Value Based Payment Contracting: Health Plan Perspective

Transcription

1 Value Based Payment Contracting: Health Plan Perspective CHCANYS Statewide Conference & Clinical Forum October 18, 2015 Harold N. Iselin / iselinh@gtlaw.com / GREENBERG TRAURIG, LLP All rights reserved.

2 Types of Value-Based Payment Arrangements Capitation Payment Total Cost of Care Partial capitation for certain services Shared savings (bonus) based on a medical budget Shared risk based on a medical budget Payments based on quality outcomes or targets Outcome measures Reducing medically unnecessary services e.g., inpatient hospitalizations and readmissions Process measures Providing proper follow-up care to a MH/SUD provider after inpatient hospitalization Medication adherence Reporting of data All rights reserved.

3 When to Contemplate a Value-Based Payment Arrangement Understand your data (information technology capabilities) Ability to manage utilization Who is performing the assessments, managing, coordinating and approving utilization? Mutuality (risk and reward) Control over the services in which you are assuming risk Risk for own services Risk for services other providers render All rights reserved.

4 Risk Mitigation Strategies Limit risk delegation based on agreed-upon budget Risk adjustment for attributed members Risk corridors Use of Stop Loss or Reinsurance Per case Total expenditures All rights reserved.

5 What do Health Plans Look For in a Partner? Business profile of MCO and Provider How much business can you bring to the table? Can you help MCO meet state requirements quality measures and goals, network adequacy requirements, etc.? Competitors of MCO and Provider What distinguishes you from other providers and can you help the MCO distinguish itself from other MCOs? Strengths and opportunities Quality of services Financial health System capabilities - IT Partnership to foster win / win Mutuality All rights reserved.

6 October 18,2015 Value-based Contracting Art Jones, MD HealthManagement.com

7 Practice Transformation Financial Model Fee-forservice PPS PCCM/PCMH P4P Shared savings Partial Capitation AccountableCareInstitute.com 2

8 Practice Redesign or Payment Reform AccountableCareInstitute.com 3

9 Practice Transformation 4 Transition to Value-Based Care Aligned Payment Transformation AccountableCareInstitute.com

10 CMS is Focused on Increasing Value Based Payment Approaches Consider Impact on New York FQHCs Category 1: Fee for Service No Link to Value Category 2: Fee for Service Link to Value Category 3: Alternative Payment Models Built on Fee-for-Service Architecture Category 4: Population-based Payment Description Payments are based on volume of services and not linked to quality or efficiency At least a portion of payments vary based on the quality and/or efficiency of health care delivery Some payment is linked to the effective management of a population or an episode of care Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk Payment is not directly triggered by service delivery so volume is not linked to payment Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., 1 year) Medicare examples FQHC Medicare fee-for-service at PPS rates Chronic care management fee Physician Value-Based Modifier Readmissions / Hospital Acquired Conditions Reduction Program MSSP ACOs Medical homes Bundled payments Comprehensive primary Care initiative Comprehensive ESRD Medicare-Medicaid Financial Alignment Initiative Fee-For-Service Model Eligible Pioneer accountable care organizations in years 3-5 Next Generation ACOs 5 Source: Adapted from Rajkumar R, Conway PH, Tavenner M. CMS engaging multiple payers in payment reform. JAMA 2014; 311:

11 Avoid Handouts Seek deal terms that force you to transform your business Don t be lulled into maintaining the financial status quo Don t become the next Kodac 6

12 Focus on the Low Hanging Fruit Initially Look at your benchmarked performance Go where the money is Look in the mirror 7

13 Evolving FQHC Focus Target Resources Based on Person Centered Needs B Address modifiable risks and integrate and coordinate care, develop advanced patientcentered medical homes, primary care disease management, public health, and social service supports, and integrated specialty care High need/ complex Chronically ill at risk of being high use Chronically ill but under control Healthy % of Beneficiaries A Care plans, support services, case management, new models, and other interventions for individuals with significant demands on health care resources C Promote and maintain health (e.g. via patientcentered medical homes) 8

14 Not all Value-Based Payments Have Value: Metrics Applicability to your membership Metric you can impact Data availability Feasibility of rapid CQI Realistic performance improvement expectation Aligned with other payers 9

15 Not all Value-Based Payments Have Value: Financial Opportunity MLR too low Miserly split of the pool Tied to performance of others Inadequate stop loss Over conservative IBNR calculation Carry over of deficits from previous years 10

16 Joint Contracting Be careful who you swim with Be sure incentives are aligned Monthly if not weekly performance reporting All or none face-toface accountability 11

17 Use of Value-based Funds Never budget on their potential revenue Direct a portion toward improving earnings for next year Create reserves with the rest to assume future risk 12

18 IPA Contracting Model Fee-for-service or primary care capitation contracting for primary care services comparable to the lowest non-fqhc rate already in the market Reconciliation to individual FQHC PPS rate equivalency by the State Medicaid Agency Clinically and financially integrated IPA able to contract for, collect and distribute value-based payments based on individual FQHC performance 13

19 Creating IPA Contracting Leverage Market share Geographic coverage Network performance across the continuum of care Preferential MCO relationships Single signature Willingness and ability to assume financial accountability 14

20 Potential Philosophical Contracting Differences Inclusive or selective with payers Response to narrow network offers from payers Populations (Medicaid, Medicare, commercial) Contracting with MCOs only vs. other payers as well Standardization and types of value-based metrics Delegation of care management Scope of health care service accountability 15

21 Potential Philosophical Contracting Differences Immediate vs. delayed gratification Risk threshold: tradeoff between upside potential and downside risk; carry forward of pool deficits; stop-loss and risk corridors What constitutes a meaningful value-based payment potential Inclusion of non-ipa providers in valuebased payment pools (ex: BH) Inclusion of TPA in value pool 16