Incentivizing Evidence Based Approaches

Washington Behavioral Healthcare Conference June 13, 2019

Kat Latet, CHPW Director, Health System Innovation Terry Lee, CHPW Behavioral Health Medical Director

Agenda

• Brief CHPW Overview

• Definitioning Evidence Based Practice

• Opportunities and challenges in measuring BH outcomes

• Federal and State Value Based Payment Overview

• Mechanisms and models to incentivize change

• Facilitated group discussion

We are a local, Washington-based Health Plan with long-established ties to communities throughout the State and well-equipped to facilitate and coordinate with local resources on behalf of our members. As a not-for-profit company, we make decisions that are motivated by the best interests of our members, providers and communities within the State of Washington. We are governed by community organizations (Community Health Centers) that are in turn governed by individuals that receive care within those organizations. The health of our members is our primary concern. Our programs are designed to proactively identify and address the behavioral, social, and medical needs of our members and to recognize the whole person’s needs. The vision of CHPW is to provide services and supports that impact the health and well-being of our members, both directly and through our valued partnerships with community-based providers. We meet this challenge by identifying and addressing needs that impact the health of our members both within the clinical setting and beyond.

Comments on BH System

• 90% of public mental health services do not deliver treatments, programs or services that have empirical support (Elliot, 1999)

• President’s Commission reports public mental health system is “in a shambles” (President’s New Freedom Commission Report, 2004)

• There are limited instances of evidence-based practices in behavioral health care delivery (AHA, 2016)

• It is doubtful whether there will be an increase in the behavioral health workforce…unless there is a significant increase of pre-payment incentives and payments tied to managed care and CMS funding (AHA, 2016)

Why US Needs a NASA for Behavioral Health (Sabbatino, 2018)

• Behavioral health delivery system remains broken

• Behavioral health outcome data is essentially non-existent

• Behavioral health providers are a generation behind physical health providers in their readiness to accept value-based payments

• Shortcomings of the current behavioral health delivery system create opportunities for innovators that develop scalable solutions

Implementing Effective Practices

• >500 effective psychosocial treatments for youth (Kazdin, 2000)

• 15-20 year lag from lab to clinic (IOM, 2001)

What is Evidence Based Practice?

One Definition of EBPs

• Defined problem/population

• Described/manualized treatment

• Measurable outcomes

• Fidelity/adherence measures

• Correlation of treatment fidelity to outcomes

• Replicated outcomes by independent groups

Other EBP Definitions

• Approach that integrates clinical expertise, patient values and best research evidence into decision-making process of patient care (Sackett, 2002)

– Knowledge of evidence informs the approach, but approach is not predetermined

• Attention to logic model and outcomes

• Role for measurement-based care

Barriers to Implementing EBPs • Cultural concerns • Clinician attitudes/acceptability to EBPs • Attitudes towards scrutiny and accountability • Lack of training • Cost of training • Cost of implementing and sustaining

– Staff turnover

• Lack of incentives to implement • Capacity to demonstrate outcomes • Don’t stifle innovation

Value-Based Payment: A National Movement

• Value based payment is quality/costs = value

• Payment reform is about changing financial incentives

to reward high-value, cost-effective care

• Payment and delivery system reform are intrinsically

linked

• There are multiple value-based payment models

ranging from pay-for-performance to capitation

• Primary goal of Healthier Washington and tied to

Medicaid Demonstration

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• Federal and state goal alignment for VBP

• Using a common lexicon and guide: Health Care Payment and Learning Action Network

• Investing in transformation at the practice level (CMMI SIM, DSRIP, CMS guidance)

• Aligning commercial, Medicare and Medicaid: MACRA, MIPS, QPP, AAAPM

• Sending common signals across the marketplace

Shared Aim: Better Care, Smarter Spending, Healthier People

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National Framework for Defining VBP HCP LAN – Alternative Payment Model Framework

HCA’s Definition of

VBP: Categories 2C

through 4B

FFS with bonus payments for

quality performance

Bundled payments with upside only, or

upside & downside risk

Capitation (full or % of premium population-

based payment)

EXAMPLES:

HCA’s Expectations

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Through Medicaid, this is done through the VBP Withhold (In 2019- 1.5% of premium; 2020- 2% of premium) Percentage of Payment: (12.5% of earnback) • By 2021, 90% of payments must be in an arrangement that is higher than 2B • By 2021, 50% of payments must be in a Category 3 or 4 arrangement • The definition of how the state measures provider payment is very important Quality Incentives: (12.5% of earnback) • Increasing percentage of premium be tied to quality incentives and/or

disincentives.

Quality Improvement Score: (75% of earnback) • Based on a set of quality measures (within the common measure set) • Show absolute performance and improvement; tied to the national

benchmarks and over self

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National Framework for Defining VBP HCP LAN – Alternative Payment Model Framework

HCA’s Definition of

VBP: Categories 2C

through 4B

FFS with bonus payments for

quality performance

Bundled payments with upside only, or

upside & downside risk

Capitation (full or % of premium population-

based payment)

EXAMPLES:

Types of models

– Pay for measurements, reporting, capacity development and system adoption

– Supplemental Payments

– Pay for Performance bonuses and withholds

– Bundled Payments

– Total cost of care with upside gainsharing and downside risk

–Quality gate and ladder utilization

–Global capitation

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What does VBP mean for providers?

Opportunities Challenges

• Further flexibility to provide the right care at the right time by the right type of provider: patient centered

• Moving off the hamster wheel: more provider centered

• Alignment in payer approaches regarding quality goals and reporting

• Ability to partner across the continuum of care and leverage non-traditional providers/partners

• Many safety-net providers have limited cash reserves to invest in the capacities necessary to manage VBP

• Gap in capacity awareness, especially in data analytics, business intelligence and population health management

• Strategic conflicts between primary care and hospitals

• Burden of poverty and illness within the safety net

How MCOs Work in Partnership with Providers in VBP Arrangements

• Define health plan value and organizational culture

• Data provision, analytics and quality improvement support

• Financial Support for targeted investments

• Care management and care coordination support

• Utilization and disease management

• Consultation and training based on capacity assessment

• Facilitate partnerships across network participants to ensure collaboration

• Partner with other plans to ensure administrative simplification

• What are you currently measuring? Either for yourself or for a contract?

• Why is it difficult? • What kinds of incentives would be

reinforcing? • What types of evidence based practices

should be eligible for incentive payments? • What support do providers need? • How change can be measured?

Group Discussion

Contact Information

Terry Lee, Behavioral Health Medical Director Terry.lee@chpw.org Kat Latet, Director, Health System Innovation Kat.latet@chpw.org

Appendix

Fee For Service (FFS) • Payment for

services rendered

FFS with Gain Share • Payment for services

rendered • Quality metrics • Total Cost of Care

(MLR) Threshold • Distribution of funds

when below threshold and quality metrics met

FFS with Shared Risk • Payment for services

rendered • Quality metrics • Total Cost of Care

(MLR( Threshold • Distribution of funds

when below threshold and quality metrics met

• Withhold when above threshold

Full Risk Capitation • Payment as a

percent of premium or PMPM

• Quality metrics • Sometimes

delegation

Service Based

Value Based

VBP Continuum – examples (Reference Slide)

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Example: Gap in care closure incentive payment

to providers