,” which published on May 8, 2017.

For more information, contact: Ellie Polack, Media Contact, Cigna, 900 Cottage Grove Road, Bloomfield, Connecticut 06002; 860-902-4906; Email: elinor.polack@cigna.com.

Approximately 61.3% of outpatient physical therapy services claims did not comply with Medicare reimbursement requirements. Reasons found for noncompliance include providing services that were not medically necessary, inaccurate coding to meet Medicare requirements, and documentation that did not meet Medicare requirements. This resulted in an estimated $367 million in Medicare reimbursements for all non-compliant claims.

These findings were reported in “Many Medicare Claims For Outpatient Physical Therapy Services Did Not Comply With Medicare Requirements” by the Office of Inspector General (OIG). OIG personnel analyzed a random sample of 300 Medicare outpatient claims for physical therapy services between July 1 and December 31, 2013. A claim consisted of all services provided to a beneficiary on the same date. These claims totaled $635.8 million. The goal was to determine the extent of any non- compliant Medicare claims through this 2013 random sample.

Additionally, the GAO found that CMS’ controls and physical therapy education were not always effective in preventing payments for physical therapy services that did not comply with Medicare requirements. For example, about 48.7% of the claims with functional reporting issues were processed and paid after CMS had started enforcing functional reporting requirements.

OIG made three overall recommendations in regards to their findings. These recommendations include:

  1. Instruct Medicare Administrative Contractors to notify providers of potential overpayments. This would allow those providers to exercise reasonable diligence to investigate and return any identified overpayments.
  2. Create methods to better monitor the appropriateness of outpatient physical therapy claims.
  3. Educate providers about Medicare requirements for submitting outpatient physical therapy claims for reimbursement.

CMS responded with comments regarding the OIG findings. While CMS agreed with the second and third recommendations, they generally disagreed with the findings and first recommendation. CMS did not agree with some of OIG’s policy interpretations and believes that further analysis of the sampled claims should be performed to better determine non-compliance and amount that was paid due to the non-compliant claims.

For more information, contact: Don White, Sr. Media Relations Specialist, Office of Inspector General, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Suite 729-D, Washington, District of Columbia 20201; 415-437-7982; Fax: 202-690-6079; Email: media@oig.hhs.gov

Behavioral health home consumer activation is more rapid in provider-supported care model which includes nurse support of consumers and other staff than in consumer self-directed models which focus on self-management strategies without nursing interventions. However, after consumers were activated for both models, their use of outpatient services increased over six months before beginning to decline.

Consumer activation is defined as confidence in, and the ability to improve or manage, one’s own health as measured by the Patient Activation Measure. Activation scores on the Patient Activation Measure are linked to improved clinical outcomes, lower costs of health care, and improved consumer ratings of their health care experience. Highly activated health care consumers are more likely to adopt healthy behaviors to have better clinical outcomes and lower rates of hospitalization and to report higher levels of satisfaction with services. Health care consumers with low activation levels are more likely to make emergency department visits, be hospitalized, or be readmitted.

These findings about consumer activation in behavioral health homes were reported in “A Payer-Guided Approach To Widespread Diffusion Of Behavioral Health Homes In Real-World Settings” by Dr.James Schuster, Cara Nikolajski, Jane Kogan,

Chaeryon Kang, Patricia Schake, et al., and published in the February, 2018 edition of Health Affairs. The researchers analyzed the Behavioral Health Home Plus model developed by the Community Care Behavioral Health Organization, a non- profit managed care organization that is part of the UPMC Insurance Services Division. The researchers are affiliated with the University of Pittsburgh Medical Center (UPMC)’s Center for High-Value Health Care.

For this study, the researchers randomly assigned 11 community mental health provider sites to either self-directed or provider- supported health home approaches. Between October 1, 2013 to January 14, 2014, 1,229 adult Medicaid beneficiaries with serious mental illness who had been receiving services at one of the 11 provider sites agreed to participate. The goal was to determine the impact of self-directed care and provider-supported models on change over two years in the participants’ engagement with the health home, their perceived health status, and number of primary care and specialty care visits.

The full text of “A Payer-Guided Approach To Widespread Diffusion Of Behavioral Health Homes In Real-World Settings” was published in the February 2018 issue of Health Affairs. A free abstract is available online.

For more information, contact:

Enhanced care coordination may be the key to low hospital readmission rates. The readmission rate for Pioneer accountable care geriatricians who provide enhanced care coordination was 3.1% lower than the 14.1% overall readmission rate for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and pneumonia.

These findings were reported in “Thirty-Day Readmissions: Relationship to Physician Attending Type and Social Connectedness” by Carey C. Thomson, M.D., MPH; Nathalie Bloch, M.D., MPA; Tafadzwa Muguwe, M.D., MS; Kendell Clement, Ph.D.; Shani Legore, BA; Orissa Viza, MSW, MPH; Joanne Kerwin, Ph.D.; and Valerie E. Stone, M.D., MPH. The researchers studied a matched subset of readmitted and nonreadmitted hospital health care consumers to examine reported reasons for readmission for the time between January 1, 2013 through December 31, 2015. The goal was to determine health care consumer and health care system factors associated with 30-day readmissions in a hospital with a Pioneer accountable care organization.

Categories analyzed included attending type, diagnosis, payer, demographic factors, and clinical factors. A total of 17,099 admissions occurred during the time studied; 2,226 of these matched the study’s analysis requirements. Additional findings include:

The researchers concluded that, while the study consisted of a bundled set of interventions studied at a single institution, enhanced care coordination may be another promising strategy for decreasing readmissions. The researchers recommend extending this study to include other institutions.

The full text of “Thirty-Day Readmissions: Relationship to Physician Attending Type and Social Connectedness” was published March 7, 2018, by The American Journal of Accountable Care. A free abstract is available online.

For more information, contact: Valerie E. Stone, M.D., Department of Medicine, Mount Auburn Hospital, 330 Mount Auburn Street, South 2, Cambridge, Massachusetts 02138; 617-499-5593, ext. 617-499-5309

On March 14, 2018, Vermont Care Partners (VCP) announced that Washington County Mental Health Services (WCMHS) and United Counseling Service (UCS) had reached full certification as a Vermont Care Partners Center of Excellence (VCP-COE) under a new program for VCP’s community-based network member provider organizations. VCP is a network of 16 community- based provider organizations that deliver supportive services to nearly 50,000 people across the state who have mental health conditions, substance use disorders, and/or intellectual/ developmental disabilities (I/DD). The COE program is intended to identify organizations that provide a continuum of high quality services.

WCMHS was the first VCP member to reach full certification in November of 2017 followed by United Counseling Service in March of 2018. The VCP-COE designation lasts for three years. The goal is that all VCP network agencies will earn the VCP- COE designation. As of April 3, 2018, another eight VCP network agencies had started the process to gain the VCP-COE designation. VCP will review all agencies by the end of 2020.

The VCP-COE framework is built upon five domains that describe a COE as an organization with excellent staff and high-quality services that are accessible, available, and integrated into the broader health environment, and that support resiliency and recovery. The VCP agencies are not federally designated health homes or patient centered medical homes. Rather, they are primary care homes for people with I/DD, mental health, and substance use disorders and are designated by the State of Vermont to provide services and supports to certain populations. The agencies coordinate other needed services with community human services and physical health care provider organizations.

Each VCP COE must meet performance benchmarks in five domains, as follows:

  1. Customer service measures include: staff satisfaction responses indicating that staff feel empowered and committed to the agency, and consumer satisfaction responses indicating they were treated with respect.
  2. Outcome measures include: hospitalization rates; employment rates for consumers supported by Developmental Services and Community Rehabilitation and Services; consumers indicating they are better off as a result of services; whether clients met their individualized treatment goals, and the share of people with I/DD living in community settings.
  3. Access measures include: community locations; number of schools in the catchment area where the VCP provider organization offers school-based services; and collaborations with medical offices to place a co-located VCP behavioral health professional in a medical office setting.
  4. Comprehensive care measures include: consumer survey responses that the VCP member organization helped them receive the right help; and whether the VCP member organization follows up quickly following discharge from a psychiatric hospital
  5. Value measures include: use of VCP member crisis day beds as an alternative to hospitalization; measures that demonstrate integration with the community health care team; and the share of people screened by a VCP member network public inebriate programs who were then diverted from jail.

VCP began developing the COE model in 2015 to help its members articulate their value and contributions to Vermont’s health system. Its members found that existing national models of accreditation were not able to capture the impact of community-based programs. The national accreditation models often required a major investment of funds and staff time, which was difficult because state funding was increasingly capped, and the state was scrutinizing spending. VCP adapted a COE framework provided by the National Council for Behavioral Health as the foundation for developing a more relevant model of certification to inform quality improvement. The VCP work toward a System of Excellence is funded through Vermont Care Network by a federal Rural Health Policy Network Development Grant. The final VCP-COE certification process and measure set opened for application in July 2017. The process relies upon peer reviewers from experts supplied from the network, and from external review by the Jeffords Institute for Quality at the University of Vermont Medical Center. VCP described its progress on the VCP- COE initiative in its 2017 outcomes and data report.

The full text of “Vermont Care Partners Fiscal Year 2017 Outcomes & Data Report” was published in December 2017, by Vermont Care Partners. A free copy is available online.

For more information, contact:

Between 2013 and 2015, the share of opioid-related hospitalizations in which the patient was uninsured fell from 13.4% to 2.9% in states that expanded Medicaid to low-income adults under the Affordable Care Act. The comparative decline in non-expansion states was relatively modest.

These findings were reported in “Medicaid Expansion Dramatically Increased Coverage for People with Opioid-Use Disorders, Latest Data Show” by Matt Broaddus, Peggy Bailey, and Aviva Aron-Dine of the Center on Budget and Policy Priorities. The researchers analyzed the most recent hospitalization data from the Healthcare Cost and Utilization Project for states with data for the entire study period, for both Medicaid expansion and non-expansion states. The goal was to evaluate across the country the change in the number of opioid-related hospitalizations and the share of these hospitalizations in which the patient was uninsured.

Additional findings include:

The full text of “Medicaid Expansion Dramatically Increased Coverage for People with Opioid-Use Disorders, Latest Data Show” was published on February 28, 2018, by the Center on Budget and Policy Priorities. A free copy is available online.

For more information, contact: Miji Bell, Media Contact, Center on Budget and Policy Priorities, 820 First Street NE, Suite 510, Washington, District of Columbia 20002; 202-408-1080; Email: mbell@cbpp.org

Starting January 1, 2018, public and some non-profit health care provider organizations began using a new accounting standard that changes how they report revenue and bad debt. Under the new standard, bad debt expense is not reported as a separate line item. Instead, the amount reported as net revenue will reflect price concessions demanded by third-party payer contracts (and managed care organizations), and will reflect an “implicit” price concession for the amount of the bill that a consumer is considered unlikely to pay.

Currently, health care provider organizations report revenue as the amount billed for the service, less concessions to third-party payers, even if it does not expect to collect the full amount that is the consumer’s responsibility. Any gap between the amount billed and the amount the provider organization expects to collect from the consumer is recorded as a provision for bad debt expense.

The amount of uncompensated care hospitals provide is not expected to change as a result of the revised standard, but it is expected to reduce the amount reported as bad debt expense. The amount of reported revenue is also expected to decrease, which is likely to have an impact on any revenue-based performance metrics. The change to bad debt expense reporting may affect how non-profit hospitals report community benefit to the Internal Revenue Service (IRS) because non-profit hospitals report bad debt expense and charity care.

For example, under the previous standard, if a hospital provided a service that it priced at $100 for an uninsured consumer, the hospital would bill the consumer $100 and record $100 as revenue, even if the hospital expected, based on historical experience, to collect less. If the consumer ultimately paid only $10, then the hospital would report $90 as bad debt. For insured consumers, the hospital applied an explicit discount to reduce the price to the third-party network price, and then recorded the discounted price as revenue. The consumer would be billed for the consumer share of the network price (even if the hospital suspected that it would collect less). If the consumer ultimately paid less than the billed amount, the hospital would record the unpaid amount as bad debt.

Under the new standard in the same scenario with an uninsured consumer, the hospital would still bill the consumer $100. However, before reporting revenue the hospital would reduce the revenue, based on its historical experience, to the predicted payment amount of $10. No bad debt would be reported from that encounter; the hospital would record the $10 as revenue. If the consumer paid less than the predicted payment, the difference between the predicted payment and the amount actually collected could be recorded as bad debt. If the consumer paid more than the predicted $10, the additional amount would be recorded as revenue. For an insured consumer, the price would be adjusted by an explicit contract discount to the network price. The adjusted charge represents the share due from the third-party payer and the share due from the consumer, but before recognizing revenue, the hospital will then apply an implicit discount to the consumer share based on its projections of what it is likely to actually collect from the consumer. That adjusted amount would be recorded as revenue. The consumer would be billed for the full consumer share. If the consumer paid more than expected, the hospital would record the additional amount as revenue. If the consumer failed to pay the expected amount that was recognized as revenue, then that amount would be recorded as bad debt.

The standard was issued as “Update No. 2014-09—Revenue from Contracts with Customers (Topic 606)” in May 2014, by the Financial Accounting Standards Board (FASB). The standard aligns FASB standards with international standards, and affects any companies that have contract revenue. The goal is to help investors and stakeholders compare companies across industries.

Previously, FASB had a multiplicity of industry-specific rules. Under the new standard, businesses, including hospitals, will recognize revenue when promised goods or services are provided to consumers, and businesses will only recognize revenue in the amount that the business expects to receive.

The American Institute of Certified Public Accountants (AICPA) is interpreting the FASB standards to develop specific guidance for industries with complicated contracting structures, such as the health care industry. Some of the guidance topics have been finalized, such as how to apply the portfolio approach to revenue from self-pay consumers and third-party payers.

Other topics are still in development, such as prepaid health plans, continuing care retirement communities (CCRC), and how other health care settings (non-CCRC) to identify the promised goods and services—the performance obligations—in a contract with a consumer, and which represent separate performance obligations in order to apply the revenue recognition guidance.

The new standard will be phased in by business structure; public organizations implemented first for annual reporting periods beginning after December 15, 2017, and non-public organizations (including non-profit organizations), which will implement for annual reporting periods beginning after December 15, 2018. Public organizations include three types of entities: publicly-traded companies; non-profit organizations that have issued bonds or iare responsible for securities that are traded, listed, or quoted on an exchange or an over-the-counter market; and employee benefit plans that file or furnish financial statements to the U.S. Securities and Exchange Commission. Organizations that do not meet the definition of a public organization are non-public organizations.

FASB issued the full text of